An Unusual Cause of Dysphagia
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CLINICAL CONUNDRUM
An Unusual Cause of Dysphagia Kapil Sikka1 · Pirabu Sakthivel1 · Aswin Chandran1 · Adil Mohammed1 Received: 15 July 2020 / Accepted: 24 August 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Case Presentation A 76-year-old man, with no addiction presented to the otorhinolaryngology outpatient clinic with a two-year history of foreign body sensation in throat, mild dysphagia only for solids, and change in voice. On flexion of neck he also had difficulty in breathing. There was no associated regurgitation of food, excessive coughing, or weight loss. Physical and fiberoptic examination revealed a mucosa-covered bulge over posterior pharyngeal wall extending above the level of epiglottis to level of arytenoids below (Fig. 1, video 1). Lateral cervical radiograph is shown in Fig. 2.
What Is the Diagnosis? Lateral cervical X-ray showed large coarse floating osteophytes compressing the esophageal lumen and narrowing of airway on flexing neck (Fig. 2). A CT scan of neck and chest
revealed multiple anterior osteophytes with preservation of intervertebral disc space of cervical and thoracic vertebrae with extrinsic compression of cervical esophagus suggestive of diffuse idiopathic skeletal hyperostosis (DISH) or Forestier disease (Fig. 3).
Discussion Forestier disease or DISH, a rheumatological condition of unknown etiology is characterized by continuous ossification of ligaments and entheses, especially in the axial skeleton but also in peripheral joints [1]. Forestier first described this entity in 1950 as a case of senile ankylosing hyperostosis of the spine, and it was renamed as DISH by Resnick et al. in 1975 [2, 3]. Radiological diagnostic criteria’s include continuous ossification of the anterior longitudinal ligament involving at least four contiguous vertebra, lack of intervertebral ankyloses or fusion, and preservation of intervertebral
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00455-020-10186-z) contains supplementary material, which is available to authorized users. * Pirabu Sakthivel [email protected] Kapil Sikka [email protected] Aswin Chandran [email protected] Adil Mohammed [email protected] 1
Department of Otorhinolaryngology & Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi 110029, India
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K. Sikka et al.: An Unusual Cause of Dysphagia
Fig. 1 Endoscopic image showing bulge in the posterior pharyngeal wall in neutral neck position causing partial obstruction of airway lumen
Fig. 2 Lateral cervical radiograph showing anterior flowing osteophytes from C3 to D1 vertebrae in extension and flexion of neck causing luminal airway compromise (arrow)
disc height [3]. Despite the impressive structural changes, patients with DISH may be largely asymptomatic. Cervical involvement with large anterior osteophytes can present with dysphagia, dyspnea, or dysphonia as in our case [1]. Treatment is mainly conservative with diet modification, a
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