Rare tracheobronchial anomalies and their clinical significance

Charitha Puvvada; Mohammed Nazim; Manish Murali; Ravindran Chetambath

doi:10.4103/jalh.jalh_15_21

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Year : 2022 | Volume : 2 | Issue : 1 | Page : 32-34

Rare tracheobronchial anomalies and their clinical significance

Charitha Puvvada¹, Mohammed Nazim¹, Manish Murali¹, Ravindran Chetambath²
¹ Department of Internal Medicine, DM Wayanad Institute of Medical Sciences, Wayanad, Kerala, India
² Department of Pulmonology, DM Wayanad Institute of Medical Sciences, Wayanad, Kerala, India

Date of Submission	26-Jun-2021
Date of Acceptance	22-Jul-2021
Date of Web Publication	17-Jan-2022

Correspondence Address:
Dr. Charitha Puvvada
Department of Internal Medicine, DM Wayanad Institute of Medical Sciences, Wayanad, Kerala
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jalh.jalh_15_21

Abstract

Tracheobronchial anomalies are often congenital and do not cause much symptoms to the individual. Majority of them are branching anomalies. Most of them are incidentally detected during bronchoscopy for unrelated diseases. However, rarely abnormal bronchi may present with symptoms. He we present two rare bronchial anomalies presenting with clinical symptoms attributed to them.

Keywords: Cardiac bronchus, supernumerary bronchus, tracheal bronchus

How to cite this article:
Puvvada C, Nazim M, Murali M, Chetambath R. Rare tracheobronchial anomalies and their clinical significance. J Adv Lung Health 2022;2:32-4

How to cite this URL:
Puvvada C, Nazim M, Murali M, Chetambath R. Rare tracheobronchial anomalies and their clinical significance. J Adv Lung Health [serial online] 2022 [cited 2022 May 16];2:32-4. Available from: http://www.jalh.com/text.asp?2022/2/1/32/335919

Introduction

The term “tracheal bronchus” encompasses a variety of bronchial anomalies originating from the trachea or main bronchus and directed to the upper lobe. This is usually seen on the right side. Most of these anomalies are asymptomatic. However, rarely, it may present with lower respiratory symptoms or with persistent cough. Tracheal bronchus presenting as upper lobe pneumonia is extremely rare.

The cardiac bronchus is an accessory bronchus seen on the right side. This is a rare congenital anomaly of the tracheobronchial tree. It arises from the medial wall of the intermediate bronchus. It may be associated with ventilated lung parenchyma or end in a discrete soft-tissue mass, presumably a vascularized bronchial or vestigial parenchymal tissue. The lumen of the airway may be filled with debris. Recognition of this anomaly is important, as it is associated with clinical complications including recurrent episodes of infection and hemoptysis.

Case Reports

Case 1

A 52-year-old male reported to the outpatient with a short history of streaky hemoptysis. He is an ex-smoker and current tobacco chewer. He had fever, cough, and hemoptysis for the past 5 days. On examination, clubbing was present. Chest X-ray showed a homogenous opacity right upper zone in the paratracheal region. On doing bronchoscopic procedure, a small tracheal bronchus just 2 cm proximal to carina on the right side is seen [Figure 1]a. There was oozing of secretions which was mucopurulent and frothy in nature from the abnormal opening. Computed tomography (CT) thorax is suggestive of necrotizing consolidation having tracheal bronchus draining into it [Figure 2]. The patient was managed with antibiotics and other symptomatic measures.

Figure 1: (a) Bronchial origin seen from the right side of trachea proximal to the main carina (marked by red arrow as anomaly). (b) There is a small bronchial orifice arising from the medial wall of intermediate bronchus distal to main carina and opposite to the origin of right upper lobe bronchus (marked by white arrow as anomaly)

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Figure 2: Computed tomography thorax lung window showing consolidation right upper lobe with a tracheal bronchus

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Case 2

An 18-year-old male presented with frequent throat clearing sensation. He felt throat irritation but there was no cough or wheeze. There was no history of hemoptysis. He was an average built young adult without any significant respiratory illness. On examination, there were no positive clinical findings. His blood routine and ear, nose, and throat examinations were within normal limit. His X-ray chest was normal. Due to his persistent upper airway symptom, fiberoptic bronchoscopy was performed which revealed an additional bronchial division on the right side. This bronchus arises from the intermediate bronchus opposite to the origin of right upper lobe bronchus and is directed medially [Figure 1]b. Scope could not be passed through this. The diameter at the orifice was smaller than that of the right middle lobe bronchus. Based on its location, this anomaly was identified as an accessory cardiac bronchus.

