Raised Hemidiaphragm on CXR

ct

Computed Tomography (CT)

• Useful for excluding mediastinal lesions causing phrenic nerve palsy and to evaluate a possible subdiaphragmatic cause for elevation of a hemidiaphragm 6

fluoro

Fluoroscopy

• Simplest, quickest, and most practical method of assessing diaphragm movement 1
• Primarily a qualitative method, quantitative information being indirectly obtained and limited geometrically by the divergent beam and object to film distance 2
• Reduced, absent or paradoxical movement of the hemidiaphragm, especially during sniffing infers hemidiaphragmatic paresis or paralysis 1,2,3
• Limitations - diaphragm motion may be diminished due to inflammatory processes such as pneumonia, pleuritis, pleural effusion, peritonitis, and subphrenic abscess, so fluoroscopic assessment is best delayed until reversible conditions that may affect the diaphragm have been treated to resolution 1

ra_diaph

Raised Hemidiaphragm

• Common causes of unilateral hemidiaphragm elevation include 1
  • Lung volume loss (atelectasis, lobar collapse, partial lung resection, radiation fibrosis, congenital hypoplasia)
  • Eventration
  • Abdominal disease (dilated stomach or colon, hepatomegaly, splenomegaly, subphrenic abscess)
  • Phrenic nerve paralysis
  • Splinting
  • Mimics (subpulmonic pleural effusion, large pleural mass, diaphragmatic hernia)
• Diaphragmatic paralysis is most frequently caused by interruption of the phrenic nerve, and may be unilateral or bilateral. Phrenic nerve invasion by a malignant neoplasm and trauma related to cardiothoracic surgery (stretch, crush, or transection) are the most common causes, although many cases are idiopathic 1

us

Ultrasound

• Useful in the evaluation of patients with suspected abnormalities of diaphragmatic movement 3,4,5
• Equivalent to fluoroscopy in diagnosing diaphragm dysfunction 3
• Superior to plain radiographs in the assessment of some supradiaphragmatic causes (e.g. pleural effusion, pleural masses) and most subdiaphragmatic causes (hepatomegaly, subphrenic collections, etc) of elevated hemidiaphragm 2
• Advantages- direct quantitative, quick and portable method of assessing hemidiaphragmatic movement

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