Abstract Introduction Esophageal bronchus is a rare congenital communicating bronchopulmonary-foregut malformation (CBPFM) in which a bronchus arises abnormally from the esophagus rather than the trachea. Fewer than 70 cases have been reported globally, with most diagnosed in infancy due to respiratory distress or recurrent infections. In adults, it is usually an incidental finding during imaging for unrelated conditions. The anomaly may coexist with other congenital disorders such as esophageal atresia, tracheoesophageal fistula (TEF), or VACTERL spectrum anomalies. Recognition is crucial, as unrecognized airway communications can predispose to aspiration, infection, or complications during procedures requiring sedation or positive-pressure ventilation. Case Presentation A 66-year-old man with a 45-pack-year smoking history and presumed COPD underwent low-dose CT (LDCT) for lung cancer screening. Imaging demonstrated severe panlobular emphysema, chronic right lower lobe changes, and a tubular air-filled structure originating from the esophagus — consistent with an esophageal bronchus. He reported chronic exertional dyspnea but denied recurrent pneumonia, cough, or aspiration events. Pulmonary function testing confirmed severe airflow obstruction (FEV1 38% predicted). The patient was treated with triple therapy (ICS/LABA/LAMA) and rescue albuterol, achieving symptomatic stabilization. No surgical intervention was pursued given the absence of infection or functional compromise. Gastroenterology and anesthesia teams were notified to avoid inadvertent positive-pressure ventilation or endoscopic instrumentation through the abnormal communication. Over 18 months of follow-up, he remained clinically stable without infections or progression on serial LDCTs. Discussion This case underscores the value of LDCT screening in revealing incidental but clinically relevant anomalies. The esophageal bronchus, though typically treated surgically in symptomatic infants, may be safely monitored conservatively in asymptomatic adults with preserved lung function. Key management principles include confirming anatomy with CT and esophagram, excluding infection, and implementing multidisciplinary coordination for airway and endoscopic precautions. Conservative observation requires vigilance for new infections or aspiration. This case also illustrates the intersection of congenital airway malformation and acquired COPD, where coexisting pathology can obscure symptom attribution. Conclusion Esophageal bronchus is an exceedingly rare anomaly that may remain undiagnosed until adulthood. Recognition during LDCT screening can prevent procedural complications and unnecessary surgery. In select asymptomatic patients, multidisciplinary conservative management with structured surveillance offers a safe and individualized approach. This abstract is funded by: None
Le et al. (Fri,) studied this question.