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SURGICAL DISORDERS OF MEDIASTINUM AND DIAPHRAGM Sina Ercan MD Professor of Thoracic Surgery.

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Presentation on theme: "SURGICAL DISORDERS OF MEDIASTINUM AND DIAPHRAGM Sina Ercan MD Professor of Thoracic Surgery."— Presentation transcript:

1 SURGICAL DISORDERS OF MEDIASTINUM AND DIAPHRAGM Sina Ercan MD Professor of Thoracic Surgery

2 Anatomy of the Mediastinum Mediastinum is the central space within the thoracic cavity bounded by: Mediastinum is the central space within the thoracic cavity bounded by: Sternum anteriorly Sternum anteriorly Lungs and parietal pleura laterally Lungs and parietal pleura laterally The vertebral column posteriorly The vertebral column posteriorly The thoracic inlet superiorly The thoracic inlet superiorly The diaphragm inferiorly The diaphragm inferiorly

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6 Compartments of mediastinum Anterior mediastinum: the area posterior to the sternum and anterior to the heart and great vessels Anterior mediastinum: the area posterior to the sternum and anterior to the heart and great vessels Thymus, substernal thyroid Thymus, substernal thyroid glands, parathyroid, lymph nodes, connective tissue

7 Middle mediastinum: the area between the posterior border of the anterior mediastinum and a line placed along the posterior aspect of the trachea and the heart Middle mediastinum: the area between the posterior border of the anterior mediastinum and a line placed along the posterior aspect of the trachea and the heart Heart, pericardium, aortic arc, Heart, pericardium, aortic arc, brachiocephalic vessels, vena cava, main pulmonary vessels, trachea, main bronchi, phrenic and upper parts of the vagus nerve, lymph nodes

8 Posterior Mediastinum: The area between the posterior aspect of middle mediastinum and the vertebrae Posterior Mediastinum: The area between the posterior aspect of middle mediastinum and the vertebrae Esophagus, azygos and hemiazygos veins, thoracic duct, descending aorta, autonomic ganglia, symphathetic chain, Esophagus, azygos and hemiazygos veins, thoracic duct, descending aorta, autonomic ganglia, symphathetic chain, lower portions of the vagus nerve, lymph nodes and connective tissue

9 Mediastinal Pathologies Non neoplastic diseases Non neoplastic diseases Mediastinitis Mediastinitis Pneumomediastinum Pneumomediastinum Congenital pathologies Congenital pathologies Cysts Cysts Hernias Hernias Acquired lesions Acquired lesions Benign Benign Malignant Malignant

10 In adults 65% of the mediastinal lesions are anterior In adults 65% of the mediastinal lesions are anterior In children 52% of the mediastinal lesions are posterior In children 52% of the mediastinal lesions are posterior 40-50% of the mediastinal lesions are malignant in children compared to 25% malignancies in adults 40-50% of the mediastinal lesions are malignant in children compared to 25% malignancies in adults Mediastinal Pathologic Lesions

11 Anterior mediastinal disorders Thymic disorders Thymic disorders Thymoma, Thymic carcinoma Thymoma, Thymic carcinoma Thymic carcinoid Thymic carcinoid Thymolipoma Thymolipoma Thymic cyst Thymic cyst Thymic hyperplasia Thymic hyperplasia Thyroid disorders Thyroid disorders Intrathoracic goiter Intrathoracic goiter Germ cell tumors Germ cell tumors Teratoma Seminoma Others Lymphoma Lymphoma Hodgkin’s disease Non-Hodgkin’s Parathyroid adenoma Parathyroid adenoma Mesenchymal tumors Mesenchymal tumors

12 Thymoma Most common adult 1 0 mediastinal neoplasm Most common adult 1 0 mediastinal neoplasm Usually >40 y/o Usually >40 y/o 40-70% have symptoms related to parathymic syndromes 40-70% have symptoms related to parathymic syndromes Myasthenia Gravis, Myasthenia Gravis, Hypogammaglobulinemia Hypogammaglobulinemia Pure red cell aplasia Pure red cell aplasia Nonthymic malignancies Nonthymic malignancies

