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Table 2 Summary of different types of thoracic hernias, their imaging findings, mimics, and brief description of the treatment

From: Imaging of thoracic hernias: types and complications

Type Imaging features Mimics Treatment
Superior thoracic aperture
Apical/cervical lung CXR: lateral deviation of trachea by unilateral lucency
CT/MRI: supraclavicular protrusion of lung posterior to the subclavian vessels. Enlargement with Valsalva manoeuvre
Supraclavicular emphysema, apical bulla Imaging follow-up in asymptomatic patients
Congenital hernias in infants may resolve spontaneously
Elective surgical repair in symptomatic patients or those with incarcerated hernia
Cervical aortic arch CXR: absence of aortic knob, tracheal deviation to contralateral side
CT/MRI: elongated aortic arch extending into the neck
Aneurysm of carotid arteries
Vascular rings
Increased risk of dilation and aneurysm that may require follow-up imaging, endovascular or surgical repair
Chest wall
Intercostal CT: protrusion of lung parenchyma or other viscera beyond the intercostal space Chest wall emphysema
Eloesser reconstruction
No intervention for asymptomatic hernia
Elective surgical repair for incarcerated hernia
Emergent surgical repair for strangulated hernia
Sternal CXR: lateral view may identify presternal opacity
CT: protrusion of pericardium, cardiac chambers or great vessels through the sternal dehiscence
Postoperative sternal infection, haematomas or seroma
Pericardiocutaneous fistula
Elective surgical repair with musculocutaneous grafts. Radical sternectomy for post-sternotomy mediastinitis
Spinal CXR: widening of mediastinum, paraspinal opacity, associated vertebral anomalies
CT/MRI: protrusion of meninges with CSF and occasionally spinal cord or nerves into posterior mediastinal, pleura or chest wall
Foregut duplication Cyst
Cystic neoplasms
Elective surgical repair
Transmediastinal CXR/CT: lung herniation across anterior-posterior junction lines
Pleural sac or fluid herniation across posterior junction line
Atelectasis from bronchial obstruction
May require placement of tissue expander for bronchial narrowing/stenosis
Intrapleural CXR: bowel loops in the hemithorax, elevated hemidiaphragm, NG tube above the left hemidiaphragm
direct sign:
Defect in the diaphragm, dangling diaphragm
Indirect: herniation of abdominal fat or viscera into the pleural cavity, collar sign
Diaphragmatic mass, lipomas Laparotomy with repair during the acute phase
Transthoracic or thoracoabdominal approach for chronic hernia
Mediastinal CXT: opacity at the anterior cardiophrenic angle.
CT/MRI: small defect in between pars sternalis and pars costalis with herniation of omentum or bowel loops
Pericardial cyst, prominent pericardial fat or mediastinal lipomatosis No treatment for asymptomatic hernia
Elective repair for herniated viscera or bowel
Pericardial CXR: air fluid level from herniated bowel in the retrosternal region
CT/MRI: herniation of abdominal organs, omentum or bowel loops into the pericardium
Pericardial haematoma, primary tumour, metastasis Elective repair for herniated viscera or bowel
Type I hiatal hernia Oesophagogram/ CT: displacement of oesophagogastric junction into thorax   No surgery for asymptomatic hernia
Medical treatment of reflux disease
Antireflux procedure
Type II hiatal hernia Oesophagogram/ CT:
GE junction in normal position, fundus herniates into thorax
Epiphrenic or traction diverticulum
Oesophageal fistula
Symptomatic hernia: elective surgical repair
Type III hiatal hernia Both GE junction and fundus herniate Epiphrenic or traction diverticulum
Gastric or oesophageal fistula
Elective surgical repair
Type IV hiatal hernia Other viscera also herniate in addition to stomach Postoperative appearance after upper gastrointestinal surgery Elective surgical repair
Sub-diaphragmatic Extension of the abdominal wall hernia through the superficial and deep fascia into thorax Surgically created vascular or bowel conduits Elective surgical repair
  1. CXR chest radiograph, GE junction gastro-oesophageal junction