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358
CHEST IMAGING
Tracheobronchial Branching
Abnormalities: Lobe-based
Classification Scheme1
Guillaume Chassagnon, MD
Baptiste Morel, MD
Elodie Carpentier, MD
Hubert Ducou Le Pointe, MD, PhD
Dominique Sirinelli, MD, PhD
Abbreviations: ACB = accessory cardiac bron-
chus, LMB = left main bronchus, LPAS = left
pulmonary artery sling, MLB = middle lobe
bronchus, RMB = right main bronchus, 3D =
three-dimensional, ULB = upper lobe bronchus,
VACTERL = vertebral defects, anal atresia,
cardiac defects, tracheoesophageal fistula, renal
anomalies, and limb abnormalities
RadioGraphics 2016; 36:358–373
Published online 10.1148/rg.2016150115
Content Codes:
1
From the Department of Radiology, Hôpital
Clocheville–CHU Tours, 49 Boulevard Béranger,
37044 Tours, France (G.C., E.C., D.S.); and De-
partment of Radiology, Hôpital Armand Trous-
seau, Paris, France (B.M., H.D.L.P.). Presented
as an education exhibit at the 2014 RSNA An-
nual Meeting. Received April 14, 2015; revision
requested June 26 and received July 14; accepted
July 31. For this journal-based SA-CME activity,
the authors, editor, and reviewers have disclosed
no relevant relationships. Address correspon-
dence to G.C. (e-mail: gchassagnon@gmail.com).
©
RSNA, 2016
SA-CME LEARNING OBJECTIVES
After completing this journal-based SA-CME
activity, participants will be able to:
■■List the main differences between the
right and left bronchial trees.
■■Discuss situations in which the radiolo-
gist must search for congenital branching
abnormalities.
■■Describe congenital branching abnor-
malities affecting the trachea, main bron-
chi, and intermediate bronchus.
See www.rsna.org/education/search/RG.
Boyden’s nomenclature, which was based on postmortem speci-
mens and published in 1955 prior to the advent of computed
tomography (CT), is commonly used to describe the normal seg-
mental bronchial anatomy and various abnormalities. However,
several additional anomalies have been recognized since that time,
and there is some confusion over the names used to describe
these anomalies. Several congenital branching anomalies affect-
ing the trachea, main bronchi, and intermediate bronchus have
been reported, all of which can be recognized at chest CT but are
often overlooked. These anomalies, which probably occur early in
fetal life, can be either supernumerary, with defects occurring at
29–30 days gestation, or displaced, with defects occurring later.
Tracheobronchial positional anomalies are often associated with
other congenital abnormalities but may be isolated. They often are
asymptomatic but can be responsible for pulmonary symptoms
such as dyspnea, recurrent pneumonia, and hemoptysis. It is essen-
tial that these anomalies are recognized prior to lung resection to
avoid complications, especially when video-assisted thoracoscopic
surgery is performed. In addition, bronchoscopists should be aware
of these anomalies before performing diagnostic or therapeutic
bronchoscopic procedures. Awareness of a few key bronchial ana-
tomic principles and use of a lobe-based classification scheme will
facilitate recognition of tracheobronchial positional anomalies.
©
RSNA, 2016 • radiographics.rsna.org
Introduction
Numerous major congenital bronchial branching anomalies have
been described, with a reported prevalence of 0.1%–2% in the general
population (1–4). Most of these anomalies were described in the out-
standing work by Boyden (5) published in 1955, before the advent of
computed tomography (CT), with additional anomalies having been
recognized since that time (6,7). There is some confusion in the litera-
ture over the names used to describe these anomalies. For example,
the terms tracheal bronchus and eparterial bronchus may designate simi-
lar or different anomalies depending on the authors. Thus, the use of
a uniform comprehensive classification scheme is essential in describ-
ing congenital positional anomalies of the tracheobronchial tree. All
congenital branching anomalies affecting the trachea, main bronchi,
and intermediate bronchus can be recognized at routine chest CT, but
they frequently are overlooked (8). Their recognition is essential prior
RG  •  Volume 36  Number 2 Chassagnon et al  359
TEACHING POINTS
■■ Normally, the carina is at the level of thoracic vertebrae T4
and T5.
■■ Most of these anomalies are either displaced or supernumer-
ary bronchi. The term displaced bronchus is used to describe
a bronchus with an abnormal origin, when the normal bron-
chus ventilating the corresponding parenchyma is absent. In
contrast, a supernumerary anomaly is seen in addition to the
normal bronchus. A supernumerary bronchus may end blind-
ly in the parenchyma of the corresponding normal bronchus
or may be associated with ventilated parenchyma, which is
thus considered to be additional lung tissue.
■■ At CT, the relationship of the ULB to the ipsilateral pulmonary
artery is the most reliable marker of bronchial situs.
■■ ACB is the only bronchus originating from the medial wall of
either the RMB or the intermediate bronchus, but it can oc-
casionally occur on the left side.
■■ In bridging bronchus, the carina is located at the normal level,
facing thoracic vertebrae T4 and T5, whereas the pseudoca-
rina is at the T6-T7 level and has an inverted T appearance due
to an increased angle.
to lung surgery to avoid complications during
lung resection (8,9). Tracheobronchial branching
anomalies may also have important implications
during tracheal intubation (4,10).
In this article, we review the embryologic
development and normal anatomy of the tra-
cheobronchial tree; describe various congenital
branching anomalies affecting the trachea, main
bronchi, and intermediate bronchus, including
abnormal bronchi directed toward the middle
and the lower lobes that arise (or should have
arisen) from the main bronchi and intermediate
bronchus; and propose a lobe-based classifica-
tion scheme for these anomalies to facilitate their
recognition. Bronchial agenesis, aplasia, hypopla-
sia, and bronchial atresia are not discussed in this
article because they should not be considered as
branching anomalies involving the trachea, main
bronchi, or intermediate bronchus.
Embryologic Development
Tracheobronchial development begins early in
fetal life. The trachea and bronchi develop as a
diverticulum of the ventral wall of the foregut at
24–26 days gestation (3,11). Shortly thereafter,
primary bronchi bud off and grow, while the
trachea separates from the esophagus. On days
30–34, five growing points are identified that cor-
respond to lobar buds: three on the right side and
two on the left (5). Bronchial buds undergo stages
of dichotomous and lateral branching that give rise
to the conducting airways (12). By days 36–38, all
segmental bronchi are present, and by the end of
the 6th week, branching up to the subsegmental
portions of the bronchial tree has occurred (3,12).
The development of bronchial arborization occurs
Figure 1.  Drawing illustrates the segmental bronchial anat-
omy according to Boyden’s nomenclature. On the right side,
B1 = apical bronchus, B2 = anterior bronchus, B3 = posterior
bronchus, B4 = lateral bronchus, B5 = medial bronchus, B6 =
superior bronchus, B7 = medial basal bronchus, B8 = anterior
basal bronchus, B9 = lateral basal bronchus, and B10 = poste-
rior basal bronchus. On the left side, B1 and B3 arise from the
same trunk and form the apicoposterior bronchus (B1 + 3), B4 =
superior lingular bronchus, and B5 = inferior lingular bronchus.
The other left segmental bronchi have the same designations
as their right-sided counterparts.
during the embryonic phase (weeks 5–7) and
pseudoglandular phase (weeks 5–17). Pulmonary
vessel organogenesis occurs simultaneously with
tracheobronchial development. Thus, at the end
of the pseudoglandular stage, all preacinar airways
as well as corresponding arteries and veins are
present (13). Lung parenchyma develops during
the canalicular stage (17–26 weeks) and sacular
stage (24 weeks–birth). At birth, development of
the lung parenchyma remains incomplete because
most alveoli are formed during the first 3 years of
postnatal life.
The pathogenesis of congenital branching
anomalies remains unknown, but these anomalies
probably occur early in fetal life. Several hypoth-
eses have been proposed (11). Evans (3) hy-
pothesized that defects involving supernumerary
bronchi may occur at about 29–30 days gestation,
whereas displaced bronchi are more likely to oc-
cur after 32 days. The term supernumerary refers
to an abnormal bronchus that arises in addition
to the normal corresponding bronchus.
Normal Tracheobronchial Anatomy
