Spontaneous Lung Herniation From a Stubborn Cough

ABSTRACT

Spontaneous intercostal herniation of the lung (SLIH) is a rare effect of a stubborn cough characterized by protrusion of the lung parenchyma through the thoracic wall. With varying presentations from chest pain and haemoptysis to severe respiratory distress, SLIH often goes overlooked as a potential differential and has no set gold standard of diagnosis or treatment. Here, a middle‐aged male with minimal risk factors developed an anterolateral left lung herniation between the 7th and 8th ribs requiring surgical repair. Early recognition via computed topography (CT) and operative management may reduce the significant morbidity and potential complications associated with SLIH.

Spontaneous lung herniation (SLIH) is a rare presentation (< 500 cases) that presents with vague symptoms and involves lung tissue protruding beyond normal boundaries. CT diagnosis is followed by a multidisciplinary team approach, often leading to thoracic surgical intervention for the greatest symptomatic relief.

1. Introduction

Lung herniation is formally defined as the protrusion of pleura‐covered lung beyond normal anatomic boundaries, usually secondary to an abnormal opening [1]. First identified in 1499 by Roland and classified in 1845 by Morel‐Lavallee by anatomy and aetiology, lung herniations are relatively rare, with fewer than 500 case reports published [2, 3]. Most cases are traumatic or post‐surgical, where physical manipulation or trauma, such as a rib fracture from a motor vehicle accident, leads to the condition [1]. The following case, however, details a rare presentation of a spontaneous lung herniation (SLIH) resulting from an unrelenting cough after a viral upper respiratory infection.

2. Case Report

A 62‐year‐old man with mild hypertension, class 2 obesity and hyperlipidaemia presented with a mild upper respiratory infection complicated by persistent dry cough, pleuritic chest pain and worsening shortness of breath. Initially, his symptoms were mild to moderate, with pain rated 4/10 and intermittent dyspnoea, progressing to continuous dyspnoea and more severe pleuritic pain rated up to 6–8/10. He had no smoking, surgical, occupational, travel or family history concerning for primary or congenital lung disease.

Vital signs remained normal on multiple outpatient visits, with no hypoxia, tachypnoea or increased work of breathing, and his review of systems and physical examination were otherwise relatively unremarkable besides some mild wheezing. Due to progressive symptoms, he was started on a 10‐day course of prednisone 5 mg for nonspecific wheezing and oral morphine 15 mg twice daily for pain, and a CT angiogram (CTA) of the chest was ordered; these therapies provided little relief while he awaited imaging. CT of the chest demonstrated a large lung herniation between the 7th and 8th ribs, leading to thoracic surgery consultation and scheduling of video‐assisted thoracoscopic surgery (VATS) with possible thoracotomy and mesh repair (Figure 1).

FIGURE 1.

Axial (A) and coronal (B) views of the lung herniation in the patient presented (indicated by arrow).

He was admitted one week later and underwent fibreoptic bronchoscopy, cryoablation of ribs 5–8 and left thoracotomy with direct repair of the chest wall hernia using a dual mesh Gore‐Tex prosthesis. Bronchoscopy excluded endoluminal lesions in the mainstem bronchi, and cryoablation was performed to improve postoperative pain control. Intraoperatively, the herniation measured 28 cm by 6 cm and was dissected and transected at its base to prevent recurrence, followed by placement of Gore‐Tex mesh and a 28‐French chest tube for drainage with good lung apposition to the chest wall.

Daily postoperative chest radiographs showed no complications, and on postoperative day 4 the chest tube was removed without issue. The patient was discharged with a planned follow‐up in two weeks, at which time he reported overall symptomatic improvement without further complaints.

3. Discussion

Lung herniations are commonly described using the Morel‐Lavallée system, which classifies them by anatomy and aetiology [1, 2]. Anatomically, they are divided into cervical (~33%), thoracic (~66%) and rare diaphragmatic types [1, 3]. Etiologically, they are first separated into congenital and acquired, with acquired herniations further grouped as pathological (~18%), spontaneous (~30%) or traumatic (~52%) [1, 2]. The current patient's lesion is a spontaneous intercostal thoracic lung herniation, representing less than 20% of acquired and about 15% of all cases [1, 2, 3].

