Management of broncholithiasis

Abstract

Broncholithiasis is a condition in which calcified material has entered the tracheobronchial tree, at times causing airway obstruction and inflammation. Broncholiths generally originate as calcified material in mediastinal lymph nodes that subsequently erode into adjacent airways, often as a result of prior granulomatous infection. Disease manifestations range from asymptomatic stones in the airway to life-threatening complications, including massive hemoptysis and post-obstructive pneumonia. Radiographic imaging, particularly computed tomography scanning of the chest, is integral in the evaluation of suspected broncholithiasis and can be helpful to assess involvement of adjacent structures, including vasculature, prior to any planned intervention. Management strategies largely depend on the severity of disease. Observation is warranted in asymptomatic cases, while therapeutic bronchoscopy and surgical interventions may be necessary for cases involving complications. Bronchoscopic extraction is often feasible in cases in which the broncholith is freely mobile within the airway, whereas partially-embedded broncholiths represent additional challenges. Surgical intervention is indicated for advanced cases deemed not amenable to endoscopic management. Complex cases involving complications such as massive hemoptysis and/or bronchomediastinal fistula formation are best managed with a multidisciplinary approach, utilizing expertise from fields such as pulmonology, radiology, and thoracic surgery.

Keywords: Surgical management; broncholithiasis; bronchoscopy.

Figure 1

Comparison of plain radiograph to computed tomography (CT) scan in the same patient with broncholithiasis. (A) Lateral chest radiograph demonstrates right middle lobe atelectasis (asterisk); (B) CT scan in sagittal reformat reveals the causative broncholith (arrow) obstructing the proximal right middle lobe bronchus.

Figure 2

Common CT imaging findings in patients with broncholithiasis. (A) Axial chest CT image demonstrates a broncholith (arrow) in the left mainstem bronchus without parenchymal involvement; (B) axial chest CT image of a different patient demonstrates a broncholith (arrow) at the origin of the right middle lobe bronchus with associated bronchiectasis and parenchymal atrophy.

Figure 3

Bronchoscopic visualization of broncholiths. (A) Bronchoscopic visualization of broncholith in right mainstem bronchus (thick red arrow) with associated mucosal edema; (B) forceps extraction (thin red arrow) of broncholith (thick red arrow) during bronchoscopic intervention.

Figure 4

Advanced complications of broncholithiasis that required surgery. (A) Axial CT image of an otherwise healthy patient with several calcified lymph nodes surrounding the distal bronchus intermedius (arrow) with complete obstruction of the right middle lobe airway and secondary bronchiectasis and pneumonitis that was treated with thoracotomy and bilobectomy; (B) a separate case demonstrating a bronchoesophageal fistula (arrow) seen on gastrografin esophagram that developed after surgical removal of a broncholith in the bronchus intermedius. This case required a second thoracotomy with esophageal repair.