Scanning electron microscopy (SEM) is effective in revealing the cellular surface structure. Since 1987 we have applied this method for studies of the following airway diseases. Ciliated columnar cells, goblet cell hyperplasia, basal cell hyperplasia and squamous metaplasia, which were mainly obtained from cases of lung cancer were examined by SEM. In an experimental ultrastructure study at the site of tracheobronchial anastomosis changes of the suture materials and the state of regeneration of the epithelium were observed at various intervals using SEM. At nine weeks we observed a nonciliated band like area which was estimated to be about 100 micron wide. After 12 weeks complete ciliation at the site of anastomosis was observed. In 27 bronchogenic cysts, of which 15 were intrapulmonary and 12 mediastinal, the mediastinal bronchogenic cysts possessed thin loose ciliated cells with many secretory granules on the surface, while intrapulmonary cysts were covered with almost normal ciliated cells with few secretory granules on the surface. Since 1987 we have treated spontaneous pneumothorax with bronchial obstruction with fibringlue. In an experimental SEM study after the infusion of fibringlue into bronchi it was clearly demonstrated that the fibringlue had completry dissapeared one week after infusion. Our experiences showed that high magnitude SEM is useful for examination of cell structures, and that low magnitude SEM should be used more for clinical studies.

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Macroscopic findings of the bronchial arteries have not been described in detail satisfactorily, and positional relations of these arteries to the surrounding structures also have been neglected. The author dissected this artery macroscopically from the origin to the pulmonary root in 100 human adults. Against the descriptions of textbooks, two right and two left bronchial arteries were most commonly observed. Origin of the arteries could be classified into five portions, 1) right aortic intercostal artery, 2) right subclavian artery, 3) left subclavian artery, 4) aortic arch, 5) descending aorta. On the other hand, four branches could be distinguished in the course along the bronchi, that is, right superior, right inferior, left superior and left inferior, which passed on the superior or inferior wall of the corresponding bronchus. A definite relationship could be observed between the above-mentioned five origins and the four branches at the pulmonary roots. That is, the right superior branch mostly arose from origin 1) (85%), sometimes from 2), and the left inferior branch arose from 5) (97%), sometimes from 4). The right inferior and left superior branches often arose in a common trunk from 4), in a few cases from 3), and in other cases, they arose independently from origin 5). Origin of the right inferior branch was most varied. The branches from 2) and 3) were mostly supplementary. Summarizing the results of this study, all the feasible arrangements of the bronchial arteries as to the origin and course were illustrated schematically in Fig.3. The bronchial veins were also dissected macroscopically in both extra-and intrapulmonary courses. Strictly speaking, clear distinction cannot be made anatomically between the pulmonary and the bronchial veins. Blood circulation of the lung was considered from the results of this study.

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Complications of TBLB which was performed in cases with diffuse lung diseases were analyzed. The total of 709 cases were consisted of ; sarcoidosis (SA) 210, idiopathic interstitial pneumonia (IIP) 126, diffuse panbronchiolitis (DPB) 69, infectious diseases 44, collagen diseases (CD) 40, hypersensitivity pneumonia 39, malignancy 38, intermediate type pneumonia (including BOOP) 30, and miscellaneous 113. In TBLB it was attempted to obtain 6 specimens, 3 from the lower lobe and 3 from the upper lobe. The analyzed complications were broken down to moderate amounts of bleeding, pneumothorax and severe episodes. 1) Moderate amount of bleeding (estimated over 20 ml) : Bleeding extended beyond the level of lobar bronchi was present in 12.6% (89 cases). The highest risk (40%) was in chronic inflammatory airway diseases (chronic bronchitis, bronchiectasis), followed by 23.3% of intermediate type pneumonia, 22.5% of CD. In SA, the frequency of bleeding was diminished as the radiological stage progressed ; 17.9% in stage 0, 4.8% in stage 4. The occurence of bleeding did not change during a period of 12 years. 2) Pneumothorax : Thirty cases were recognized. Continuous tube drainage was performed in 6 cases. The most frequent episodes were presented in DPB, 14.5%, followed by PIE syndrome of 13.3%. The site of biopsy causing pneumothorax was thought to be more frequent in upper lobes (86.7%) than lower lobes (6.7%). The episodes of pneumothorax decreased with passage of time. 3) After TBLB, two cases of IIP resulted in death ; one by myocardial infarction and one by worsening of respiratory insufficiency. Experience might decrease the risk of pneumothorax but not of moderate amounts of bleeding. The occurence of bleeding varied in various diseases and according to the radiological stage of sarcoidosis.

