Chapter 9

Airway and Parenchymal Anomalies

• Bronchopulmonary abnormalities
– Heterogenous group of entities, originate from
primitive foregut or lung bud
– Interfere normal develompent 3rd-24th weeks of
gestation
• Failure of development of lung bud 
agenesis
• Incomplete development  pulmonary
hypoplasia
• Majority  manifested in early childhood
(occasionally first recognized in adolescents or
adults)
• This chapter limits discussion to
developmental in adults
Anomalous Tracheobranchial Branching
• Tracheal bronchus
– An anomalous bronchus arises from the right lateral wall of the
trachea
– Less than 2 cm from carina
– Supplies apical segment of RUL / entire lobe (pig bronchus or
bronchus suis)
– Normal vascular supply
– End blindly  tracheal diverticulum
– Asymptomatic  incidentally
• Recurrent RUL pneumonia
• Air trapping or atelectasis of apical segment or RUL
• Focal emphysema
• Bronchiectasis
• A  Small bronchus
from right tracheal wall
• B and C  supplying the
apical segment of RUL
• A 3D VRT shows TB from
Trachea
• B virtual bronchoscopy show
TB,R,L from level of lower
trachea
• C coronal 3D shows tracheal
bronchus entering right lung
• Accessory Cardiac Bronchus
– Supernumerary bronchus that arises from the medial
wall of right main or intermediate bronchus opposite
the origin of the RUL bronchus
– Courses medially and caudally
– Ends blindly
– Asymptomatic; cough and hemoptysis to infection / Ca
– CT  airway originates from medial wall of
mainbronchus or bronchus intermediate cephalad to
the origin of the middle lobe bronchus
• A and B.
Cardiac
bronchus from
medial wall of
bronchus
intermedius,
ending blind
• C (MIP) and D (3D
VRT) show a medial
and inferior course of
cardiac bronchus,
ends blindly
 Congenital Bronchial Atresia
• Rare congenital anomaly characterized by short-
segment obliteration of a lobar, segmental, or
subsegmental bronchus at or near its origin
• Most common : Apicoposterior segment of LUL
 segment bronchi of RUL  middle lobe 
lower lobe
• Airway and airspaces distal to obstruction
develop normally  collateral channels
• Asymptomatic; recurrent pneumonia
• Patophysiology
– Bronchial tree peripheral to point of obliteration is patent + normal
number of airways and airspaces  accumulation mucus  a
mucocele (distal to atresia)
– Alveoli in affected area ventilated by collateral pathways  air
trapping with hyperinflation
• Radiography  area of pulmonary hyperlucency and a hilar
nodule or mass
– Hyperlucency = oligemia + increase in volume of air (air trapping)
– Adjacent normal lung and or mediatinum  compressed and
displaced
– Mucus  ovoid, round, or branching opacities near the hilum
– Expiratory CXR  air trapping
• CT
– Mucoid impaction w/ bronchial dilatation
(bronchele) distal to atresia
– Bronchial occlusion
– Decreased vascularity and attenuation and
increased volume of affected segment
• MRI
– Mucoid impaction
• Variable signal at T1
• Very high signal at T2
• A. increased lucency in left middle and upper lung zone
• B. CT  marked decreased attenuation and vascularity of
superior segment of LLL + anterior displacement of left major
fissure + bronchocele distal to atretic bronchus (arrow)
CT demonstrates
decreased
attenuation and
vascularity +
bronchial atresia
(arrow) + pectus
excavatum
 • CT  modality of
choice
• DD/
– Foreign body
– Endobronchial tumor