13 Thymomas represent neoplastic proliferation of thymic epithelial cells mixed with mature lymphocytes Thymomas represent neoplastic proliferation of thymic epithelial cells mixed with mature lymphocytes CT demonstrates a homogenious soft tissue mass CT demonstrates a homogenious soft tissue mass CT guided needle biopsy, mediastinoscopy, mediastinotomy or VATS for diagnosis CT guided needle biopsy, mediastinoscopy, mediastinotomy or VATS for diagnosis

14 Thymoma

15 Thymic Carcinoma: Thymic Carcinoma: Malignant histologic features Malignant histologic features Pulmonary, regional lymph node or pleural metastasis can be present Pulmonary, regional lymph node or pleural metastasis can be present Thymic carcinoid: Thymic carcinoid: a rare agressive neoplasm that originates from thymic neuroendocrine cells a rare agressive neoplasm that originates from thymic neuroendocrine cells Thymolipoma: Thymolipoma: a rare benign tumor composed of mature adipose and thymic tissue a rare benign tumor composed of mature adipose and thymic tissue

16 CT image of a Thymolipoma (Exhibits fat and thymic soft tissue)

17 Thymic cysts: May be congenital or acquired in association with inflammation or malignancy Thymic cysts: May be congenital or acquired in association with inflammation or malignancy Thymic hyperplasia: May be a rebound phenomenon after lymphoma or germ cell tumor treatment or seen in MG Thymic hyperplasia: May be a rebound phenomenon after lymphoma or germ cell tumor treatment or seen in MG

18 Mediastinal Lymphoma 10-20% of all mediastinal neoplasms in adults 10-20% of all mediastinal neoplasms in adults May be 1 o in anterior or middle mediastinum or part of systemic malignancy May be 1 o in anterior or middle mediastinum or part of systemic malignancy 20-30% of patients are asymptomatic 20-30% of patients are asymptomatic Symptoms of local invasion or systemic symptoms (fever, weight loss, pruritis) Symptoms of local invasion or systemic symptoms (fever, weight loss, pruritis)

19 Hodgkin’s disease: Bimodal age peak (20-30 years; >50 years) Hodgkin’s disease: Bimodal age peak (20-30 years; >50 years) Majority of patients have asymmetric, bilateral mediastinal LAP Majority of patients have asymmetric, bilateral mediastinal LAP

20 Non-Hodgkin’s Lymphoma: Usually in older patients Non-Hodgkin’s Lymphoma: Usually in older patients Usually systemic upon presentation and spreads unpredictably Usually systemic upon presentation and spreads unpredictably Diffuse Large B-cell Lymphoma Diffuse Large B-cell Lymphoma Lymphoblastic Lymphoma Lymphoblastic Lymphoma

21 Mediastinal Germ-Cell Tumors Teratomas: Teratomas: Account 60-70% of cases Account 60-70% of cases Consist of tissue that may derive from more than one of the germ cell layers Consist of tissue that may derive from more than one of the germ cell layers Mostly benign, radiologically spheric, lobulated, well circumscribed and may contain calcification Mostly benign, radiologically spheric, lobulated, well circumscribed and may contain calcification Seminomas: Seminomas: Affect men in 3rd and 4th decades Affect men in 3rd and 4th decades 40-50% of mediastinal malignant germ cell tumors 40-50% of mediastinal malignant germ cell tumors

22 Teratoma (well formed teeth within the mass is diagnostic)

23 Germ cell tumor

24 MIDDLE MEDIASTINAL DISORDERS Lymphoma Lymphoma Benign lympadenopathy Benign lympadenopathy Granulomatous disease Granulomatous disease Infectious Infectious Non infectious Non infectious Miscellaneous Miscellaneous Amyloidosis Amyloidosis Drugs Drugs Metastatic lymphadenopathy Metastatic lymphadenopathy Cysts Cysts Bronchogenic cysts Pericardial cyst Vascular Lesions Vascular Lesions Aneurism Hemangioma Miscellaneous Miscellaneous Diaphragmatic hernias Pancreatic pseudocyst

25 Benign mediastinal lymphadenopathy Infectious Infectious Tuberculosis: Usually unilateral and asymmetric, may have calcification Tuberculosis: Usually unilateral and asymmetric, may have calcification Fungal infections Fungal infections Histoplasmosis Histoplasmosis coccidioidomycosis coccidioidomycosis Non infectious Non infectious Sarcoidosis: Usually bilateral, symmetric Sarcoidosis: Usually bilateral, symmetric Silicosis: nodal calsification with eggshell configuration Silicosis: nodal calsification with eggshell configuration