Spontaneous lung herniations (unlike those associated with trauma) are usually associated with chronic obstructive pulmonary disease (COPD) and obesity, which both chronically elevate intrathoracic pressure and strain the chest wall [2, 4]. COPD contributes via compensatory hyperinflation, while central obesity—present in about 31% of cases in one case series—amplifies baseline pressure and mechanical stress [2, 3]. Male sex has also been reported in roughly 50% of cases [3]. In this patient, a persistent cough was the likely inciting factor, superimposed on these structural vulnerabilities (obesity).

Pathophysiologically, chronic coughing generates repetitive, opposing forces from the serratus anterior and external oblique muscles across the intercostal space [3, 5]. This ongoing tension raises intrathoracic pressures and chest wall forces, gradually weakening intercostal musculature and predisposing to herniation [1, 2, 3, 5]. Despite this, spontaneous herniation remains rare because of the protective thoracic musculature, except between the 8th and 9th ribs where intercostal muscles are relatively deficient [2, 3].

Clinical presentation is heterogeneous. Cough is reported in about 98% of patients, making it the most common symptom [1, 2]. Other manifestations can include visible or palpable bulging, chest pain, dyspnoea, haemoptysis, localized bruising and mild hypoxic respiratory failure due to pain‐limited ventilation [2, 4]. In this case, only cough and subjective pleuritic pain were present, without obvious bulging or significant hypoxia, underscoring how subtle spontaneous lung intercostal hernias can appear. Consequently, spontaneous intercostal lung herniation should be considered a rare but important differential diagnosis for pleuritic or atypical chest pain that seems disproportionate to objective findings in patients with chronic cough.

There is no universal management standard, but published algorithms guide treatment based on symptom severity, red‐flag features and response to conservative therapy [2]. Typically, patients with severe pain, progressive symptoms or complications are directed towards surgical repair, while milder cases may be observed, though individualized decision‐making is essential [2, 4, 5]. CT is the diagnostic modality of choice, with near‐100% sensitivity compared with roughly 20% for chest X‐ray, and its yield can be enhanced with multiplanar reconstructions and advanced post‐processing techniques [4]. Computed tomography, often ordered with angiography to assess for pulmonary embolism, may incidentally reveal lung herniations in thorough outpatient pulmonology assessments. Conservative measures such as weight loss and steroids typically have limited durability, and many patients ultimately require surgery focused on defining the herniation, re‐approximating ribs and reinforcing chest wall integrity with sutures or mesh, including polypropylene prostheses as used in this patient [2, 3, 4, 5].

Lung herniation repair is chosen based on the size, cause and stability of the defect: small, reducible and less symptomatic hernias may be repaired with thoracoscopic or hybrid surgery, while larger traumatic, incarcerated or unstable chest wall defects more often need open thoracotomy with reinforcement [5, 6]. Mesh is typically used when the main goal is structural support and the field is clean enough for prosthetic material, whereas a muscle flap is preferred when the wound needs vascularized soft‐tissue coverage, especially in contaminated, infected, irradiated or poor‐quality tissue [5, 6]. In more complex cases, surgeons combine them, using mesh for strength and a flap for coverage and healing [6]. In our patient, the deformity of the herniation was anatomically more structural given his weight and spontaneous aetiology, and so structural support via mesh repair was more than sufficient to address his herniation.

In conclusion, SLIH is a rare condition with variable presentations, most often presenting with chronic cough and dyspnoea, particularly in patients with obesity or COPD [1, 2, 3]. CT thorax confirms diagnosis and early, tailored surgical repair should be considered to reduce patient morbidity [4, 5].

Author Contributions

Kush Kapadia: manuscript writing, image creation. Samuel Yoon: manuscript writing and review. Sapna Bhatia: diagnosis and patient case details, manuscript review. Arnold Chung: surgical recommendations and plan, manuscript review. Yi Mcwhorter: manuscript writing, manuscript review and clinical coordination.

Consent

The authors declare that written informed consent was obtained for the publication of this manuscript and accompanying images and attest that the form used to obtain consent from the patient(s) complies with the Journal requirements as outlined in the author guidelines.

Conflicts of Interest

The authors declare no conflicts of interest.

Kapadia K., Yoon S., Bhatia S., Chung A., and Mcwhorter Y., “Spontaneous Lung Herniation From a Stubborn Cough,” Respirology Case Reports 14, no. 4 (2026): e70585, 10.1002/rcr2.70585.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.