Tracheal bronchus in the apical segment of the right upper lung: A case report

Tracheal bronchus (TB) is a congenital developmental anatomical variation in which a bronchus abnormally originates from the trachea. This paper reports a case of tracheal bronchus in the apical segment of the right upper lung, along with incomplete stenosis and occlusion of the apicoanterior and apicoposterior segments of the right upper lung. The patient was a 62-year-old male who had undergone a left upper lobectomy one year prior. A follow-up chest CT scan revealed a solitary nodule in the right lower lobe, highly suggestive of metastatic carcinoma, as well as postoperative changes in the apicoanterior and apicoposterior segments of the left upper lobe. Additionally, an abnormal bronchial opening on the right side was identified approximately 0.8 cm above the tracheal carina. The patient opted for surgical resection and subsequently underwent a "thoracoscopic right lower lobectomy with lymph node dissection and pleural adhesion cauterization" under "total intravenous anesthesia with tracheal intubation combined with a bronchial blocker and paravertebral nerve block anesthesia." Intraoperatively, fiberoptic bronchoscopy revealed an abnormal bronchial opening in the main trachea, approximately 0.8 cm above the carina, supplying the apical segment of the right upper lung. Narrowed and occluded openings were observed at approximately 0.2 cm and 0.5 cm distal to the right upper lung apical segment bronchial opening, corresponding to the apicoanterior and apicoposterior segments, respectively. This patient was classified as Conacher Type III TB. Since the surgery involved the ipsilateral lower lobe, the degree of lung inflation did not interfere with the surgical procedure, and no special intervention was required. The patient regained spontaneous breathing immediately after surgery and was successfully discharged five days later. TB is a rare condition with an unclear etiology, and Conacher classification provides valuable guidance for anesthesiologists in airway management. Familiarity with the imaging and fiberoptic bronchoscopic characteristics of TB, comprehensive preoperative assessment, timely intraoperative identification of abnormal airways, and early detection and management are crucial in preventing potential surgical complications in TB patients.