26 Normal mediastinal lymph nodes

27 Sarcoidosis Unilateral hiler enlargement

28 Cysts Bronchogenic cyst: Originate from abnormal budding of ventral foregut Bronchogenic cyst: Originate from abnormal budding of ventral foregut Commonly in subcarinal and paratracheal regions 15% in pulmonary paranchyme Commonly in subcarinal and paratracheal regions 15% in pulmonary paranchyme Lined by respiratory epithelium and may contain serous fluid, mucus, milk of calcium, blood or purulent material Lined by respiratory epithelium and may contain serous fluid, mucus, milk of calcium, blood or purulent material

29 Bronchogenic cyst

30 Enterogenous cysts: Enterogenous cysts: Esophageal dublication and neurenteric cysts Esophageal dublication and neurenteric cysts Located in the middle or posterior mediastinum Located in the middle or posterior mediastinum Pericardial Cysts: Pericardial Cysts: In the cardiophrenic angles (R>L) In the cardiophrenic angles (R>L) Fibrous walls and contain clear fluid Fibrous walls and contain clear fluid Diaphragmatic hernias: Diaphragmatic hernias: Hiatal hernia Hiatal hernia Morgagni hernia Morgagni hernia Bochdalek hernia Bochdalek hernia

31 Pericardial cyst

32 Vascular lesions: Constitute approximately 10% of the mediastinal masses Vascular lesions: Constitute approximately 10% of the mediastinal masses May originate from the arterial or venous portions of the systemic or pulmonary circulation May originate from the arterial or venous portions of the systemic or pulmonary circulation They may mimic neoplasms on chest radiographs They may mimic neoplasms on chest radiographs

33 Thoracic aortic aneurisym Vascular lesions

34 Superior Vena Cava Syndrome: (Facial, upper limb swelling, headache, shortness of breath, superficial venous dilatation, conjunctival hyperemia) Superior Vena Cava Syndrome: (Facial, upper limb swelling, headache, shortness of breath, superficial venous dilatation, conjunctival hyperemia) Lung cancer (50-75%) (small cell most common) Lung cancer (50-75%) (small cell most common) Lymphoma Lymphoma Germ cell tumors of the mediastinum Germ cell tumors of the mediastinum Thymic malignancies Thymic malignancies Benign causes (5-10%) Benign causes (5-10%) Syphilitic aneurism Syphilitic aneurism Tuberculosis lymphadenopathy Tuberculosis lymphadenopathy Mediastinal fibrosis Mediastinal fibrosis

35 Posterior Mediastinal Disorders Neurogenic tumors Neurogenic tumors Peripheral nerve Peripheral nerve Schwannoma, neurofibroma etc Schwannoma, neurofibroma etc Sympathetic ganglia Sympathetic ganglia Ganglioneuroma, neuroblastoma etc Ganglioneuroma, neuroblastoma etc Paraganglionic tumors Paraganglionic tumors pheochromocytoma pheochromocytoma Esophageal disorders Esophageal disorders Benign tumors Esophageal diverticulum Spinal Spinal Lateral thoracic meningocele Paraspinal abscess Miscellaneous Miscellaneous Thoracic duct cysts

36 CT of neurofibroma Extramedullary hematopoiesis

37 Symptoms and signs in mediastinal pathologies Benign ones usually asymptomatic Benign ones usually asymptomatic Chest pain ( Traction of the mediastinal structures, bone erosion) Chest pain ( Traction of the mediastinal structures, bone erosion) Cough Cough Dyspnea (Compression of tracheobronchial tree, mediastinal shift) Dyspnea (Compression of tracheobronchial tree, mediastinal shift) Dysphagia (Compression of esophagus) Dysphagia (Compression of esophagus) Hoarseness (Recurrent laryngeal paralysis) Hoarseness (Recurrent laryngeal paralysis) Horner syndrome (Compression of the stellate ganglion) Horner syndrome (Compression of the stellate ganglion)

