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Lobar emphysema in the neonate is usually congenital, resulting from cartilage deficiency causing bronchomalacia and distal air trapping. Acquired forms are usually associated with chronic lung disease or endobronchial obstruction such as mucus plugging. We report a pedunculated endobronchial polyp in a 2-month old ex-premature infant causing intermittent hyperinflation of the right middle lobe. The polyp was seen prolapsing in and out of the bronchus intermedius at bronchoscopy. Possible aetiological links with mechanical ventilation are discussed. We also emphasise the value of bronchoscopy prior to lobectomy in cases of congenital lobar emphysema (CLE).

Clinicians frequently see the “right middle lobe” referred to in radiology reports, textbooks, and medical journals. Yet, there is no “left” middle lobe to distinguish it from, save a rare patient with Kartagener syndrome. We do not refer to the lingula as the “left” lingula. “Right” adds nothing to our understanding of the anatomic position of the lobe. So “right” is redundant when talking about the middle lobe. Yet, PubMed has 5,266 right middle lobe references, and a Google Scholars search found 22,900 publications used the phrase in the past 161 years. Th at is the equivalent of the length of two and one-half football fi elds worth of wasted words in just a Google search, nevermind those found in radiology reports, textbooks, or Index Medicus references (in Calibri font size 12, “right” 5 1 cm 3 22,900 search results 5 228.99 m).

Purpose: In this study we present the clinical, radiological, pathological, bronchoscopic and surgical results of 40 patients with diagnosis of middle lobe syndrome who were referred to our thoracic surgery unit for surgical intervention in a 10 years period. Methods: Forty patients with obstructive and non-obstructive causes of middle lobe syndrome referred to our thoracic surgery unit. Clinical data were collected from the patients’ records in a ten years period. This study evaluates diagnostic approaches and surgical treatments in right middle lobe syndrome. Results: We studied 23 females (57.5%) and 17 males (42.5%) with a mean age of 31.7. Clinical findings were cough 95%, sputum 80% and intermittent hemoptysis in 50% of patients. Middle lobe collapse was seen in CT scan of all patients. Bronchiectasis was the most common pathologic finding (55%). Tuberculosis was not rare and was final pathology in 20% of patients. In three patients ruptured hydatid cyst was final finding. Surgery was done without mortality and with only minor complications. Conclusion: Lobectomy of right middle lobe is a good therapeutic option in these patients. Due to high prevalence of tuberculosis and hydatid cyst in Middle Eastern countries these two must be considered as causes of middle lobe syndrome.

中葉からのリンパ流は，通常分岐部を経由し上縦隔へ向かうものが主体だが，上葉気管支周囲リンパ節（＃１２u）を経由し上縦隔へ向かうとの報告もある．当院では，中葉原発非小細胞肺癌（NSCLC）切除時に標準郭清（ND2a）に加え＃１２u郭清を選択的に行っているが，その意義は不明であり，その適否を検討した．対象は，１９８０年～２００４年までに完全切除施行の中葉原発NSCLC１３３例のうち，多発肺癌を除くND2aを行った８６例（＃１２u郭清/非郭清：４７/３９例）．リンパ節転移率は，N0/N1/N2：７６/９/１５％．＃１２u転移はN2症例２例のみで，多領域リンパ節転移を伴い予後不良であった．５生率は，＃１２u郭清/非郭清で６８/７８％であり有意差を認めなかった（P＝０.３２）．再発は２５例（２９％）に認め，＃１２u郭清群に有意に多かったが（P＝０.００１），＃１２uの局所再発は認めなかった．以上より，中葉原発NSCLCにおいて＃１２u郭清の効果は明らかでなく，意義はないものと考えられた．

Summary: This report presents the case of successful removal of a distally located foreign body using a guide sheath (GS). A 78-year-old man was brought for x-ray examination after a dental treatment at a local clinic. A dental instrument, a diamond bur, was missing after the treatment. The chest x-ray revealed a needle-like instrument located in the peripheral right middle lobe. The distally located foreign body was removed with a flexible bronchoscope using a curette and a biopsy forceps placed through a GS. This is the first report of use of a GS to remove a foreign body.