In radiology and thoracic surgery, Boyden’s
nomenclature is commonly used to describe
segmental bronchial anatomy (Fig 1) (5). In
each lung, segmental bronchi (B) are assigned a
number from 1 to 10, similar to the number of
360  March-April 2016 radiographics.rsna.org
the corresponding segment (S). These numbers
differ from those in the endoscopists’ nomen-
clature, in which anterior bronchi of the upper
lobes are labeled B3 (B2 in Boyden’s nomencla-
ture) and posterior bronchi of the upper lobes
are labeled B2 (B3 in Boyden’s nomenclature)
(5,14). Variations in the prevailing pattern of
segmental bronchial distribution are common.
For example, the typical trifurcation of the right
upper lobe bronchus (ULB) is seen in only
30%–38% of the population (5,11). To under-
stand tracheobronchial positional anomalies,
three points must be emphasized:
1. Normally, the carina is at the level of tho-
racic vertebrae T4 and T5.
2. The relationship of the bronchi to the
pulmonary arteries differs between the lungs.
The right ULB lies behind and beneath the right
pulmonary artery, whereas the left main bron-
chus (LMB) passes beneath the left pulmonary
artery before it gives rise to the left ULB. Thus,
the right ULB is said to be eparterial, since it
arises above the point where the right pulmonary
artery crosses the right main bronchus (RMB),
whereas the left ULB is said to be hyparterial,
since it originates below the point where the left
pulmonary artery crosses the LMB. On the right
side, the normally situated right ULB (eparte-
rial bronchus) serves as a point of reference to
describe the position of the abnormally located
bronchus directed toward the upper lobe terri-
tory, whereas on the left side, the point of refer-
ence is the crossing point of the left pulmonary
artery and the LMB.
3. Bronchovascular distribution to the lungs is
asymmetric. The RMB is shorter than the LMB.
The right ULB arises alone, several centimeters
above the middle lobe bronchus (MLB), and the
right superior bronchus (B6) arises just inferior
to the orifice of the MLB, nearly opposite to it.
In the left lung, the superior and inferior divi-
sions (lingular bronchi) arise together from the
left ULB, and B6 arises at a distance. Indeed,
the common trunk of the left lower lobe is longer
than that of the right lower lobe and extends for a
distance of 10–12 mm (5).
Congenital Tracheo­-
bronchial Branching Anomalies
Numerous tracheobronchial branching anoma-
lies have been described. In this article, we focus
on anomalous branching of the trachea, main
bronchi, and intermediate bronchus. These
tracheobronchial branching anomalies can be cat-
egorized into five groups: (a–d) those involving
(a) the entire lung, (b) the upper lobes, (c) the
middle lobe, or (d) the lower lobes; and (e) other
tracheobronchial branching anomalies.
Most of these anomalies are either displaced
or supernumerary bronchi. The term displaced
bronchus is used to describe a bronchus with an
abnormal origin, when the normal bronchus ven-
tilating the corresponding parenchyma is absent.
In contrast, a supernumerary anomaly is seen in
addition to the normal bronchus. A supernumer-
ary bronchus may end blindly in the parenchyma
of the corresponding normal bronchus or may
be associated with ventilated parenchyma, which
is thus considered to be additional lung tissue
(15). This additional lung tissue is more often
ventilated and may be delineated by an accessory
fissure. Blind-ended bronchi are termed congenital
bronchial diverticula and should not be confused
with acquired bronchial diverticula, which can be
observed in chronic obstructive pulmonary disease.
There can be associated abnormal distribution of
the pulmonary vasculature (eg, a left pulmonary
artery sling [LPAS] in the case of a bridging bron-
chus) (16,17).
Most congenital tracheobronchial anomalies
are asymptomatic and are discovered incidentally.
Inverted pulmonary situs in cases of situs inver-
sus, as well as tracheal bronchus and preepar-
terial bronchus, can be recognized easily at
chest CT, but other tracheobronchial branching
anomalies are often overlooked, and preoperative
recognition of these variations is important, es-
pecially in cases involving video-assisted thoraco-
scopic surgery (8,9).
Tracheobronchial branching anomalies can
be isolated. However, some of these anomalies,
such as bronchial situs anomalies, tracheobron-
chial branching anomalies of the upper lobes,
and bridging bronchus, are often associated with
other tracheobronchial branching anomalies and/
or congenital heart disease, lung abnormalities, or
foregut malformations (3,4,7,18). In an autopsy
study, Evans (3) found that three of four infants
with a displaced or supernumerary bronchus had
congenital heart disease and other malformations.
Similarly, Ming and Lin (4) reported that tra-
cheal bronchi occurred 13 times more frequently
in children with congenital heart disease than in
those without this disease entity. Congenital heart
diseases associated with tracheobronchial branch-
ing anomalies include ventricular septal defects,
conotruncal heart defects, aortic coarctation, and
atrioventricular canal defects (3,4,19). Down
syndrome also appears to be overrepresented
among patients with tracheal bronchus (10).
Tracheobronchial Branching
Anomalies of the Entire Lung
Bronchial situs is one aspect of visceroatrial situs,
which refers to the position of the cardiac atria,
lungs, liver, stomach, and spleen relative to the
RG  •  Volume 36  Number 2 Chassagnon et al  361
midline (20,21). Situs solitus corresponds to the
usual arrangement of these organs, whereas situs
inversus is the mirror image arrangement and
situs ambiguus (or heterotaxy) includes other
arrangements that cannot be categorized as either
situs solitus or situs inversus. Among types of
situs ambiguus, right isomerism describes a bilat-
eral right-sidedness and left isomerism describes
a bilateral left-sidedness (19,21).
Right isomerism (formerly known as asplenia
syndrome) is typically associated with right bron-
chial isomerism, bilateral right morphologic atria,
asplenia, midline liver, and variably located stom-
ach. In contrast, left visceroatrial isomerism (for-
merly known as polysplenia syndrome or Ivemark
syndrome) is usually associated with left bronchial
isomerism, bilateral left morphologic atria, poly-
splenia, midline liver, and variably located stom-
ach. However, these features are variably associ-
ated, and bronchial situs does not always correlate
with atrial and abdominal situs (22).
Situs anomalies can be associated with con-
genital heart diseases, primary ciliary dyskinesia
(including Kartagener syndrome), and intesti-
nal malrotation and other abdominal anomalies
(23–25). Congenital heart diseases are quite com-
Figure 2.  Drawings illustrate the rela-
tionship of the ULB to the pulmonary
arteries as a marker of bronchial situs.
(a) In situs solitus, the right ULB is in an
eparterial position (arrow) and the left
ULB is in a hyparterial position (arrow-
head). In situs inversus, just the oppo-
site is true. (b) When both ULBs are in
the same position, bronchial situs corre-
sponds either to right isomerism in cases
of bilateral eparterial bronchi or to left
isomerism in cases of bilateral hyparte-
rial bronchi.
mon in right isomerism, which is associated with
an 80%–90% mortality rate during the first year of
life (26). Patients with left isomerism have a bet-
ter outcome and a less frequent association with
congenital heart disease (27). Left isomerism is as-
sociated with a 60% mortality rate during the first
year of life (19), and, in autopsy series, congenital
heart diseases have been reported to occur in 50%
or more of cases (28). However, these percentages
are probably overestimated because the number
of cases of left isomerism without congenital heart
disease diagnosed during adulthood has increased
with use of cross-sectional imaging (25).
At CT, the relationship of the ULB to the
ipsilateral pulmonary artery is the most reliable
marker of bronchial situs (Fig 2) (22). A lung with
an eparterial bronchus is morphologically a right
lung, whereas a lung with a hyparterial bronchus is
morphologically a left lung. Thus, bilateral eparterial
ULBs characterize right bronchial isomerism (Fig
3), whereas bilateral hyparterial ULBs characterize
left bronchial isomerism (Fig 4). Other features such
as the number of lobes, ratio of left to right main
bronchial lengths, and branching pattern are less re-
liable markers (22). The main differential diagnosis
of right isomerism is a left eparterial bronchus.
362  March-April 2016 radiographics.rsna.org

