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Ann Thorac Surg 2005;79:1774-1776
© 2005 The Society of Thoracic Surgeons
a Department of Respiratory Medicine, Maison Blanche Hospital, Reims, France
b Department of Radiology, Maison Blanche Hospital, Reims, France
c Department of Thoracic Surgery, Robert Debré Hospital, Reims, France
d Department of Pathology, Robert Debré Hospital, Reims, France
Accepted for publication October 30, 2003.
* Address reprint requests to Dr Deslee, Service des Maladies Respiratoires et Allergiques, Oncologie Thoracique, Hôpital Maison Blanche, Chu de Reims, 45, Rue Cognacq-Jay, 51092 Reims, France
gdeslee{at}chu-reims.fr
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Abstract |
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Introduction |
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We describe herein 4 cases of broncholithiasis. The sex ratio (M:F) was 1:3. Age ranged from 62 to 71 years (median, 67). All patients had an history of tuberculosis. All patients presented with clinical symptoms: cough (n = 4), asthenia (n = 3), purulent sputum and fever (n = 4), hemoptysis (n = 3), chest pain (n = 2), dyspnea (n = 2), and lithoptysis (n = 1). Symptom duration ranged from 4 to 23 years (median, 9). Chest radiography and computed tomography scan showed hilar calcifications (n = 2), parenchymal calcifications (n = 3), bronchiectasis (n = 2), and pulmonary mass (n = 1). An evident endobronchial broncholithiasis was seen in only 1 case (Fig 1, A). Fiberoptic bronchoscopy revealed broncholithiasis in all 4 cases (Fig 1, B). Three broncholithiases were observed in 1 patient, whereas only one broncholithiasis was observed in the other patients. All but one broncholithiases were located in the right bronchial tree. In 2 cases, the broncholithiases were firmly embedded in bronchial mucosa although others were loose. Complications included bronchiectasis related to obstructive broncholithiasis (n = 2), massive hemoptysis (n = 1), and bronchopyocele (n = 1). Microbiologic findings revealed Pseudomonas aeruginosa (n = 2), Aspergillus fumigatus (n = 2), Stenotrophomas maltophilia (n = 1), Branhamella catarrhalis (n = 1), and Actinomyces species (n = 1), but no case of active tuberculosis.
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Surgical resection by lobectomy was performed in 2 cases because of embedded and obstructive broncholithiasis with bronchiectasis (n = 1) and massive hemoptysis with bronchiectasis and suspected neoplasm owing to a pulmonary mass (n = 1). In this last case, a bronchopyocele was found. No postoperative complications occurred. In these 2 cases, bronchoscopic removal was not tried, and surgical management was chosen first.
The course was favorable in these 4 cases, with complete clinical improvement. Follow-up ranged from 1 to 5 years (median, 2).
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Usual indications for surgery include bronchiectasis, massive hemoptysis, uncertainty about the diagnosis, failure at bronchoscopic broncholithectomy related to a too firmly embedded broncholith or to the unability to reach broncholithiasis, massive bleeding during the procedure, and bronchoesophageal fistula [2–7]. In surgical series, procedures involve lobectomy in 21% to 53% of the cases, segmentectomy in 10% to 48%, pneumonectomy in 0% to 7%, and broncholithectomy in 1% to 34% of the cases [2–7]. Mediastinal and hilar fibrocalcific reaction increases blood vessels and leads to a higher risk of complications. Complications including bleeding, fistula, and infections are reported in 9% to 47% of the cases, with death in 0% to 3% of the cases [2–7]. Long-term results are usually excellent without any recurrence in 68% to 100% of cases [1–7].
Bronchoscopic removal of broncholithiasis has been extensively described in the literature as ending successfully in 43% to 87% of cases [2–7]. In a large series, loose broncholithiasis was completely removed without any complication in all cases [2], as in 2 of our cases. For partly eroding or embedded broncholithiasis, bronchoscopic removal is successful in only 48% of the cases [2]. In these difficult cases, rigid bronchoscopy provides greater success than flexible bronchoscopy [1, 2]. Laser therapy can be used to fragment a mobile broncholith that is too hard to be broken with a biopsy forceps and too large to be pulled through the upper airways [8]. Complications of bronchoscopic removal are rare (less than 5%) and include massive hemoptysis and acute dyspnea due to the loss of broncholith in the trachea [2]. Hemoptysis has been suggested to be a risk factor for bleeding during bronchoscopic removal. In a recent study and in 1 of our cases, however, bronchoscopic removal succeeded without major bleeding despite moderate hemoptysis [2]. Only massive hemoptysis should be considered a contraindication for bronchoscopic removal.
We conclude that the treatment of broncholithiasis depends on clinical, radiographic, and bronchoscopic findings. In uncomplicated and loose broncholithiasis, therapeutic bronchoscopy should be chosen first. Surgical resection should be considered in cases with complications or failure at bronchoscopic removal. The main therapeutic indications for broncholithiasis are summarized in Table 1.
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  R. J. Cerfolio, A. S. Bryant, and L. Maniscalco Rigid bronchoscopy and surgical resection for broncholithiasis and calcified mediastinal lymph nodes J. Thorac. Cardiovasc. Surg., July 1, 2008; 136(1): 186 - 190. [Abstract] [Full Text] [PDF]
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 A. J. Reddy, J. A. Govert, T. A. Sporn, and M. M. Wahidi Broncholith Removal Using Cryotherapy During Flexible Bronchoscopy: A Case Report Chest, November 1, 2007; 132(5): 1661 - 1663. [Abstract] [Full Text] [PDF]
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 H. Tsubochi, S. Endo, K. Suhara, and Y. Sohara Endobronchial aspergillosis and actinomycosis associated with broncholithiasis Eur. J. Cardiothorac. Surg., June 1, 2007; 31(6): 1144 - 1146. [Abstract] [Full Text] [PDF]
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