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Weekly Chest CasesArchive of Old Cases

Case No : 697 Date 2011-03-03

  • Courtesy of Inyoung Song, MD, Chin A Yi, MD / Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
  • Age/Sex 71 / M
  • Chief ComplaintAsymptomatic
  • Figure 1
  • Figure 2
  • Figure 3

Figure 1

Diagnosis With Brief Discussion

Diagnosis
Extrathoracic lung herniation
Radiologic Findings
The patient had a history of traffic accident and was treated for multiple fractures about 10 years ago. A dumbell-shaped lesion was found on chest CT, which straddled across the right anterior chest wall. The lesion showed low attenuation as much as the air in the lung (figure 1). On bone window setting, chest CT demonstrates non-union of old fracture involving anterior arc of right 3rd rib (figure 2). When tracing the lesion up and down, the low attenuated lesion was continuous with lung parenchyma in the thorax and connecting pulmonary vessels were squeezed through the slit of non-union of right 3rd rib. Figure 3 is a 3D reconstructed image with SSD (surface shaded display)-technique. The communication between the herniated lung and intrathoracic lung parenchyma is nicely demonstrated on this 3D volume image.
Brief Review
Herniation of the lung and pleural membranes outside of the bony thorax is a rare occurrence. Broadly, the etiology is either congenital (accounting for 18% of cases) or acquired. When congenital, the hernia is caused by rib or intercostal hypoplasia or agenesis. An acquired extrathoracic lung hernia can be either caused by trauma (52% of cases), which is more often penetrating than blunt injury, or spontaneously acquired (30% of cases).These hernias can be asymptomatic and uncomplicated; therefore, presentation can be delayed. Presentation in these individuals occurs with a slowly enlarging fluctuant swelling more conspicuous on Valsalva manoeuvre.
Plain chest radiography may produce only subtle findings. Bony or joint trauma may be seen. Owing to the sharply defined density difference between herniated aerated lung and the surrounding chest wall soft tissues, the hernia itself may be apparent. The absence of contrast within the vessels of a herniated lung on contrast-enhanced CT can be taken as an indication of strangulation and therefore of imminently at-risk lung or already non-viable lung. Management decisions depend on whether the herniated lung is viable, the patient’s condition, and the site, type and size of the thoracic wall defect. Conservative treatment relies upon spontaneous regression of the hernia. Serial clinical and imaging examinations are vital for the conservatively managed patient.
References
Clark AJ, Hughes N, Chisti F. Traumatic extrathoracic lung herniation. Br J Radiol 2009; 82:e82-84.
Keywords
Lung, Chest wall, Trauma, Postoperative complication,

