An unusual cause for neck swelling: apical lung hernia.

To cite: Prasad S, Rao K, Belle J, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013202952 DESCRIPTION A 50-year-old woman with a history of pulmonary tuberculosis 20 years ago presented to us with cough with copious expectoration and a swelling in the right side of neck which increased on coughing since 2 months. Her physical examination revealed rales in the left interscapular and infrascapular areas. Her routine blood workup was normal. Her chest radiograph showed bronchiectatic changes in the left mid-zone and lower zones and right mid-zone and a radiolucent shadow (marked by arrow) pushing the trachea to the left (figure 1). CT of the chest showed a right apical lung hernia (figures 2 and 3). She was diagnosed as a case of post-tubercular bronchiectasis with right apical lung hernia. Lung hernias can be divided into apical hernia, intercostal hernia and diaphragmatic hernia. Each of them can be subdivided into congenital and acquired varieties. Apical lung hernia is a rare variety and has been confined to few case reports and series. Herniation occurs through a defect in the Sibson’s fascia and the apical segment of the lung protrudes in between the scalenus anterior and sternocleidomastoid muscles. In our patient, this defect may be attributed to her chronic cough resulting in tearing of the Sibson’s fascia. It is generally asymptomatic except for a swelling in the neck during coughing and Valsalva manoeuver. It can be diagnosed on posteroanterior and lateral chest radiographs but CT of the chest provides a confirmatory diagnosis. Surgical treatment is rarely warranted unless it undergoes incarceration. It may cause problems during insertion of internal jugular or subclavian catheters and may result in an inadvertent pneumothorax if a vigilant eye is not maintained. Figure 1 Chest radiograph posteroanterior view showing bronchiectatic changes in the left mid-zone and lower zones and right mid-zone and a radiolucent shadow (marked by arrow) pushing the trachea to the left.