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We performed bronchofiberscopy in 42 times for 34 patients, 9 of which had untreated small cell lung cancer, 15 cases of treated small cell lung cell cancer and the remaining 10 of which suffered from hematologic diseases, i. e., acute myelogenous leukemia, lymphoma and polycythemia vera. After the examination, 24.3% of patients suffered from fever, but none of the untreated cases of small cell lung cancer suffered from fever. In paticular poor performance status and hypoalbuminenia were the principal predisposing factor, and extreme importance of nutrition of patients with malignancy was suggested. A significant reverse relation between performance status and the serum albumin value was also recognized. Another predisposing factor for fever was post-radiotherapy state, which seemed to be related to impaired air-way clearance. Fever following the examination subsided within five days in all cases. Other complications were recognized in two cases of major bleeding (>50ml), one of which was also complicated by pneumothorax, but no other patients showed poor in respiratory condition. Bronchofiberscopy was useful to establish the diagnosis of Pneumocystis carini pneumonia or pulmonary tuberculosis which need specific therapy. We consider that bronchofiberscopy is valuable even in immunosuppressed patients.

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To investigate mitigative and physiological effects of intravenously administered sedatives at bronchoscopy, flunitrazepam and pentazocine were administered in addition to routine local anesthesia. Prior to bronchoscopy, 24 patients, aged 43-80 averaging 65.6 yrs and consisting of 17 males and 7 females, were premedicated by atropine sulfate and hydroxydine and given local anesthesia with 4% lidocaine. They were then divided into 4 groups with 6 cases in each. Group A was administered 0.005mg/kg of flunitrazepam (F), group B 0.01mg/kg of F, group C 0.005mg/kg of F and 15mg/body of pentazocine (P) and group D nothing. Arterial blood pressure, heart rate, respiratory rate and arterial blood gas values were successively measured. Endoscopists made an assessment on mitigation during the procedure and asked them about discomfort, recall and acceptability of the examination after 2 hours. There was no significant change in arterial blood pressure and heart rate in all the groups. Group C indicated concomitant mid-course decline in respiratory rate and rise in arterial carbon dioxide tension. Artrial oxygen tension showed no significant change after the injections, but fell during bronchoscopy. Patients in group C were most sedated. Amnesic action was effective in group B. All the patients in group B and C claimed no discomfort and agreed to undergo repeated examination. Intravenous administration of F or F combined with P was effective for sedation and reduction of discomfort from bronchoscopy and induced minimal respiratory and circulatory suppression.

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A 56-year-old man experienced recurrent pneumonia in left lower lobe. A polypoid tumor in left lower bronchus was observed bronchoscopicaly. Left lower lobectomy was inadequate for the invasion of tumor cell to the bronchial margin, therefore wedge resection of the bronchial margin was appended. Pathological diagnosis was atypical carcinoid, and tumor cells grew over the bronchial cartilage. Electron microscopically dense-cored neurosecretory granules were observed in the cytoplasm of tumor cells. Some tumor cells were positive for the Grimelius argyrophil stain, but none were positive for Van Gieson's stain. He is presently doing well without any recurrence 6 months after the operation.

