An 80-yr-old woman with a history of progressive dysphagia was hospitalized for aspiration pneumonia. Her medical history included a stroke 2 yrs previously, severe osteoporosis with a T-score of −4.1 by dual energy x-ray absorptiometry, and changes in spinal alignment, that is, thoracic kyphosis and cervical hyperlordosis. The patient had maintained a puree-type diet to prevent aspiration since the stroke event.
A videofluoroscopic swallowing study showed preserved movement of the larynx. However, the hyperlordotic curvature of the cervical spine prevented epiglottic closure and bolus passage, which resulted in supraglottic pooling and aspiration of food residues (Fig. 1); even puree-type food was aspirated during our examination. Therapeutic swallowing maneuvers were tried but proved to be ineffective, as they only worsened the neck pain and prevented oropharyngeal food transport. After 2 wks of futile swallowing training, percutaneous endoscopic gastrostomy was performed for enteral feeding.
Dysphagia is usually caused by either a neuromuscular dysfunction or a mechanical obstruction, and obstructive dysphagia associated with degenerative osteophytes is a well known cause of dysphagia.1 Initially, our patient had typical neurogenic dysphagia of stroke characterized by intolerance to liquids. However, the condition was aggravated by mechanical obstruction caused by degenerative change of the cervicothoracic spinal curvature, specifically cervical hyperlordosis. Osteoporotic thoracic kyphosis is a major contributor to cervical hyperlordosis, and in the elderly, it causes the head to be moved backward to preserve forward gaze, resulting in cervical hyperlordosis.2 It has been noted that 7%-17% of women with severe kyphosis have a lower bone mineral density.3 Furthermore, dysphagia caused by mechanical obstruction of the distal esophagus by severe kyphosis has also been reported in an elderly woman.4
Therefore, in older stroke patients with dysphagia and aggravated swallowing difficulty, structural degeneration of the spinal curvature, including cervical hyperlordosis, should be considered in addition to neurogenic etiologies.
1. Lee SA, Kim KE, Paik NJ: Dysphagia caused by multilevel cervical osteophytes. Am J Phys Med Rehabil
2. Boyle JJ, Milne N, Singer KP: Influence of age on cervicothoracic spinal curvature: An ex vivo radiographic survey. Clin Biomech
3. Ettinger B, Black DM, Palermo L, et al: Kyphosis in older women and its relation to back pain, disability and osteopenia: The study of osteoporotic fractures. Osteoporos Int
4. Goyal N, Narlawar R, Garrett A: Kyphosis, a rare cause of dysphagia. Age Ageing