Discussion

Tracheal bronchus is a congenital anomaly, in which a bronchus arises from the trachea usually from right side above the carina supplying the right lobe. This is a specific malformation, in which a single right upper lobe bronchus arises from the right side of the trachea above the carina. This configuration is seen normally in pigs and other ruminant animals. It is seen more in males and the incidence varies from 0.1% to 5%.^[1] The prevalence of the right tracheal bronchus is 0.1%–2% and that of the left tracheal bronchus 0.3%–1%.^[1]

There are two types of tracheal bronchus. Supernumerary bronchus is seen as a separate bronchus arising from the lower end of trachea which does not supply any segment and displaced bronchus usually supplies one segment or the whole of the upper lobe.^[2] Tracheal bronchus is detected in 0.5% of pediatric bronchoscopy procedures.^[3] These are usually asymptomatic and detected incidentally on bronchoscopy. In children, it presents with stridor, recurrent pneumonia, nonresolving pneumonia, and respiratory distress.^[3] Adults can present as intrathoracic mass. There can be atelectasis of right upper lobe, lobar emphysema, or even pneumothorax due to intubation of tracheal bronchus. Other congenital anomalies such as a laryngeal web, rib and vertebral anomalies, tracheal stenosis, and congenital heart disease are occasionally associated with this condition.^[4]

Tracheal bronchus is usually diagnosed by bronchoscopy or CT scan. Asymptomatic patients can be managed conservatively. Chest physiotherapy and postural drainage of the affected lobe are required. If the patient has repeated episodes of infection or hemoptysis, he/she may be subjected to resection of the affected lobe.

The accessory cardiac bronchus was first described by Brock^[5] in 1946. Its incidence ranges from 0.08% to 0.5% in the general population, reaching as much as 16% among patients with associated major tracheobronchial anomalies.^[6],[7] It occurs predominantly in men, with a male-to-female ratio of 2.8:1. It is detected incidentally in most cases and it is associated rarely with clinical manifestations.^[8],[9] Occasionally, recurrent hemoptysis and infections (pneumonia, empyema, and bronchiectasis) involving the anomaly can occur.

The accessory cardiac bronchus arises from the medial wall of the truncus intermedius, above and opposite the origin of the superior segmental bronchus, and the origin of the middle lobe bronchus. Its configuration may range from a short, blind-end diverticulum to a longer structure with distal bronchiolar and alveolar ramifications.^[10] Flexible bronchoscopy usually demonstrates a narrow orifice with normal-appearing mucosa and cartilaginous rings within the abnormal bronchus.^[11] These findings are considered definitive for the characterization of this tracheobronchial anomaly. Differential diagnosis includes acquired bronchial fistula, traction diverticula, adenoid recess, and mucus strands in the intermediate bronchus.^[12] Even though it is of low clinical relevance, its recognition and correct diagnosis is important because it could be associated with pathologies that may require clinical, endobronchial, and in some instances surgical interventions.

Conclusion

The tracheal bronchus and accessary cardiac bronchus are rare congenital anomaly of the tracheobronchial tree which occurs as a result of an additional out growth early in the embryonic life. Bronchoscopy or CT scan of thorax is necessary for a definitive diagnosis of tracheal bronchus and cardiac bronchus. Both of them are detected incidentally during bronchoscopy for unrelated illnesses. However, both of them can present with clinical disease due to stagnation of secretions and secondary infection. Rarely, these anomalies can interfere with bronchoscopy or endotracheal intubation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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