radiology bronkitis

7/26/2019 Radiology Bronkitis

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67 1

E c top ic R igh t

B ronchus : In d ica tio n fo r

B ro ncho g raphy

Gen H . R its em a1 Ectop ic r igh t-s ided b ronchus is a rare anom a ly . In th is re tro spec tive s tudy , e igh t

p atie n ts are d esc rib ed . A ll w ere fro m a p o p u la tio n th a t c lin ica lly w as su sp ec ted o f

su ffe r in g fro m ch ro n ic b ro n ch itis . In o ne p atie n t th e ec to p ic bro n ch u s w as m is sed o n

b ro n ch o sco p y b u t n o t o n b ron ch o g rap h y; in th e o th er s even p a tien ts b ro n ch o sco p y

an d b ro n ch o g rap h y b o th revea led th e ec to p ic b ro n chu s . T h e firs t p a tien t h ad a p er-

s is ten t inh o m og eneo u s co n so lid a tio n o n ly in th e ec to p ic a re a w ith ex ten s iv e bro n ch ie c -

ta s is ; o n e p a tien t h ad s lig h t b ro n ch ie c ta s is ; th e o th e r s ix p a t ie n ts h ad no n e o f th e se

p ath o lo g ic a lte ra tio ns . O n ly in th e firs t p a tien t d id th e an o m a ly h ave th erap eu tic

co nseq u en ces as th ere w as an ex tens ive b ro n ch ie c ta s is . In p a tien ts w ith a p e rs is ten t

in ho m o g en eo u s co n so lid a tio n o n ly o n th e s ite o f th e ap ica l s eg m en t o f th e r ig h t u p p er

lo be m ay an ecto p ic b ro nch u s w ith ex ten s iv e b ro n ch ie c tas is b e su sp ected . In su ch

p atie n ts a b ro nch og rap hic e xam in atio n is ind ic a ted .

Ec to p ic b ron ch i on th e rig h t s id e o f th e trach ea or th e rig h t m a in b ro nchu s a re

ra re . H ow ever th ey m ay have th e rapeu tic im p lica tio ns . B ro ck [1 ] D av id son [2 ],

a nd M a rks [3 ] de sc ribe ca se s in w h ich an ab sce ss , b ron ch ie c tas is , an d re cu rren t

p n eum on ia , re sp ec tive ly , m ade su rg ica l e xc is ion ne ces sa ry . F rom a lite ra tu re

re v iew , it se em ed th e abno rm a lity m ay som etim es be unde tec te d b y b ron chos -

co py . Y e t b ro nchography in su ch ca se s re vea led th e e c top ic b ron chus and its

com p lica tion s [4 -7 ].

T o de ve lo p a be tte r u n de rs tan d in g o f the ind ic a tion s fo r b ro n chog raph y when

an e c to p ic b ro n chu s is su spec te d , a re tro sp ec tive s tud y was done us in g th e

fo llo win g de fin it io ns :

1 . An ec top ic o r d isp la ced b ro nchu s a rise s from an abnorm a l p la ce ; in th is

s tud y from th e rig h t s id e o f the tra chea or from the rig h t m a in b ron chus .

2 . T he ec top ic b ronchus is supe rnum e ra ry if the r igh t lobe has the no rm a l

tn ifu rc a tio n in to a p ica l, po s te rio r, a nd an te rio r s egm en ta l b ro n ch i [8 -1 1 ]. The

eco to p ic b ro nchu s is n o t supe rnum e ra ry if th e r ig h t u pper lo be ha s on ly a

b ifu rca tio n and th e m iss in g segm en ta l b ro nchu s a rise s in d ependen tly from th e

tra chea or the m a in b ro n chus [1 2 -14 ].

3 . A trach ea l b ro nchu s , s upe rnum e ra ry o r no t, a ris es from the tra chea , c ra n ia d

from th e trach eob ro nch ia l a ng le .

S u b jec ts an d M e th o d s

. .

