What is abnormal diaphragmatic excursion? The B-mode was applied for diaphragmatic identification, and the M-mode was employed for the recording of the amplitude of diaphragm contraction during quiet breathing, deep breathing and sniffing. [QxMD MEDLINE Link]. . Diaphragmatic crural thickness in eventration and paralysis. Cugell DW. (Coronal image reproduced from Nason LK, Walker CM, McNeely MF, etal. and transmitted securely. It refers to the assessment of the lungs by either the vibration intensity felt on the chest wall (tactile fremitus) and/or heard by a stethoscope on the chest wall with certain spoken words (vocal resonance). Pulmonary examination findings of common disorders. A paralyzed hemidiaphragm will lack downward motion on inspiration and may have paradoxical motion on sniffing. In eventration the diaphragm, although thin, remains visible as a continuous layer over the elevated abdominal viscera and retroperitoneal or omental fat. Chest. There may even be transient upward (paradoxical) motion, particularly of the right anterior hemidiaphragm. [8,11], Acquired hiatal hernias in the adult population are caused by an enlargement of the esophageal hiatus in conjunction with the weakness of phrenoesophageal ligaments.[8]. In pitting one hemidiaphragm against the other, sniffing is analogous to arm wrestling, in which the arm of the stronger opponent pushes forward, forcing the weaker opponents arm backward (i.e., paradoxically), even though the weaker arm is not paralyzed. Diaphragmatic excursion is the movement of the thoracic diaphragm during breathing. Methods: 23 hemiplegic patients who were diagnosed with a single-hemisphere lesion (mean age 60.5 years; 13 males and 10 females) and a control group of 20 patients (13 males and 7 females) were all evaluated by ultrasonography. This anatomy article is a stub. It usually involves the anteromedial portion of the right hemidiaphragm and only rarely the left, but it can involve the central portion of either cupola. The diaphragm is anterolaterally connected to the sternum, the xiphoid process, and to the last six costal cartilages through muscle bundles (or diaphragmatic slips), while posteriorly it is attached to the first lumbar vertebral bodies through two musculotendinous structures (the crura). The lung exam. Learn how and when to remove this template message, "Diaphragmatic Excursion-Posterior Lungs", https://en.wikipedia.org/w/index.php?title=Diaphragmatic_excursion&oldid=973014894, Articles needing additional references from January 2014, All articles needing additional references, Creative Commons Attribution-ShareAlike License 3.0, This page was last edited on 14 August 2020, at 22:53. Normally the right dome of the diaphragm is higher in position as compared to the left dome, if the left dome of the diaphragm is elevated (>2 cm) diaphragmatic palsy should be suspected. Documentation of a basic, normal respiratory exam should look something along the lines of the following: The chest wall is symmetric, without deformity, and is atraumatic in appearance. [QxMD MEDLINE Link]. The examiner places the ulnar edge of the hand on the chest wall while the patient repeats a specific phrase, typically ninety-nine or one, two, three. The strength of the vibrations felt indicates the attenuation of sounds transmitted through the lung tissues. As a result, weakness or paralysis with impaired excursion and cranial dislocation of the diaphragm can be detected, with consequent lung parenchyma atelectasis and respiratory distress. One dog with bilateral diaphragmatic paralysis showed paradoxical movement of both crura at the end of inspiration. Bilateral hemidiaphragmatic weakness can also occur after prolonged mechanical ventilation and may signal that the patient cannot be weaned from the ventilator. Table 1. Evaluation of the diaphragm by a subcostal B-scan technique. This can occur in a pneumothorax, hemothorax, pleural effusion, or parenchymal consolidation, which includes the feeding airway. Characteristics of Diaphragmatic and Chest Wall Motion in People with Normal Pulmonary Function: A Study with Free-Breathing Dynamic MRI. Various authors have described ultrasound techniques to assess diaphragmatic . Hence, the aim of this paper is to provide an overview of normal and pathological features of the diaphragm on MRI and, therefore, to demonstrate the usefulness of this technique in different clinical circumstances. 1. The diaphragm is a dome-shaped musculotendinous structure placed between the thorax and the abdominal cavity. Keywords: 78.3 ). The breathing pattern encompasses the rate, rhythm, and volume of a patients breathing. A real-time imaging of diaphragmatic function can be performed through fluoroscopy, US, and MRI during normal respiration, deep breathing, or sniffing. Bickley LS, Szilagyi PG. Rales or crackles, abnormal sounds heard over the lungs with a stethoscope. 