[1, 2]. 286-322. 2013 Dec. 89(1058):693-7. 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. The position a patient assumes during respiration may also lend clues to a diagnosis. 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. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. The thorax and lungs. Thus, they are caused by pathology leading to the narrowing of bronchi, most commonly COPD, asthma, and bronchitis. 78.4 ). This measures the contraction of the diaphragm. On quiet and deep inspiration both hemidiaphragms move downward as the anterior chest wall moves upward. Unable to load your collection due to an error, Unable to load your delegates due to an error. Visual inspection can be used to appreciate the level of distress, use of accessory muscles, respiratory position, chest structure, respiratory pattern, and other clues outside of the chest. Congenital variations include pectus excavatum, in which the sternum is depressed relative to the ribs, or, conversely, pectus carinatum, which is characterized by anterior protrusion of the sternum. CT also is important in assessing the thickness of diaphragm muscle. [6], Normally the diaphragm looks like a thin band with low signal intensity on both the T1-w and T2-w images.[3]. Functional cookies help to perform certain functionalities like sharing the content of the website on social media platforms, collect feedbacks, and other third-party features. The purpose of this study was to . [8,9], The usual classification includes: Intrapleural (or Bochdalek), mediastinal (or Morgagni), and hiatal herniations: The formers mainly cause lung hypoplasia and mediastinal shift to the contralateral side due to the thoracic herniation of abdominal content; mediastinal hernias occur posteriorly to the sternum, with the involvement of liver and bowel, and are mainly related to cardiac malformations; hiatal hernias arise posteriorly within the mediastinum, usually together with esophageal alterations. Normal areas of dullness are those overlying the liver and spleen at the anterior bases of the lungs. 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. History and physical examination. Bilateral paralysis occurs occasionally after cardioplegia for cardiac surgery; this form is usually reversible with time. Please enable it to take advantage of the complete set of features! Hemidiaphragmatic weakness often becomes more obvious on rapid, deep inspiration, with the weak hemidiaphragm lagging behind the normal side. Analytical Prevalence Study. Right diaphragm visualization by B-mode ultrasound. [4], Palpation is the tactile examination of the chest from which can be elicited tenderness, asymmetry, diaphragmatic excursion, crepitus, and vocal fremitus. Copyright 2023 Journal of Clinical Imaging Science All rights reserved. Though the lung is collapsed, a large amount of air is trapped in the pleural space. Average diaphragmatic excursion in M-mode 14.58 15.00 19.00 10.00 2.14 Maximum diaphragmatic excursion M mode 21.14 16.00 213.00 11.00 28.07 M-mode expiratory velocity 6.19 1.90 218.00 0.80 30.57. Schraufnagel DE, Murray JF. Share cases and questions with Physicians on Medscape consult. Differential breathing patterns can give clues to diseases of multiple different organ systems as much as the respiratory system itself. Language links are at the top of the page across from the title. 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. If a patient is to remain recumbent, roll the patient from one side to the other to examine the back. [QxMD MEDLINE Link]. Fluoroscopy. Percuss for diaphragmatic excursion. Nath AR, Capel LH. 2009 Feb;135(2):391-400. doi: 10.1378/chest.08-1541. Right diaphragm visualization by B-mode ultrasound. To assess movement of the diaphragm. The diaphragm is seen as a thick, Visualization and measurement of right diaphragmatic excursion by M-mode ultrasound. Place the palms of both your hands over the lower thorax, with your thumbs adjacent to the spine and your fingers stretched laterally. Diagnostics (Basel). Although diaphragm fluoroscopy is often called the sniff test, sniffing is not the most important part, and sniffing by itself does not diagnose paralysis. Complete eventration of a hemidiaphragm is a rare, congenital abnormality that is almost always on the left. During positive pressure ventilation (PPV) after anesthesia and neuromuscular blockade and depending on tidal volume, the nondependent region (top) undergoes the greatest excursion, or the diaphragm moves uniformly. [1, 2]. Listen to the chest with a stethoscope. Diaphragmatic excursion: Is 4-6 centimeters between full . RATIONALE: Tracheal deviation is a medical emergency when it is caused by a tension pneumothorax. Normal and abnormal diaphragmatic motion and diaphragmatic paralysis can be assessed