• 3D VRT shows atresia of RUL

bronchus + abnormal branching
pattern of right middle lobe
bronchus
 Bronchogenic Cyst
• Abnormal separation of localized portions of
the tracheobronchial tree from the adjacent
airways
• 75% at mediastium and 25% at lung
• Asymptomatic; compression
trachea/bronchi/esophagus
• Thin walled, unilocular, roughly spherical,
mucoid or serous
• Radiography 
– Round or oval masses in right paratracheal or
subcarinal region
– Sharply circumscribed, solitary
• CT 
– Homogenous cystic mass with thin smooth wall
– Near water density (-10 - +10 HU)
– No enhancement
• A. focal convexity subcarinal
with mild displacement of
bronchus intermedius
• B. Cystic mass in subcarinal
region
• C. Mass homogenous high
signal  fluid (MRI T2)
• MRI
– Low signal at T1
– High signal at T2
• Imaging algorithm  CT or MRI recomended
• DD
– Lung tumor
– Abscess
– Congenital cystic adenomatoid malformation
 Congenital Cystic Adenomatoid
Malformation
• Multicystic mass of pulmonary tissue with
abnormal proliferation of bronchial structures
• Neonatal  Respiratory distress
• Adult  incidental; recurrent infection
• Type
– Type I: large, multiloculated cysts > 2 cm (adults)
– Type II : more uniform small cysts < 2 cm
– Type III : solid-appearing lesions that
microscopically demonstrate tiny cysts
• Radiography
– Unilocular or multiloculated cyst or as a complex
soft tissue and cystic mass
– Contralateral shift of mediastinum
• CT
– Unilocular or multiloculated cyst or as a complex
soft tissue and cystic mass from 4-12 cm
• Imaging algorithm  CT
• Large cystic lesion in the
RLL, increasing in size.
• Thin-walled cyst with
septation
Intralobar and Extralobar Sequestration
• Malformation in which a portion of lung is
detached from the remaining normal lung and
receives its blood supply from a systemic artery
• Intralobar  bronchial obs and chronic infection;
the detached portion is contiguous with normal
lung parenchyma and contained within the same
visceral pleural envelope
• Ekstralobar  congenital; separate from normal
lung and enclosed within its own pleural
membrane
• Asymptomatic; superimposed infection
• DD/ bronchiectasis and lung abscess
• Radiography
– Intralobar  homogenous opacity in posterior basal
segment of a lower lobe, almost invariably
contiguous with the hemidiaphragm
– Extralobar  sharply defined, triangular-shaped
opacity in the posterior costophrenic angle, adjacent
to the left hemidiaphragm
– Both  most frequently in left lower
• PA and lateral CXR
show an area of
homogenous
increased opacity
in the posterior
basal region of the
left lower lobe,
abuts the
diaphragm
• CT
– Intralobar : focal areas of lucency or irregular cystic spaces w/ or
w/out fluid
– Extralobar : homogenous opacity or well circumscribed mass
• MRI
– Differentiating cystic, solid, hemorrhagic, and mucous components
of mass
• Aortography
– Feeding vessels, esp extralobar
• Imaging algorithm
– MRI  free radiation + MRA = excellent visualization of vessels
– CT  exclude DD
• DD/
– Pneumonia
– Bronchial obstruction
– Recurrent atelectasis
– Lung abscess
– Bronchogenic cyst
– CPAM
• A subtle area of
increased
lucency in the
left lower lung
• CT  sharply
defined focal
area of
decreased
attenuation in
left lower lung
Enhance CT  a
large vessel
originating
from aorta
and coursing
toward the
sequestered
lung
• Aortogram 
large aberrant
vessel originating
from the aorta
 Pulmonary Agenesis, Aplasia and
Hypoplasia
• Agenesis : complete absence of one lung
• Aplasia : suppresion of all but a rudimentary
bronchus that ends in a blind pouch, with no
evidence of pulmonary vascularture or
parenchyma
• Hypoplasia : reduction in the number of size of
airways, vessels, and alveoli
• Most die in neonatal period
• Radiography
– Total or almost total absence of aerated lung in one
hemithorax
– Elevation ipsilateral hemidiaphragm
– Ipsilateral shift of the mediastinum and the ribs
• CT
– Aplasia : rudimentary bronchus
– Hypoplasia : patent bronchus, pulmonary artery, and
hypoplastic lung
• DD/
– Pneumonectomy
– Atelectasis
– Bronchiectasis
– Fibrothorax
Akhirnyaa……..