The firs t p a tien t

in th is se r ies w ith th is a nom a ly wa s a 54-yea r-o ld m an . Be ca use o f

R ece ived June 8 , 1 982 ; accep ted a fte r rev is ion

. . . . .

Novem ber 1 2 1 982 . p e rs is ten t p rod uc tiv e co ugh and a loca l in hom ogeneous co nso lid a tion o n ly on th e r igh t

. . , .

s ide o f the su pe rio r m ed ia s t inum , b ro nch os co py wa s d one . N o th ing a bn orm a l w a s no te d .

R ad iod iagnostic Depa rtm en t Zu lde rz ieken -

. .

hu is , G roen e H illed ijk 3 1 5 , 3 07 5 EA R otte rd am , F or the d e tec t ion o f b ron ch iec tas is , b ro ncho gra ph y wa s pe rfo rm ed . A sm a ll con tra s t s ta in

The N ethe rlands . o n the righ t s ide , ou ts ide the tra ch ea , w as seen . T he rig h t u ppe r lo be had a norm a l

R

140 :6 71 -6 74 A pr il 19 8 3 trifu rc a tio n . A n ec to p ic b ro n ch u s w as su sp ec ted . O n a rep eat b ro nch o sco p ic exam in a t io n

0361 -80 3X /83 /1404-0671 the ectop ic ope n ing w as seen , a tu be was inse rted , and a fte r the in jection o f con trast

Am erican Roen tgen Ray Socie ty m a te ria l it a ppeare d th a t th e re w as cy lind rica l b ro nch iec ta s is in th e re g ion o f the aberran t


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F ig. 1 .-Ec top ic supe rnum e rary tra chea l b ron chus w ith b ron ch ie c tas is . T ra chea and rig h t-u ppe r- F ig . 2 .-E c top ic supe rnum e ra ry b ron chus w ith

lob e b ro nchu s a re ju s t v is ib le . s lig h t b ro nch ie c ta s is , lo ca lize d ju s t d is ta l to tra ch eo -

b ron ch ia l an gle .

67 2

R ITSEMA

A JR :14 0 , Ap ril 1 98 3

b ro nchu s (fig .

1 ).

The conne c tio n be tw een the e c to p ic b ro n chus

and the trac hea w as na rrow .

As th is ra re a nom a ly d id h ave the rap eu tic s ig n if ica nce in th is

p a tien t, o the r p a t ien ts w ith a n ec to p ic righ t b ronchu s w ere sou gh t

from th e file s . A no th e r se ven pa tie n ts w ere fo und in a co lle c tio n

pe rio d o f a bo u t 1 5 yea rs . In ea rlie r d ay s , it w as n o t u nu sua l, a s it is

n ow , to d o ro u tine b ro ncho gra ph y in pa tie n ts w ith ch ro n ic b ron ch i-

tis . A bo u t 80 0 bro ncho gra ph ies w ere don e in th e co llec tio n pe r iod .

The se rie s to ta ls e ig h t pa tie n ts w ith a rig h t-s id ed e c top ic b ro n -

chu s, tw o wom en and s ix m en aged 1 2-73 yea rs (a ve rag e , 4 9 .5 ).

As th e pa tie n ts c am e from a popu la tio n w ith c h ro n ic b ron ch itis , a ll

e ig h t pa tien ts ha d ch ron ic p rod uct ive co ug h . The re w ere n o spe c ific

c lin ica l sym p tom s conce rn in g the e cto p ic b ro nchu s. E x cep t fo r th e

firs t pa t ien t ju s t d esc rib ed , th e o th e r seven p a tie n ts h ad no co nso l-

ida tion o n the ir rad iog rap hs .

In e x tra in ve s tig a tion , a tu be was p lac ed in th e ec to p ic b ron chus

unde r b ro nchos co p ic g u id an ce a fte r w h ich b ron cho grap hy w as

pe rfo rm ed (th ree pa tien ts ). O ne o th e r p a tien t h a d s ligh t b ro n ch iec -

tas is in the ec top ic b ro nch ia l re g io n (fig . 2 ); the o the r s ix pa tie n ts

had an ec top y w ith ou t b ro nch iec ta s is .