with dynamic MRI. On deep breathing downward excursion is nearly or completely absent. New York: McGraw-Hill; 1994. . Again observe two deep breaths, then two quiet breaths, and note the resting positions of both hemidiaphragms at end expiration. Early inspiratory crackles occur immediately after initiation of inspiration and are more often associated with interstitial lung disease. In fact, the ability of ultrasonography to assess diaphragmatic thickness and changing thickness with respiration is a potential advantage over fluoroscopy. Objective: The aim of this study was to evaluate the effect of hemiplegia on diaphragmatic movements using motion-mode ultrasonography. Yang X, Sun H, Deng M, Chen Y, Li C, Yu P, Zhang R, Liu M, Dai H, Wang C. J Clin Med. The ideal position for auscultation is to place the patient in a sitting position. Inflammation or neoplasia can cause thickening of the pleural surfaces, which then creates more friction when sliding along one another, creating this sound. 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. Diaphragmatic excursion values presented in this study can be used as reference values to detect diaphragmatic dysfunction in clinical practice. [9], Fine crackles are typically produced by the forced reopening of alveoli that had closed during the previous expiration. Paralysis of left hemidiaphragm. [6, 8] Typically, there is a pause between inspiratory and expiratory sounds, as the involved parenchyma does not fill with air during this time in inspiration. Background. Observe a couple of quiet breaths. Beyond the morphologic and structural assessment, the use of dynamic gradient echo recalled acquisitions for the evaluation of diaphragmatic excursion has been longstanding established. Coach the patient in taking in a slow deep breath with the mouth open and then letting it out without forcing it or pursing the lips. Repeat. However, in many cases the etiology is unknown. Ultrasonography recordings were . Those with comorbidities, skeletal deformity, acute or chronic respiratory illness were excluded. Careers. The paralyzed or weak hemidiaphragm is elevated and has an accentuated domed shape on the posteroanterior radiograph. Nonpulmonary sounds must also be appreciated during auscultation of the chest. Fremitus is abnormal when it is increased or decreased. Compared to 82 abnormal hemidiaphragms, 76 had abnormal sonographic findings (size < 2mm or decreased thickening with inspiration); compared to 49 normal hemidiaphragms, there were no false-positive ultrasound findings. This determines the range of movement of the diaphragm. Charting of these normal findings might be: resp rate-20/min, regular, no SOB1 . At ultrasonography the diaphragm appears as a thick echogenic line. The crus atrophies with paralysis but not with eventration ( Fig. J Clin Imaging Sci 2020;10:1. Unauthorized use of these marks is strictly prohibited. The .gov means its official. M-mode ultrasound; diaphragmatic excursion; diaphragmatic motion; diaphragmatic ultrasound; normal values; reference values. Lung sound nomenclature. Temporary or permanent, unilateral or bilateral diaphragmatic functional deficiencies can arise at three levels: The nervous system, the muscle, or the neuromuscular junction. I love to write and share science related Stuff Here on my Website. Before Left dominance is twice as common as right dominance and the mean left excursion is greater than the mean right excursion. 6th Ed. Unilateral diaphragmatic paralysis or weakness is usually asymptomatic and is found incidentally on chest radiographs obtained for a different reason. Take measurements at the end of deep inspiration and expiration. Always follow this sequence: inspection, auscultation, percussion, and palpation. This site needs JavaScript to work properly. The patients level of distress should be immediately assessed, as those in severe distress may be experiencing impending respiratory failure that requires intubation. The diaphragm is the primary muscle of ventilation, and dysfunction of the diaphragm is an underrecognized cause of dyspnea. Methods: 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 sniffing there is usually upward (paradoxical) motion. How does Parkinson's disease affect blood pressure? Dyspnea with mild to moderate effort may develop in patients with underlying lung disease. 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. This sound is characterized by crackles synchronous with cardiac contraction, and not with respiration. Diaphragmatic excursion: Is 4-6 centimeters between full inspiration and full expiration. One dog with bilateral diaphragmatic paralysis showed paradoxical movement of both crura at the end of inspiration. 