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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 .
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1
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