Anomalous origin of the anterior segmental bronchus of the right upper lobe.

Anomalies of bronchial anatomy have been categorised as "displaced", when a normal bronchus arises from an abnormal site, and "supernumerary", when there is evidence that all normal bronchi are present, together with an additional bronchus.' In a 15-year period slightly more than 2500 bronchograms were made in the course of routine investigation of respiratory disease. Three bronchograms revealed a right upper bronchus with only two segmental branches, their disposition being clearly apical and posterior, and the middle lobe bronchus carried an additional segmental bronchus the direction of which was anterior and rostral, to supply lung which occupied that area normally supplied by the anterior segmental bronchus of the right upper lobe. Two of the three bronchograms did not show bronchiectasis, and are of good quality (figs 1, 2). In the third (fig 3), made some weeks after removal of a long-retained foreign body from the intermediate bronchus, quality is less good, there is a little leftsided filling which obtrudes in the right lateral radiograph, and there is bronchiectasis of the right lower lobe and at least the lateral segment of the middle lobe. The displaced anterior segmental bronchus is not obviously bronchiectatic and can be seen to lie caudal to a fissure which runs upwards and forwards from the pulmonary hilum to the midpoint of the manubrium sterni. The child whose bronchogram is shown in fig 3 is at present symptom-free, and a decision on the need for resection of bronchiectasis has been deferred. As a general rule, to leave only two segments of a lung, the rest having been resected, courts postoperative complications because the residual segments can rarely be of a size sufficient to fill the pleural space. Middle and lower lobectomy, should it prove necessary in this child, would leave an upper lobe in whichi there are only two segments. Pneumonectomy would be an anatomically expensive resection, and a bronchogram of technically better quality would be an essential preliminary to reaching a decision on how much of the middle lobe could be spared.