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. The most common cause of bilateral diaphragmatic paralysis is spinal cord injury. Cugell DW. Ask the client to take a deep breath while you observe the movement of your hands and any lag in movement. 2018;96(3):259-266. doi: 10.1159/000489229. Whispered pectoriloquy can be elicited by having the patient whisper a repeated phrase (typically ninety nine). (A) Coronal CT shows focal elevation of both hemidiaphragms with undercut edges. Normal diaphragmatic excursion should be 35 cm, but can be increased in well-conditioned persons to 78 cm. 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]. 476 0 obj <>stream Thus the finding of an elevated hemidiaphragm with normal thickness of the crus likely reflects eventration rather than paralysis. Healthy volunteers were included in this study. Then the patient takes a deep breath in and holds it as the provider percusses down again, marking the spot where the sound changes from resonant to dull again. [2], Table 1. Fluoroscopy (not shown) demonstrated absent downward motion on deep inspiration and paradoxical upward motion of the left hemidiaphragm on sniffing. Absence of downward motion on slow, deep inspiration is the critical finding that indicates paralysis. What is abnormal diaphragmatic excursion? On the other hand, partial eventration is common; it may be acquired, and it usually affects patients older than 60 years, typically involving the anteromedial portion of the right hemidiaphragm. Physical Assessment Author: A. Chandrasekhar, MD . Bickley LS, Szilagyi PG. The diaphragm can be affected by a plethora of benign or malignant primary tumors. Diaphragmatic ultrasound was 93% sensitive and 100% specific for the diagnosis of neuromuscular diaphragmatic dysfunction. Soft heart sounds: Interposition of fluid (pericardial effusion) or Lung (hyper inflated lungs). FOIA The most common scenario, due to contiguity, consists of the direct extent from the liver (0.616%). Local tenderness can indicate trauma or costochondritis. Tactile fremitus is normally found over the mainstem bronchi near the clavicles in the front or between the scapulae in the back. The anteroposterior (AP) diameter of the normal adult male cervical canal has a mean value of 17-18 mm at vertebral levels C3-5. Comparison of ultrasound with fluoroscopy in the Assessment of suspected hemidiaphragmatic movement abnormality. See Table 1 for percussion findings in several common disorders. Diaphragm movements and the diagnosis of diaphragmatic paralysis. The diaphragm is a dome-shaped musculotendinous structure placed between the thorax and the abdominal cavity. 11, 24, 25 This study, with a cut-off point of TFdi of 30%, obtained a good . On deep inspiration downward excursion is less than one rib interspace. 1974 Nov. 29(6):695-8. [QxMD MEDLINE Link]. Thorax. Congenital diaphragmatic hernias are determined by an incomplete fusion of the pleuroperitoneal membranes and/or the embryologic mesodermal elements of the diaphragm. 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. Changes in pectoriloquy for several common disorders are shown in Table 1. Various authors have described ultrasound techniques to assess diaphragmatic . [12,13], Nevertheless, additional sequences can be acquired in all three planes, allowing at the same time lesion characterization and surrounding body tissue evaluation [Figures 4-7 and Videos 2 and 3].[3,6]. Diaphragmatic motion recorded by M-mode ultrasonography: limits of normality. 78.2 ). Medical Definition of hyperresonance : an exaggerated chest resonance heard in various abnormal pulmonary conditions. c. assess respiratory excursion (expansive movements of the chest during breathing) d. assess skin condition (temperature, etc.) An adult male without spinal stenosis has a diameter of 16-17 mm in the upper and middle cervical levels. Therefore, radiologists and physicians should be aware of the diagnostic possibilities of this safe and valuable technique and confident with the images achievable. 146(7):1411-2. Philadelphia: Lippincott Williams & Wilkins; 2005. PDF Diaphragmatic Excursion in Healthy Adults: Normal Values. Analytical Diaphragmatic motion studied by m-mode ultrasonography: methods, reproducibility, and normal values. 2021 Mar 22;7(1):00714-2020. doi: 10.1183/23120541.00714-2020. Clin Radiol 1995;50:958. Tracheal deviation may occur ipsilateral to an abnormality (such as in collapse or mucous plugging) or contralateral to an abnormality (such as in pleural effusion or pneumothorax). But opting out of some of these cookies may affect your browsing experience. There may be upward (paradoxical) motion on deep or even quiet breathing. Background: Diaphragmatic excursion during spontaneous ventilation (SV) in normal supine volunteers is greatest in the dependent regions (bottom). It is performed by asking the patient to exhale and hold it. 