Figure 3.  Right bronchial isomerism in a 4-month-old female infant with double outlet ventricle. (a) On
a contrast material–enhanced three-dimensional (3D) reconstructed CT image of the tracheobronchial
tree, the left bronchial tree has the same morphologic features as the right bronchial tree, with the early
rise of the ULB at a distance from the MLB. LLB = lower lobe bronchus, RLLB = right lower lobe bronchus,
RULB = right ULB. (b) On a 3D reconstructed CT image of the tracheobronchial tree and pulmonary
arteries, both ULBs are eparterial, since they originate behind the ipsilateral pulmonary arteries. These
findings are consistent with right bronchial isomerism. The patient also had right atrial isomerism and an
ambiguous visceral situs associated with asplenia and cavoazygos continuation.

Figure 4.  Left bronchial isomerism in an asymptomatic 61-year-old man. LULB = left ULB. (a) Contrast-
enhanced 3D reconstructed CT image of the tracheobronchial tree shows that, similar to the left ULB,
B4 and B5 on the right side arise with the ULB. (b) Superimposed 3D reconstructed CT images of the
tracheobronchial tree and pulmonary arteries show that both ULBs are hyparterial, since they arise below
the crossing of the ipsilateral pulmonary artery and main bronchi. These findings are consistent with left
bronchial isomerism. The patient also had left atrial isomerism and an ambiguous visceral situs associated
with polysplenia and truncated pancreas.

