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Correspondence

Life-threatening airway obstruction caused by cervical osteophytes

Sturgess, J. E.; Leary, T. S.

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European Journal of Anaesthesiology: December 2003 - Volume 20 - Issue 12 - p 988-989

EDITOR:

Cervical osteophytes are common in the elderly (20-30%) [1], rare before 50 yr of age and occur more frequently in males than in females. They are most often due to a degenerative arthritis within the spine, but may be part of diffuse idiopathic skeletal hyperostosis (DISH). Symptoms arising from cervical osteophytes are unusual, but dysphagia is the commonest complaint. We describe a case of life-threatening airway obstruction due to cervical osteophytes.

An independent 79-yr-old female tripped at home and fell onto her face. She had a past medical history of a cerebrovascular accident, with no residual neurological deficit, and hypertension and hyperlipidaemia. She managed to telephone for an ambulance and walk towards the paramedics as they entered her house and gave a history. However, soon after this she complained of difficulty in swallowing and subsequently of breathing. Examination in the resuscitation room showed obvious gross neck swelling and marked respiratory distress: sudden complete loss of the airway occurred. Despite senior assistance, endotracheal intubation proved impossible at this time because of the swelling, oedema and anatomical distortion combined with brisk fresh bleeding arising from within the oropharynx. It was felt that the patient's pharynx was too swollen to insert a laryngeal mask airway. She then developed pulseless electrical activity secondary to hypoxia - cardiac output was restored after one cycle of cardiopulmonary resuscitation and an emergency airway was provided by needle cricothyroidotomy until attempts at blind oral intubation with a size 6 endotracheal tube were successful. Primary and secondary surveys elicited the previously mentioned neck swelling and a haematoma over the left eyebrow, but were otherwise unremarkable.

Plain lateral cervical spine radiographs demonstrated large anteriorly directed osteophytes in the mid-cervical region. A computed tomographic (CT) scan of the patient's head showed mild cerebral atrophy, but nothing else of note. Further CT images of the patient's neck (Figs 1 and 2) were reported as showing 'extensive pronounced soft tissue attenuation in the pre-vertebral and peri-vascular spaces extending from the base of the skull to beyond the root of the neck, with anterior displacement of the trachea and oesophagus'. There was a very slight widening of the C3/4 disc space with a locule of gas within the space, which raised the possibility of disruption of the anterior longitudinal ligament secondary to a hyperextension injury.

Figure 1
Figure 1:
CT scan of the cervical spine (transverse view) showing a prevertebral haematoma (thin arrow), anteriorly directed osteophyte (thick arrow) and intubated trachea.
Figure 2
Figure 2:
Reconstructed CT scan of the cervical spine (sagittal view) showing anteriorly directed osteophytes at C5 (arrow).

The patient was managed conservatively in our intensive therapy unit. Surgery and attempts to identify and ligate the bleeding point were considered futile. After 48 h, the prevertebral swelling started to subside and oral bleeding abated. An air leak was detected when the tracheal tube cuff was deflated. The amount of sedation was reduced and the patient responded to the nursing staff appropriately and obeyed commands. No focal neurological signs were detected. Unfortunately, the patient developed severe hypertension and her level of consciousness deteriorated on the fourth day after admission: a second CT head scan revealed a large cerebral infarct. Active treatment was withdrawn at this stage and the patient died soon afterwards.

We made a presumptive diagnosis of massive cervical haematoma secondary to trauma caused by anteriorly facing osteophytes during a hyperextension injury.

The most common symptom arising from cervical osteophytes is dysphagia [2]. The oesophagus is often deviated, and dysphagia arises either from mechanical obstruction or from inflammation in the area of the osteophyte. Aspiration pneumonia has also been reported. Management of this condition is predominantly medical using anti-inflammatory agents, muscle relaxants, and speech and language therapy advice. Surgical intervention should be reserved for the most severe or resistant cases and is not without risk [3].

Upper airway obstruction and stridor are rare but have been reported and they may be due to a number of different mechanisms. Direct laryngoscopy in our patient confirmed a narrowed supralaryngeal airway due to extrinsic compression by anterior vertebral osteophytes. The laryngeal inlet was normal distal to the bulge. The patient required a tracheostomy under general anaesthetic, because endotracheal intubation was impossible, and the airway was secured with a microlaryngoscopy tube. Hassard [4] reported two patients who had emergency tracheostomy formation for airway obstruction with prominent anterior osteophytes. These patients had suffered postcricoid ulceration, thought to be due to constant movement of the cricoid lamina over a projecting osteophytic mass. This was associated with impaired voice.

Crosby and Grahovac [5] presented diffuse idiopathic skeletal hyperostosis as an unusual cause for difficult intubation. They felt that difficulty in intubation arose from a number of problems, including an immobile neck, mechanical obstruction and anterior displacement of the larynx. They went on to state that these difficulties were encountered despite preoperative airway assessment suggesting normal flexion and extension of the neck and a Mallampati Class I airway assessment. Broadway described a similar experience where a difficult intubation was not anticipated at preoperative assessment, yet became evident following induction of anaesthesia [6]. He re-emphasized that when tracheal intubation was planned, predictive tests could be useful but that the unexpected could still occur.

J. E. Sturgess

T. S. Leary

Norfolk and Norwich University Hospital; Norwich, UK

References

1. Bone RC, Nahum AM, Harris AS. Evaluation and correction of dysphagia-producing cervical osteophytosis. Laryngoscope 1974; 84: 2045-2050.
2. Strasser G, Schima W, Schober E, Pokieser P, Kaider A, Denk DM. Cervical osteophytes impinging on the pharynx: importance of size and concurrent disorders for the development of aspiration. Am J Roent 2000; 174: 449-453.
3. Kibel SM, Johnson PM. Surgery for osteophyte-induced dysphagia. J Laryn Oto 1987; 101: 1291-1296.
4. Hassard AD. Cervical ankylosing hyperostosis and airway obstruction. Laryngoscope 1984; 94: 966-968.
5. Crosby ET, Grahovac S. Diffuse idiopathic skeletal hyperostosis: an unusual cause of difficult intubation. Can J Anes 1993; 40: 54-58.
6. Broadway JW. Forestier's disease (ankylosing hyperostosis): a cause for difficult intubation. Anaesthesia 1994; 49: 919-920.
© 2003 European Academy of Anaesthesiology