2009 Feb;135(2):391-400. doi: 10.1378/chest.08-1541. Crackles (rales) in the interstitial pulmonary diseases. We also use third-party cookies that help us analyze and understand how you use this website. Beyond the limits of a time-consuming exam and the indispensable patients compliance, MRI is currently the most comprehensive imaging modality in the evaluation of diaphragmatic pathologies. Unilateral diaphragmatic paralysis or weakness is usually asymptomatic and is found incidentally on chest radiographs obtained for a different reason. The lower cervical canal measures 12-14 mm. [5, 6] Breath sounds can be classified as vesicular, bronchial, or absent/attenuated. Table 2. The main findings quantifiable on the US are diaphragmatic thickness and amplitude of excursion during free or forced breathing. A rocking motion may ensue on lateral view, with the anterior eventrated segment moving upward while the posterior portion moves downward. Any lung or pleural disease can give rise to a decrease in overall chest expansion. 5376 Diaphragmatic Excursion in Healthy Adults: Normal alues. Percussion a. assess any areas of dullness, flatness, tympany . It is generally defined as a zoonotic infection caused by the incidental ingestion of the eggs of a small tapeworm parasite (Echinococcus granulosus), and the involvement of the diaphragm is of rare occurrence. The normal breathing rate is 10-14 breaths per minute, with an approximate 1:3 ratio of inspiration to expiration. 78.2 ). [8,14], Benign entities are usually asymptomatic unless their size leads to a mass-effect, generally with respiratory impairment. Also, there is often 1 to 2cm upward displacement of the resting position of the hemidiaphragms. 2021 Mar 22;7(1):00714-2020. doi: 10.1183/23120541.00714-2020. Left dominance is twice as common as right dominance and the mean left excursion is greater than the mean right excursion. Accessibility Although diaphragm fluoroscopy is often called the sniff test, sniffing is not the most important part, and sniffing by itself does not diagnose paralysis. This website also contains material copyrighted by 3rd parties. While auscultation is most commonly practiced, both percussion and inspection are equally valuable techniques that can diagnose a number of lung abnormalities such as pleural effusions, emphysema, pneumonia and many . How to cite this article: Cicero G, Mazziotti S, Blandino A, Granata F, Gaeta M. Magnetic resonance imaging of the diaphragm: From normal to pathologic findings. [2]. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. Axial and coronal CT images show a large right upper lobe mass that has invaded the adjacent mediastinum, injured the phrenic nerve, and paralyzed the right hemidiaphragm. The author shows that unequal excursion of the two leaves of the diaphragm is a normal finding. [1, 2]. Bilateral paralysis occurs occasionally after cardioplegia for cardiac surgery; this form is usually reversible with time. Learn and reinforce your understanding of Pleural effusion, pneumothorax, hemothorax and atelectasis: Pathology review through video. Normal diaphragmatic excursion should be 3-5 cm, but can be increased in well-conditioned persons to 7-8 cm. Ultrasonography can be used in intubated patients to detect diaphragmatic thinning, which can influence weaning the patient from the ventilator. (Reproduced from Nason LK, Walker CM, McNeely MF, etal. Complete eventration of a hemidiaphragm is a rare, congenital abnormality that is almost always on the left. Postgrad Med J. Seldom, the diaphragm can be the primary and only site of the implant of the hydatid cysts (1%), through a vascular or lymphatic spread from the bowel. This study aimed to define the normal range of diaphragmatic motion (reference values) by Mmode ultrasound for the normal population. Diaphragmatic excursion values presented in this study can be used as reference values to detect diaphragmatic dysfunction in clinical practice. Diaphragmatic excursion; Ausculate breath sound; Ausculate voice and . The diagnosis of paralysis requires observing quiet and deep inspiration. For the rest of this chapter we will use eventration to mean partial eventration . ; Decreased tactile fremitus, because vibrations travel poorly through air filled spaces. Would you like email updates of new search results? The available chest radiographs and the clinical findings were reviewed and correlated with the sonographic findings. Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina. The diaphragm can be affected by a plethora of benign or malignant primary tumors. The lateral view is needed to show the excursion of the posterior portion of the diaphragm, which is usually more vigorous than the anterior portion. The main role of CT in patients with eventration is in distinguishing the abnormality from a focal bulge along the diaphragm that might represent hernia or even tumor. Normal: The lung is filled with air (99% of lung is air). eCollection 2021 Jan. Scarlata S, Mancini D, Laudisio A, Benigni A, Antonelli Incalzi R. Respiration. %PDF-1.7 % Left dominance is twice as common as right dominance and the mean left excursion is greater than the mean right excursion. Nazir A Lone, MD, MBBS, MPH, FACP, FCCP Physician in Pulmonary and Critical Care Medicine, Peconic Bay Medical Center, Northwell Health %%EOF It is usually no more than 90 degrees, with the ribs inserted at approximately 45-degree angles. LEMNKA$'dX"8u&HG _$T5 7 v [10], However, when positive, the US is usually followed by MRI for a more accurate assessment in terms of fetal lung volume, organ herniation, and neonatal survival prediction [Figure 2].[10]. because of the position of the liver. [QxMD MEDLINE Link]. Medical Definition of hyperresonance : an exaggerated chest resonance heard in various abnormal pulmonary conditions. [14], Moreover, the diaphragm can be affected by metastasis from primary tumors, especially breast, ovarian, and thymus, or it can be infiltrated by tumors arising in the adjacent, thoracic, or abdominal structures [Figure 8].[1,8,14]. Nath AR, Capel LH. A decrease suggests air or fluid in the pleural spaces or a decrease in lung tissue density, which can be caused by diseases such as chronic obstructive pulmonary disease or asthma. The thorax and lungs. If it is less than 35cm the patient may have a pneumonia or a pneumothorax in which a chest x-ray is diagnostic for either.[1]. Wheezing rhonchi, and crackles: Reflect narrowed bronchial lumina secondary to inflammation and mucous. Both hemidiaphragms are elevated, often with atelectasis in the lung bases. Thus the finding of an elevated hemidiaphragm with normal thickness of the crus likely reflects eventration rather than paralysis. This causes increased transmission of whispered words, called pectoriloquy. There was a statistically significant difference between right and left diaphragmatic excursion among all studied subjects. Therefore, radiologists and physicians should be aware of the diagnostic possibilities of this safe and valuable technique and confident with the images achievable. This point is also marked. With the patient upright, adjust collimation to show the entire chest. History and physical examination. Thorax. An important role of computed tomography (CT) in the assessment of patients with diaphragmatic paralysis is to rule out tumor, lymphadenopathy, aneurysm, or other lesion that may be compromising the phrenic nerve ( Fig. Coarse crackles are typically a combination of alveolar reopening and bubbling of air through retained secretions in smaller airways. This measures the contraction of the diaphragm. Koster ME, Baughman RP, Loudon RG. Comparison of ultrasound with fluoroscopy in the Assessment of suspected hemidiaphragmatic movement abnormality. Lung crackles in bronchiectasis. Necessary cookies are absolutely essential for the website to function properly. Differential Diagnoses of Crackles (Open Table in a new window). Changes in pectoriloquy for several common disorders are shown in Table 1. Fluoroscopy allows a two-dimensional evaluation mainly focused on the assessment of the anterior central tendon movements, although with the limit of radiation exposure. [3], Observations outside of the chest add information to the initial assessment. At MRI, these types of hernias are usually detected as incidental findings [Figure 3]. Partial eventration is much more common than the complete form. See Table 78.1 for a summary of fluoroscopic findings in the various conditions. Early inspiratory crackles occur immediately after initiation of inspiration and are more often associated with interstitial lung disease. CT also is important in assessing the thickness of diaphragm muscle. 1995 Sep. 8(9):1584-93. The diaphragmatic excursion is measured as the amplitude of wave seen in M-mode during breathing. On the other hand, conventional fluoroscopy, ultrasound (US), and magnetic resonance (MR) are able to overcome the mere morphologic assessment, extending the evaluation to the diaphragmatic functionality, through a real-time appraisal.