American Journal of Physical Medicine & Rehabilitation:
From the Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea.
All correspondence and requests for reprints should be addressed to Nam-Jong Paik, MD, PhD, Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea.
An 85-yr-old man complaining of swallowing difficulties was referred for a videofluoroscopic swallowing test for the evaluation of dysphagia. He had experienced swallowing difficulties for 7 yrs, but he had no complaint of dyspnea or dysphonia. Specifically, he complained of intermittent aspiration symptoms when drinking water or eating semisolid food, and he felt considerable discomfort when swallowing solid food. On physical examination, his gross motor and sensory functions were normal, and no pathologic reflex was detected. In addition, a cranial nerve examination that included gag reflex, mastication, and tongue movement evaluations produced normal findings. However, a videofluoroscopic swallowing test revealed epiglottic closure failure attributable to anterior bony spurring at the C3–6 levels, which presumably explained his complaint of aspiration. In addition, a diffuse osteophyte was found anteriorly encroaching the posterior aspect of the oropharynx and esophagus (Fig. 1). However, his swallowing reflex was prompt, and other swallowing movements were normal.
Dysphagia can be caused by hypertrophic anterior cervical osteophytes,1 and about 100 such cases have been reported in the literature.2 Large bridging anterior osteophytes of the cervical spine causing compression of the oropharyngeal swallowing structure are usually the result of diffuse idiopathic skeletal hyperostosis. Diffuse idiopathic skeletal hyperostosis is more frequent in men than in women. It affects up to 10% of patients older than 65 yrs of age, and dysphagia is the most common complaint associated with diffuse idiopathic skeletal hyperostosis.3 Moreover, 17% of patients with diffuse idiopathic skeletal hyperostosis complain of dysphagia,4 whereas anterior cervical bony protrusion is found in only about 10.6% of patients older than 60 yrs undergoing dysphagia evaluations.1 According to our review of 31 reported cases in 19 recent case reports issued from 2002, patients are usually men (81%), and the mean patient age is 68 yrs. Typically, patients have a long history of dysphagia, and the C3–6 levels are most commonly involved. Therefore, cervical osteophytes should be suspected as a cause of swallowing difficulties when other explainable causes are absent. Moreover, although rarely encountered, these osteophytes are most commonly found between C3 and C6.
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3. Resnick D, Shaul SR, Robins JM: Diffuse idiopathic skeletal hyperostosis (DISH): Forestier's disease with extraspinal manifestations. Radiology
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