Tracheobronchial Branching
Anomalies of the Upper Lobes
Tracheal Bronchus.—Tracheal bronchus was de-
scribed for the first time by Sandifort in 1785 as a
right ULB originating from the trachea (5). Since
then, several authors have expanded this defini-
tion to include any bronchus originating from
the trachea or main bronchi and directed toward
the upper lobe territory (5,11,29); thus, the term
tracheal bronchus may seem inappropriate (29).
A bronchus abnormally originating directly from
the trachea is exposed to additional risks during
tracheal intubation, such as lobar or segmental
atelectasis due to luminal occlusion by the tube or
respiratory failure due to inadvertent intubation of
the tracheal bronchus (4,10). Thus, in accordance
with the original definition given by Sandifort and
RG  •  Volume 36  Number 2 Chassagnon et al  363

Figure 5.  Drawing illustrates tra-

cheobronchial branching anoma-
lies of the upper lobes. A = right tra-
cheal bronchus, B = right preeparte-
rial bronchus, C = right posteparte-
rial bronchus, D = left tracheal bron-
chus, E = left eparterial bronchus,
F = left prehyparterial bronchus.

Figure 6.  Recurrent pneumonia in a 16-month-old boy with displaced right tracheal bronchi and tetralogy of
Fallot. (a) Supine chest radiograph shows consolidation in the right upper lobe (*) with associated retrocardiac
consolidation in the left lower lobe (arrowhead). (b) Contrast-enhanced chest CT image obtained 3 days later
shows areas of consolidation in both the right upper lobe (black arrows) and left lower lobe (arrowhead). Red
arrow = displaced right tracheal bronchus ventilating consolidated parenchyma.

others (4,15), we suggest restricting the defini-
tion of a tracheal bronchus to any bronchus that
abnormally originates directly from the trachea or
carina. ULB originating from the main bronchi
and intermediate bronchus should be labeled dif-
ferently to avoid confusion (Fig 5).
Tracheal bronchus is almost invariably located
on the right side. Almost all reported cases of left
tracheal bronchus have originated from the LMB
and thus correspond to left eparterial or left pre-
hyparterial bronchi.
To our knowledge, 12 cases of bronchi origi-
nating from the trachea and directed toward the
left upper lung have been reported in the English
language literature (4,18,30–35). Among these
bronchi, 11 were bilateral tracheal bronchi and at
least three should be considered as bilateral right
tracheal bronchi because they were associated
with right pulmonary isomerism.
The frequency of occurrence of right tracheal
bronchus is debated. According to various bron-
choscopic, bronchographic, and CT studies, right
tracheal bronchus is seen in 0.1%–1.3% of adults
and in 1.5%–2% of the pediatric population (2,4).
Associated conditions have been reported in 78% of
children with a right tracheal bronchus. These condi-
tions include Down syndrome; malformations of the
thoracic cage, foregut, or lung; tracheal stenosis; and
other tracheobronchial branching anomalies (2,16).
Ming and Lin (4) observed a 13-fold increase in the
frequency of occurrence of right tracheal bronchi in
children with congenital heart disease.
Clinically, tracheal bronchus may be associ-
ated with recurrent pneumonia (Fig 6), stridor,
or respiratory distress in children (36). Adults are
almost invariably asymptomatic.
At CT, tracheal bronchus is easily recognized.
It usually arises from the distal part of the trachea,
364  March-April 2016 radiographics.rsna.org

Figure 7.  Displaced right tracheal bronchus in a
15-year-old boy. Three-dimensional reconstructed chest
CT image of the tracheobronchial tree shows an aber-
rant right tracheal bronchus arising from the right wall
of the trachea, less than 2 cm above the carina. The B1
and B2 segmental bronchi arise from the tracheal bron-
chus, which is associated with proximal stenosis of the
right ULB (arrow). The right ULB gives rise to B3 only.
Figure 8.  Displaced right preeparterial bronchus in an
18-year-old man with tetralogy of Fallot. Three-dimen-
sional reconstructed CT image of the tracheobronchial
tree shows an aberrant right preeparterial bronchus aris-
ing from the RMB and corresponding to a displaced B1
segmental bronchus. These findings are consistent with
a displaced right preeparterial bronchus. RLLB = right
lower lobe bronchus.