38 Superior Vena Cava Syndrome Superior Vena Cava Syndrome Weakness/Myastenia Gravis Symptoms Weakness/Myastenia Gravis Symptoms Mental Confusion (Hypercalcemia due to parathyroid adenoma or carcinoma) Mental Confusion (Hypercalcemia due to parathyroid adenoma or carcinoma) Neurogenic symptoms (Neurogenic tumors) Neurogenic symptoms (Neurogenic tumors) Diaphragmatic paralysis (Phrenic nerve paralysis) Diaphragmatic paralysis (Phrenic nerve paralysis) Pleural effusion/Chylothorax (Obstruction of thoracic duct) Pleural effusion/Chylothorax (Obstruction of thoracic duct) Arrhytmias (Cardiac compression or involvement of myocardium with tumor) Arrhytmias (Cardiac compression or involvement of myocardium with tumor) Pericardial tamponade (Lymphoma) Pericardial tamponade (Lymphoma) Gynecomastia (Germ cell tumors) Gynecomastia (Germ cell tumors)

39 Diagnostic Procedures Physical examination (Signs of Sup. V. Cava or Horner Syndrome) Physical examination (Signs of Sup. V. Cava or Horner Syndrome) Plain Chest Radiography (PA and Left lateral) Plain Chest Radiography (PA and Left lateral)

40 CT CT Arteriography/ Venography Arteriography/ Venography

41 Ultrasound Ultrasound MRI MRI Barium esophagram Barium esophagram Histologic evaluation Histologic evaluation Fine needle aspiration Fine needle aspiration Mediastinoscopy/mediastinotomy Mediastinoscopy/mediastinotomy Thoracoscopy (VATS) Thoracoscopy (VATS) Thoracotomy Thoracotomy

42 Non neoplastic Disorders of the Mediastinum Pneumomediastinum Pneumomediastinum Pneumopericardium Pneumopericardium Acute Mediastinitis Acute Mediastinitis Chronic Mediastinitis Chronic Mediastinitis

43 Pneumomediastinum Caused by alveolar overdistention and rupture Caused by alveolar overdistention and rupture

44 Etiology of pneumomediastinum Spontaneous Spontaneous Acute asthma attack Acute asthma attack Scuba diving Scuba diving Mechanic ventilation Mechanic ventilation Vomiting Vomiting Trauma Trauma Surgery Surgery Tracheostomy Tracheostomy Bronchoscopic procedures Bronchoscopic procedures Respiratory tract infections Respiratory tract infections Dental infections or procedures Dental infections or procedures Acute mediastinitis Acute mediastinitis Pneumoperitoneum Pneumoperitoneum Esophageal perforation Esophageal perforation

45 Substernal chest pain is the most frequent symptom Substernal chest pain is the most frequent symptom Crepitation; air dissecting under the skin Crepitation; air dissecting under the skin Dyspnea Dyspnea Dysphagia Dysphagia Dysphonia Dysphonia Hypotension (hemodynamic changes) Hypotension (hemodynamic changes)

46 Physical examination reveals palpable subcutaneous emphysema in the neck Physical examination reveals palpable subcutaneous emphysema in the neck On auscultation of the chest a clicking sound over the pericardium synchronous with the heartbeat (Hamman’s sign) On auscultation of the chest a clicking sound over the pericardium synchronous with the heartbeat (Hamman’s sign)

47 Chest Radiograph: a thin radiolucent strip along the mediastinal fascial plane, left heart border Chest Radiograph: a thin radiolucent strip along the mediastinal fascial plane, left heart border CT CT

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49 Treatment: Treatment: Supportive Supportive Supplemental oxygen Supplemental oxygen Management of causes Management of causes Surgery, chest tube insertion when hemodynamic deterioriation is present or when associated with mechanical ventilation Surgery, chest tube insertion when hemodynamic deterioriation is present or when associated with mechanical ventilation

50 Acute Mediastinitis A life threatening condition A life threatening condition Etiology Etiology Esophageal or tracheobronchial perforation Esophageal or tracheobronchial perforation Sternotomy for cardiac surgery Sternotomy for cardiac surgery Direct extension of infection from lung, spine or pancreas Direct extension of infection from lung, spine or pancreas Descending necrotizing mediastinitis (Oropharyngeal infections) Descending necrotizing mediastinitis (Oropharyngeal infections) Anthrax Mediastinitis Anthrax Mediastinitis

51 Iatrogenic esophageal perforation is the most common cause of acute mediastinitis Iatrogenic esophageal perforation is the most common cause of acute mediastinitis Can also be: Can also be: Postemetic (Boerhaave’s syndrome) Postemetic (Boerhaave’s syndrome) Trauma Trauma Operative injury Operative injury Cancer erosion Cancer erosion Foreign body Foreign body Esophageal perforation

