Answers to the questions
Answer to question 1: B
Middle lobe syndrome is recurrent or chronic collapse of the middle lobe of the right lungs. It is characterized by awedge-shaped density that extends anteriorly and inferiorly from the hilum of the lungs. (Best visualized on lateral chest x-ray)
Answer to question 2: A, B, C
Etiology–> Obstructive–> Intra-luminal, extra-luminal Non-obstructive
Intra-airway origin
- Asthma
- Bronchopulmonary dysplasia
- Chronic pneumonia or bronchitis
- Cystic fibrosis
- Foreign body aspiration
- Primary ciliary dyskinesia (Immotile ciliary syndrome)
- Endobronchial tumors
- Mucous plugging
Extra-airway origin (extra luminal compression)
- Cardiovascular anomalies
- Congenital malformations such as situs inversus and other anatomical defects such as anomalous branching or abnormal diameter, length or structure of the bronchi
- Lymphadenopathy of peribronchial nodes
- Tumors (hamartomas, metastasis, lungs tumour)
- Traction diverticula of the oesophagus
Infectious etiologies
- Common bacterial causes in children –>Streptococcuspneumoniae, Haemophilusinfluenzae
- Fungal causes –> histoplasmosis, allergic bronchopulmonary aspergillosis (ABPA)
- Mycobacteria, including Mycobacteriumtuberculosis, Mycobacteriumavium-intracellulare, and Mycobacteriumfortuitum
Answer to question 3: A,B,C
- Spirometry can be used to establish a previously unidentified asthmatic component
- High resolution CT scan are helpful in identifying subtle endobronchial abnormalities, distal bronchiectasis and other parenchymal abnormalities. It is also informative in evaluating bronchial patency, lymph node enlargement and calcifications or other causes of extrinsic compression of airway.
- Bronchoscopy – therapeutic in removing mucous and foreign body and clearing airway. It allows visualization of the airway and determine its patency. Bronchoalveolar lavage can also be performed and send for C&S.
Answer to question 4: A,B,C
Treatment depending on etiology
- Conservative medical treatment (1st line) (except neoplasia and bronchiectasis)
- Treatment of asthma if asthmatic component is present
- Appropriate antibiotics according to sputum/bronchoalveolar lavage culture (broad spectrum antibiotics if C&S is not available)
- Anti TB treatment for tuberculous infection.
- Chest physical therapy and postural drainage are hallmark of therapy.
- Surgical intervention- lobectomy in cases of malignancy and bronchiectasis that are unresponsive to medical therapy.
References
( 1 ) Jonathan Corne, Kate Pointon, n.d., chest x-ray made easy (third edition), churchill livingstone Elsevier
( 2 ) Nemr S Eid, (2018), Right Middle lobe syndrome, Medscape website, assessed 25th Sep 2022 [https://emedicine.medscape.com/article/1003864-treatment#:~:text=Chest%20physical%20therapy%20and%20postural,to%20help%20optimize%20airway%20clearance.]
( 3 ) Tomas Gudbjartsson, Gunnar Gudmundsson, (2012), Middle Lobe Syndrome: A Review of Clinicopathological Features, Diagnosis and Treatment, Karger Journal, assessed 25th Sep 2022
[https://www.karger.com/Article/Fulltext/336238]
( 4 ) Umair Shaikh; Daniel Heller, (June 27 2022), Right middle lobe syndrome, National Centre for Biotechnology Information, National Library of medicine, National Institute of Health, US Government website, assessed 25th September 2022
[https://www.ncbi.nlm.nih.gov/books/NBK547657/]
Author information
Hnin Thuzar Aung1, Yadanar Kyaw2
( 1 ) M.B.,B.S, M.Med.Sc (Paediatrics), DCH (LONDON), MRCPCH (UK), FRCP (Edinburgh), Diploma in Allergy &Asthma (C.M.C, Vellore, India), Consultant Paediatrician
( 2 ) M.B.,B.S, Medical Officer, Parami General Hospital