less than 2 cm above the carina (Fig 7). The dis-
tance between the tracheal bronchus and the ca-
rina should be stated in the report for the anesthe-
siologist. In some cases, the abnormally branched
bronchus may be tiny or manifest with proximal
stenosis (4,15,36,37). A blind-ended right tracheal
bronchus is also possible and is referred to as a
congenital right tracheal diverticulum.
Tracheal bronchi are more frequently dis-
placed than supernumerary bronchi. Of the
eight right tracheal bronchi reported by Ghaye
et al (11), 75% were displaced bronchi, whereas
only 25% were supernumerary bronchi. A right
tracheal bronchus may ventilate the entire right
upper lobe, one or two segments, a subsegment,
or a subsubsegment. A displaced tracheal bron-
chus often supplies at least a portion of the apical
segment. When the entire right ULB is displaced
on the trachea, the right tracheal bronchus is
classically termed “pig bronchus” because it cor-
responds to normal anatomy in swine.
Lung parenchyma ventilated by a supernumer-
ary tracheal bronchus has been referred to as a
tracheal lobe by several authors and may be delin-
eated by an accessory fissure (38). This tracheal
lobe may be intra- or extralobar and is not related
to the azygos lobe, seen in cases of azygos pseudo-
fissure due to an anomalous pathway of the azygos
vein (16). Only a few cases of double right tracheal
bronchus have been described (36,39).
In cases of an entirely displaced right ULB,
the underlying RMB can be stenotic, possibly
owing to the absence of contribution of the right
upper lobe to the development of the RMB dur-
ing fetal life (15).
A left tracheal bronchus is usually associated
with a right tracheal bronchus, forming true bilat-
eral tracheal bronchi, in contrast to the bilateral
right tracheal bronchi that can be observed in
cases of right isomerism (4). In all reported cases
of true bilateral tracheal bronchi, the left tracheal
bronchus originated opposite to the right tracheal
bronchus (31,33). Bilateral tracheal bronchi can
be associated with a decrease in the diameter of
the downstream trachea (31).
Right Preeparterial Bronchus.—The term right
preeparterial bronchus refers to any bronchus
directed toward the right upper lobe that arises
abnormally from the RMB, above the level of
the right ULB (eparterial bronchus) (Fig 5). The
term eparterial bronchus was introduced by Boy-
den (5) and originally described both right preep-
arterial bronchus and right tracheal bronchus.
The frequency of occurrence of right preeparte-
rial bronchus is almost twice that of right tracheal
bronchus (0.9% versus 0.4% in a study of 1200
bronchograms by Atwell [1]), and both share the
same predisposing conditions. Right preeparterial
bronchus is often asymptomatic (1,11).
At CT, right preeparterial bronchus arises from
the lateral wall of the RMB (Fig 8). Displaced
forms represent 82% of cases, and a blind-ended
bronchus may rarely be encountered (11). The
RG  •  Volume 36  Number 2 Chassagnon et al  365

Figure 9.  Displaced right posteparterial bronchus in a 15-year-old boy with a surgically corrected aber-
rant left pulmonary artery and partial anomalous pulmonary venous return. RULB = right ULB. (a) Coronal
3D reconstructed CT image of the tracheobronchial tree shows that the B2 and B3 segmental bronchi
arise from the MLB. (b) Oblique reconstructed CT image shows that B1 is the only segmental bronchus
to originate from the right ULB, whereas B3 originates directly from the MLB, and B2 arises from B4.

main differential diagnosis in cases of an abnor-
mally branched bronchus arising from the RMB
is an accessory cardiac bronchus (ACB), which
always arises from the medial wall and is directed
toward the heart.
Right Posteparterial Bronchus.—The term right
posteparterial bronchus refers to any bronchus
directed toward the right upper lobe that arises
from the right bronchial tree at a level below
that of the right ULB (eparterial bronchus) (Fig
5) (5).
Segmental and subsegmental right ULB origi-
nating from the MLB are considered by some au-
thors to be minor variants (37,40) but correspond
to the initial description of posteparterial bronchus
proposed by Boyden (5) (Fig 9). Another variant
is a gross downward displacement of the ULB that
originates at the same level as the MLB. To our
knowledge, only one case of this variant has been
reported in the English language literature (5).
Left Eparterial Bronchus.—The term left eparte-
rial bronchus refers to any bronchus directed
toward the left upper lobe that arises from the
LMB above the level where the left pulmonary
artery crosses the LMB (Fig 5). It represents
the most common left-sided bronchial branch-
ing anomaly. In a study by Ghaye et al (11), left
eparterial bronchus occurred 1.7 times more
frequently than left prehyparterial bronchus but
five times less frequently than right preeparte-
rial bronchus.
Affected patients are usually asymptomatic.
Similar to right preeparterial bronchus, left
eparterial bronchus does not expose the patient
to additional risk during tracheal intubation. An
association with congenital malformations such
as VACTERL (vertebral defects, anal atresia,
cardiac defects, tracheoesophageal fistula, renal
anomalies, and limb abnormalities), congenital
heart diseases, and other airway malformations
has been reported (8,18,41).
At CT, a left eparterial bronchus originates
from the posterolateral or lateral wall of the
LMB above the level where the left pulmonary
artery crosses the left MLB (Fig 10). Most of
the reported cases in the literature are displaced
eparterial bronchi (5,8,11,42). The anomalous
bronchus usually ventilates at least the apico-
posterior segment (segments S1 + 3) and may
also ventilate the anterior (S2) or superior (S6)
segment of the left lower lobe (8). A trilobed
left lung due to an accessory fissure is often
observed (8,42). The accessory fissure may cor-
respond to a left minor fissure similar to that en-
countered in 8%–18% of the general population
and that separates the anterior (S2) and superior
(S4) lingular segments (8,42–45). It may also be
different from left minor fissure and be situated
between the apicoposterior (S1 and S3) and
anterior (S2) segments (5,8). Hyperinflation,
air trapping, bronchiectasis, or lymphangiecta-
sia can also be encountered, probably related
to vascular compression by the left pulmonary
artery (29).
Left eparterial bronchus is often overlooked.
In a study by Oshiro et al (8), eight of 10 cases
of left eparterial bronchi were surgical findings
that were retrospectively visible at preoperative
366  March-April 2016 radiographics.rsna.org