Resu l t s

Fou r pa tien ts had supe rnum e ra ry ec top ic b ronch i, one

from th e tra ch ea (fig . 1 and th re e from th e rig h t b ron chu s

(fig . 3 ). O ne had a loc a l, pe rs is ten t, inh om ogeneou s con -

so lid a tion on ly in th e e c top ic se gm en t w ith e x te ns ive b ro n -

ch iec ta s is ; on e pa tie n t h a d s ligh t b ron ch ie c tas is .

F o u r had non supe rn um era ry e c to p ic b ron ch i, on e from

the tra ch ea (fig . 4 ) an d th re e from the rig h t m a in b ron chus

(fig . 5 ). N one had a con so lida tio n , n o r b ron ch ie c ta s is .

Dis cuss ion

The tra ch ea l b ro nchu s and the ap ica l se gm en ta l b ro nchu s

o f the righ t u ppe r lo be , a ris ing from th e rig h t m a in b ron chus ,

a re fo u nd no rm a lly in sw in e , ca ttle , sh eep , g o a ts , cam e ls ,

g ira ffe s , a n d wha les [1 5 ]. In m an , h ow ever, th e righ t lu ng

bud g ives o rig in to a m onopod ia l c ran io d o rs a l d iv e rticu lum

w h ich la te r be com es the on ly b ro nchu s o f th e righ t u ppe r

lo be [1 6 ]. I s ha re the op in io n o f G ruen fie ld and G ra y [1 7 ],

H e id e nb lu t [1 8 ], a n d H arr is [7 ] th a t the ec to p ic b ro nchu s

re p re sen ts a n a ta v is tic a n om a ly . I a lso be lie ve tha t th e

d ive rticu la o f th e tra chea , a s desc rib ed by B rem e r [1 9 ], a re

underd e ve lop ed va rian ts o f th is p a tte rn ; th is d ive n ticu lum

even tua lly g row s ou t to a trac hea l b ron chus , a s w as pro -

po sed by Bo yden [2 0 ] a lso .

T he s ite o f the ec to p ic b ron chus depends on th e pe rio d

in w h ich th e abno rm a l d ive rticu lum a rises , in o u r o p in ion . A

tra chea l b ron chus w ou ld a rise ea rlie r in th e em b ryon ic pe -

nod th a n an e c to p ic b ro nchu s from th e m a in b ron chus .

B oyden [2 0 ] s ta te s tha t a n e c top ic b ro nchu s m igh t b e

ra re r tha n agenes is o f a lu n g . Ina da and K ish im o to [5 ]

m en tion in c id e nce s o f 0 .2 5 and 4 in b ron chog ra ph ic


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F ig . 3 .-E c to p ic su pernum e ra ry b ron chu s. R igh t up pe r lo be sh ow s norm a l s how s b ifu rca tio n .

trifu rca tio n . F ig . 5 .-E c top ic no nsup ern um era ry b ro nchus . R igh t up per lo be show s

F ig . 4 .-E c top ic no nsup ern um era ry trache a l b ro nchu s. R igh t u pp er lob e b ifu rca tion .

A J R : 1 40 A p r i l 1 9 8 3 EC TO P IC R IG H T BRONCHUS

67 3

W e acknow ledge th e sugges tion s and gu ida nce o f D r. D . N .

H {2 52 }p sche r ,R ad io log is t, S t. C la ra H osp ita l, R o tte rd am and D r. J .

exam ina tions in adu lts . In m y serie s the in c idence was abou t

1 .

Kub ik and M {252 }n tene r[21 ] conc lude , a fte r a s tudy o f the

lite ra tu re , tha t the anom a ly occu rs on the r igh t s ide seven

tim es m ore o ften than on the le ft s ide . T hey show tha t the

anom a ly on the le ft s ide is assoc ia ted ve ry o ften w ith o the r

se rious congen ita l abno rm a litie s , e spec ia lly o f the bra in , so

tha t p rem a tu re dea th is the consequence . B rem e rs find ings

[1 9 ] tha t th e anom a ly occu rs m ore o ften in em b ryo s th a n in

adu lts se em to suppo rt th is hy po the s is .

