Images
Diffuse Idiopathic Skeletal Hyperostosis as a Cause of Dysphagia
in a Young Patient With Metabolic Syndrome
Mehmet Agirman, MD, Oguz Durmus, MD, Tugrul Ormeci, MD, Bahri Teker, MD,
Engin Cakar, MD
Case Presentation
A 42-year-old male patient was admitted to our clinic with neck pain, stiffness, limited range of motion in the neck, and dysphagia upon eating solid foods. The pain had started about 5 years previously and increased over time. The patient had no history of trauma to the neck. He had a history of type 2 diabetes mellitus (for 3 years), hypertension (for 10 years), chronic renal fail-ure, and dyslipidemia. The patient was morbidly obese (body mass index: 41). He had experienced frequent infections of the upper respiratory tract during recent years. Motor, sensory, and other neurologic examina-tions showed no signs of cervical radiculopathy. Range of motion in the neck was limited in all directions, and widespread cervical paravertebral spasm and tender-ness were detected. Radiologic investigations showed contiguous vertebrae, bridging osteophytes (Figure 1). Findings of sacroiliac joint radiography were normal.
Serologic and biochemical markers for rheumatic dis-eases were normal. A physical therapy program was started for the neck pain and stiffness, and surgery was considered after a videofluoroscopic examination.
Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by ligamentous ossification of the spinal column (often the anterior longitudinal ligament and, less frequently, the posterior longitudinal ligament). The most common sites of involvement in the spine are the thoracic, lumbar, and cervical regions [1]. DISH is observed more frequently in males than in females, and the prevalence increases with age, especially after 60 years. The most common symptoms are pain, stiffness, dysphagia, and neurologic abnormalities [2]. Giant os-sifications may cause dysphagia and upper respiratory tract infection, as seen in our patient, and should be included in the differential diagnosis of these symp-toms. In cases of severe dysphagia, surgical intervention may be indicated. However, conservative approaches,
Figure 1. (A) Bridging osteophytes (white arrow) from C3-C4 resulting in esophageal and mild tracheal impingement (asterisk). (B) Flowing ossifications (black arrow) are seen along the anterior aspect of contiguous vertebrae in the thoracic spine. The end plates are minimally irregular, but disk spaces are preserved.
PM R 7 (2015) 451-452
www.pmrjournal.org
1934-1482/$ - see front matterª 2015 by the American Academy of Physical Medicine and Rehabilitation
such as diet modification and advice about mastication, should be the first steps in treatment[1]. In the litera-ture, the average age of dysphagia and/or airway obstruction in persons with DISH disease is 69 years, and fewer than 1% of cases begin before age 45 years[3].
Surgical approaches can lead to symptom improve-ment if conservative measures fail [4]. In this report, the patient had been prescribed a low-calorie diet for obesity for several years. The patient was also receiving less food because of dysphagia. Given the patient’s comorbid conditions, diet modification was not suc-cessful and surgery was considered.
References
1.Goh PY, Dobson M, Iseli T, Maartens NF. Forestier’s disease pre-senting with dysphagia and dysphonia. J Clin Neurosci 2010;17: 1336-1338.
2.Kiss C, Szila´gyi M, Paksy A, Poo´r G. Risk factors for diffuse idiopathic skeletal hyperostosis: A case-control study. Rheumatology (Oxford) 2002;41:27-30.
3.Verlaan JJ, Boswijk PF, de Ru JA, Dhert WJ, Oner FC. Diffuse idio-pathic skeletal hyperostosis of the cervical spine: An under-estimated cause of dysphagia and airway obstruction. Spine J 2011; 11:1058-1067.
4.Oppenlander ME, Orringer DA, La Marca F, et al. Dysphagia due to anterior cervical hyperosteophytosis. Surg Neurol 2009;72:266-271.
Disclosure
M.A. Department of Physical Medicine and Rehabilitation, Istanbul Medipol University, Istanbul, Turkey. Address correspondence to: M.A.; Medipol Uni-versite Hastanesi, Fizik Tedavi Bo¨lu¨mu¨, Goztepe Mah. Bagcilar, 34200, Istanbul, Turkey; e-mail:[email protected]
Disclosure: nothing to disclose
O.D. Department of Physical Medicine and Rehabilitation, Istanbul Medipol University, Istanbul, Turkey
Disclosure: nothing to disclose
T.O. Department of Radiology, Istanbul Medipol University, Istanbul, Turkey Disclosure: nothing to disclose
B.T. Infectious Diseases and Clinical Microbiology, Nisa Hospital, Istanbul, Turkey Disclosure: nothing to disclose
E.C. Department of Physical Medicine and Rehabilitation, Istanbul Medipol University, Istanbul, Turkey
Disclosure: nothing to disclose
Submitted for publication October 30, 2014; accepted November 12, 2014.