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Pulmonary plasma cell granuloma is a rare entity among lung tumors. Sometimes it is hard to differentiate it from lung cancer because the lesion is usually asymptomatic, and is most commonly detected on routine chest film as a circumscribed mass. It is quite rare that this lesion develops as endobronchial mass. Two cases of pulmonary plasma cell granuloma developing as polypoid masses within a major airway were presented. Case 1 : A 41-year-old male was hospitalized with cough, sputum and fever. A chest X-ray film disclosed a mass shadow in the right lower lobe. Bronchofiberscopy detected a polypoid mass which almost completely occluded the right lower lobe bronchus. The tissue biopsy showed no malignancy. Middle and lower lobectomy was performed, and the patient's postoperative course was uneventful. Grossly the polypoid tumor was measured 1.8×2.0×1.8cm growing within the right lower lobe bronchus. Microscopically, it was composed of plasma cells, lymphocytes, histiocytes and fibroblasts arranged in a whorled pattern, which is a characteristics of plasma cell granuloma. Case 2 : A 33-year-old female who had a two-year history of recurrent bloody sputum was hospitalized. A chest X-ray film disclosed a mass shadow in the hilum of the left lung. Bronchofiberscopy confirmed a polypoid mass in the orifice of B^6, and the tissue biopsy was diagnosed as plasma cell granuloma. Left S^6 segmentectomy was performed, and the patient's postoperative course was uneventful. Grossly the tumor was a gourd-shaped endobronchial soft tissue mass measuring 4.3×1.7×3.0cm. Microscopical diagnosis was plasma cell granuloma.

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A case of solitary tracheal papilloma (a 74-year-old woman) complaning of bloody sputum was reported. Bronchoscopic examination revealed the tumor with an irregular surface located in the left anterior wall of the trachea. Histologically the biopsy specimen showed papillary growth of the epithelium consisting of columnar cells and metaplastic squamous cells. Nd-YAG laser treatment was successfully carried out, and the tumor did not reccur on bronchofiberoptic examination 26 months later. Follow-up studies are important for the early detection of malignant transformation or local reccurence.

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A 28-year-old woman, who had been treated under a diagnosis of bronchial asthma was admitted with severe dyspnea. We found a tracheal tumor on her chest lateral X-ray film. At bronchofiberscopy the tumor almost occluded the tracheal lumen. Subsequently, bronchofiberscopic polypectomy was performed by electrosurgery using a polypectomy snare. It was impossible for resected tumor to pass the vocal cord because of its large size. So we removed it by tracheotomy using a basket catheter. Her dyspnea improved markedly after the tracheal tumor was removed. Histologic diagnosis revealed a pleomorphic adenoma. Since some of the tumor stalk remained in the trachea, we plan radical operation in the near future.

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Two neonatal cases of pulmonary sling accompanied with congenital tracheal stenosis (ring-sling complex) were reported. They came to our hospital because of stridor. Chest tomogram showed lowered position and widened angle of the tracheal bifurcation. Corrective surgery was performed but they died because of respiratory distress. Autopsy revealed defect of the membranous portion in trachea and cartilage ring extending around the entire trachea. Their final diagnosis was ring-sling complex. This unusual anomaly is often difficult to diagnose during life, but bronchoscopic examination might be helpful to reveal complete cartilage rings. Surgical correction is still difficult. This rare anomaly should be considered for differential diagnosis in cases of neonates complaining respiratory distress and stridor.

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A case of achondroplasia associated with tracheobronchial anomaly and right aortic arch was reported. A 29-year-old female was admitted to our hospital for evaluation of an abnormal chest shadow found by a mass survey. Chest X-ray revealed her abnormal chest shadow due to right aortic arch. Contrast enhanced chest computed tomography and aortography demonstrated the right aortic arch with an aberrant left subclavian artery (Type II right aortic arch). The esophagus, trachea and left main bronchus were partially stenotic due to compression of the right aortic arch and diverticulum immediately behind them. Furthermore, bronchofiberscopic examination and bronchography revealed the patient to have tracheobronchial anomaly where left B^<1+2, 3>, B^<4+5> and left inferior lobe bronchus trifurcated at the same level directly from the left main bronchus. She had been rather short with short extremities from childhood and was diagnosed as achondroplasia based on characteristic systemic bone X-ray examinations. According to these results, this was a rare case with three different kinds of morphological anomalies. The mutual relationship among embryological factors responsible for development of these three morphological anomalies was considered from the viewpoint of the literature.

