Pediatr Radiol (1992) 22:379-381
Pediatric Radiology 9 Springer-Verlag 1992
Neonatal phrenic nerve paralysis resulting from intercostal drainage of pneumothorax J. C. Odita 1, A. S. S. I. Khan 2, M. Dincsoy 2, M. Kayyali;, A. Masoud 2, and A. Ammari 2 Department of Radiology and ~Department of Pediatrics, Hamad Medical Corporation, Doha Qatar Received: 18 September 1991; accepted: 20 January 1992
Abstract. F o u r cases of phrenic nerve paralysis complicating chest tube placem e n t in the n e w b o r n for p n e u m o t h o r a x are presented. This complication is related to abnormal location of the medial end of the chest tube. It is suggested that on the frontal chest radiograph, the medial end of the chest tube should be no less than I cm from the spine.
The commonest causes of iatrogenic phrenic nerve injury in the n e w b o r n is birth injury and cardiothoracic surgery [1-3]. Phrenic nerve palsy complicating chest tube placement for the management of p n e u m o t h o r a x is so rare that it has been the subject of only three isolated case reports within the past decade [4-6]. We recently observed this complication in four n e w b o r n infants who had intercostal drainage of p n e u m o t h o r a x associated with positive pressure ventilation and wish to present the clinical and radiological features of these cases and highlight an a b n o r m a l l o c a t i o n of medial end of chest tube as a causative factor.
nerve paralysis. The child did well on mechanical ventilation after the chest tube was removed and was subsequently weaned at 5 weeks.
Case 2 A male infant delivered by Caesarian section after 36 weeks of gestation. The birth weight was 2.48 kg. The apgar score was 9 and 10 at 1 and 5 min respectively. Respiratory distress, consistent clinically and radiologically, with RDS developed at birth. The patient was intubated and placed on mechanical ventilation. At 2 days he developed bilateralpneumothotax and chest tubes were inserted on both sides. The right pneumothor ax resolved while the left pneumothorax was recurrent requiring multiple chest tube insertions. A followup chest examinationobtained on the 5th day of life showed the medial end of the chest tube overlying the spine (Fig. 2 a). The former was finally removed on day 9. Post chest tube removal films showed persistently elevated left hemidiaphragm (Fig. 2 b) which was confirmed to be due to phrenic nerve paralysis by fluoroscopy and ultrasound. Plication of the diaphragm was carried out on 36th day of life. One year post plication the child has had recurrent episodes of respiration distress and the left hemidiaphragm remains high.
Case 1 Case 3 A male infant, delivered by Caesarian section after 31 weeks of gestation. The birth weight was 1.2 kg and the apgar score was 5 and 8 at 1 and 5 rain respectively. At birth he developed respiratory distress syndrome and was intubated and subsequentlyplaced on mechanical ventilation. On the 4th day of life he developed a left pneumothorax (Fig. 1 a) and a chest tube was inserted. On day 6 a follow-up chest radiograph has shown complete resolution of the pneumothorax. The medial end of the chest tube was noted to overly the spine and the left hemidiaphragm was much higher than the right (Fig.lb). Fluoroscopy and ultrasound examination confirmed phrenic
Male infant was a product of a spontaneous vaginal delivery after 35 weeks of gestation. The birth weight was 2.20 kg. The apgar score was 8 and 9 at 1 and 5 rain respectively. At birth he had respiratory distress from a spontaneous left pneumothorax. He was intubated and a left chest tube placed (Fig. 3 a). The chest radiograph on day 3 showed elevated left hemidiaphragm, and the end of the chest tube was noted to overly the spine (Fig.3b). Four days later after removal of chest tube and extubation, the left hemidiaphragm had remained persistently elevated with a mediastinal shift to the right (Fig. 3 c).
Plication was carried out at one month of age, and patient has since remained asymptomatic.
Case 4 Male infant delivered by Caesarian section after 33 weeks of gestation. The birth weight was 1.8 kg. He developed RDS at birth and was placed on mechanical ventilation.A right pneumothorax and surgical emphysema developed on the second day of life. He also developed extensive pulmonary interstitial emphysema and the pneumothorax was of a recurrent nature. Figure 4 a shows extensive pulmonary interstitial emphysema with the end of the right chest tube just adjacent to the right lateral border of the spine. He subsequentlydeveloped severe bronchopulmonary dysplasia which required intermittent ventilation for over nine months. Figure 4b shows extensive bronchopulmonary dysplasia with associated elevated right hemidiaphragm due to phrenic nerve paralysis. Plication was carried out at the age of one year. Recurrent respiratory distress and high riding right hemidiaphragm has persisted despite the procedure.