[3-5]. The distance between the two markings indicates the range of motion of the diaphragm. Costal angle. Note that this maneuver should be a single long sniff, not a series of short sniffs. Careers. This technique should be applied to the regions shown in the images below, comparing the two hemithoraces. The thorax and cardiovascular system. The elevation extends all the way to the posterior chest wall on lateral view, unlike with large eventration. NORMAL FINDINGS. There was a significant difference in diaphragmatic excursion among age groups. J Clin Imaging Sci 2020;10:1. Pulmonary Examination Findings of Common Disorders, Table 2. The purpose of this study was to . DeGowin RL. Inspiratory crackles and mechanical events of breathing. I am currently continuing at SunAgri as an R&D engineer. Fluoroscopy. Once an abnormality is detected, percussion can be used around the area of interest to define the extent of the abnormality. Areas of well-aerated lung will be resonant, or tympanic, to percussion. Sniffing is best viewed as a stress test that elicits relative weakness (not only paralysis) of a hemidiaphragm. Tilt the fluoroscopic table to the supine position. [7], Bronchial breath sounds often result from consolidation within lung parenchyma with a patent airway leading to the involved area. The statistical analysis showed that the diaphragmatic excursions were larger in men compared to women, supporting the determination of normal values based on sex, and the lower and upper limits of normal excursion were determined for men and women for both hemidiaphragms during the three manoeuvres. Normal findings . The ratio of right to left diaphragmatic excursion during quiet breathing was (1.0090.19); maximum 181% and minimum 28%. The patients level of distress should be immediately assessed, as those in severe distress may be experiencing impending respiratory failure that requires intubation. New York: Elsevier; 2010. 73(3):333-9. Palpation of the chest includes evaluation of thoracic expansion, percussion, and evaluation of diaphragmatic excursion. RI: Right Index, REXI: Right Membranatic Excursion, SAFI: ratio regarding saturation to inspired oxygen fraction (SO 2 /FiO 2), LI: Lefts Index, LEXI: Left Diaphragmatic Excursion.. Consonant to previously published recommendations, the manner of weigh right and left diaphragmatic excursion was performed [].B-mode was first utilized to find the our focus and to select an scan line the each . Diagnoses that may present with stridor include epiglottitis, vocal cord dysfunction, croup, and airway edema (which could be secondary to trauma or an allergic reaction). Diminished chest movement occurs with barrel chest, restrictive disease, and neuromuscular disease. This inequality is obvious without measurement in one out of . Only 19 cases showed a right to left ratio of less than 50% (5 men and 14 women). Philadelphia: Lippincott Williams & Wilkins; 2005. government site. Results: A total of 742 hemidiaphragms were evaluated in 278 children. RATIONALE: Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Then observe two quiet breaths and note the resting positions of both hemidiaphragms at end expiration. Kussmaul breathing is a rapid, large-volume breathing caused by acidotic stimulation of the respiratory center; it can indicate metabolic acidosis. These techniques may be used to evaluate suspected abnormalities. Note the hyper-resonance of the left lower anterior chest due to air filled stomach. Diaphragmatic ultrasound has gained importance because of its many advantages, including the fact that it is noninvasive, does not expose patients to radiation, is widely available, provides immediate results, is highly accurate, and is repeatable at the bedside. Unequal movement, or a minute amount of movement, indicates asymmetry and poor diaphragmatic excursion, respectively. Again, because upward (paradoxical) motion on sniffing could reflect weakness, eventration, or paralysis, the fluoroscopic diagnosis of hemidiaphragmatic paralysis is not based on sniffing but instead on the absence of downward motion on slow, deep inspiration. This category only includes cookies that ensures basic functionalities and security features of the website. Normally, fremitus is most prominent between the scapulae and around the sternum. This sound is characterized by crackles synchronous with cardiac contraction, and not with respiration. Bronchiectasis, which can be secondary to the following: Wheezes are continuous, high-pitched, musical, predominantly expiratory sounds that are produced by air flowing through narrowed bronchi, causing fluttering and resonance of the bronchial walls. MRI has demonstrated to be particularly accurate in the detection and characterization of the fluid and solid components of the cysts [Figure 9].