Headscarf needle aspiration is a rare event, especially in Middle and Western European countries. Here, we report the case of a 37-year-old Austrian woman of Turkish origin who accidentally aspirated a turban pin. Repeated bronchoscopy was not successful in removing the aspirated foreign body, which extended past the right middle lobe to the interlobar fissure. The needle was finally removed by video-assisted thoracoscopic surgery.

Bilateral thoracotomies spaced at least 4 weeks apart are often required for the resection of bilateral pulmonary metastases. The anatomic distribution of the metastatic disease may rarely permit excision of bilateral pulmonary deposits through one thoracotomy incision. We demonstrate a successful bilateral pulmonary metastasectomy in the right upper lobe, right middle lobe, and left upper lobe through a right thoracotomy in a 40-year-old man with a past history of rectal adenocarcinoma and of left open pulmonary metastasectomy 1 year previously. The left upper lobe was approached by opening the pleura anterior to the ascending aorta.

No abstract available. Article truncated at 150 words. A 73 year-old woman, a lifetime non-smoker, presented to the pulmonary clinic with chronic dyspnea on exertion and cough. Physical exam was unremarkable and pulmonary function testing showed normal spirometry. A chest radiograph revealed calcified mediastinal adenopathy and increased density in the right middle lobe region (Figure 1). A computed tomography scan of the chest revealed significant narrowing of the right middle lobe bronchus with partial atelectasis and prominent calcified mediastinal lymphadenopathy (Figure 2). Bronchoscopy showed no endobronchial lesions but there was evidence of extrinsic compression surrounding the right middle lobe orifice. An endobronchial biopsy revealed noncaseating granulomas. Bronchoscopy cultures and cytology were negative and this was presumed to be from a previous infection with histoplasmosis given the patient’s long-term residence in an endemic area. Given chronic narrowing of right middle lobe bronchus with persistent atelectasis of the right middle lobe, the patient was diagnosed with right middle lobe syndrome. ...

Between May 1988 and July 2002, six patients with pneumonia due to diesel, animal, or vegetable oil aspiration were admitted to Kaohsiung Medical University Hospital. The purpose of this study was to demonstrate distinctive radiographic findings of oil-induced lipoid pneumonitis on initial serial chest roentgenograms and high-resolution computerized tomography (CT) scans. Initial chest roentgenograms (n = 6), CT scans (n = 6), and roentgenography and CT follow-up studies were analyzed retrospectively by two chest radiologists and two surgeons, focusing on the pattern and distribution of parenchymal abnormalities. The most common location was the right middle lobe, followed by the right lower lobe, the left lower lobe, and the lingular lobe. Follow-up chest roentgenograms (n = 6) showed complete disappearance of the parenchymal lesions in only one patient and partial decrease in the extent of lesions in five patients. Lipoid pneumonia presents non-specific findings on chest roentgenography. It is commonly located in both lower and the right middle lobes. On high-resolution CT, the lesions appear most commonly as areas of consolidation, ground-glass attenuation mixed with paving pattern, and poorly defined nodules.

This case report describes a solitary fibrous tumour presenting as a pedunculated mass arising from an almost completely atretic right middle lobe of lung. The intraoperative findings and pathologic diagnostic criteria used are described. To our knowledge, this is the first case report of a solitary fibrous tumour associated with partial lung atresia.

A 53-year-old man with bleeding from a sternal mass associated with a toxic syndrome. Computed tomography (CT) revealed a destructive sternal mass, bilateral pleural effusion and an endobronchial lesion in the right middle lobe bronchus. Immunohistopathological study of an incisional biopsy confirmed metastasic lung adenocarcinoma.