Discussion Phrenic nerve paralysis developed on the side of chest tube placement, and was associated with i m p i n g e m e n t of the chest tube on the mediastinum or spine. Furthermore, three of the four infants were delivered by Caesarian section, thereby excluding the possibility of birth injury resulting in phrenic nerve palsy. E v e n t r a t i o n of the diaphragm presents essentially similar radiographic features as phrenic nerve palsy. Whilst eventration is a congenital anomaly consisting of partial or total hypoplasia of the diaphragm, phrenic nerve palsy is acquired and results from the disruption of
380
Fig.la, b. Case 1. a There is a left pneumothorax, b Chest radiograph showing elevated left hemidiaphragm. The medial end of the chest tube overlies the spine Fig. 2 a,b. Case 2. a Chest radiograph: There are bilateral chest tubes. The medial end of the left tube overlies the spine, b The left hemidiaphragm has remained elevated after removal of chest tube
Fig.3 a---e. Case 3. a Chest radiograph: There is a residual anterior pneumothorax, and a left chest tube. The diaphragm is normal, b Chest radiograph: There is elevation of the left hemidiaphragm and the left chest tubeimpingesonthespine, c Postchest tuberemovalthereispersistent elevated left hemidiaphragm and mediastinal shift to the right Fig.4a, b. Case 4. a Chest radiograph: There is extensive bilateral pulmonary interstitial emphysema and a localised right lower pneumothorax. The right chest tube end impinges on the spine, b At 9 months: the right hemidiaphragm is markedly elevated. Note extensive bronchopulmonary dysplasia
transmission of nerve impulses through the phrenic nerve. Chin and Lynn claimed that these two conditions can be distinguished by F a r a d i c stimulation of the phrenic nerve [7]. O n the other hand O h et al. suggest that a diagnosis of phrenic nerve palsy can be m a d e on plain chest radiographic findings when prior radiographs, with n o r m a l diaphragm, are available for comparison [8]. The four infants in this reports all had previous chest radiographs with n o r m a l diap h r a g m prior to the insertion of chest tubes. We feel therefore that these are cases of phrenic nerve palsy resulting from a crush injury of the ipsilateral phrenic nerve.
381 In two of the three previous reports, chest tube compression of the phrenic nerve was suggested as cause of diaphragmatic paralysis [4, 5]. In both reports it was suggested that chest radiographs should be obtained to check the position of the chest tube immediately after the latter was inserted. They did not however give an indication of the optimal position of the tube end. As a rule of thumb, we suggest that on the frontal radiograph, the medial end of the chest tube should be no less than one centimeter from the spine or mediastinum. The precise onset of phrenic nerve paralysis post chest tube is difficult to determine in view of the associated lung disease in the infants. In three infants however phrenic nerve paralysis was diagnosed within a week of insertion of chest tube. This early onset of phrenic
nerve palsy was also observed in the previous reports.
References
1. Smith CD, Sade RM, Crawford FA, Otherson HB (1986) Diaphragmatic paralysis and eventration in infants. J Thorac Cardiovasc Surg 91:490 2. Zhao HX, D'Agostino RS, Pitlick PT, Shumway NE, Miller DC (1985) Phrenic nerve injury complicating closed cardiovascular surgical procedures for congenital heart disease. Ann Thorac Surg 39:445 3. Watanabe T, Trusler GA, Williams WG, Edmonds JF, Coles JG, Hosokawa WG (1987) Phrenic nerve paralysis after pediatric cardiac surgery. Retrospective study of 125 cases. J Thorac Cardiovasc Surg 94:383 4. Philips AF, Rowe JC, Raye JR (1981) Acute diaphragmatic paralysis after chest tube placement in a neonate. AJR 136:824
5. Marrineili PV, Ortiz A, Alden (1981) Acquired eventration of the diaphragm: a complication of chest tube placement in neonatal pneumothorax. Pediatrics 67:552 6, Arya H, Williams J, Ponsford, Bissenden JG (1991) Neonatal diaphragmatic paralysis caused by chest drains. Arch Dis Child 66:441 7. Chin EF, Lynn RB (1956) Surgery of eventration of the diaphragm. J Thorac Surg 32:6 8. Oh KS, Newman B, Bender MB, Bowen A (1988) Radiologic evaluation of the diaphragm. Radiol Clin North Am 26:355
Dr. J. C. Odita E O. Box 3050 Department of Radiology Hamad Medical Corporation Doha Qatar
Pediatric Radiology 9 Springer-Verlag 1992
Neonatal phrenic nerve paralysis resulting from intercostal drainage of pneumothorax J. C. Odita 1, A. S. S. I. Khan 2, M. Dincsoy 2, M. Kayyali;, A. Masoud 2, and A. Ammari 2 Department of Radiology and ~Department of Pediatrics, Hamad Medical Corporation, Doha Qatar Received: 18 September 1991; accepted: 20 January 1992
Abstract. F o u r cases of phrenic nerve paralysis complicating chest tube placem e n t in the n e w b o r n for p n e u m o t h o r a x are presented. This complication is related to abnormal location of the medial end of the chest tube. It is suggested that on the frontal chest radiograph, the medial end of the chest tube should be no less than I cm from the spine.