In m y stu d y th e fin d in g o f an ec to p ic bro n ch u s w as

acc iden ta l, a s the re w e re no spec ific c lin ic a l sym p tom s.

O ther au tho rs [4 -6 , 22 -2 6 ] d e sc ribe a cc ide n ta l d isc ove ry

a lso . O ne o f the e igh t pa tien ts in m y study , how eve r, had a

pe rs is ten t inhom ogeneous conso lida tion in vo lv ing on ly the

r igh t u pper lo be on the s ite co rre spond ing to the e c top ic

b ronchus . H erxhe im e r [27 ], Fe rguson and Neuhause r [28 ],

and M a rks [3 ], e ach in o ne pa tien t, d esc rib ed the sam e . S o

from m y find ings and from the lite ra tu re , it is appa ren t tha t

a lo ca l, pe rs is ten t, inhom ogenous conso lida tion on ly on the

s ite o f th e ap ica l segm en t o f th e righ t up per lob e m ay

sugge s t a n ec to p ic b ro n chu s .

The pa tien t w ith conso lida tion had b ronch ie c tas is in the

abe rran t pu lm ona ry segm en t. B rock [1 ] rep o rte d the sam e

fin d ings in one pa tien t, and so d id Dav idson [2 ]. In case o f

a pneum on ia in an ec to p ic p u lm ona ry segm en t, b ro nch iec -

ta s is m ay be su spe c te d . C on sequen tly I b e lie ve tha t the

anom a ly d oe s have c lin ica l a n d the rapeu tic s ig n ifica nce if

the re is b ro nch iec ta s is in the abno rm a l p a r t o f th e lu ng . I

d isag re e w ith H a rris [7 ] w ho de sc r ib ed one ca se and is o f

th e op in ion th a t th e ec to p ic b ro nchu s has no pa rticu la r

c li ni ca l s ig ni fic an ce .

T he tre a tm en t depends on the c lin ica l a nd rad io lo g ic

p ic tu re . In ca se s o f a n ab sce ss [1

] l oc al b ro nc hie ct as is

[2 ], o r rec u rren t p neum on ia [3 ], su rg ica l ex c is io n w as done .

T he pa tien t w ith ex te n s ive b ro nch ie c ta s is com p lic a ting th e

ec to p ic tra ch ea l b ron chus w as th e re fo re a dv ise d to h ave it

rem oved su rg ica lly . In th e o th e r pa tie n t w ith o n ly s lig h t

b ro nch iec ta s is , co nse rv a tiv e tre a tm en t w as adv ise d .

F ra se r a nd P are [29 ] s ta te th a t it is do ub tfu l w he th e r

b ro nchog raphy is in d ica te d in pa tie n ts w ith c lin ica lly su s -

pe c ted ch ron ic b ro nch itis , e xcep t to ex c lu d e po te n tia lly

cu rab le b ro nch ie c ta s is . F rom th is s tud y it is c lea r tha t in

pa tie n ts w ho have a lo ca l, p e rs is te n t, in hom ogeneou s con-

so lid a tion on ly o n th e s ite o f th e ap ica l se gm en t o f th e rig h t

up pe r lob e , b ron chog ra ph y m ay re vea l th e cu ra b le le s io n o f

an ec to p ic b ron chus w ith b ron ch ie c tas is .

A C KNOW L EDGMEN TS


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67 4

R ITSEMA A J R : 1 40 A p ri l 1 9 8 3

Mo ll, P ro fesso r o f A na tom y, E rasm us Un ive rs ity , R o tte rdam ;

we

thank W illy de Boo fo r typ in g .

REFERENCES

1 . B rock RC . O bse rva tions on the ana tom y o f the b ronch ia l tree ,

w ith spec ia l re fe rence to the su rge ry o f lung abscess .

