Dysphagia Due to Diffuse Idiopathic Skeletal Hyperostosis

Abstract

Diffuse Idiopathic Skeletal Hyperostosis (DISH) affects up to 20% of the elderly population, with a greater prevalence in men. It is characterized by the non-inflammatory ossification of spinal ligaments and soft tissues. Most patients are asymptomatic, but the developing osteophytes may cause esophageal compression and DISH should be considered in evaluation of dysphagia. Our case illustrates the importance of maintaining a high index of suspicion, and the difficulty in resolving dysphagia secondary to DISH. A 68-year-old man referred for persistent dysphagia reported solid dysphagia up to 85% of the time with occasional regurgitation. He complained of no odynophagia, dyspepsia, or heartburn. Physical exam was grossly normal. The patient had a history of hepatic steatosis, well controlled gastroesophageal reflux disease, diabetes mellitus, hyperlipidemia, and hypertension. An esophagram revealed large anterior bridging osteophytes from C3-C7, which were effacing portions of the hypopharynx and upper esophagus. The osseous findings were consistent with a diagnosis of DISH. Of note, a CT scan from five years ago had identified osteophytes in the thoracic and lumbar spine. Esophagogastroduodenoscopy (EGD) was remarkable for severe extrinsic stenosis of the upper third of the esophagus. Dilation was performed without subsequent symptom improvement. The patient was counseled regarding possible surgical options but declined further intervention. Over the next eight months the patient continued to report dysphagia prompting two more upper endoscopies with dilation, each failing to provide symptom resolution. A repeat esophagram revealed 40-50% narrowing of the cervical esophagus of about 10 cm in length. Aspiration of barium contrast was also noted. Chest computed tomography with contrast revealed only a small hiatal hernia and hypertrophic spondylosis of the dorsal spine. This patient with DISH experienced dysphagia secondary to osseous esophageal compression. Esophageal dilation is not an effective treatment for dysphagia secondary to DISH. Surgical resection of the osteophytes may be considered, although sufficient studies are lacking regarding outcomes of surgical management. In conclusion, DISH is surprisingly common and should be considered more often in the evaluation of dysphagia in elderly patients. This disorder will be encountered with increasing frequency as the geriatric population expands.2973_A Figure 1. CT showing anterior osteophyte formation (arrows) with narrowing of the oropharynx (Image from similar case)2973_B Figure 2. Barium swallow radiogram showing obstruction opposite C5 (arrow) and DISH bridging C4-C6 (Image from similar case)