671

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Ectopic
Right
Bronchus:
Indication
Bronchog

Gen H. Ritsema1

Ectopic

for

raphy

right-sided

bronchus

is a rare anomaly.

In this retrospective

study,

eight

patients
are described.
All were from a population
that clinically
was suspected
of
suffering
from chronic bronchitis.
In one patient, the ectopic bronchus
was missed on
bronchoscopy
but not on bronchography;
in the other seven patients
bronchoscopy
and bronchography
both revealed
the ectopic bronchus.
The first patient
had a persistent inhomogeneous
consolidation
only in the ectopic area with extensive
bronchiectasis; one patient had slight bronchiectasis;
the other six patients
had none of these
pathologic
alterations.
Only in the first patient
did the anomaly
have therapeutic
consequences,
as there was an extensive
bronchiectasis.
In patients with a persistent
inhomogeneous
consolidation,
only on the site of the apical segment
of the right upper
lobe may an ectopic
bronchus
with extensive
bronchiectasis
be suspected.
In such
patients,
a bronchographic
examination
is indicated.

Ectopic
rare.

bronchi

However

and

Marks

on the

right

side

may

have

therapeutic

they

[3] describe

cases

pneumonia,
respectively,
review,
it seemed
the
copy.
Yet
complications
To develop

in which

made
abnormality

bronchography
[4-7].

or the right

implications.

understanding

the

from

2.

The

tnifurcation
ecotopic
bifurcation

the

right

ectopic

side

of the

bronchus

trachea

or from

Subjects
Received

November

June

8, 1 982;

revision
.

Radiodiagnostic

huis,

after

1 2 1 982.
.

The

accepted

Groene

Hilledijk

Department

31 5, 3075

Netherlands.

AJR 140:671-674,
0361-803X/83/1404-0671
American
Roentgen

Ray

Society

in this

persistent
productive
side of the superior
the
the

detection
right

bronchus

was

main

arises

using

place;

the

in this

bronchus.

lobe

from

its

when

done

an abnormal
right

if the right

or not,

and

has the normal

[8-1
has

1 ]. The
only
a
from the

the trachea,

craniad

outside

An ectopic
opening

it appeared

this

anomaly

was

a 54-year-old

the

bronchus
was

a local
inhomogeneous
bronchoscopy
was

done.

consolidation
Nothing

man.

Because

of

only
abnormal

on the right
was noted.

of bronchiectasis,
side,

the

material

with

cough
and
mediastinum,

trifurcation.
ectopic

recurrent

for bronchography
study

For

series

Zulderzieken-

EA Rotterdam,

[2],

Methods

patient

on

April 1983

and

The first

are

Davidson

anterior
segmental
bronchi
if the right
upper
lobe
bronchus
arises
independently

trachea
or the main bronchus
[1 2-14].
3. A tracheal
bronchus,
supernumerary
from the tracheobronchial
angle.

the

is supernumerary

into apical,
posterior,
and
bronchus
is not supernumerary
and the missing
segmental

bronchus
and

ectopic

indications

an ectopic
bronchus
is suspected,
a retrospective
following
definitions:
1 . An ectopic
or displaced
bronchus
arises
from
study

],

necessary.
From
a literature
be undetected
by bronchos-

revealed

of the

[1

bronchiectasis,

excision
sometimes

cases

main

Brock

an abscess,

surgical
may

in such

a better

of the trachea

seen,

that there

bronchography

trachea,

was

was suspected.
a tube

was

was cylindrical

seen.

was

The

performed.

right

On a repeat

inserted,

and

bronchiectasis

upper

A small

lobe

bronchoscopic
after

the

injection

in the region

contrast

had

stain

a normal

examination,
of

contrast

of the aberrant

RITSEMA

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672

Fig.