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53 Clinical signs and symptoms Abrupt onset of severe chest pain, fever, dyspnea, SVC symptoms Abrupt onset of severe chest pain, fever, dyspnea, SVC symptoms Tachypnea, tachycardia, hypotension, cervical emphysema Tachypnea, tachycardia, hypotension, cervical emphysema Shock develops quickly Shock develops quickly Chest Radiology: Upper mediastinal enlargement, emphysema, hydropnomothorax, multiple air fluid levels Chest Radiology: Upper mediastinal enlargement, emphysema, hydropnomothorax, multiple air fluid levels

54 Mediastinitis

55 Treatment: Treatment: Surgical debridement of the necrotic tissue Surgical debridement of the necrotic tissue Closure of the perforation Closure of the perforation Drainage Drainage Broad spectrum antibiotics with anaerobic coverage Broad spectrum antibiotics with anaerobic coverage Mortality rises when the treatment delay is more than 24 hours Mortality rises when the treatment delay is more than 24 hours

56 Poststernotomy mediastinitis: Poststernotomy mediastinitis: Prolonged preoperative hospitalization, reoperation or reexploration, presence of D. Mellitus, use of internel thoracic artery grafts are the risk factors. Prolonged preoperative hospitalization, reoperation or reexploration, presence of D. Mellitus, use of internel thoracic artery grafts are the risk factors. Staphlococcus epidermidis and aureus, various gram (-) organisms and candida and atypical mycobacteria are commonly isolated Staphlococcus epidermidis and aureus, various gram (-) organisms and candida and atypical mycobacteria are commonly isolated Insidious presentation with low grade fever, leukocytosis, wound problems Insidious presentation with low grade fever, leukocytosis, wound problems Surgical debridement and prolonged proper antibiotic therapy is the treatment Surgical debridement and prolonged proper antibiotic therapy is the treatment

57 Antrax Mediastinitis: Antrax Mediastinitis: Caused by Bacillus anthracis (Gr + ) Caused by Bacillus anthracis (Gr + ) Farm animals are the main reservoir Farm animals are the main reservoir Inhaled antrax spores are transported to the mediastinal lymph nodes by alveolar macrophages Inhaled antrax spores are transported to the mediastinal lymph nodes by alveolar macrophages A hemorrhagic mediastinitis occurs A hemorrhagic mediastinitis occurs Penicillin and streptomycin is the treatment of choice Penicillin and streptomycin is the treatment of choice

58 Chronic Mediastinitis Granulomatous mediastinitis Granulomatous mediastinitis Tbc, histoplasmosis, nocardia and other fungi Tbc, histoplasmosis, nocardia and other fungi Disease of mediastinal lymph nodes Disease of mediastinal lymph nodes Coalescence of caseous mediastinal lymph nodes can result in a single large mass, encapsulation and mediastinal granuloma Coalescence of caseous mediastinal lymph nodes can result in a single large mass, encapsulation and mediastinal granuloma Compression of trachea, superior V. Cava or esophagus can occur Compression of trachea, superior V. Cava or esophagus can occur Right paratracheal area is the most common site Right paratracheal area is the most common site

59 Excision is the treatment of choice (if possible) Excision is the treatment of choice (if possible) Specimens for culture and special stains for diagnosis at the time of operation Specimens for culture and special stains for diagnosis at the time of operation

60 Fibrosing Mediastinitis: Fibrosing Mediastinitis: Dense fibrosis surrounding trachea, hila of the lungs. Dense fibrosis surrounding trachea, hila of the lungs. Compression of the airway, pulmonary arteries or veins may occur Compression of the airway, pulmonary arteries or veins may occur Etiology: Etiology: Tuberculosis Tuberculosis Histoplasmosis or other fungi Histoplasmosis or other fungi Silicosis Silicosis Drugs (Methisergide) Drugs (Methisergide) Autoimmune disorders Autoimmune disorders Familial multifocal fibrosclerosis Familial multifocal fibrosclerosis

61 Symptoms are caused by the compression of vital organs Symptoms are caused by the compression of vital organs Treatment is symptomatic Treatment is symptomatic Methisergide should be stopped for the relief of symptoms Methisergide should be stopped for the relief of symptoms END