肺内穿孔をきたし緊急手術を行った縦隔奇形腫の1例を経験した.症例は18歳, 男性.2001年4月の検診にて右肺門部に腫瘤陰影を認め同月の胸部CTで前縦隔腫瘍と診断し手術予定で外来経過観察をしていたが, 2001年5月17日より胸痛, 血痰, 高熱が出現し, 同年5月20日右中下肺野に浸潤影を認めたため当科緊急入院した.エコーガイド下縦隔腫瘍穿刺吸引による腫瘍内溶液の性状はアミラーゼ0IU/l, リパーゼ4U/l, トリプシン19ng/lと低値であり, 腫瘍内溶液は黄色ブドウ球菌に感染していた.全身状態の悪化が著しいと考えたため, 2001年5月22日縦隔腫瘍摘出術及び右肺中葉切除術を行った.摘出標本の病理組織学的検査で縦隔奇形腫と診断された.術前に上昇していたSCC抗原, CA19-9, 可溶性IL-2レセプターは術後正常化しており嚢胞内産生が考えられた.

Herein, we report a patient with a rare disease, intrapulmonary schwannoma. The patient was a 61-year-old woman who had a 20 mm × 18 mm nodule, with a clear boundary and homogeneous content, on the central side of S4 in the right lung on chest CT. On PET with 18- fluorodeoxyglucose scanning, 18-fluorodeoxyglucose accumulations with a maximal standardized uptake value of 2.5 and 3.3 were observed in the early and late phases, respectively, suggesting a malignant tumor. A thoracoscopic right middle lobectomy was performed because the tumor was present in the segmental bronchial region of the middle lobe. Intrapulmonary schwannoma accounts for 0.2% of lung tumor cases, and cases involving patients who have undergone preoperative PET with 18- fluorodeoxyglucose scanning have rarely been reported.

Aspirated foreign bodies continue to present challenges to the Otorhinolaryngologists. The major issues involve the accurate diagnosis at the earliest and speedy, safe removal of the foreign body. Endoscopic removal is the mainstay of management of foreign body in tracheobronchial tree. Spontaneous expulsion of foreign body bronchus is a rare entity with few cases reported in literature. We report a rare and interesting case of 18-year-old male patient presented with sharp and pointed metallic foreign body in Right Middle lobe Bronchus i.e., sewing machine needle. Patient was admitted and planned for bronchoscopy. But prior to it, foreign body was spontaneously expelled out. The patient was discharged next day without any complication. Spontaneous expulsion saves the patient from the dangers of endoscopic removal of foreign body, but impose a great danger of subglottic lodgement of foreign body.

RationaleGiven that the diagnosis of chronic obstructive pulmonary disease (COPD) relies on demonstrating airflow limitation by spirometry, which is known to be poorly sensitive to early disease, and to regional differences in emphysema, we sought to evaluate individual lobar contributions to global spirometric measures.MethodsSubjects with COPD were compared with smokers without airflow obstruction, and non-smokers. Emphysema (% low attenuation area, LAAinspResultsThe right middle lobe had the highest %LAAinspConclusionsBecause of the right middle lobe's disproportionate contribution to CT-based emphysema measurements, and low contribution to spirometry, longitudinal studies of emphysema progression may benefit from independent analysis of the middle lobe in whole lung quantitative CT assessments. Our findings may also have implications for heterogeneity assessments and target lobe selection for lung volume reduction.Clinical trial registrationClinicalTrials.gov NCT00608764.

A 70-year-old female patient was admitted to the hospital with complaints of dyspnea on exertion, fatigue, weight loss and palpitation lasting for one year but accentuated in the previous month. The radiological examinations revealed right middle lobe agenesis along with Macleod syndrome localized at the right inferior lobe. Macleod syndrome is a rare disease but the localization at the right inferior lobe accompanying a right middle lobe agenesis is even rarer. We present this case with an overview of the literature. (Tur Toraks Der 2010; 11: 87-9)

Naxos disease is a rare cardiocutaneous disorder characterized by palmoplantar keratoderma, woolly hair and arrythmogenic right ventricular cardiomyopathy. We report two siblings with Naxos disease with right middle lobe syndrome in one of them.

Middle lobe syndrome is a term that refers to a recurrent collapse of a lung segment, typically the right middle lobe. We present here a case of middle lobe syndrome which occurred in an unusual lung segment and which was related to an unusual cause.