1 .-Ectopic

supernumerary

lobe bronchus

tracheal

As

from

this

800

totals

patients

clinical
first

patient

under

just

from

ectopic

the

years

Four

ectopic

ectopic

There

seven

patients

bron49.5).

bronchitis,
were

bronchus.

guidance

after

which

One other

patient

bronchial

all

no specific

Except

for the

had

no consol-

in the ectopic

bronchus

region

(fig.

2);

bronchography

had slight
the

other

was

bronchiecsix

patients

bronchiectasis.

chiectasis;

had

nonsupernumerary

patients

had

supernumerary

ectopic

only
one

in the

ectopic

patient

had

slight

bronchi,

one

from the right bronchus

inhomogeneous
con-

segment

with

bronchiectasis.

bronchus

localized

ectopic

the trachea
(fig. 4) and three from
(fig. 5). None had a consolidation,

just distal

bronchi,

with

to tracheo-

one

from

the right main bronchus

nor bronchiectasis.

The tracheal
bronchus
of the right upper
lobe,
are

found

giraffes,

normally
and

and
arising

in swine,

whales

[1 5].

the apical
segmental
from the right main
cattle,

bud gives origin

to a monopodial
which
later becomes
the only
lobe [1 6].
Heidenblut
represents
diverticula

I share
[1 8],
an

the
and

opinion
Harris

atavistic

extensive

bron-

tracheal

rarer
mention

than

would

agenesis

of

of Gruenfield
[7] that the

and
ectopic

I also

as described

arise

a lung.

of 0.25%

camels,
right

lung

craniodorsal
diverticulum
bronchus
of the right upper
Gray [1 7],
bronchus

believe

by Bremer

that

the

[1 9], are

diventiculum
as was pro-

depends
on the period
arises,
in our opinion.
A

earlier

in the

an ectopic
bronchus
from the
[20] states
that an ectopic
incidences

the

variants
of this pattern;
this
out to a tracheal
bronchus,
[20] also.

bronchus

nod than
Boyden

bronchus
bronchus,

goats,

however,

anomaly.

of the trachea,

underdeveloped
eventually
grows
posed
by Boyden

sheep,

In man,

The site of the ectopic

bronchus
in which
the abnormal
diverticulum

the trachea
(fig. 1 ) and three
3). One had a local,
persistent,

solidation

supernumerary

Discussion

period.

(average,

with chronic
cough.

other

collection

a right-sided

a tube was placed

patients).

without

2.-Ectopic

as it is
bronchi-

Results

from
(fig.

Fig.

1983

in a collection
unusual,
chronic

in the

1 2-73

a population
the

not
with

done

with

aged

productive

described,

(three

in the

right-upper-

April

sought

radiographs.

bronchoscopic

had an ectopy

men

chronic

investigation,

performed

and

Four

in this

were

found

it was

in patients

patients

six

bronchus

were

days,
were

concerning

on their

In extra

tasis

came
had

symptoms

idation

Trachea

bronchus

significance

right

patients

In earlier

eight
and

the ectopic

therapeutic

bronchography

women

As the patients
eight

have

bronchographies

The series
two

between

an ectopic

seven

1 5 years.

to do routine

chus,

did
with

Another

of about

About

bronchiectasis.

slight bronchiectasis,
bronchial
angle.

anomaly
patients

the files.

now,
tis.

rare

other

period

with

are just visible.

bronchus
(fig. 1 ). The connection
and the trachea was narrow.
patient,

bronchus

AJR:140,

Inada
and

4%

embryonic

main bronchus.
bronchus
might
and

Kishimoto

in bronchographic

pebe
[5]

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AJR:140,

ECTOPIC

April 1983

Fig. 3.-Ectopic
trifurcation.
Fig. 4.-Ectopic

supernumerary

bronchus.

nonsupernumerary

examinations

in adults.

Right upper

tracheal

In my series

lobe shows

bronchus.

Right

the incidence

RIGHT

normal

upper

lobe

was about

BRONCHUS

673

shows bifurcation.
Fig. 5.-Ectopic
bifurcation.

tasis

may

be

suspected.