Figure 10.  Displaced left eparterial bronchus in an asymptomatic 69-year-old man. (a) Coronal contrast-
enhanced 3D reconstructed CT image of the tracheobronchial tree shows a displaced left B1 bronchus arising
from the LMB and directed toward the left upper lobe (arrow), as well as a displaced right tracheal bronchus
(B1). LULB = left ULB, RULB = right ULB. (b) Superimposed 3D reconstructed CT images of the tracheobron-
chial tree and pulmonary arteries (oblique posterior view) show that the displaced left B1 bronchus (arrow)
arises above the level where the left pulmonary artery crosses the left MLB (LULB). (c) On an axial CT image,
the displaced left B1 bronchus (arrow) passes behind the interlobar artery (*). These findings are consistent
with a displaced left eparterial bronchus associated with a right tracheal bronchus.

Figure 11.  Double displaced left prehyparterial bronchi (left isomerism) in a 2-year-old girl with tetral-
ogy of Fallot. (a) Coronal contrast-enhanced 3D reconstructed CT image of the tracheobronchial tree and
pulmonary arteries shows bilateral hyparterial bronchi consistent with left isomerism. On the right side
(morphologically left bronchial tree), displaced B1 + 3 and B2 bronchi originate independently from the
ULB that gives rise to B4 + 5. These displaced bronchi arise below the crossing artery. (b) On an axial CT im-
age, the displaced B2 bronchus (arrow) passes anterior to the interlobar artery (*), as do B1 + 3 and B4 + 5.

CT. The main differential diagnosis is pulmonary
right isomerism.
Left Prehyparterial Bronchus.—Left prehyparte-
rial bronchus is defined as an anomalous bronchus
directed toward the left upper lobe that arises from
the LMB between the level where the left pulmo-
nary artery crosses the LMB and the level of the
left ULB (hyparterial bronchus) (Fig 5). Few data
are available about this rare anomaly.
In the study by Ghaye et al (11), left prehyp-
arterial bronchus was less common than left
eparterial bronchus. There may be other associ-
ated airway anomalies, such as right preeparterial
bronchus and left isomerism (Fig 5).
At CT, left prehyparterial bronchus is seen as
a supernumerary or displaced bronchus origi-
nating from the lateral wall of the LMB, below
the arch of the left pulmonary artery but above
the normally positioned left ULB (Fig 11). The
RG  •  Volume 36  Number 2 Chassagnon et al  367

Figure 12.  Displaced left eparterial bronchus in a 7-month-old boy with tetralogy of Fallot. (a) Posterior
oblique contrast-enhanced 3D reconstructed CT image of the tracheobronchial tree shows a displaced B1 bron-
chus (arrow) that arises at the same level as the left ULB (LULB). LLLB = left lower lobe bronchus. (b) Posterior
oblique 3D reconstructed CT image of the tracheobronchial tree and pulmonary arteries shows a supernumerary
bronchus (arrow) that seems to arise below the level where the left pulmonary artery crosses the main bron-
chus. (c) On an axial CT image, the supernumerary bronchus (arrow) passes behind the interlobar artery (*),
similar to the (eparterial) right ULB. Thus, the displaced B1 bronchus (cf a) should be considered a displaced
left eparterial bronchus.

level of the origin of the bronchus relative to the Tracheobronchial Branching

crossing of the bronchi and the left pulmonary
artery is important for distinguishing between
left eparterial and left prehyparterial bronchi but
may be difficult to establish, especially on axial
images. Thus, we suggest that bronchi taking a
path behind the pulmonary arteries, similar to
the right ULB, should be considered left eparte-
rial bronchi, whereas bronchi taking a path in
front of these arteries should be considered left
prehyparterial bronchi (Fig 12). As in left ep-
arterial bronchus, an accessory fissure may also
be present (11,46). Although having a similar
appearance, left eparterial and left prehyparte-
rial bronchi probably have different pathoge-
netic features because the former is usually a
displaced bronchus, whereas the latter is usually
supernumerary (11).
Left Posthyparterial Bronchus.—Left posthyp-
arterial bronchus has previously been defined
as an anomalous bronchus directed toward the
left upper lobe that arises below the left ULB.
It has been included in a previous classification
scheme for abnormally positioned ULB (11);
to our knowledge, however, no cases have been
reported in the English language literature. This
variant is not included in the present classifica-
tion scheme because it would arise from the left
lower lobe bronchus.
Anomalies of the Middle Lobe
Gross Upward Displacement of the MLB.—Gross
upward displacement of the MLB corresponds
to an MLB arising at the level of the right ULB.
The MLB may arise from the right ULB, or even
from B2. This variation is very rare and has been
reported only once (5). We have encountered two
such cases in our experience; in both cases, the
patient had congenital heart disease.
At CT, a displaced MLB arises with or from
the right ULB at a distance from the origin of B6.
Its appearance is similar to that of normal left lung
anatomy, in which the left ULB gives rise to supe-
rior and inferior divisions (lingular bronchi) (Fig
13). However, the right ULB remains eparterial
and is not displaced downward. The main differ-
ential diagnoses are left bronchial isomerism and
displaced posteparterial bronchus. In the latter con-
dition, the right upper lobe is displaced downward
and originates at almost the same level as B6.
Tracheobronchial Branching
Anomalies of the Lower Lobes
Suprasuperior Bronchus.—Suprasuperior
bronchus is defined as a displaced subsegmental
bronchus of the superior segment of the lower
lobe (S6) that arises from the main bronchus or
368  March-April 2016 radiographics.rsna.org

Figure 13.  Gross upward displacement of the MLB in a 4-year-old girl with tetralogy of Fallot. (a) An-
terior oblique contrast-enhanced 3D reconstructed CT image of the tracheobronchial tree shows that
the MLB is displaced and arises with the right ULB (RULB) from a common trunk, at a distance from B6.
RLLB = right lower lobe bronchus. (b) Posterior 3D reconstructed CT image shows that the bronchial
situs is solitus type because the right ULB (RULB) is eparterial and the left ULB (LULB) is hyparterial.