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. Diaphragmatic motion is affected by several factors including age, sex and body mass index. Observe two quiet breaths, and then observe two deep breaths with the second one followed by the sniff. normal, asbestosis, sarcoidosis) Coarse: loud, low-pitched . The resulting breath sounds are amplified through the consolidation, leading to a louder breath sound. Its motility, unintentional or voluntary, is crucial for the physiologic respiratory function due to its contribution to lung volume expansion and contraction. [4], In particular, the latter considerations are particularly important in the challenging differential diagnosis of lung diseases from diaphragm weakness in patients suffering from respiratory failure.[6]. Patients with a severe obstructive defect may breathe with pursed lips, as this can partially ameliorate the obstruction. Computed tomography (CT)-scan can provide morphological but not functional information about the diaphragm. Bettencourt PE, Del Bono EA, Spiegelman D, Hertzmark E, Murphy RL Jr. Clinical utility of chest auscultation in common pulmonary diseases. Diaphragm movements and the diagnosis of diaphragmatic paralysis The injuries of the diaphragm are a relatively rare occurrence in subjects suffering from thoracic-abdominal trauma (0.88%) and can be related to blunt or penetrating traumas. Normal breath sounds are classified as tracheal, bronchial, bronchovesicular, and vesicular sounds. Pulmonary Examination Findings of Common Disorders (Open Table in a new window). Diaphragm fluoroscopy is positive in more than 90% of patients with unilateral phrenic nerve paralysis. anterior = upper sternum in 1st and 2nd intercostals spaces. Diaphragm Disorders (Diaphragmatic Dysfunction) Workup Imaging of the diaphragm: anatomy and function. Eur Respir J. Tilt the fluoroscopic table to 45 degrees elevation. . Normally, the rest of the lung fields are resonant. 424 0 obj <> endobj Degowin & Degowin's Diagnostic Examination. [1,2], Different imaging modalities can be employed for the evaluation of the diaphragm. 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]. When the patient inspires, each hand should rotate away from the midline equally. 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. 8600 Rockville Pike However, US limitations consist in the restricted field of view, the possible impairment of lung air or bowel gas superimposition, and the strictly reliance on the operators expertise. Areas of well-aerated lung will be resonant, or tympanic, to percussion. While the patient is speaking, palpate the chest from one side to the other. For the remaining normal dogs, the lower limit values of diaphragmatic excursion were 2.85-2.98 mm during normal breathing. The patient can be asked to temporarily cease respiration to appreciate this difference. -, Houston JG, Fleet M, Cowan MD, McMillan NC. Reproducibility and Clinical Correlates of Supine Diaphragmatic Motion Measured by M-Mode Ultrasonography in Healthy Volunteers. LEMNKA$'dX"8u&HG _$T5 7 v The usual imaging test to demonstrate hemidiaphragmatic paralysis, weakness, or eventration is fluoroscopy, but ultrasonography or dynamic magnetic resonance (MRI) can be used. 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). this is in accordance with our findings and suggests that diaphragm mobility analysis is a sensitive method to detect subtle changes in respiratory function upon physiotherapy. You are being redirected to 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. [2, 3, 4], Table 1 illustrates changes in fremitus in several common disorders. The transmitted sounds will be louder over the area of consolidation. 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. 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. When spoken words travel through aerated lung, they are attenuated by airspaces as they move toward the periphery. The left crus is normally slightly thinner than the right. The diaphragm is a musculotendinous structure that divides the chest from the abdomen. This website uses cookies to improve your experience while you navigate through the website. Crepitus is the sensation of crackles under the fingertips during superficial palpation of the chest wall. There may be transient upward motion of the segment on deep or even quiet breathing. Bronchophony:Ask the patient to say 99 in a normal voice. These crackles are softer, and higher in pitch, while coarse crackles are louder and lower in pitch. Among all, magnetic resonance imaging (MRI) has demonstrated to be the most accurate technique in providing a morphologic and functional assessment of the diaphragm as well as information about the adjacent structures. 