Elevated Hemidiaphragm



Elevated Hemidiaphragm


Sudhakar Pipavath, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Normal Variant


  • Phrenic Nerve Paralysis or Injury


  • Eventration of Diaphragm


  • Diaphragmatic Weakness


  • Lobectomy or Pneumonectomy


  • Lobar Collapse


Less Common



  • Subpulmonic Effusion


  • Hepatomegaly


  • Pleural, Diaphragmatic, or Abdominal Tumor


  • Ascites


  • Unilateral Lung Transplantation


Rare but Important



  • Bochdalek Hernia


  • Morgagni Hernia (Mimic)


  • Diaphragmatic Tear (Mimic)


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Focal vs. uniform elevation



    • Causes of focal elevation



      • Eventration


      • Lobectomy


      • Diaphragmatic hernia


      • Diaphragmatic rupture


    • Causes of uniform elevation



      • Phrenic nerve paralysis


      • Diaphragmatic weakness


      • Unilateral lung transplantation


  • Fluoroscopic evaluation of diaphragm helps distinguish phrenic nerve paralysis from other causes of weakness or eventration



    • Paradoxical motion is evident on forced inspiration (sniff maneuver) with phrenic nerve paralysis


    • Eventration shows no paradoxical motion


Helpful Clues for Common Diagnoses



  • Normal Variant



    • Left hemidiaphragm is normally lower than right hemidiaphragm


    • Left hemidiaphragm can be slightly elevated or at same level as right hemidiaphragm in up to 10-15% of normal subjects


    • Dextrocardia or situs inversus: Left hemidiaphragm is at higher level


  • Phrenic Nerve Paralysis or Injury



    • Uniform elevation


    • Paradoxical motion at fluoroscopy


    • Abnormal nerve conduction at electromyography studies


  • Eventration of Diaphragm



    • Focal elevation


    • Focal muscle weakness or thinning


    • Typically right anterior diaphragm is affected


  • Diaphragmatic Weakness



    • Indicates either neurogenic or muscular impairment


    • Can be reversible


    • Causes of diaphragmatic weakness



      • Recent surgery, typically cardiac surgery


      • Systemic lupus erythematosus (SLE): Vanishing lung syndrome from diaphragmatic myopathy


      • Guillain-Barré syndrome


      • Poliomyelitis


      • Polymyositis and dermatomyositis


  • Lobectomy or Pneumonectomy



    • Will have definite clinical history


    • Mediastinal shift to side of surgery


    • Signs of prior thoracotomy or lung resection are usually evident


    • Pneumonectomy may show “whiteout” hemithorax and crowding of ribs


  • Lobar Collapse



    • Direct or indirect signs of lobar collapse are visible


Helpful Clues for Less Common Diagnoses



  • Subpulmonic Effusion



    • Lateral tenting (shouldering) on upright chest x-ray


    • Mobile or layering effusion on lateral decubitus radiographs


  • Hepatomegaly



    • Differential considerations are same as uniform elevation of right hemidiaphragm


    • Most causes of hepatomegaly show abnormal liver function


  • Pleural, Diaphragmatic, or Abdominal Tumor



    • Lobulated contour or focal apparent elevation


    • Associated pleural effusion in patients with pleural metastasis



    • History of primary malignancy elsewhere


    • Unusual cause of apparent elevation of hemidiaphragm


  • Ascites



    • Ground-glass density with lack of gas-filled loops in upper abdomen


    • Clinical examination and US evaluation are often useful


Helpful Clues for Rare Diagnoses

Tags:
Aug 8, 2016 | Posted by in CARDIOLOGY | Comments Off on Elevated Hemidiaphragm

Full access? Get Clinical Tree
Get Clinical Tree app for offline access