62 Diseases of the Diaphragm Diaphragma is a dome shaped musculotendinous structure that separates thoracic and abdominal cavities Diaphragma is a dome shaped musculotendinous structure that separates thoracic and abdominal cavities It consists of two parts: It consists of two parts: Right hemidiaphragm Right hemidiaphragm Left hemidiaphragm Left hemidiaphragm Middle portion is made of the central tendon that doesn’t contract, it has two holes on Middle portion is made of the central tendon that doesn’t contract, it has two holes on The caval opening The caval opening The esophageal hiatus The esophageal hiatus

63 Diaphragma thoracic view

64 Diaphragma abdominal view

65 The muscle fibers of the crural part originate from lomber vertebrae The muscle fibers of the crural part originate from lomber vertebrae The muscle fibers of the costal part originate from the processus xiphoideus and 7-12 ribs The muscle fibers of the costal part originate from the processus xiphoideus and 7-12 ribs The costal part contraction lowers the diaphragm and increases the rib cage The costal part contraction lowers the diaphragm and increases the rib cage When the crural part contracts only the diaphragm moves downward When the crural part contracts only the diaphragm moves downward

66 Motor inervation comes from cervical motor neurons (C3-5) conducted via N. Frenicus Motor inervation comes from cervical motor neurons (C3-5) conducted via N. Frenicus Diaphragm is the major inspiratuar muscle responsible from 70% of normal breathing. Diaphragm is the major inspiratuar muscle responsible from 70% of normal breathing.

67 Contraction of the diaphragm has the following effects that promote air movement into the lungs Contraction of the diaphragm has the following effects that promote air movement into the lungs It decreases intrapleural pressure It decreases intrapleural pressure It raises and inflates the rib cage It raises and inflates the rib cage It expands the rib cage by generating positive intraabdominal pressure It expands the rib cage by generating positive intraabdominal pressure

68 Diaphragmatic paralysis: Can be bilateral or involve only one side (unilateral) Can be bilateral or involve only one side (unilateral) In this setting the accessory muscles of the respiration assume some or all the work of breathing In this setting the accessory muscles of the respiration assume some or all the work of breathing

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70 Patients with bilateral diaphragmatic paralysis typically present with dyspnea. It is associated with tachypnea and rapid shallow breathing Patients with bilateral diaphragmatic paralysis typically present with dyspnea. It is associated with tachypnea and rapid shallow breathing Paradoxal motion of the anterior abdominal wall during inspiration can be detected Paradoxal motion of the anterior abdominal wall during inspiration can be detected Hypoxemia is common due to atelectasis and V/Q mismatch which worsens with sleep Hypoxemia is common due to atelectasis and V/Q mismatch which worsens with sleep Disease progression is associated with progresive hypercapnia Disease progression is associated with progresive hypercapnia

71 Chest radiograph reveals elevated hemidiaphragms, small lung volumes, atelectasis Chest radiograph reveals elevated hemidiaphragms, small lung volumes, atelectasis In pulmonary function test 50% decrease in VC in supine position is thypical (should be up to 10% in normal individuals). PI- max is lowered In pulmonary function test 50% decrease in VC in supine position is thypical (should be up to 10% in normal individuals). PI- max is lowered Electromyography may show either neuropathic or myopathic pattern Electromyography may show either neuropathic or myopathic pattern The gold standart is the measurement of transdiaphragmatic pressure The gold standart is the measurement of transdiaphragmatic pressure

72 Unilateral diaphragmatic paralysis is more common Unilateral diaphragmatic paralysis is more common Often discovered incidentally on a chest radiograph and diagnosis can be made only by radiology (fluoroscopic sniff test) Often discovered incidentally on a chest radiograph and diagnosis can be made only by radiology (fluoroscopic sniff test) Patients who do not have underlying lung disease are usually asymphtomatic Patients who do not have underlying lung disease are usually asymphtomatic In fluoroscopic sniff test paradox elevation of the paralysed hemidiaphragm is positive >90% of the patients In fluoroscopic sniff test paradox elevation of the paralysed hemidiaphragm is positive >90% of the patients

73 Diaphragmatic Fatique Can be seen in several conditions that effect motor neurons, neuromusculer junction or muscle cells Can be seen in several conditions that effect motor neurons, neuromusculer junction or muscle cells

