1. AN INTERESTING X-RAY FOR
DISCUSSION
M5 UNIT

2. HISTORY
• A 75 year old male, smoker & alcoholic
presented with c/o
1. Breathlessness- 1 month duration
2. Cough- 1 month duration.
No H/O fever, hemoptysis.
Not a diabetic or hypertensive.

3. EXAMINATION
• General examination was unremarkable.
• Vitals stable
• Respiratory rate 20/min.
RESPIRATORY SYSTEM EXAMINATION:
Trachea- central
Dullness found in Right mammary, Infra axillary ,
infra scapular area.
Decreased breath sounds found in same areas.
No added sounds.

4. CHEST X RAY
Discussion x ray Control x ray

5. DIFFERENTIAL DIAGNOSIS
• LUNG
1.Consolidation
2.Collapse
3.Lung mass
4.Pulmonary infarction
• PLEURA
1.Subpulmonic pleural effusion
2.Pleural mass
• DIAPHRAGM
• SUBDIAPHRAGMATIC REGION
1.liver / stomach mass
2.Phrenic nerve palsy

6. CT SCAN

8. EVENTRATION OF DIAPHRAGM
• CONGENITAL-Failure of muscular development
of all or part of diaphragm(thin membranous
sheet replaces it)
• Present similar to Congenital diaphragmatic
hernia
• Complete – almost always Left sided
• Partial – common on right side( anteromedial
portion of the Right hemidiaphragm)
• More common in men

9. • Eventration of diaphragm-asymptomatic in
adults
• Diagnosis-incidentally on normal screening of
chest X-ray
• Symptoms-related to GI tract, respiratory
embarrassment, and rarely cardiac
dysfunction.

10. CAUSES OF EVENTRATION IN ADULTS
• True eventration -Congenital- due to defective
muscle development
• A subclinical viral infection.
• Acquired paralysis-loss of contractility due to
progressive muscular atrophy.
1.Secondary to trauma eg: Cardiac Surgery.
2.Viral infection- polio, herpes zoaster,
Influenza & bacterial – Diphtheria.
3.Neoplastic & autoimmune pathologies

11. INVESTIGATION
• Chest X ray- PA view & lateral view
• PA view
the elevated diaphragm forms a round unbroken
line arching from the mediastinum to the costal
arch
• CXR-useful modality for assessment of the
functional status of an elevated diaphragm as the
evaluation of the shape of an elevated diaphragm
may preclude the need for fluoroscopic sniff test
to determine diaphragmatic paralysis

12. • Flouroscopy - the most reliable way to document
diaphragmatic paralysis.
• SNIFF TEST – Confirmatory test for paralysis rather than
weakness.
• USG- establishing the diagnosis of partial eventration &
in distinguishing it from diaphragmatic nerve
interruption.
• continuous thin layer above the elevated abdominal
viscera and on real-time ultrasound the abnormal
region can be seen to move downward with the normal
portion although it may show a slight lag in its
inspiratory excursion.
• CT scan may be ordered to rule out a cancer or a tumor
inside the chest as a cause for the paralyzed diaphragm

13. TREATMENT
• Asymptomatic patients are managed
conservatively(e.g., with physical therapy,
pulmonary rehabilitation, and counselling on
weight loss, if necessary)
• patients with symptoms require
surgery(Diaphragmatic plication).
• Paradoxical movements suggest complete
paralysis and if symptomatic, is a strong
indication of surgery.

14. THANK YOU