Middle Lobe Displacement Post Lobectomy in a Child With Congenital Pulmonary Airway Malformation

Congenital pulmonary airway malformations (CPAMs) are an important cause of structural lung disease in children and may remain undetected until later childhood. Although surgical resection is well established for symptomatic lesions, the long-term anatomical effects of lobectomy in pediatric patients remain incompletely understood. Postoperative changes in lung mechanics and lobar positioning can result in uncommon airway complications that are often under-recognized and diagnostically challenging. Obstruction of the right middle lobe (RML) bronchus due to postoperative lobar displacement is particularly rare, with reported cases originating from the adult surgical literature. We report a 9-year-old girl with mild persistent asthma who presented with an infected cystic lesion in the right upper lobe consistent with CPAM. She completed antimicrobial therapy and underwent right upper lobectomy, with pathology confirming type 1 CPAM. One month later, she developed a persistent cough refractory to optimized asthma treatment. Chest computed tomography (CT) demonstrated hyperinflation and poor visualization of the right upper and middle lobe bronchial orifices. Bronchoscopy identified RML bronchial obstruction, and fluoroscopy-guided bronchoscopy confirmed superior displacement of the RML with resultant bronchial kinking, likely related to postoperative lobar migration. Endobronchial stenting was unsuccessful, and further surgical intervention was not advised because of the anticipated risks of a second operation. Conservative management was pursued, resulting in modest symptomatic improvement, with the patient remaining clinically stable for 2 years. This case highlights a rare postoperative complication of CPAM resection in a child and emphasizes the need for heightened awareness, multidisciplinary evaluation, and pediatric-focused studies to guide management.