Reply to the Letter to the Editor Letter to the Editor Reply to Khalil and Sarkar

We appreciate the comments of Khalil and Sarkar [1] that they made concerning our paper about traumatic diaphragmatic rupture [2]. We also appreciate the fact that they mentioned the difficulties in the early diagnosis of right-sided diaphragmatic injuries. Meanwhile, we did not understand why they do not agree with our conclusion that a high index of suspicion is of utmost importance for the diagnosis of these patients, since they mentioned that a persistently elevated right hemidiaphragm on routine X-ray must arouse suspicion. Clearly, we reported 11 patients with right-sided injury where 2 of them had late diagnosis. Although the major complaint of these two patients was dyspnea, we agree with Khalil and Sarkar that a high index of suspicion should also be held when dealing with post-trauma patients who complain of persistent right-sided chest discomfort after trauma. Furthermore, in our paper, we emphasized the sensitivities of radiological investigations, where a chest X-ray reached 17% sensitivity, while this rose to 50% with a CT in right-sided injuries. In other words, chest X-ray can be normal in such cases. Certainly, diagnosis can be elusive, as we stated. There are reviews questioning the role of each imaging method [3]. Shanmuganathan et al. highlighted that if the chest radiography is indeterminate, spiral computed tomography with thin sections and reformatted images is the next study of choice and magnetic resonance imaging is only used to evaluate the diaphragm for patients with clinical suspicion but an indeterminate diagnosis after chest radiography and spiral CT [4]. Herein, it is stated that detection of diaphragmatic injuries has improved with helical CTand should further improve with multisection CT for more accurate analysis of the diaphragm.