Pediatric emergency medicine trisk 4073 4073
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While rare in children, primary tracheobronchial tumors may create symptoms
due to varying degrees of airway obstruction. Such lesions can be benign or
malignant, and may be present at various locations in the tracheobronchial tree,
with the majority of lesions occurring in the larynx, trachea, and larger bronchi.
Clinical Recognition
Clinical presentation depends on the site and type of tumor, and less severe
symptoms can masquerade as bronchitis, pneumonia, or asthma episodes with
delayed ultimate diagnosis.
Right Middle Lobe Syndrome
Right middle lobe syndrome is the recurrence or persistence of atelectasis or
pneumonitis of the right middle lobe, sometimes associated with bronchiectasis. It
has been described in all age groups, in both the right middle and lower lobes
concomitantly, and has also been observed in the lingula segment. This process
can be caused by extraluminal or intraluminal obstruction, or by nonobstructive
causes. The right middle lobe is anatomically predisposed to compression of its
bronchus by the lymph nodes in the vicinity that encircle it, which can lead to
sequestered areas of collapsed or infected lung. Since it is bordered by two
fissures, it also receives less collateral ventilation than other lobes, making
reinflation of collapsed lung more challenging. Because the right middle and
lower lobes are favored sites for aspirated material (Fig. 124.1 ), recurrent
inflammation caused by pneumonia can lead to chronic atelectasis and
adenopathy. A similar situation can be seen with intraluminal tumors and other
space-occupying lesions. In children, nonobstructive causes such as asthma,
cystic fibrosis, and immobile cilia syndrome can also result in prolonged
atelectasis, which promotes recurrent infection and eventual bronchiectasis.
Clinical Recognition
Right middle lobe syndrome is a radiographic diagnosis, so physical
manifestations vary widely but commonly include persistent cough, intermittent
wheezing, or dyspnea. Patients may have wheezing, rales, or decreased aeration
on lung examination, particularly appreciated anteriorly. Chest radiographs
typically reveal atelectasis of the right middle lobe, which may be recurrent or
persistent. They may also show bronchiectasis or pneumonitis of the affected
area. Recurrent episodes of pneumonia and associated atelectasis in the lingula or
right middle (and often lower) lobes occur in these patients and are not responsive
to chest percussion, postural drainage, or antibiotic treatment.
