Diaphragm Eventration: Radiologic Assessment and Respiratory Implications-An Updated Review

Abstract

Background: Diaphragm eventration is an abnormal elevation of all or part of a hemidiaphragm caused by thinning and weakness of muscle with preserved anatomic continuity. It may be congenital—due to incomplete myoblast migration and muscularization—or acquired, most commonly from phrenic nerve injury, trauma, thoracic surgery, or neurologic disease. Although often asymptomatic, extensive involvement can impair ventilatory mechanics, reduce lung volumes, and precipitate recurrent infections and failure to thrive in pediatrics.

Aim: To synthesize contemporary concepts in embryology, etiology, epidemiology, imaging diagnosis, functional assessment, management, and multidisciplinary care of diaphragm eventration, emphasizing radiologic differentiation from mimics and respiratory implications across age groups.

Methods: Narrative review of developmental anatomy, pathophysiology (congenital neurogenic muscular aplasia versus acquired denervation atrophy), population patterns, and diagnostic pathways integrating chest radiography, computed tomography (CT), ultrasonography, dynamic fluoroscopic sniff testing, and adjunct MRI; appraisal of pulmonary function testing (PFT) profiles; and comparative discussion of conservative care versus surgical plication (open, VATS, laparoscopic, robotic), perioperative care, and rehabilitation.

Results: Chest radiography suggests diagnosis; CT confirms continuity and delineates morphology; ultrasound provides bedside dynamic assessment (especially in children); fluoroscopic sniff testing differentiates paradoxical motion. Symptomatic patients exhibit restrictive physiology (reduced FVC/FEV₁). Indications for plication include refractory dyspnea, ventilator weaning failure, growth failure, and recurrent atelectasis/pneumonia. Plication improves mechanics and quality of life, with typical FEV₁/FVC gains up to ~30% on followup PFTs. Complications arise from underlying mechanics (atelectasis, pneumonia) and from surgery (effusions, DVT, arrhythmias), mitigated by standardized perioperative bundles and rehabilitation.

Conclusion: A radiologyled diagnostic pathway combined with tailored functional assessment supports riskstratified management. Conservative observation suffices for asymptomatic cases; minimally invasive plication offers durable benefit for selected symptomatic patients when embedded in coordinated, multidisciplina