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Eventration or Paralysis
Some authors have used eventration as a synonym for diaphragmatic paralysis, while some have made distinctions between them. Both of them have the same clinical and radiological appearance, and paralysis which do not resolve can cause atrophy of the muscle and eventration.

Unilateral eventration and paralysis have the same effect on ventilation. Diaphragmatic weakness causes a decrease in ventilation and oxygenation. This can be aggravated by abdominal pressure in the supine position and by a small caliber bronchial tree. A flexible chest wall, weak intercostal and accessory muscles, and mobile mediastinum add to this effect.

Clinical presentation
Incidence of eventration at birth and infancy 1/1400-1/13000 (both congenital and birth trauma)
Incidence post cardiac surgery paralysis is 0.5-1.5%
Most paralysis occurs on the right side.
75% have ipsilateral Erb's palsy.

Signs and symptoms
Depending on the respiratory compromise:
1. Tachypnea, decreased breath sounds on the affected side and cyanosis
2. The "belly-dancer's sign": umbilicus shifts up and to the side of the paralyzed diaphragm during inspiration.
3. Unexplained severe respiratory distress needing ventilatory support
4. Erb's palsy
5. Recurrent pneumonia
6. Failure to thrive, nausea and vomiting

Differential diagnosis
1. Congenital diaphragmatic hernia.
2. Non paralytic eventration
3. Congenital heart disease (CHD): If presenting with dyspnea and cyanosis within hours of birth then it may be confused with CHD.
4. Intracranial hemorrhage.

1. CXR: the affected hemi-diaphragm is elevated in relation to the normal side.
2. Fluoroscopy in spontaneously breathing confirms immobility or paradoxical motion of the affected side during inspiration.
3. Ultrasound: proved feasible and useful in evaluating diaphragmatic motion. It may replace fluoroscopy (Gerocovich et al 2001.
4. Phrenic nerve conduction time: gives a direct evaluation of function and integrity.
5. EMG: assess during spontaneous breathing
6. Stimulation of Phrenic nerve to see the response of the diaphragm. If it contracts adequately it suggests a favorable prognosis
7. Measurement of transdiaphragmaitc pressure (Pdi) also gives an idea of the strength of the diaphragm.

Will depend on the degree of respiratory compromise, likelihood of recovery, and age of the child.
1. Intubation and positive pressure ventilation in severe cases.
2. Continuous distending airway pressure during spontaneous breathing (CPAP,BIPAP)
3. Tracheostomy for prolonged ventilatory support.
4. Diaphragmatic plication.

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