Guy s

Hosp Rep 1944 ;93 :90 -107

2 . D av id son SW . Som e anom a lie s o f th e res p ira to ry sy s tem .

J

F acu lty R ad io l 1956;8 :

1-18

3 . M arks C . T he ec to p ic tra ch ea l b ro nchu s : m anagem en t o f a

ch ild b y ex c is io n and segm en ta l pu lm onary re se c tio n .

D is

Che s t 1 9 66;5 0 : 6 52 -6 54

4 . G e rso n C E , R o th s te in E . A n anom a lou s tra ch ea l b ron chus to

th e righ t u ppe r lo b e .

Am R ev Tube rc 1 95 1 6 4: 68 6- 69 0

5 . In ada K , K ish im o to S . A n anom a lo us trach ea l b ron chus to th e

righ t u p pe r lo b e .

D is C hes t 1957;3 1 : 1 09 -1 12

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c ha ire A . B ro nch e tra ch { 23 3}a lee t e x {23 3}r {2 32 }s e.

u ll M {23 3}m oires S oc

MedPassy 1958 ;43 :151 -155

7 . H arris JH Jr. T he c lin ica l s ign ific an ce o fth e trac hea l b ron chu s .

AJR 1 9 58 ;7 9 : 228 -23 4

8 . H u iz ing a E , Sm e lt G J .

Bronchog raphy .

Assen , T he N e th e r-

lan d s : v an G orkum , 1 949 :4 3 -46

9 . F o s te r-C arte r AF . B ro ncho -p u lm ona ry a bnorm alit ie s .

B r J T ub -

e rc D is C he st 1946 ;40 : 1 11 -12 4

1 0. B oyde n EA . The d is tribu t ion s o f b ro nch i in g ros s a nom a lie s o f

th e righ t u ppe r lo be , pa rtic u la rly lob es subd iv id ed b y th e a zy -

go s ve in a nd tho se con ta in in g p re -ep a r te ria l b ro nch i.

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797-807

1 1

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12 . F e lso n B . Chest r oen tgeno logy P hila d e lph ia : S aunders ,

1973 :150 -158

13. Caffey J. P e di a tr i c x r a y d i ag n os i s

C h ica go : Y ea r B oo k M ed-

ica l ,

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1 5. Na ra th A . De r B ron ch ia lb aum der S {22 4 }u ge tie re u nd de s

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1

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Cam bridg e : H e ffe r, 19 64 :2 32

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1941 ;31 :39 2 -4 07

1 8 . H e ide nb lu t A . B e it rag zu r K enn tn is d es T rach ea lb ron chu s.

ROFO 196195 :77 -85

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Ana t R e c 1 9 32 ;5 4 :36 1-37 4

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1 9 55 ;8 9 :7 9 8 9

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te rie lle u nd p rdeparte rie lle B ro n ch i.

ROFO 1 9 71 ; 1 1 4:14 5-

16 3

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J T ho ra c S u rg

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rep o rt o f un u sua l ca se . J T ho ra c Su rg 1 951 ;21 :3 62 -3 69

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la ryn x , trach ea , b ro nch i a nd oesophagu s .

J La ryn go l

1961 ;75 : 1 44

25 . Z a ffra n M A, H a ssoun M Ile . B ron ches trac h {2 33 }a le s e t lo ba ire s

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1 9 53 ;5 7 : 97 9-9 92

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cong {233 }n ita le s d e s b ro n ches che z Ie n fa n t. A nn P {2 35 }d ia tr

1965;1

2 :5 1 9 -5 24

27 . H e rxh e im e r G . U ebe r e in en Fa ll vo n ech te r N eben lu n ge .

Zen -

tra /b lA /Ig P ath o l 1901 ;12 :529 -532

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(agene s is ) an d o the r a nom a lies o f tra ch eobro n ch ia l tree .

AJR

1

94 4 ;52 : 459-47 1

29 . F ra se r AG , P a re JA P . D iag nos is o f d is ea ses o f the ch es t.

P hilad elph ia : S au nd ers ,

1978: 13 67

radiology bronkitis

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