[15-17]. This should occur symmetrically between the two hemithoraces so that sounds may be compared between sides. Paralysis of right hemidiaphragm resulting from phrenic nerve injury by lung cancer. Normal diaphragmatic excursion should be 35 cm, but can be increased in well-conditioned persons to 78 cm. Again observe two deep breaths, then two quiet breaths, and note the resting positions of both hemidiaphragms at end expiration. MRI overcomes the achievements of conventional fluoroscopy and US, thanks to its safeness and the wide field of view [Figure 1 and Video 1]. Normal areas of dullness are those overlying the liver and spleen at the anterior bases of the lungs. The diaphragm is seen as a thick white line moving with respiration. Diaphragmatic excursion is the movement of the thoracic diaphragm during breathing. Because sound is transmitted more strongly through nonair-filled lung, increased fremitus suggests a loss or decrease in ventilation in the underlying lung. [9], Fine crackles are typically produced by the forced reopening of alveoli that had closed during the previous expiration. These muscles include the sternocleidomastoid, upper trapezius, pectoralis major, and others. Average diaphragmatic excursion was 2.5 cm between inspiratory and expiratory scans (2.7 cm in men, 2.3 cm in women; p = .5 . This determines the range of movement of the diaphragm. PMC Often the finding of asymmetry is more important than the specific percussion note that is heard. ABNORMAL FINDINGS. The site is secure. [QxMD MEDLINE Link]. Diaphragmatic ultrasound was 93% sensitive and 100% specific for the diagnosis of neuromuscular diaphragmatic dysfunction. Clipboard, Search History, and several other advanced features are temporarily unavailable. The expected finding is that the words will be indistinct. The diaphragm is seen as a thick, Visualization and measurement of right diaphragmatic excursion by M-mode ultrasound. On lateral view excursion is usually greater posteriorly, particularly on the right; it may be slightly asymmetric, and the right side may lag, particularly anteriorly. Left dominance is twice as common as right dominance and the mean left excursion is greater than the . Asymmetry and diaphragmatic excursion can be assessed by placing one hand posteriorly on each hemithorax near the level of the diaphragm, palms facing anteriorly with thumbs touching at the midline. Less common causes are herpes zoster, West Nile virus, cervical spondylosis, poliomyelitis, amyotrophic lateral sclerosis, and pneumonia. The diaphragm is a musculotendinous structure that divides the chest from the abdomen. One important nonpulmonary sound is a mediastinal crunch, caused by pneumomediastinum. 8(2):265-72. Crepitation refers to situations where noises are produced by the rubbing of parts one against the other, as in: Crepitus, a crunching sensation felt in certain medical problems. A. distance between the transition point on full expiration and the transition point on full inspiration is the extent of diaphragmatic excursion (normally 3-5.5 cm). The patterns of normal breath sounds are created by the effect of body structures on air moving through airways. 78.5 ). 1986 Jul. [2, 3]. These sounds occur in addition to the breath sounds described above. -. Healthy volunteers were included in this study. These cookies will be stored in your browser only with your consent. the diaphragm relaxes during expiration: moves upwards; both hemidiaphragms move together; in healthy patients 1-2.5 cm of excursion is normal in quiet breathing 2; 3.6-9.2 cm of excursion is normal in deep breathing 2; up to 9 cm can be seen in young or athletic individuals in deep inspiration 2; excursion in women is slightly less than men 2 On quiet and deep inspiration both hemidiaphragms move downward as the anterior chest wall moves upward. Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: Academy of Persian Physicians, American Academy of Sleep Medicine, American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, Association of Pulmonary and Critical Care Medicine Program Directors, Association of Specialty Professors, California Sleep Society, California Thoracic Society, Clerkship Directors in Internal Medicine, Society of Critical Care Medicine, Trudeau Society of Los Angeles, World Association for Bronchology and Interventional PulmonologyDisclosure: Nothing to disclose. The mean right hemidiaphragmatic excursion was 2.320.54, 5.541.26 and 2.900.63 for quiet breathing, deep breathing and sniffing, respectively, while the left hemidiaphragmatic excursion was 2.350.54, 5.301.21 and 2.970.56 cm for quiet breathing, deep breathing and sniffing, respectively. [1, 2, 3] Although inspection begins when the physician first visualizes the patient, it should ideally be