Presentation of Case A 71-year-old woman was admitted to the hospital because of fever, dyspnea, and hypotension. Her history included an inferior myocardial infarction 19 years earlier; hypertension; renal insufficiency ascribed to chronic pyelonephritis, with a creatinine level ranging from 1.8 to 2.2 mg per deciliter (159.1 to 194.5 μmol per liter); a left nephrectomy; and chronic paranoid schizophrenia. There was a mass in the right middle lobe and a calcified right hilar lymph node, both of which had remained unchanged on periodic radiographic assessment for seven years. Twelve weeks before the current admission, the patient was admitted to the . . .

We describe a case of a 25 year old female from Lithuania who presented with a productive cough. Chest radiograph demonstrated an infiltrate in the left upper lobe and a cavitating lesion in the right middle lobe. Sensitivity testing of her sputum led to a diagnosis of extensively drug-resistant tuberculosis (XDR-TB). This is the first case in Ireland and highlights the need for physicians to be aware of the possibility of XDR-TB. Moreover it underlines the need for improvement in service provision in terms of a TB reference laboratory and TB clinics.

We present a 54 year old male patient who had a bilateral lung transplant sixteen years ago for Alpha-1 Antitrypsin Deficiency-related emphysema. He was referred for flexible bronchoscopy with transbronchial biopsies to evaluate new mild exertional dyspnea and worsening of his FEV1. Eight transbronchial biopsies were done from the right middle lobe and the right lower lobe. Post procedure he developed bilateral pneumothoces that required emergent bilateral pleural ‘pigtail’ catheters. To our knowledge, this is the first reported case of bilateral pneumothoraces that developed after a unilateral procedure in a bilateral lung transplant recipient relatively late after the transplant.

We report a patient with multiple congenital pulmonary anomalies, including unilateral pulmonary artery agenesis with an atretic left lung, "buffalo chest," and a variant of the anatomic anomaly "horseshoe lung," discovered during double lung transplantation. Both hemithoraces were filled by the right lung. The right chest was occupied primarily by the anatomic right lower lobe, and the left chest by the right middle lobe at the apex and the anatomic right upper lobe at the base.

Summary Pneumothorax is a well-known complication of transbronchial lung biopsy. But pleural space infection and empyema following TBLB, although theoretically possible, has not been documented. A 35-year-old gentleman presented with a non-resolving pneumonia of the right middle lobe. As a part of evaluation he underwent fiberoptic bronchoscopy and TBLB without fluoroscopic guidance. He developed pneumothorax, which was managed by needle aspiration. Subsequently, he developed fever and was detected to have right-sided empyema which was successfully managed by antibiotics and intercostal tube drainage. Early identification and treatment of empyema is essential to prevent further morbidity. This case emphasizes the importance of adequate monitoring of those who develop pneumothorax after TBLB for development of pleural space infection.

Background Historically, right middle lobe (RML) non-small cell lung cancer (NSCLC) has been reported to be associated with a higher rate of pneumonectomy than other right-sided locations. Because this would discourage minimally invasive approaches in RML-NSCLC, we sought to update this assertion through the study of a large surgical series. Methods Clinical records of patients who underwent operations for right-sided NSCLC in 2 French surgical centers were prospectively entered and retrospectively reviewed. Demographic and pathologic characteristics of RML NSCLC were compared with other right-sided NSCLC. Results This study included 3,234 right-sided and 211 RML (6.5%) NSCLC patients. After exclusion of 14 patients who underwent exploratory thoracotomy, patients were a mean age of 61.5 years, most RML resections occurred in men (134 [72.8%]), and most were lobectomies (wedge, n = 4; lobectomy, n = 102; bilobectomy, n = 22; pneumonectomy, n = 56). Pathologic analysis revealed adenocarcinoma in 88 patients (47.8%) and squamous cell carcinoma in 80 (43.5%). pStaging was stage I in 86 patients (46.7%), II in 42 (22.8%), III in 47 (25.5%), and IV in 9 (4.9%). Superior and inferior mediastinal N2 were found in 45.4% and 54.6% of patients, respectively, when 1 station was involved. When compared with other right-sided NSCLC, RML was characterized by higher T status and higher rates of bilobectomy (10.9% vs 5.6%, p = 0.0017) and pneumonectomy (30.3% vs 22.3%, p = 0.0071) but similar 5-year survival (47.4%). Conclusions Compared with other right-sided NSCLC, RML location is associated with a higher albeit limited rate of pneumonectomy.

