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Coughing up a lung
  1. K Hightower,
  2. J E Teitelbaum
  1. Department of Paediatrics, Monmouth Medical Center, 300 Second Avenue, Long Branch, NJ 07740, USA; jteitelbaum{at}sbhcs.com

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Figure1

A 10 year old girl presented with a harsh “barky” cough which resolved with sleep. Physical examination revealed lungs clear to auscultation, no cervical crepitus or other neck deformities. An upper gastrointestinal series was performed to investigate whether gastro-oesophageal reflux was causative. During a Valsalva manoeuvre the radiographs revealed a lucency in the neck on the right, representing herniation of a portion of the right lung (see figure). There was mass effect on the trachea with shift to the left.

Lung hernias, uncommon occurrences in children, can be classified using the system devised by Movall-Lovallee. Congenital versus acquired hernias describes the defect based on aetiology. Cervical thoracic versus diaphragmatic lung hernias describes the defect based on location.1

Congenital hernias are more common in children than acquired hernias and are primarily the result of weakness in Sibson's fascia.1 Sibson's fascia is a continuation of the endothoracic fascia over the apex of the lung inserting posteriorly onto the transverse process of the first thoracic vertebra and ramifying anterolaterally around the margins of the first rib.1,2 The herniation may present throughout infancy and childhood, usually as a painless mass in the neck exacerbated by events increasing intra-abdominal pressure.1–3 Apical lung hernias are more common on the right.3

Treatment of apical lung hernias is seldom necessary because they spontaneously reduce with decreasing intra-abdominal pressure.4 This patient was diagnosed with a psychogenic cough that responded well to behavioural modification therapy.

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