Aydın Şanli

A case of a bronchogenic cyst in a rare location

Bronchogenic cysts occur as a result of a developmental fault during the division and budding of the tracheobronchial tree in the embryonic period. They are usually located in the mediastinum and intrapulmonary regions. They may cause serious respiratory distress in childhood; they present less commonly in adults and often present with a variety of symptoms, including recurrent infections. We report the case of an adult female patient who presented with recurrent pulmonary infections and swelling of the neck because of a bronchogenic cyst that was unusually located in the cervical region.

Morgagni hernia: late diagnosis in a case with Down syndrome.

Accessible online at: www.karger.com/res A 37-year-old woman was admitted for right-sided chest pain for the previous 1–1.5 months. She had been taken to an emergency service for abdominal ache, nausea and vomiting 1.5 months previously. No chest X-ray was taken in the emergency service as pulmonary symptoms were absent. She was of short stature, and developmental retardation was evident besides her mongoloid face. In the pulmonary system, auscultation respiratory sounds were decreased in the right lower zone. The right cardiac contour was not easily detected on chest X-ray. A nonhomogenous increase in density, which had its convexity facing the lateral chest wall, was detected in the right middle and lower zones (fig. 1). A defect in the diaphragm localized at the cardiophrenic sinus in the anterior mediastinum, as well as herniated intestinal segments, were seen on the thorax CT (fig. 2). A hernia sac with a diameter of 20 cm showing adhesions to the anterior chest wall, pericardium and lung was seen during the surgery. Congenital diaphragmatic hernias usually develop posterolaterally, but Morgagni hernias (MHs) are retrosternal and account for 3% of congenital diaphragmatic hernias; they are 90% right-sided. In Down syndrome, accompanying abnormalities may be present. MH is an uncommon defect accounting for only 3% of such abnormalities. Hernias of Morgagni’s foramen are found on the medial or anterior side of the diaphragm and are localized parasternally or retrosternally [1]. Diagnosis is confirmed by showing an empty hernia sac with barium enema, CT or ultrasonography. Fusion of the pleuroperitoneal membrane with the septum transversum in the 8th fetal week makes up the diaphragm. MHs occur as a result of an embryological defect in the septum transversum between the lateral aspect of the diaphragm and the anterior chest wall [1]. A literature review showed variations in age distribution between neonatal and 12 years in patients with concurrence of Down syndrome and MH [2]. Although a transabdominal approach has been advocated, we performed transthoracic surgery because of adhesions to surrounding tissue in the present case. Treatment of MH is surgery even if cases are asymptomatic because of the risk of intestinal obstruction and perforation [1]. We wish to emphasize the association of Down syndrome with MH, which can stay asymptomatic until an advanced age. In such cases with late presentation, as there is the possibility of adhesion of the hernia sac to intrathoracic organs, a transthoracic surgical approach is preferred, which is an easy and safe procedure. References 1 Kı̇lı̇ç D, Nadir A, Döner E, Kavukcu Ş, Akal M, Özdemir N, Akay H, Ökten I: Transthoracic approach in surgical management of Morgagni hernia. Eur J Cardiothorac Surg 2001;20:1016–1019. 2 Becmeur F, Chevalier-Kauffmann I, Frey G, Sauvage P: Laparoscopic treatment of a diaphragmatic hernia through the foramen of Morgagni in children. A case report and review of eleven cases reported in the adult literature (in French). Ann Chir 1998;52:1060–1063. Fig. 1. Appearance of the lung before surgery in our case. Fig. 2. CT of the thorax showed significant omental fatty tissue and herniated intestinal segments in the right chest cavity. 1