A 65-year-old man with severe chronic obstructive pulmonary disease (COPD) was admitted with a four-day history of chest pain and worsening shortness of breath. He explained the chest pain started suddenly when he tried to reach out for something on his computer table. It was located on the right anterior chest, sharp in nature, 7/10 in intensity, pleuritic, and worse with coughing and deep breathing. He had a past medical history of severe COPD with frequent exacerbations recently necessitating multiple antibiotics and steroid courses, coronary artery disease, gastroesophageal reflux disease (GERD), and hypertension. He had a 30-pack per year smoking history and quit about 10 years ago. He was a retired fireman living with his family.\nVitals signs in the emergency department (ED) were stable; he was breathing on ambient air. The physical examination demonstrated decreased breath sounds bilaterally without any wheezing or Ronchi. Moderate tenderness was present in the mid-axillary line in the fifth intercostal space, but no other abnormalities were noticed. Laboratory investigations were negative for any leukocytosis, troponin, or any other abnormalities. The electrocardiogram (EKG) showed a normal sinus rhythm. Computed tomography (CT) angiography was done to rule out pulmonary embolism (PE). The CT was negative for PE but showed mild peribronchial infiltrate in the right middle lobe and posterolateral lung herniation between the seventh and eighth ribs, with minimal subcutaneous emphysema along the right chest wall (Figure ).\nThe patient was admitted to the hospital and managed conservatively on broad-spectrum antibiotics, including vancomycin, levofloxacin, and 40 mg per day of prednisone. Two days later, his face swelled up suddenly with a change in the quality of his voice while he was eating dinner. An examination showed a swelling in the neck, diffuse crepitations on his body involving the face, all the way down to the buttocks. Repeat CT chest and neck showed extensive subcutaneous emphysema in the face, neck, chest, and mediastinum with a right-sided pneumothorax at the level of the previous lung herniation (Figures -).\nThe prevertebral and retropharyngeal air was demonstrated as compressing the oropharynx (Figure ). His oxygen requirement went up to 6 liters nasal cannula. A blowhole incision was made on the anterior chest wall, and he was observed in the medical intensive care unit (MICU). Surgery to close the defect was deferred due to his other comorbidities and the higher risk of post-operative complications. He improved gradually over the course of the next few days, completed the course of antibiotics with steroids, and was discharged to a rehabilitation center and did well post-discharge.
A 46-year-old obese man (body mass index: 40.2) was presented to our emergency department with moderate left-sided chest pain that started immediately after heavy lifting 2 days before the examination. The patient had no history of trauma, surgical procedures in his thoracic wall, or COPD. His comorbidities were arterial hypertension, congestive heart failure, and type II diabetes mellitus. At the time of admission, the patient was alert and oriented. His vital signs were as follows: blood pressure – 140/90 mmHg, heart rate – 90 per minute, respiratory rate – 18 per minute, and body temperature – 36.7°C. Physical examination revealed a swelling of the left flank (from mid-thorax to the gluteus) with red-bluish colorization of the skin and tenderness on palpation []. On auscultation, diminished breath sounds on the left were established.\nChest X-ray presented stable intercostal lung herniation – through sixth intercostal space []. Subsequent chest computed tomography (CT) confirmed the stable left intercostal lung herniation. Moreover, hematoma of the left flank, displaced fracture of the seventh left rib, and fluid into the left costophrenic angle with a density of 21 Hounsfield units were found [Figure and ]. The spirometry test was performed with volume of a FEV1 of 2.42 L (64% of predictive) and FEV1/FVC of 72%.\nThe patient was hospitalized and operated on the 2nd day of his hospitalization. Left mid-lateral thoracotomy under general anesthesia with intubation with a double-lumen endotracheal tube was performed. The incisional line was made over the side of the thoracic wall defect (through sixth intercostal space). Exploration of the left hemothorax revealed thoracic wall hematoma, lung herniation through the sixth intercostal space with compressed herniated part of the lung, minimal hemothorax in costophrenic angle (<150 ml), dislocated fracture of the left seventh rib-type “costochondral joint separation,” and laceration of the diaphragm (approximately 4 cm and close to esophageal hiatus), with herniation of a small portion of the great omentum into the pleural cavity.\nBlood from costophrenic angle was sucked out. The herniated part of the great omentum was reponated back into the peritoneal cavity, and the defect of the diaphragm was closed by nonabsorbable interrupted sutures. The pleural cavity was irrigated with sterile saline solution. The thoracic cage was closed with pericostal sutures around the 6th and 7th ribs, after inserting a chest tube drain. Thoracic wall hematoma, along the incisional line, was cleaned, and the soft tissues were irrigated with povidone-iodine 10 % solution.\nThe patient was discharged on the 9th postoperative day in a good condition. Control chest CT 2 years after the operation found no deformation of the thorax or recurrence of the lung herniation.\nWritten informed consent was obtained from the patient for his anonymized information to be published.