Figure 14.  Suprasuperior bronchus in an 80-year-old man. (a) Oblique anterior contrast-enhanced 3D reconstructed
CT image shows an aberrant bronchus (arrow) arising from the posterior wall of the intermediate bronchus, above B6.
(b) On an axial CT image, the aberrant bronchus (arrow) is directed toward the superior segment (S6) and corresponds
to a suprasuperior bronchus. (c) Axial CT image obtained at a lower level than b reveals that the B6 bronchus originates
at almost the same level as the MLB.

the intermediate bronchus (5,47). Six cases of
right suprasuperior bronchi have been reported
by Boyden (5), all of which corresponded to
displaced subsegmental bronchi involving at
least the B6a subsegmental bronchus. At CT, a
suprasuperior bronchus originates above the level
where the MLB arises (Fig 14). It must be differ-
entiated from a subsuperior bronchus (B*) cor-
responding to a supernumerary bronchus that is
directed toward the superior segment and arises
below B6. Subsuperior bronchus is very common
and has been observed in 56% of right lungs and
26% of left lungs (11), whereas suprasuperior
bronchus is rare. Subsuperior and suprasuperior
bronchi have been described as different enti-
ties by Boyden (5). In contrast to a subsuperior
bronchus, which is always displaced, a suprasupe-
rior bronchus, which is supernumerary in nature,
suggests a different pathogenesis.
Other Tracheo-­
bronchial Branching Anomalies
Accessory Cardiac Bronchus.—ACB is a supernu-
merary bronchus that originates from the medial
wall of the main bronchus or intermediate bronchus
RG  •  Volume 36  Number 2 Chassagnon et al  369

Figure 15.  Bilateral ACB in an asymptomatic 70-year-old woman. LULB = left ULB, RULB = right ULB.
(a) Coronal contrast-enhanced minimum intensity projection reformatted CT image shows bilateral
supernumerary bronchi (arrows) arising from the medial wall of the intermediate bronchus and LMB.
(b) Three-dimensional reconstructed CT image shows that the right ACB is intermediate type, appear-
ing as a long diverticulum without arborization, whereas the left ACB is short diverticular type (arrows).

and is directed caudally toward the heart. ACB is
the only bronchus originating from the medial wall
of either the RMB or the intermediate bronchus,
but it can also occasionally occur on the left side
(48,49). First described in 1946 by Brock (50),
ACB is seen in 0.07%–0.5% of the general popu-
lation (48). It usually ends blindly but may also
supply ventilated parenchyma (48,51,52).
ACB is usually asymptomatic, but patients
may experience symptoms such as recurrent
pneumonia, hemoptysis, cough, or dyspnea (52).
Cases of lung tumors arising from ACB have
also been reported (53,54). ACB is not always
isolated. Patients with double ACB or other as-
sociated bronchial anomalies such as preeparte-
rial bronchus and left or right tracheal bronchus
have been encountered (51,55–57), and the
prevalence of ACB among patients with other
major tracheobronchial positional anomalies is
reported to be higher (52).
At chest CT, ACB is easily recognized as
the only bronchus arising from the medial wall
of the main bronchus or intermediate bron-
chus (Fig 15). The abnormal bronchus most
frequently originates from the medial wall of
the proximal third of the intermediate bron-
chus, almost directly opposite the origin of the
right ULB. Median length is 12 mm (11) and
mainly depends on the morphologic features of
the bronchus. Indeed, Mangiulea and Stinghe
(51) have recognized three types of ACB at
bronchoscopy: (a) a short diverticular type,
(b) a long type ventilating a small undeveloped
lobule, and (c) an intermediate type with a
long diverticulum but no bronchial or alveolar
arborization. At CT, lung tissue associated with
the supernumerary bronchus may appear as a
tissue mass around the tip of the bronchus or as
a ventilated lobule that can be delineated by an
accessory fissure. The tissue mass, which is seen
in 35.7%–50% of patients, can show enhance-
ment after contrast material injection and has
been attributed to vestigial or rudimentary lung
parenchyma (11,52). In the same CT studies,
the prevalence of lobules delineated by an acces-
sory fissure was 28.5%–66%, with some patients
presenting with both a tissue mass and at least a
ventilated lobule (11,52).
The main differential diagnosis is the medial
basal bronchus (B7), which is the only bron-
chus to arise from the inner wall of the lower
lobe bronchus (48). ACB has no relationship to
anatomic variations and anomalies of B7 that are
restricted to the lower lobe bronchus (51).
Bridging Bronchus.—Bridging bronchus is an ab-
errant bronchus that partially or totally supplies
the right lung but that originates from the LMB
(58). It is an extremely rare bronchial malforma-
tion and was named by Gonzalez-Crussi et al (6)
in 1976. Wells et al (7) reported a second variant
in 1988. Thus, bridging bronchi can be divided
into two main subtypes (Fig 16):
1. In type 1, the RMB ends in the right ULB,
and the intermediate bronchus abnormally arises
from the LMB, forming a pseudocarina (Fig 17)
(59). The middle lobe is supplied by either the
right bronchus or the bridging bronchus.
2. In type 2, the RMB ends in a diverticu­lum or
is absent (59). The entire right lung is ventilated
370  March-April 2016 radiographics.rsna.org

Figure 16. Drawings il-

lustrate type 1 and type 2
bridging bronchi.