The commonest causes of iatrogenic phrenic nerve injury in the n e w b o r n is birth injury and cardiothoracic surgery [1-3]. Phrenic nerve palsy complicating chest tube placement for the management of p n e u m o t h o r a x is so rare that it has been the subject of only three isolated case reports within the past decade [4-6]. We recently observed this complication in four n e w b o r n infants who had intercostal drainage of p n e u m o t h o r a x associated with positive pressure ventilation and wish to present the clinical and radiological features of these cases and highlight an a b n o r m a l l o c a t i o n of medial end of chest tube as a causative factor.
nerve paralysis. The child did well on mechanical ventilation after the chest tube was removed and was subsequently weaned at 5 weeks.
Case 2 A male infant delivered by Caesarian section after 36 weeks of gestation. The birth weight was 2.48 kg. The apgar score was 9 and 10 at 1 and 5 min respectively. Respiratory distress, consistent clinically and radiologically, with RDS developed at birth. The patient was intubated and placed on mechanical ventilation. At 2 days he developed bilateralpneumothotax and chest tubes were inserted on both sides. The right pneumothor ax resolved while the left pneumothorax was recurrent requiring multiple chest tube insertions. A followup chest examinationobtained on the 5th day of life showed the medial end of the chest tube overlying the spine (Fig. 2 a). The former was finally removed on day 9. Post chest tube removal films showed persistently elevated left hemidiaphragm (Fig. 2 b) which was confirmed to be due to phrenic nerve paralysis by fluoroscopy and ultrasound. Plication of the diaphragm was carried out on 36th day of life. One year post plication the child has had recurrent episodes of respiration distress and the left hemidiaphragm remains high.
Case 1 Case 3 A male infant, delivered by Caesarian section after 31 weeks of gestation. The birth weight was 1.2 kg and the apgar score was 5 and 8 at 1 and 5 rain respectively. At birth he developed respiratory distress syndrome and was intubated and subsequentlyplaced on mechanical ventilation. On the 4th day of life he developed a left pneumothorax (Fig. 1 a) and a chest tube was inserted. On day 6 a follow-up chest radiograph has shown complete resolution of the pneumothorax. The medial end of the chest tube was noted to overly the spine and the left hemidiaphragm was much higher than the right (Fig.lb). Fluoroscopy and ultrasound examination confirmed phrenic
Male infant was a product of a spontaneous vaginal delivery after 35 weeks of gestation. The birth weight was 2.20 kg. The apgar score was 8 and 9 at 1 and 5 rain respectively. At birth he had respiratory distress from a spontaneous left pneumothorax. He was intubated and a left chest tube placed (Fig. 3 a). The chest radiograph on day 3 showed elevated left hemidiaphragm, and the end of the chest tube was noted to overly the spine (Fig.3b). Four days later after removal of chest tube and extubation, the left hemidiaphragm had remained persistently elevated with a mediastinal shift to the right (Fig. 3 c).
Plication was carried out at one month of age, and patient has since remained asymptomatic.
Case 4 Male infant delivered by Caesarian section after 33 weeks of gestation. The birth weight was 1.8 kg. He developed RDS at birth and was placed on mechanical ventilation.A right pneumothorax and surgical emphysema developed on the second day of life. He also developed extensive pulmonary interstitial emphysema and the pneumothorax was of a recurrent nature. Figure 4 a shows extensive pulmonary interstitial emphysema with the end of the right chest tube just adjacent to the right lateral border of the spine. He subsequentlydeveloped severe bronchopulmonary dysplasia which required intermittent ventilation for over nine months. Figure 4b shows extensive bronchopulmonary dysplasia with associated elevated right hemidiaphragm due to phrenic nerve paralysis. Plication was carried out at the age of one year. Recurrent respiratory distress and high riding right hemidiaphragm has persisted despite the procedure.