No. of Applicants : 125

▶ Correct Answer : 112/125,  89.6%
  • - Osaka University , Japan Hiromitsu Sumikawa
  • - Assam Medical College , India Karunakaran M
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Teleradiology , India Savith Kumar
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - McGill University Health Center , Canada Alexandre Semionov
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - Institute of Chest Diseases Calicut , India Dr.Divya Nair
  • - James Paget Hospital , U.K , United Kingdom nabil mahmood
  • - Assam Medical College , India Pankaj Nagori
  • - Dongnam Institute of Radiological and Medical Sciences , Korea (South) Dae Wook Yeh
  • - Auckland hospital , New Zealand (Aotearoa) Yuranga Weerakkody
  • - Severance Hospital , Korea (South) Hyun Gi Kim
  • - Assam Medical college , India samudra borah
  • - HCG-MEDISURGE HOSPITAL , India PRAKASH ODEDRA
  • - Vital Imaging Centre, Mumbai,India , India Ganesh Agrawal
  • - University of Iowa, USA , United States Archana Laroia
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Saga University , Japan Ryoko Egashira
  • - private , United States magdi girgis
  • - NTUH , Taiwan Kuei-pin Chung
  • - Hangang sacred heart hospital , Korea (South) You Mie Han
  • - Chonnam National University Hwasoon Hospiral , Korea (South) You Ri Choi
  • - radiologist, aditya imaging centre , India vivek patel
  • - Goa Medical College , India Paresh Desai
  • - Chungnam National University hospital, Korea , Korea (South) sunkyoung you
  • - Sahyadri Speciality Hospital, Karad , India SUNIL ALMALE
  • - Okayama University , Japan Akihiro Tada
  • - Vitalife Clinics , Pune , India. , India Rahul Deshmukh
  • - McGill University , Canada Ben Smith
  • - Univ. of Miami/Jackson Memorial , United States mantosh rattan
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Songtan public health center, Goduk substation , Korea (South) Jaewang Shin
  • - Teleradiology solutions , India harish bhambore
  • - Retd. Prof Thoracic Surgery B.J.MEDIDCAL COLLEGE Punr India;Visitng Prof of Thoracic Surgery KLE University Belgaum , India Bankim Amin
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Seoul National University Hospital , Korea (South) Yeo Kim
  • - SMC , Korea (South) JIHYE MIN
  • - Amrita Institute of Medical Sciences. , India Mangal Mahajan
  • - Radiologie Brabois adultes , France ROPION helene
  • - PRINCESS MARGARET HOSPITAL , Bahamas SHUJAUDDIN RAHIMI
  • - Catholic medical center , Korea (South) hyuna kim
  • - Chonnam National University , Korea (South) se hee Jung
  • - Kasturba Medical College , India Chandan Kakkar
  • - Severance hospital, shinchon , Korea (South) yeojin lee
  • - HSC , Brazil Diogo Pinheiro
  • - Fukuyama daiichi Hospital , Japan Mototsugu Saeki
  • - Seoul national university hospital , Korea (South) A Jung Chu
  • - Severance hospital , Korea (South) Saerom Hong
  • - Ewha womens university, mok dong hospital , Korea (South) Cho Hyun hae
  • - chp st martin , France Mariotte benoit
  • - All India Institute of Medical Sciences , India Ashish Gupta
  • - , Korea (South) Pyeong Guk Kang
  • - University of British Columbia , Canada Amr Ajlan
  • - Istanbul , Turkey Armagan Sarac
  • - Hotel-Dieu Montreal , Canada nicolas gautier
  • - CNUH , Korea (South) Seoin Jeong
  • - Chonnam National University Hospital , Korea (South) Jung hyun Kim
  • - Chonnam national university hospital , Korea (South) Yunhong Yoon
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Yonsei University College of Medicine, Severance Hospital , Korea (South) Hyung Jin Rhee
  • - Chonnam national univ. hospital , Korea (South) Choi Seul Gi
  • - CHRU lille , France manuel toledano
  • - Gifu Chuo Hospital , Japan Yo Kaneko
  • - Youngdong Hospital , Korea (South) Sang Min Lee
  • - aarthi scans , India abirami mahadevan
  • - Chonnam university hospital , Korea (South) Minyoung Jung
  • - Radnet Teleradiology , Turkey Murat Ulusoy
  • - NIMS , India HARSHA KR
  • - All India Institute of medical sciences , India Justin Moses
  • - Yonsei Severance Hospital , Korea (South) Ah hyun Kim
  • - EKH-Berlin , Germany Michael Weber
  • - A.P.Chest hospital , India k bhaskar
  • - Calicut Medical College , India Lisha PV
  • - SMC , Korea (South) Yi Kyung Kim
  • - Az Osp Santa Maria , Italy angelo carloni
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Doctors Hospital , Bahamas muneesh sharma
  • - Shiga university of medical science , Japan Akitoshi Inoue
  • - TELERADIOLOGY SOLUTIONS, BANGALORE , India ZAHOOR AHMED
  • - Chonnam university hospital , Korea (South) LEE JI HYUN
  • - Hospices Civils de Lyon , France Thomas Sanzalone
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - KING KHALID UNIVERSITY HOSPITAL , Saudi Arabia Elbagir Nasser
  • - Kobe City Medical Center General Hospital , Japan Hitomi Nagano
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - NDMVP Nashik , India Imran Jindani
  • - Kyungpook National Univ. Hospital , Korea (South) Sang-yub Lee
  • - Soonchunhyang University Cheonan Hospital , Korea (South) Park Sang Hyun
  • - IRSA , France jean-luc BIGOT
  • - Ishikawa Matto Central Hospital , Japan Manabu Akimoto
  • - DrRP GMEDICAL COLLEGE TANDA , India DINESH SOOD
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - Zaid Alsheriti hospital- Alsweida , Syria jehad alakabani
  • - Yonsei University College of Medicine, Shinchon Severance hospital , Korea (South) Young Joo Suh
  • - Hopital Louis Pradel Lyon , France Clement Proust
  • - Saint Malo , France jean-baptiste Noel
  • - St-Luc Bruxelles , Belgium Tancredi Illario
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Montreal , Canada D J
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - Seoul St Mary Hospital , Korea (South) Chaehun Lim
  • - NASA SCANS , India RAKESH BHATIA
  • - Chonnam national university hospital , Korea (South) seo yeon Park
  • - Chonnam national university hosipital , Korea (South) Byung chan Lee
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - chonnam national university , Korea (South) Byung Hyun Baek
  • - Okayama university , Japan Mayu Uka
  • - Shree Diagnostics , India amol jagdale
  • - KUMC ansan , Korea (South) kihwan kim
  • - Seoul Nationial University Bundang Hospital , Korea (South) Hee Seok Choi
▶ Correct Answer as Differential Diagnosis : 3/125,  2.4%
  • - Iwate Medical University , Japan Akio Akahane
  • - mugla state hospital , Turkey hakan altay
  • - Homs National Hospital , Syria Rami Abou Zalaf
▶ Semi-Correct Answer : 2/125,  1.6%
  • - Toyama University Hospital, Laboratory of Pathology , Japan TOMONORI TANAKA
  • - Ondokuz Mayis University , Turkey Cetin Celenk
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