Background. In a series of 229 patients infected with mycobacterial organisms, we noted a specific female phenotype that involves isolated infections of the middle lobe and lingula. Methods. Thirteen patients were found to have infections of the middle lobe, lingula, or both. All of them were infected with Mycobacterium other then Mycobacterium tuberculosis , all were women, 12 of the 13 were slender, and most had variable combinations of skeletal abnormalities. All underwent resection of the middle lobe, lingula, or both. Results. There were no operative deaths. Only 2 patients have had reactivation requiring additional antibiotic therapy. All patients have had a decreased number of pulmonary infections in the postoperative period. Anatomic findings at operation included a complete major fissure and at least a partially complete minor fissure with middle lobe resections or an elongated lingula. Conclusions. Mycobacterial infection of the middle lobe and lingula is primarily a disease of asthenic women and is often associated with skeletal abnormalities and complete fissures or an elongated lingula. We recommend that surgical intervention be performed early once the condition is identified.

症例は, 38歳女性.胸部X線上異常陰影の精査のため当院受診.胸部X線上右中肺野に嚢胞陰影を混在した浸潤影を呈し, CTでは正常肺組織に接して隔絶された領域を認めた.気管支造影では, 右中肺野に気管支の分布を認めず, 上葉, 中葉気管支は各々圧排されていた.種々の血管造影では異常動脈を検出し得なかったが, 肺葉内分画症を疑い手術施行した.S4領域の一部は嚢胞状変化を来し, 胸部大動脈から直径約3mmの異常血管が流入していた.稀な中葉発生の肺葉内分画症と診断し, 中葉切除術を施行した.

Journal of Thoracic Oncology • Volume 8, Number 1, January 2013 A 60-year-old woman presented to our clinic with complaints of cough and expectoration for 1 week. The expectoration was persistent, non–foul smelling and often contained thin brown silky hairs (Fig. 1). She had otherwise been well and denied breathlessness, febrile sensation, and weight loss. Chest radiograph showed a right hilar mass and collapse of the right middle lobe. Computed tomography of the chest showed a fat-containing mass measuring 6.2 × 4.7 × 3.2 cm in the right Intrapulmonary Teratoma Presenting with Trichoptysis

The role of bronchoalveolar lavage (BAL) in children remains to be defined, and to date there has been no standardization of acquisition and processing of the BAL fluid. The aim of the present study was to evaluate a standardized protocol for obtaining, processing, and analyzing BAL fluid and to establish reference values for healthy children. Eighteen children 3 mo to 10 yr of age were lavaged with three 1-ml/kg aliquots of normal saline, using a flexible bronchoscope into the right middle lobe. The first aliquot was processed separately; the second and the third were pooled. There was a higher percentage of neutrophils and epithelial cells in the first aliquot. The number of total cells per milliliter (median, Q1 to Q3) in the first aliquot was 60 (45 to 90) x 10(3)/ml; in the pooled sample it was 155 (75 to 257) x 10(3)/ml. Percentages (median, Q1 to Q3) of different cell types in the pooled sample were: macrophages, 91% (84 to 94); lymphocytes, 7.5% (4.7 to 12.8); neutrophils, 1.7% (0.6 to 3.5); eosinophils, 0.15% (0.0 to 0.3). The ratio of helper/cytotoxic T-cells was 0.58 (0.4 to 1). The results of this study demonstrate that BAL, using a standardized protocol adjusting instilled fluid volume by weight, appears to be appropriate in children and that cellular and protein values from healthy children are, apart from differences in lymphocyte subsets, similar to those found in healthy adults.