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A case of immotile cilia syndrome with pulmonary abscess was presented. The patient was a 35-year-old man who had a history of sinusitis and had been infertile for 11 years. He had been suffering from bloody sputum since 5 years previously and purulent and bloody sputum from the previous year. Chest roentgenography and computed tomography revealed an abscess formation in the left lower lobe of the lung and bilateral bronchiectasis. Since bloody sputum was not reduced by bronchial arterial embolization, left lower lobectomy was performed. He recovered uneventfully. His sperm were living but immotile. Electron microscopic examination of the bronchial cilia of the resected specimen revealed the defect of inner dynein arms, the defect of inner and outer dynein arms, the defect of central microtubules and the transposition of outer doublet microtubules.

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Case 1 was a 46 year-old male admitted with hemoptysis. Chest X-ray showed a triangular configuration shadow with several calcifications in the left upper lobe. CT scan findings suggested broncholithiasis, but broncholiths were not visualized by broncoscopy. A Left upper lobectomy was performed and broncholiths were found in left B 3b which had succular ectatic changes. There were no calcified lymph nodes in the hilar region. Histologic examination of the broncholiths showed no specific structures. Therefore these stones were cosidered to be caused by calcification of mucus in the bronchus. Case 2 was a 47 year-old male who complained of cough and fever. His chest x-ray showed infiltrates in right S^4 and a tomogram revealed calcification in the proximal region of the right B^4. Bronchoscopic examination disclosed a yellowish broncholith which had eroded into the bronchial wall. This broncholish seemed to be derived from a clcified lymph node. Fifty-four cases of broncholithiasis collected from the Japanese literature since 1970 were reviewed and their etiology discussed.

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We reported a case of tracheopathia osteochondroplastica accompanied with an aneurysm of the thoracic aorta. A 79-year-old woman complaining of cough and dysphagia was admitted to Saga Medical School Hospital. Her chest X-ray film showed a huge mass shifting the trachea markedly to the right side. Bronchoscopically, a number of small nodular lesions were found on the left wall of the trachea. On the 6th hospital day, the patient died of massive hemoptysis. The autopsy revealed that a saccular aneurysm of the thoracic aorta shifting the trachea had ruptured into the left upper lobe. The small nodular lesions were located on the left wall of the trachea compressed by the aneurysm. The histological findings of the lesions were compatible with those of tracheopathia osteochondroplastica. This case suggests that local conditions can play an important role in the pathogenesis of tracheopathia osteochondroplastica.

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We reported two cases of the bronchial fistula following pulmonary lobectomy which were successfully closed by bronchoscopic therapy. Case1 : A 64-year-old man was performed right middle and lower bilobectomy for lung cancer. On the third postoperative day, bronchoscopy revealed a pin-hole sized fistula in the bronchial stump. At this time fibrin glue mixed with antibiotics was injected into the fistula through the bronchoscope and the air leak soon ceased. The fistula is completely closed at 8 months after the operation. Case 2 : A 59-year-old woman was performed right upper lobectomy for lung cancer. On the sixty-ninth postoperative day bronchoscopy revealed a pin-hole sized fistula in the bronchial stump. The injection of fibrin glue mixed with antibiotics and coloring matter into the fistula through the bronchoscope was unsuccessful. The fistula was brushed to induce the growth of granulation tissue and it is closed at 5 months after bronchoscopic treatment. These bronchoscopic approaches are effective for small fistulas.

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A 63-year-old male with bronchogenic carcinoma underwent right upper sleeve lobectomy and developed middle lobe atelectasis. Bronchoscopy showed edematous stenosis of the middle lobe bronchus. The atelectasis persisted in spite of vigorous physiotherapy snd repeated tracheal suctions through a minitracheostomy tube (Trahelper). A suction tube was then inserted into the trachea through the minitracheostomy tube and guided into the middle lobe bronchus by a bronchofiberscope. After repeated suctions and toiletting through the suction tube as well as temporary bronchial stenting, the atelectasis disappeared at ten days postoperatively and the patient was discharged three weeks after surgery.

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