Kubik and M#{252}ntener[21] conclude,

after a study of the
literature,
that the anomaly
occurs on the right side seven
times more often than on the left side. They show that the
anomaly
on the left side is associated
very often with other
serious congenital
abnormalities,
especially
of the brain, so
that premature
death is the consequence.
Bremers
findings

there
is bronchiectasis
in the abnormal
disagree
with Harris
[7] who described
the opinion
that the ectopic
bronchus

[1 9] that

[2],

anomaly

occurs

more

often

in embryos

hypothesis.
of an ectopic

accidental,

no specific

Other

as there

authors

[4-6,

were
22-26]

describe

than

bronchus

in

was

clinical

symptoms.

accidental

discovery

clinical

significance.

The
picture.

treatment
In cases

or recurrent

clinical

and

[3],

surgical

conservative

treatment

Fraser
and
bronchography

right

pected
curable

chronic
bronchitis,
except
bronchiectasis.
From
this

patients
solidation

who have a local,

only on the site

upper

lobe

on the

Herxheimer

and

[3],

Marks

each

from my findings
a local, persistent,
site

of

suggest

the

apical

an ectopic

site

[27],
in one

corresponding

Ferguson
patient,

to the

ectopic

and Neuhauser
described

the

[28],

same.

So

and from the literature,

it is apparent
that
inhomogenous
consolidation
only on the
segment

of

the

right

upper

lobe

may

that

the
if

and

radiologic

bronchiectasis

excision

was

done.

complicating
the
advised
to have it
with
only
slight

was

advised.

Pare
[29] state
that it is doubtful
whether
is indicated
in patients
with clinically
sus-

upper lobe, bronchography

an ectopic
bronchus
with

to exclude
potentially
study
it is clear
that

persistent,
of the apical
may reveal
bronchiectasis.

inhomogeneous
segment
of the
the curable

lesion

in

conright
of

bronchus.

The patient with consolidation

had bronchiectasis
in the
aberrant
pulmonary
segment.
Brock [1 ] reported
the same
findings
in one patient, and so did Davidson
[2]. In case of
a pneumonia

shows

part of the lung.

I
one case and is of
has no particular

The patient
with extensive
bronchiectasis
ectopic
tracheal
bronchus
was therefore
removed
surgically.
In the other
patient
bronchiectasis,

lobe

significance

depends
on the clinical
of an abscess
[1 ], local
pneumonia

upper

I believe

therapeutic

also. One of the eight patients

in my study, however,
had a
persistent
inhomogeneous
consolidation
involving
only the
bronchus.

Right

Consequently

anomaly

the

have

bronchus.

1%.

adults
seem to support
this
In my study
the finding

does

nonsupernumerary

in an ectopic

pulmonary

segment,

bronchiec-

ACKNOWLEDGMENTS
We acknowledge
the suggestions
and
H#{252}pscher,Radiologist,
St. Clara Hospital,

guidance
of Dr. D. N.
Rotterdam
and Dr. J.

RITSEMA

674

Moll, Professor
thank

Willy

of Anatomy,

Erasmus

University,

Rotterdam;

we

AJR:140,

1 4.

Atwell

1 5.

Chest 1967;52:61 1-615

Narath
A. Der
Bronchialbaum

de Boo for typing.

SW.

Menschen.
1 6.

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REFERENCES
1.