Discussion Phrenic nerve paralysis developed on the side of chest tube placement, and was associated with i m p i n g e m e n t of the chest tube on the mediastinum or spine. Furthermore, three of the four infants were delivered by Caesarian section, thereby excluding the possibility of birth injury resulting in phrenic nerve palsy. E v e n t r a t i o n of the diaphragm presents essentially similar radiographic features as phrenic nerve palsy. Whilst eventration is a congenital anomaly consisting of partial or total hypoplasia of the diaphragm, phrenic nerve palsy is acquired and results from the disruption of
380
Fig.la, b. Case 1. a There is a left pneumothorax, b Chest radiograph showing elevated left hemidiaphragm. The medial end of the chest tube overlies the spine Fig. 2 a,b. Case 2. a Chest radiograph: There are bilateral chest tubes. The medial end of the left tube overlies the spine, b The left hemidiaphragm has remained elevated after removal of chest tube
Fig.3 a---e. Case 3. a Chest radiograph: There is a residual anterior pneumothorax, and a left chest tube. The diaphragm is normal, b Chest radiograph: There is elevation of the left hemidiaphragm and the left chest tubeimpingesonthespine, c Postchest tuberemovalthereispersistent elevated left hemidiaphragm and mediastinal shift to the right Fig.4a, b. Case 4. a Chest radiograph: There is extensive bilateral pulmonary interstitial emphysema and a localised right lower pneumothorax. The right chest tube end impinges on the spine, b At 9 months: the right hemidiaphragm is markedly elevated. Note extensive bronchopulmonary dysplasia
transmission of nerve impulses through the phrenic nerve. Chin and Lynn claimed that these two conditions can be distinguished by F a r a d i c stimulation of the phrenic nerve [7]. O n the other hand O h et al. suggest that a diagnosis of phrenic nerve palsy can be m a d e on plain chest radiographic findings when prior radiographs, with n o r m a l diaphragm, are available for comparison [8]. The four infants in this reports all had previous chest radiographs with n o r m a l diap h r a g m prior to the insertion of chest tubes. We feel therefore that these are cases of phrenic nerve palsy resulting from a crush injury of the ipsilateral phrenic nerve.
381 In two of the three previous reports, chest tube compression of the phrenic nerve was suggested as cause of diaphragmatic paralysis [4, 5]. In both reports it was suggested that chest radiographs should be obtained to check the position of the chest tube immediately after the latter was inserted. They did not however give an indication of the optimal position of the tube end. As a rule of thumb, we suggest that on the frontal radiograph, the medial end of the chest tube should be no less than one centimeter from the spine or mediastinum. The precise onset of phrenic nerve paralysis post chest tube is difficult to determine in view of the associated lung disease in the infants. In three infants however phrenic nerve paralysis was diagnosed within a week of insertion of chest tube. This early onset of phrenic
nerve palsy was also observed in the previous reports.
References
1. Smith CD, Sade RM, Crawford FA, Otherson HB (1986) Diaphragmatic paralysis and eventration in infants. J Thorac Cardiovasc Surg 91:490 2. Zhao HX, D'Agostino RS, Pitlick PT, Shumway NE, Miller DC (1985) Phrenic nerve injury complicating closed cardiovascular surgical procedures for congenital heart disease. Ann Thorac Surg 39:445 3. Watanabe T, Trusler GA, Williams WG, Edmonds JF, Coles JG, Hosokawa WG (1987) Phrenic nerve paralysis after pediatric cardiac surgery. Retrospective study of 125 cases. J Thorac Cardiovasc Surg 94:383 4. Philips AF, Rowe JC, Raye JR (1981) Acute diaphragmatic paralysis after chest tube placement in a neonate. AJR 136:824
5. Marrineili PV, Ortiz A, Alden (1981) Acquired eventration of the diaphragm: a complication of chest tube placement in neonatal pneumothorax. Pediatrics 67:552 6, Arya H, Williams J, Ponsford, Bissenden JG (1991) Neonatal diaphragmatic paralysis caused by chest drains. Arch Dis Child 66:441 7. Chin EF, Lynn RB (1956) Surgery of eventration of the diaphragm. J Thorac Surg 32:6 8. Oh KS, Newman B, Bender MB, Bowen A (1988) Radiologic evaluation of the diaphragm. Radiol Clin North Am 26:355
Dr. J. C. Odita E O. Box 3050 Department of Radiology Hamad Medical Corporation Doha Qatar
