FIGURE 124.12 A 4-year-old boy admitted with 1-day history of recurrent severe upper abdominal colicky pain with dyspnea and decreased breath sounds in the left base Posteroanterior (A ) and lateral (B ) chest films demonstrate multiple bowel loops in the lower, posterior, left side of chest, indicative of a foramen of Bochdalek hernia that was subsequently repaired without difficulty Diaphragmatic Eventration Eventration is an abnormal elevation of one or both hemidiaphragms, and may present to the emergency clinician as an unexpected finding on a chest radiograph obtained for another reason Eventration may be congenital or acquired Acquired diaphragmatic eventration is commonly the result of a phrenic nerve paralysis, which may be caused by birth, operative, or other trauma Neoplastic or inflammatory processes in close proximity to the phrenic nerve can also lead to eventration Diaphragmatic eventration occurs most commonly on the left side, but may be bilateral The affected hemidiaphragm moves paradoxically during inspiration and expiration, with compromise of pulmonary mechanics and function A large enough congenital eventration may affect prenatal and postnatal lung development, potentially resulting in pulmonary hypoplasia Clinical Recognition Patients with eventration are often asymptomatic, but may exhibit respiratory distress as a result of alveolar hypoventilation and paradoxical diaphragmatic movement This frequently manifests as tachypnea, pallor, and feeding difficulties Physical examination findings of nonaerated lung, including absent breath sounds and dullness to percussion, should be investigated by chest radiograph Chest radiographs usually confirm the presence of an elevated hemidiaphragm (Fig 124.14 ) This finding may be confirmed by fluoroscopy or ultrasound, which will demonstrate paradoxical motion of the hemidiaphragm and mediastinal shift with inspiration and expiration Management Minor, asymptomatic eventrations may be observed The need for repair is based on the severity of the eventration and the degree of pulmonary dysfunction Treatment consists of plication of the attenuated portion of diaphragm, and can be performed thoracoscopically or via open thoracotomy In selected cases of acquired diaphragmatic dysfunction due to phrenic nerve paralysis, an implanted pacemaker can be used to stimulate the phrenic nerve and produce diaphragmatic motion Paraesophageal Hernia A paraesophageal hernia is a form of hiatal hernia in which the stomach and potentially other intra-abdominal organs protrude through the esophageal hiatus It is uncommon in children, and may be congenital and/or associated with other anomalies Clinical Recognition A paraesophageal hernia typically presents with symptoms of respiratory distress, vomiting, and failure to thrive Symptoms of upper abdominal pain, tachypnea, and tachycardia may accompany the condition as the herniated stomach distends with swallowed air inside the chest Such symptoms may also be indicative of gastric volvulus, strangulation, and necrosis, although these findings are uncommon in children with paraesophageal hernia FIGURE 124.13 Diaphragmatic defects in infants and children The nature of these defects are often better appreciated on a lateral view of the chest Eventration of the diaphragm (A ); foramen of Morgagni hernia (B ); and left foramen of Bochdalek hernia (C ) Physical examination may reveal decreased breath sounds and dullness to percussion over the left chest if a significant amount of abdominal viscera has migrated into the chest Rarely, herniation of colon or small bowel may result in bowel sounds heard over the left lower chest Upright chest radiographs may show an air- and fluid-filled mass in the left lower chest, which should be particularly evident on the lateral view Management Respiratory distress should be appropriately addressed and the patient should be fluid resuscitated Attempts should be made to place a nasogastric tube to decompress the stomach in the patient with associated respiratory compromise or abdominal pain, but may be difficult or impossible because of angulation of the gastroesophageal junction (Fig 124.15 ) Surgical consultation should be sought because urgent operative intervention may be necessary if the patient has signs of obstruction or strangulation If symptoms are significant or if concern for strangulated viscera exists, patients should be admitted to the inpatient ward for observation and acute management Symptomatic paraesophageal hernias warrant surgical repair, which can be done via laparoscopic or open abdominal approach CHEST WALL TUMORS CLINICAL PEARLS AND PITFALLS Many chest wall tumors are discovered incidentally by caregivers or on routine chest imaging Over half of chest wall neoplasms in children are malignant Chest radiographs and cross-sectional imaging such as CT and MRI are helpful initial diagnostic modalities