Figure 17.  Type 1 bridging bronchus in a 6-year-old girl with pulmonary atresia and a ventricular septal defect. (a) On
a coronal contrast-enhanced minimum intensity projection reformatted CT image, the RMB ends in the right ULB, and
the intermediate bronchus arises from the LMB, forming a pseudocarina (arrowhead). (b) Three-dimensional recon-
structed CT image superimposed on a coronal reformatted image shows the pseudocarina at the T6 level (arrowhead),
with the carina remaining at the T4 level (arrow). IB = intermediate bronchus.

by a displaced RMB arising from the LMB, form-
ing a pseudocarina (Fig 18).
One probable case of left bridging bronchus
arising from the RMB and supplying the left lower
lobe has also been reported, but autopsy confirma-
tion was not obtained (60). In bridging bronchus,
the carina is located at the normal level, facing
thoracic vertebrae T4 and T5, whereas the pseudo-
carina is at the T6-T7 level and has an inverted T
appearance due to an increased angle (7).
Most cases of bridging bronchus have been
reported in association with LPAS. Bridging
bronchus has been reported in 52%–78% of
patients with LPAS, and the association has been
termed “left pulmonary artery sling type II” in
the classification scheme of Wells et al (7,17). In
patients with LPAS, type 1 bridging bronchus
(LPAS type II-A) has been reported in 22%–27%
of patients, whereas type 2 bridging bronchus
(LPAS type II-B) was encountered in 30%–57%
(7,17). Rare cases of bridging bronchi without
LPAS have been reported, and almost all were
type 1 bridging bronchi (59,61–63). This entity
is probably underdiagnosed or misdiagnosed as
a tracheal bronchus. Congenital cardiovascular,
vascular, abdominal, genitourinary, and gastroin-
testinal malformations are also frequently associ-
ated, as well as airway stenosis or bronchomalacia
(63,64). In bridging bronchus type 2, the right
lung is frequently hypoplastic (17).
Bridging bronchus is often but not exclusively
discovered in infants. Patients with bridging
RG  •  Volume 36  Number 2 Chassagnon et al  371

Figure 18.  Type 2 bridging bronchus in a 14-year-old girl with chronic dyspnea and wheezing. (a) Coronal
contrast-enhanced minimum intensity projection reformatted CT image shows that the normally located
RMB is diverticular, at the level of the carina (arrow). The right lung is ventilated by a displaced RMB arising
from the LMB, forming a pseudocarina (arrowhead). (b) Three-dimensional reconstructed CT image with
superimposition of the tracheobronchial tree and pulmonary arteries shows the absence of an LPAS. (c) Three-
dimensional reconstructed CT image superimposed on a coronal reformatted image shows the pseudocarina
at the T6 level (arrowhead), with the carina remaining at the T4 level (arrow). The stenosis of the LMB explains
the patient’s wheezing.

bronchus may experience wheezing or respira-
tory distress because of tracheal and/or LMB
stenosis (64). These stenoses may be related to
the presence of cartilage in the posterior wall
of the narrowed airways (cartilage rings) and/or
absence of the pars membranacea (7).
Chest CT is an ideal diagnostic tool in diagnos-
ing bridging bronchus and in searching for associ-
ated tracheobronchial stenosis or LPAS (17,59).
It allows differentiation of the various subtypes.
The main differential diagnosis of type 1 bridging
bronchus is a displaced tracheal bronchus. In some
cases, the CT appearance of entirely displaced right
tracheal bronchus may mimic that of type 1 bridg-
ing bronchus because of the decreased diameter
of the trachea downstream from the origin of the
right tracheal bronchus. However, in right tracheal
bronchus, the carina remains at the T4-T5 level,
compared with the T6-T7 level of the pseudoca-
rina in bridging bronchus. In addition, the angle
of the carina helps differentiate between the two
diagnoses: In displaced tracheal bronchus, this
angle remains normal, whereas the pseudocarina
in bridging bronchus has an increased angle with
an inverted T appearance (7). Chest CT cannot
help determine the presence or absence of tracheal
or bronchial cartilage rings, and bronchoscopy
remains necessary in cases of stenosis (59).
Conclusion
Congenital branching anomalies affecting the
trachea, main bronchi, and intermediate bron-
chus are often overlooked but can have important
implications, especially in cases involving surgery.
These anomalies are related to defects occurring
early in fetal life and often are associated with
other congenital malformations. Thus, several con-
genital malformations such as Down syndrome,
congenital heart diseases, VACTERL syndrome,
and tracheal stenosis, as well as the presence of
other tracheobronchial positional anomalies,
should prompt the radiologist to search for associ-
ated tracheobronchial branching anomalies that
may otherwise be overlooked.
Even if most tracheobronchial branching
anomalies are incidentally discovered, they can
also be symptomatic, especially in children,
leading to recurrent pneumonia, hemoptysis,
or dyspnea. Knowledge of several anatomic
principles, such as the eparterial position of the
right ULB, hyparterial position of the left ULB,
and T4-T5 level of the trachea, are critical for
recognizing these anomalies. With use of a lobe-
based classification scheme (Fig 19), congenital
branching anomalies affecting the trachea, main
bronchi, and intermediate bronchus can easily
be categorized.
Acknowledgment.—The authors thank John Scatarige, MD,
for English language assistance.
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