74 N. Spinalis and peripheric nerve pathologies N. Spinalis and peripheric nerve pathologies Acute ant. Poliomyelitis Acute ant. Poliomyelitis Peripheric neuropathies Peripheric neuropathies Infection Infection Alcohol Alcohol Toxic Toxic Metabolic Metabolic Guillain barre syndrom Guillain barre syndrom Myoneural block Myoneural block Myastenia gravis Myastenia of Carsinomatozis Anticholinesterase Musculer pathologies Musculer pathologies Progressive muscular distrophia myopathies

75 Diaphragmatic Eventration Eventration of the diaphragm is a disorder in which all or part of the diaphragmatic muscle is replaced by fibroelastic tissue. Eventration of the diaphragm is a disorder in which all or part of the diaphragmatic muscle is replaced by fibroelastic tissue.

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77 Eventration of the diaphragm can be congenital or acquired Eventration of the diaphragm can be congenital or acquired Many patients are asymptomatic, especially when the eventration is localized Many patients are asymptomatic, especially when the eventration is localized Can be seen incidentally on chest x ray and The diagnosis is confirmed by fluoroscopy or ultrasonography. Can be seen incidentally on chest x ray and The diagnosis is confirmed by fluoroscopy or ultrasonography. In infants the management depends on the extent of the respiratory distress, often no need to treatment In infants the management depends on the extent of the respiratory distress, often no need to treatment

78 Diaphragmatic Hernia Hiatal Hernias: Hiatal Hernias: Result when an abdominal structure usually the stomach extends through the diaphragmatic esophageal hiatus into the thorax. Manifests as a retrocardiac mass in the middle mediastinum Traumatic rupture Traumatic rupture Seen in 1-4% of blunt chest or abdominal trauma usually on the left posterolateral region

79 Traumatic rupture of the left hemidiaphragm

80 Congenital Hernias: Congenital Hernias: These are due to the failure of the normal fusion of the diaphragmatic components during embryologic development Morgagni hernias: herniation of omentum and other abdominal contents into the thorax manifest as a right cardiophrenic angle mass Morgagni hernias: herniation of omentum and other abdominal contents into the thorax manifest as a right cardiophrenic angle mass Bochdaleks hernias: May protrude into the posterior mediastinum Bochdaleks hernias: May protrude into the posterior mediastinum Diagnosis can be established in diaphragmatic hernias by gastrointestinal barium study or CT. Treatment is surgical in symptomatic cases.

81 Morgagni hernia

82 Bochdaleks hernia

83 Diaphragmatic infections Subdiaphragmatic abscess: Can be seen due to perforation or abdominal surgery. Local pain, fever, tachicardia, leucocytosis are common. Ipsilateral hemidiaphragm is elevated on chest radiology. Pleural efusion, pulmonary infiltration or atelectasis can also be present. Surgical drainage with appropiate antibiotics is the treatment Subdiaphragmatic abscess: Can be seen due to perforation or abdominal surgery. Local pain, fever, tachicardia, leucocytosis are common. Ipsilateral hemidiaphragm is elevated on chest radiology. Pleural efusion, pulmonary infiltration or atelectasis can also be present. Surgical drainage with appropiate antibiotics is the treatment Parasitic infections: Amebiasis, trichinella spiralis Parasitic infections: Amebiasis, trichinella spiralis

84 Diaphragmatic neoplasms Metastatic: Breast, ovarian and gastric cancer metastasis are the most common type. Lung cancer and mesothelioma are also seen Metastatic: Breast, ovarian and gastric cancer metastasis are the most common type. Lung cancer and mesothelioma are also seen Primary benign neoplasms: Primary benign neoplasms: Fibroma Fibroma Angiofibroma Angiofibroma neurofibroma, neurofibroma, Neurilemmoma Neurilemmoma Hemangioperistoma Hemangioperistoma

85 Primary malign neoplasms: Primary malign neoplasms: Fibrosarcoma Fibrosarcoma Myosarcoma Myosarcoma Fibrangioendothelioma Fibrangioendothelioma Sarcoma Sarcoma Neurofibrosarcoma Neurofibrosarcoma Hemangioendothelioma Hemangioendothelioma Hemangioperistoma Hemangioperistoma Leiomyosarcoma Leiomyosarcoma Malign snovioma Malign snovioma


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