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Calcified Bronchocele
F HAQUE, SZ ABBAS, H PANDEY, HSP BABU, S WAHAB
Ind J Radiol Imag 2006 16:1:123-125
Keywords: congenital, bronchi, computed tomography
INTRODUCTION:
Congenital bronchial atresia, a rather uncommon
congenital anomaly, consists of atresia or stenosis of a
lobar, segmental or subsegmental bronchus at or near
its origin with normal development of distal structures.
Distal to the stenosis the bronchi may become filled with
mucus to form a bronchocele. The contents of the dilated
bronchus may vary from mucoid contents to inspissated
material or very rarely the contents may get calcified.
Chest roentgenograms, spiral CT and MRI features of
congenital bronchial atresia with or without bronchocele
have been described though at present, spiral CT is
accepted as the most sensitive investigation in making
the diagnosis. To the best of our knowledge very few reports
of calcified bronchocele associated with congenital
bronchial atresia have been described.
We report a case of calcified bronchocele associated with
congenital bronchial atresia.
CASE REPORT:
An asymptomatic 28 year old male was referred for the
evaluation of a branching, tubular opacity in the right
l ower l ung fi el d, detected on a routi ne chest
roentgenogram. The patient denied any specific respiratory
symptoms and there was no other relevant medical or
surgical history. The patient was a nonsmoker. The
physical examination was unremarkable. Routine blood
and urine examinations were normal.
Evaluation of the chest roentgenogram revealed tubular,
branching opacities in the right lower lung field surrounded
by an area of hyperlucency. Computed Tomography (CT)
scan was performed which revealed homogenous, tubular
l obul ated branchi ng opaci ti es, surrounded by
hyperinflated, oligemic lung parenchyma in the right lower
lung lobe. The CT absorption coefficients of the lesion
ranged between 450&500HU and the opacities did not
show any enhancement following intravenous contrast
administration. There was no contralateral mediastinal
shift or significant collapse of adjacent lobes. Fibreoptic
bronchoscopy was performed which confirmed the
diagnosis of bronchial atresia .
Fig 1 : a,b Chest radiograph (PA & lateral view) showing
tubular branching opacity in Rt lower lung field.
DISCUSSION:
Congenital bronchial atresia is seen most commonly in
young, adul t mal es.50% of these pati ents are
From the Deptt. of Radiodiagnosis, JNMC, Aligarh
Request for Reprints: Dr. Faisal Haque, 41, Alig Appartments, Shamshad Market, Aligarh - 202002
Received 28 April 2005 ; Accepted 25 February 2006
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124 F Haque et al IJRI, 16:1, February 2006
asymptomatic. The abnormality is usually discovered on
a routine chest roentgenogram (1,2). Symptomatic
patients may present with recurrent pneumonia,
dyspnoea, cough, hemoptysis or rarely as neonatal
respiratory distress. A localized area of reduced breath
sounds is the most common finding in most patients
reported in the literature (1) and wheezing is heard in
patients with a history of asthma. The diagnosis is
suspected by the radiographic finding of a juxtahilar mass
surrounded by regional hypertranslucency (3). Additional
radiographic features may include mucus filled bronchi
(bronchocele) and branching opacities radiating from the
hilum. Air trapping around the affected area that cannot
be eliminated during expiration probably due to a check
valve mechanism, results in an obstructive segmental or
lobar emphysema. A CT scan confirms the above finding
and is currently the most sensitive test available for
demonstrating the features of congenital bronchial atresia
and to rule out the presence of an obstructing
endobronchial lesion (4). Spiral CT with multiplanar
volumetric reconstruction is helpful in distinguishing a
mucocele from vascular malformation (4). Other imaging
techniques including bronchography and MRI, are either
difficult to interpret or unable to define the regional
hypertranslucency around the bronchocele that is well
visualized by CT scan. Thoracic MRI when performed,
reveals the bronchocele as a branching opacity displaying
hyperintensity on both T1 Weighted and T2 Weighted
images due to the high level of protein content. The
impacted mucus in bronchoceles may get calcified (5)
and then these lesions are depicted as signal voids on
both T1W and T2W images(6). Arteriography is used to
exclude the presence of pulmonary sequestration,if
suspected.
Spiral CT is the examination of choice, not only to show
all the components of the anomaly and to estimate the
extent of air trapping but also for ruling out differential
diagnosis such as bronchogenic cyst, bronchiectasis,
aspergillosis, completely thrombosed arteriovenous
malformation or pulmonary aneurysms and tumors.
The frequency of bronchial involvement is in the following
order: left upper lobe 64%, left lower lobe 14% and right
lower and middle lobes in only 8%(2).
Development of bronchial buds occurs between the 4th
and 15th weeks of gestation (7). A vascular insult during
this period may cause interruption of the process, resulting
in fibrosis and atresia of the involved segment. The normal
appearance of the lung parenchyma distal to the atretic
segment is supportive of a late development of the atresia
after bronchial development is completed. The high
frequency of involvement of the left upper lobe supports
the ischemic theory, since the left upper lobe is the area
of embryonic instability that develops late in utero. Beside
congenital bronchial atresia, bronchoceles are seen in
cases of acquired bronchial obstruction secondary to
allergic bronchopulmonary aspergillosis, malignant tumors
and tuberculous bronchostenosis and can be confused
with tuberculomas, hydatid cysts and solitary pulmonary
nodules. However, distal hyperinflation is seen only in
bronchial atresia, intralobar pulmonary sequestration and
bronchogeni c cysts(8). Radi ography, CT and
bronchoscopy usually help make the distinction among
these differentials.
Fi g 2 : a,b (Medi asti nal and l ung wi ndow) showi ng
homogenous lobulated tubular branching opacity surrounded
by regional hypertranslucent,oligemic area.
Pathologic findings in patients who underwent resection,
revealed that the left upper lobe was the most common
location. Grossly the involved segment or lobe is markedly
emphysematous and free of anthracotic pigment because
of the relative lack of regional ventilation. Cystic dilatation
of the atreti c bronchus i s di sti ngui shed from
bronchiectasis by the presence of normally branching and
distally extending bronchi. The involved parenchyma
shows alveolar hypoplasia, a probable consequence of
decreased ventilation and perfusion. These alveoli however
remain open by collateral air drift occurring by the
interalveolar pores of Kohn (air drift) or the bronchoalveolar
channels of Lambert or the interbronchiolar channels (1).
In conclusion,spiral CT scan appears to be the imaging
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125
IJRI, 16:1, February 2006
modality of choice to evaluate and diagnose patients with
congeni tal bronchi al atresi a and bronchocel e.
Asymptomatic patients may be, managed conservatively
while patients presenting with complications like recurrent
pneumonia are preferably treated surgically.
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