performed with the patient properly draped so the chest wall can be visualized. Epub 2008 Nov 18. This website uses cookies to improve your experience while you navigate through the website. Cheyne-Stokes respiration is characterized by periods of apnea that are interspersed between cycles of progressively increasing then decreasing respiratory rates, which often indicates uremia or congestive heart failure (CHF). The aims of this study were to determine reference values for diaphragmatic excursion and thickness, as evaluated by sonography in healthy infants and children, and identify correlations between them and anthropometric measurements, age, and sex. Other common causes include trauma (natural or surgical) and cardioplegia for cardiac surgery (phrenic frostbite). Eventration is a congenital anomaly consisting of failure of muscle development of part or all of one or both hemidiaphragms. [1, 2]. Percussion produces sounds on a spectrum from flat to dull depending on the density of the underlying tissue. Right diaphragm visualization by B-mode ultrasound. When the patient inspires, each hand should rotate away from the midline equally. Therefore, diaphragmatic dysfunction may cause a respiratory failure without any pathology of the lungs. This type of crackle is more often associated with pulmonary edema and asthma. The use of accessory muscles can also indicate increased work of breathing and should be noted on initial assessment. . See this image and copyright information in PMC. Normal diaphragmatic excursion is 5-6 cm. Medscape Education, Nocardia pseudobrasiliensis Co-infection in SARS-CoV-2 Patients, encoded search term (Pulmonary Examination) and Pulmonary Examination, Pediatric Anti-GBM Disease (Goodpasture Syndrome), Improving Swallowing May Mitigate COPD Exacerbations, Type of Insurance Linked to Length of Survival After Lung Surgery, Genetic Analysis Shows Causal Link of GERD, Other Comorbidities to IPF, Invasive Aspergillosis in Coronavirus Disease 2019. The crus atrophies with paralysis but not with eventration ( Fig. Joseph Z Springer, MD Resident Physician in Internal Medicine, Olive View-UCLA Medical CenterDisclosure: Nothing to disclose. On supine views there may excess elevation of the resting position of the hemidiaphragm. 241-77. If the paralysis is on the left, the stomach and splenic flexure of the colon relate to the inferior surface of the hemidiaphragm and usually contain more gas than normal. This measures the contraction of the diaphragm. The study included 757 healthy subjects [478 men (63.14%) and 279 women (36.86%)] with normal spirometry and negative history of previous or current respiratory illness. Eur Respir J. Collapsed lung can be caused by an injury to the lung. American Association for Bronchology and Interventional Pulmonology, International Association for the Study of Lung Cancer, American College of Critical Care Medicine, Association of Pulmonary and Critical Care Medicine Program Directors, World Association for Bronchology and Interventional Pulmonology. On upright views the excursion of both hemidiaphragms may appear to be normal if the patient is using abdominal muscles to passively move the diaphragm. Backward, physicians and radiologists should be aware of the undoubted advantages of MRI and confident about the normal or pathologic imaging features, to avoid misdiagnosis. Beyond the morphologic and structural assessment, the use of dynamic gradient echo recalled acquisitions for the evaluation of diaphragmatic excursion has been longstanding established. An official website of the United States government. The easiest place to observe muscle thickness is the crus of the hemidiaphragm. (A) Coronal CT shows focal elevation of both hemidiaphragms with undercut edges. You can help Wikipedia by expanding it. The .gov means its official. They are often characterized by secretions within the large airways and can be heard in a wide variety of pathologies, any of which cause increased secretions, such as in cystic fibrosis, pneumonia, bronchitis, pulmonary edema, or emphysema. Within the formers, the left hemidiaphragm has demonstrated to be the most vulnerable, due to the lack of liver protection and the inherent structural weakness. The lung adjacent to a paralyzed hemidiaphragm often has subsegmental atelectasis resulting from elevation and reduced motion. Three principal abnormal patterns of breathing have been described. Soft heart sounds: Interposition of fluid (pericardial effusion) or Lung (hyper inflated lungs). Eventration involving the anterior right hemidiaphragm can be distinguished from a Morgagni hernia by its contour on the lateral radiograph.
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