Cambridge:

Brock RC. Observations

on the anatomy of the bronchial tree,
with special reference to the surgery of lung abscess. Guys

Hosp Rep 1944;93:90-107

2. Davidson
SW. Some anomalies
of the respiratory
system.
J
Faculty Radiol 1956;8: 1-18
3. Marks C. The ectopic
tracheal
bronchus:
management
of a
child by excision
and segmental
pulmonary
resection.
Dis
Chest 1 966;50 : 652-654
4. Gerson CE, Rothstein
E. An anomalous
tracheal
bronchus
to
the right upper lobe. Am Rev Tuberc 1951 64:686-690
5. Inada K, Kishimoto
S. An anomalous
tracheal
bronchus
to the
right upper lobe. Dis Chest 1957;31 : 1 09-1 12
6. Rautureau
A, Joly H, Ducreux
P, Sassure
P, Jospin G, Porchaire A. Bronche
trach#{233}aleet ex#{233}r#{232}se.
Bull M#{233}moires Soc
MedPassy
1958;43:151-155
7. Harris JH Jr. The clinical significance
ofthe tracheal bronchus.
AJR 1 958;79 : 228-234
8. Huizinga
E, Smelt GJ. Bronchography.
Assen, The Netherlands: van Gorkum,
1949:43-46
9. Foster-Carter
AF. Broncho-pulmonary
abnormalities.
Br J Tuberc Dis Chest. 1946;40:
111-124
1 0.

Boyden

Hamilton

EA.

The

distributions

of bronchi

in gross

anomalies

of

the right upper lobe, particularly

lobes subdivided
by the azygos vein and those containing
pre-eparterial
bronchi.
Radiology 1 952;58 : 797-807
1 1 . Taybi H. Congenital
malformations
of the larynx, trachea, bronchi and lungs. Prog PediatrRadiol 1967;1 :231-255
12. Felson
B. Chest roentgenology,
Philadelphia:
Saunders,
1973:150-158
13. Caffey J. Pediatric x-ray diagnosis. Chicago:
Year Book Medical, 1978:357

1 7.

Gruenfield
1941;31

1 8.

Heidenblut

1 9.

20.
21

22.
23.
24.

25.

26.

27.

29.

anomalies

Stuttgart:
WJ,

Boyd

Heffer,
GE,

of the

Erwin
JD,

tracheobronchial
der

Nftgele,
Mossman

tree.

S#{224}ugetiere

1 901
HW.

und

Dis
des

73-96

Human

embryology.

1964:232

Gray

SH.

Malformations

ofthe

lung.

Arch

Pathol

:392-407
A.

Beitrag

zur

Kenntnis

des

Trachealbronchus.

ROFO
196195:77-85
Bremer JL. Accessory
bronchi
in embryos;
their occurrence
and probable
fate. Anat Rec 1 932;54 :361-374
Boyden EA. Developmental
anomalies
of the lungs. Am J Surg
1 955;89 :79-89
Kubik St, M#{252}ntenerM. Bronchus
anomalien:
tracheale,
eparterielle
und prdeparterielle
Bronchi.
ROFO 1 971 ;1 14:145163
Schaff B, Baum G. The tracheal
bronchus.
J Thorac
Surg
1957;33:282-286
Epstein I. Bronchial
adenoma
in supernumerary
tracheal
lobe;
report of unusual case. J Thorac
Surg
1951;21
:362-369
Holinger
PH. Clinical aspects
of congenital
anomalies
of the
larynx,
trachea,
bronchi
and
oesophagus.
J Laryngol
1961;75:
1-44
Zaffran
MA, Hassoun
MIle. Bronches
trach#{233}ales et lobaires
sup#{233}rieures
droites
surnum#{233}raires.
Alg#{233}rie
Med
1 953;57 : 979-992
Cremer V, Couvreur
J, Gerbeaux
J. Anomalies
topographiques
cong#{233}nitales des
bronches
chez
Ienfant.
Ann
P#{235}diatr
1965;1 2:51 9-524
Herxheimer
G. Ueber einen Fall von echter Nebenlunge.
Zentra/blA/Ig

28.

Major

April 1983

Pathol

1901;12:529-532

Ferguson
CF, Neuhauser
EBD. Congenital
absence
of lung
(agenesis)
and other anomalies
of tracheobronchial
tree. AJR
1 944;52
: 459-47
1
Fraser
AG, Pare JAP. Diagnosis
of diseases
of the chest.
Philadelphia:
Saunders,
1978: 1367