The patient is a 74-year-old man who had been showing worsening symptoms of the cough and sputum of which he had complained for years. He had smoked 20 cigarettes a day for more than 50 years. Because his chest roentgenogram revealed right middle lobe atelectasis, bronchoscopy was performed

A 72-year-old woman, who had previous bilateral reconstruction mammoplasty, underwent video-assisted thoracoscopic surgery for a right middle lobe pulmonary carcinoid. Five months after her surgery, the patient noticed an acute pronounced reduction in her right breast volume, with shortness of breath and cough. A computed tomography study of the chest revealed intrathoracic migration and rupture of her right breast implant, with associated silicone thorax. Subsequent video-assisted thoracoscopic surgery confirmed this diagnosis.

Inferior vena cava filter (IVCF) placement has been recommended by clinicians for patients with venous thromboembolism who are at high risk for pulmonary embolism. There are a number of complications with IVCF insertion, removal, and migration that have been reported in the literature. Although those resulting from structural failure are rare, they can also be among the most critical. We describe a 48-year-old woman with a history of hypercoagulability whose IVCF fractured during retrieval, resulting in partial embolization to the right middle lobe pulmonary artery.

Objective: Right middle lobe syndrome is a rare entity in children, causing high morbidity. Our experience of these patients including their clinical and laboratory characteristics, indications forsurgical management, postoperative courses, and follow-up results was evaluated. Methods: A retrospective analysis was performed involving 20 children with right middle lobe syndrome who were hospitalized and treated with surgical resection of the right middle lobe in Van Training and Research Hospital and Yüzüncüyil university hospital, Turkey, between January 2002 and January 2011. Results: The mean age of the patients was 10.5 years (range, 5 to 15 years). Twelve patients were boys and eight were girls. The most frequent symptom was chronic cough (75%). Hemoptysis was present in two (10%) patients. One patient was being treated for asthma. 25% positive cultures were identified among the patients. Streptococcus pneumoniae was the most frequently identified agent in sputum. All patients underwent chest computed tomography. There were bronchiectasis in 11 (55%) patients, atelectasis and bronchiectasis in five (25%) patients, and destroyed lung in four (20%) patients. A narrowed middle lobe bronchus was shown in 15 (75%) patients. Bronchoscopy was performed in 18 (90%) patients. Stenosis due to external compression was seen in 12 (60%) patients, hyperemia and bronchitis in two (10%) patients, granulation tissue in two (10%) patients, and dense secretions in two (10%) patients. A history of doctor-diagnosed tuberculosis was present in two (10%) patients. These patients had completed antituberculous treatment. The patients had been symptomatic for the last 1 to 10 years (mean, 4 years) and had received several medical treatments. All patients (totally 20 patients) underwent right middle lobe resection. In one patient, a bronchial abnormality was found intraoperatively. One patient died on postoperative day 10 due to a brain abscess. Three other patients had postoperative complications (15%). Mean duration of follow-up of the patients was 4.5 years (range, 2 months to 12 years). Seventeen patients were asymptomatic, and two patients had improved. Conclusions: Children with right middle lobe syndrome unresponsive to medical treatment should undergo early lobe resection to avoid serious complications and the progression of the disease to other segments or lobes.

The rigid bronchoscope has been the instrument of choice for removal of tracheobronchial foreign bodies in pediatric patients. Application of the flexible bronchoscope for this purpose is somewhat controversial. We report our experience with six pediatric patients with tracheobronchial foreign bodies, in all of whom foreign bodies were successfully removed using a small-caliber flexible bronchoscope and an ultrathin flexible bronchoscope supplemented with forceps and baskets normally employed for the extraction of ureteral stones. In one child, a straight pin had lodged in the periphery of the right middle lobe. Flexible bronchoscopy and ureteral stone forceps were used under fluoroscopic guidance to extract the straight pin. We believe that this approach alleviated the need for thoracotomy and should be considered in the removal of any small foreign object in the distal bronchial tree. There were no complications associated with any of the procedures. In selected patients, flexible bronchoscopic removal of even large foreign bodies is feasible provided that the bronchoscopist is prepared to manage potential complications associated with the procedure and successfully employ the rigid bronchoscope if the flexible bronchoscopic technique fails.

