Abstract
Case report: A 73-year-old male incurred extensive third-degree burns on his abdomen. Although dysphagia had not been identified before the patient sustained burn injuries, VideoFluoroscopy (VF) performed for poor ingestion revealed severe dysphagia after skin grafting surgery and Ankylosing Spinal Hyperostosis (ASH). Although the cause of dysphagia was not identified, a Percutaneous Endoscopic Gastrostomy (PEG) tube was inserted. The patient was subsequently transferred to our hospital for rehabilitation. Direct rehabilitation for dysphagia began with jelly ingestion, and meal consistency was gradually increased. On day 50, he could completely ingest meals. However, beginning on day 70 of hospitalization, the patient began to complain of mental stress because his burns were taking too long to heal, which caused him to lose sleep at night. He was diagnosed with depression and began to choke when eating meals. VF findings again revealed aspiration after swallowing, and the patient’s state of deglutition that should have improved deteriorated again. Nutrition and fluid administration required a PEG tube to be re-introduced. After the patient’s wounds healed and his mental condition stabilized, he gradually recovered the ability to ingest food. VF findings on day 103 of hospitalization revealed an improvement compared with his previous examination, and aspiration had disappeared. Discussion: The patient’s condition improved temporarily but became aggravated with the deterioration of his depressive symptoms. Subsequently, with an improvement in his depression, dysphagia improved concomitantly. Apart from the deterioration of his depressive symptoms, we did not identify any cause that may have aggravated dysphagia in the patient. We believe that aggravation of dysphagia in the pharyngeal stage could have been caused by the deterioration of the patient’s depressive symptoms when he was barely able to swallow, such as in ASH.
Highlights
It has been reported that 9%-42% psychiatric patients suffer from complications such as dysphagia and eating disorders [1], which can result in serious problems such as aspiration pneumonitis and suffocation [2,3,4]
We describe a case of Ankylosing Spinal Hyperostosis (ASH), known as Forestier’s disease [9,10,11,12,13,14], in which deterioration of depressive symptoms aggravated dysphagia despite not increasing the medication dosage during follow-up, and spontaneous remission occurred because of improvements in depression
Dysphagia complications in ASH may be caused by the following reasons: (1) obstructed food passage due to mechanical pressure on the pharynx and esophagus; (2) inflammation-induced adhesion of the pharynx and esophagus, fibrillization, and convulsions; (3) traction of the ascending branch of the recurrent laryngeal nerve and abnormal sensitivity of the sympathetic nerve; or (4) psychogenic factors [11,12,13,14,15,16,17,18]
Summary
The patient was initially diagnosed with ASH on the basis of the following criteria: (1) ossification on the anterior aspect of the vertebral bodies that formed a bridge between two or more vertebral bodies; (2) absence of any underlying disease that may have caused spondylitis; (3) ossification not attributable to trauma such as compression fractures; and (4) absence of ileosacral arthritis [9,10,11]. According to our understanding of patients believed to develop a certain degree of difficulty with swallowing, such as those with cerebrovascular disease as mentioned above, the deterioration of depressive symptoms may result in aggravation of dysphagia in the pharyngeal stage.we believe that there is a lack of general consensus for these cases. In Japan, there are extremely few occasions when hospital physicians who normally diagnose and treat dysphagia, such as rehabilitation specialists and otolaryngologists, are involved in the care of patients with psychiatric disorders [26] In this case, we obtained advice regarding the patient’s prescriptions during routine check-ups by the psychiatrist who had been treating the patient before he sustained burn injuries. We hope that our report will help future clinical studies of dysphagia in psychiatric patients
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