An unusual differential of neck swelling: left apical hernia

Abstract

Pulmonary herniation is a protrusion of the lung beyond the usual boundaries of the thoracic cavity, which is caused by increased intrathoracic pressures coupled with thoracic wall defects. Most lung hernias are asymptomatic, but when symptomatic they present as a bulging, crepitant mass protruding through the chest wall. A computed tomographic scan is usually diagnostic, and a small subset of patients requires surgery to correct the defect. In my report there is a 49 year old male patient with cystic swelling in the left side of the neck which increases on coughing, along with a small nodular midline swelling which moves on deglutation. Probable diagnosis of thyroid swelling with laryngocele as a differential was made. FNAC of nodular swelling was suggestive of nodular colloid goitre. CECT neck implied solitary thyroid nodule. The patient was taken for surgery to remove the thyroid nodule but surprisingly left apical lung hernia was diagnosed along with the thyroid nodule. Apical lung hernias are more common in males than in females (2:1) and more common on the right side than on left (6:1). However this patient had herniation on the left side which is quite rare. Usually asymptomatic, surgical treatment is rarely warranted unless it undergoes incarceration. Apical lung hernia though a rare entity should be considered in the differential diagnosis of a neck swelling.