A 25-year-old woman with a history of chronic bronchitis since age 12 and 3-4 previous episodes of pneumonia presented to the emergency room with cough and shortness of breath. A CT scan of her chest revealed findings consistent with Morgagni hernia with herniation of omental fat, causing near complete compressive atelectasis of the right middle lobe. The diaphragmatic defect was successfully treated with a laparoscopic repair. The patient was discharged home on the first postoperative day after tolerating regular diet.

A 3-year-old boy presented to our Accident and Emergency (A&E) department after biting on a glass mercury thermometer. He was clinically stable. A chest x ray revealed small globules of mercury in the lungs (fig 1). Figure 1 An anterior–posterior erect chest and abdominal radiograph shows multiple specks of metallic density over the right middle lobe and lower lobe proximally with a speck overlying the …

We report a rare case of chronic eosinophilic pneumonia with subpleural curvilinear shadow. CT scan showed a patchy consolidation in the bilateral upper lungs. In addition, subpleural curvilinear shadow was found in the bilateral upper lungs. A bronchoalveolar lavage obtained from the right middle lobe showed 25 % eosinophils. Although very rare, we should therefore keep in mind that patients, who have patchy consolidation with areas of subpleural curvilinear shadow in the bilateral upper lungs, may have chronic eosinophilic pneumonia.

Objective:LadyWindermere syndromeis a well-knownbut poorly understood femalepredominant phenotypeof isolatedright middlelobeand lingular bronchiectasis associated with non-tuberculous mycobacterial (NTM) infection. Despite lengthy multidrug antibiotic treatment, the presence of damaged parenchymal tissue leads to symptomatic disease recurrence, often with resistant organisms. The use of surgical resection as an adjunct to medical therapy may alter this cycle, although little is known about the use of thoracoscopic lung resection in this patient population. Methods: This is a retrospective review of a prospectively collected database of patients with pulmonary NTM disease from July 2004 to December 2009. All patients had focal bronchiectasis of the right middle lobe and lingula, treated with targeted antimicrobial therapy for several months prior to resection. Results: A total of 134 patients underwent 172 operations, with 38 patients having staged bilateral resections. The cohort was predominately female (96%) and Caucasian (95%), with a mean age of 59 years (range 34—81 years). Using a thoracoscopic approach in all patients, 102 middle lobectomies and 70 lingulectomies were performed. Conversion to open thoracotomy occurred in five cases (3%). Secondary procedures were performed in 20 cases (12%). There was no operative mortality. Postoperative morbidity was noted following 12 operations (7%), primarily consisting of prolonged air leak. The mean length of stay was 3.3 days (range 1—15 days). Conclusions: Although medical therapy remains the primary treatment modality for patients with pulmonary NTM disease, the selective use of pulmonary resection may reduce the incidence of symptomatic disease recurrence. The addition of thoracoscopic resection to treatment regimens for patients with Lady Windermere syndrome can be accomplished with minimal morbidity and mortality. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Previous studies have shown that the underlying patterns of lung injury influence subsequent responses to aerosolized exogenous surfactant. The purpose of this study was to compare aerosolized versus tracheally instilled surfactant in a nonuniform lung injury. Adult sheep underwent whole lung lavage with subsequent HCl instillation into the right middle lobe (RML) and lingula (LING) to create a nonuniform injury. Animals were treated with either nebulized surfactant (Neb.Surf.), tracheally instilled surfactant (Inst.Surf.), or nebulized saline (Neb. Saline). PaO2, alveolar-arterial O2 gradient (PAO2-PaO2), PaCO2, and peak inspiratory pressure (PIP) values all significantly improved during 180 min of continuous aerosolization for Neb.Surf. animals compared with pretreatment values (p0.01) and with the other two treatment groups (p0.01). Although PaO2 and (PAO2-PaO2) values improved for the Inst.Surf. group by 180 min after treatment (p0.05), PaCO2 and PIP values were significantly increased 30 min after surfactant instillation (p0.05). Neb. Saline animals had no significant changes in physiologic parameters over 180 min. Approximately 8% of the total aerosolized surfactant deposited in lung tissue was recovered from the more severely damaged RML and LING, compared with approximately 50% of the total instilled surfactant recovered from these lobes. This resulted in significantly greater percentages of the total aerosolized surfactant deposited in each of the remaining lobes compared with the percent deposition of instilled surfactant (p0.05). Both the underlying pattern of lung injury and the exogenous surfactant delivery technique may influence clinical responses to surfactant therapy in patients with the adult respiratory distress syndrome (ARDS).