1. Normal TFdi values in the literature vary from 29% to 36%, a cut-off of 30% has a reported sensitivity of 88%, specificity of 71%, and AUC of 0.79, being the combined use (TFdi and diaphragmatic excursion), relevant parameters when evaluating the suspension of MV. 78.5 ). Introduction. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? Phrenic nerve stimulation may benefit patients with intact phrenic nerve function and absence of myopathy, such as those with high cervical spine injuries causing bilateral hemidiaphragmatic paralysis. hbbd```b``A$u"(d9V DEXM:X6, How to Perform Diaphragmatic Excursion - YouTube List three factors that affect the normal intensity of tactile fremitus. A paralyzed hemidiaphragm will lack downward motion on inspiration and may have paradoxical motion on sniffing. Hence, percussion of it gives a resonance. Sonographic Evaluation of Diaphragmatic Excursion and Thickness in B. This anatomy article is a stub. New York: Elsevier; 2010. Normal findings . Postgrad Med J. Normal lung tissues have a substantial amount of airspace to attenuate and soften the sound. The patient does not exhibit signs of respiratory distress. . If both hemidiaphragms are elevated, but the thicknesses of the crura are preserved, bilateral paralysis is unlikely, and some cause of abdominal distension, such as mass, ascites, or excess fat, is more likely. The author shows that unequal excursion of the two leaves of the diaphragm is a normal finding. Wheezing rhonchi, and crackles: Reflect narrowed bronchial lumina secondary to inflammation and mucous. Scott G, Presswood EJ, Makubate B, Cross F. Lung sounds: how doctors draw crackles and wheeze. Imaging of the diaphragm: anatomy and function. Overlying fatty tissue, increased airspace (such as in COPD), or fluid outside the lung space may decrease perceived fremitus. Eventration is usually asymptomatic but may become symptomatic if the eventration is large or the patient is obese because obesity can raise intraabdominal pressure and further compromise diaphragmatic function. My thesis aimed to study dynamic agrivoltaic systems, in my case in arboriculture. These sounds occur in addition to the breath sounds described above. Age, sex and BMI significantly affected the diaphragmatic motion. 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 . 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]. The liver is used as an echogenic window. M-mode sonography of diaphragmatic motion: description of technique and Dullness noted to the left of the ster-num between the third and fifth intercostal spaces is a normal finding because it is the location of the heart. Injuries can include a gunshot or knife wound to the chest, rib fracture, or certain medical procedures. 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. In some cases, a collapsed lung is caused by air blisters (blebs) that break open, sending air into the space around the lung. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. Bookshelf Then the provider will measure the distance between the two spots. Granata F, Gaeta M. Magnetic resonance imaging of the diaphragm: from normal to pathologic findings. Examination of the shape of the chest is used to assess the structure of the ribs and spine. 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. Small eventration of the right hemidiaphragm. 5376 Diaphragmatic Excursion in Healthy Adults: Normal alues. PMC The pulmonary exam is one of the most important and often practiced exam by clinicians. Adventitious sounds can be classified as crackles, wheezes, rhonchi, or stridor. Excursion is again greater posteriorly. The sounds heard during auscultation can be classified as breath sounds, created by air movement through the airways, and adventitious, or added sounds, which have multiple mechanisms of generation. This step helps identify areas of lung devoid of air. J Asthma. Normal diaphragmatic excursion should be 35cm, but can be increased in well-conditioned persons to 78cm. Maximum diaphragm excursion and slopes during inspiration and expiration . 2020 Jun 26;8(12):2408-2424. doi: 10.12998/wjcc.v8.i12.2408. These cookies will be stored in your browser only with your consent. [1, 2]. (Reproduced from Nason LK, Walker CM, McNeely MF, etal. [1,4,8], US focuses more on the posterior and lateral muscular components of the diaphragm and can assess excursion, muscular velocity, and trophism. Even decubitus positioning can be used if clinically relevant. This technique should be applied to the regions shown in the images below, comparing the two hemithoraces. On supine position there may be excess elevation of the resting position of the eventrated segment.
Which Cambridge College Quiz,
Where To Donate Winter Hats Near Me,
Who Is The Richest Battle Rapper,
Hampton County Shooting,
Paisley Grammar School Former Teachers,
Articles D