One case of tracheal diverticulum and eleven cases of bronchial diverticula were detected in 4127 subjects examined by fiberscopic bronchoscopy. The tracheal diverticulum was located in the right posterior portion of the trachea, and the bronchial diverticula were located in the right truncus intermedius (5 cases), the right basal bronchus (5 cases) and the right middle lobe bronchus (1 case). From our studies and reviewing the previous reports in Japan, we came to the conclusion that the frequent site of the tracheal diverticulum was at the right posterolateral portion and that of the bronchus was at the truncus intermedius. There was redness of the mucosa and vascular engorgement in 2 of the 12 cases of tracheobronchial diverticula. In most cases, diverticula were clinically silent, however in some cases, they tended to lead to the foci of inflammation. Therefore in case of the recurrent pulmonary inflammation, bronchofiberscopic examinations are highly recommended to rule out the tracheal or bronchial diverticula.

The right lung of the masked palm civet (Paguma larvata) consists of the cranial, middle, caudal and accessory lobes. The left lung has no cranial and accessory lobes and has a bilobed middle and caudal lobes. On either side, there are four bronchiole systems, i.e. dorsal, lateral, ventral and medial. The right cranial lobe is formed by the first bronchiole of the dorsal bronchiole system. However, this bronchiole arises from the right lateral side of the trachea, the so-called tracheal bronchus (bronchiole). The right middle lobe is formed by the first bronchiole of the lateral bronchiole system, and the right accessory lobe is formed by the first bronchiole of the ventral bronchiole system. The remaining bronchioles of the dorsal, lateral and ventral bronchiole systems and a bronchiole of the medial bronchiole system constitute the right caudal lobe. In the left lung, the left middle lobe is formed by the first bronchiole of the lateral bronchiole system. This bronchiole divides into two branches, each of which forms a lobule. The remaining bronchioles constitute the left caudal lobe as in the right lung. The branches of pulmonary arteries mostly run along the dorsal or lateral side of bronchioles. The pulmonary veins run the ventral or medial side of bronchioles and between the bronchioles.

A 79 year-old ex-smoker gentleman presented for a few months history of cough and dyspnoea on exertion. He was evaluated for persistent right lower lobe mass-like density with multiple chest-computed tomography (CT) scans (Figures 1a and 1b). He also received four courses of antibiotic and he underwent flexible bronchoscopy, which revealed swelling and narrowing of the right middle lobe with purulent discharge. Cytology and cultures were negative and the diagnosis remains uncertain. The patient was then referred for endobronchial ultrasound (EBUS) diagnostic procedure. Flexible bronchoscopy with EBUS showed mucosal oedema with erythema of the right hilar area and purulent discharge originating from the posterior wall of the proximal right middle lobe bronchus, which was consistent with bronchial fistulisation (Figures 1c and 1d). The EBUS scope, which was positioned in the right lower lobe revealed a heterogeneous mass posteromedially with multiple cystic-like large areas of hypoechogenicity most consistent with abscesses formation (Figure 1e). Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) of this mass revealed purulent discharge and grew streptococcus mitis/oralis. Six weeks of intravenous ertapenem treatment was ineffective

Patients who undergo resection of the right upper lobe of the lung may be predisposed to developing atelectasis when compared to other lung resections. The radiographic examinations of four patients with collapse of the right middle lobe following right upper lobe lobectomy were reviewed. The diagnosis of right middle lobe collapse is based on the findings of increased opacification in the right upper paramediastinal region and volume loss of the right hemithorax.