Diagnosis Of Diffuse Idiopathic Skeletal Hyperostosis Research Articles

Forestier disease: A possible cause of decannulation failure

Diffuse Idiopathic Skeletal Hyperostosis (DISH) [1] also known as Forestier disease, is a noninflammatory, systemic skeletal disease of unknown aetiology. DISH is a common but underdiagnosed disease that is usually observed in elderly people and has been reported to affect up to 10% of patients over 65 years of age [2]. The diagnosis is primarily radiological characterised by the ossification of the anterior longitudinal ligament, with osteophytes formation along the spinal column of at least four contiguous vertebral bodies, a minimal degree of degenerative disc disease and absence of apophyseal joint ankylosis and sacroiliac joint fusion, erosions, or sclerosis [3]. DISH is usually asymptomatic but may compress the posterior wall of the aero digestive tract and lead to dysphagia, globus, hoarseness, stridor, dyspnea and neurological problems. Although dysphagia is not uncommon among the presenting symptoms of DISH, dysphonia and stridor are rarely reported. Cervical hyperostosis in patients with DISH is responsible for 17%-28% incidence of dysphagia, and about 8% of patients failed to respond to conservative treatment and surgical excision through an anterior cervical approach was required [3]. Many studies have been conducted on the surgical approach [4] and anaesthetic evaluation of patients with DISH [5]. Less known are the difficulties in weaning from the tracheostomy tube in these patients, especially when the diagnosis of DISH is unknown.

High prevalence of diffuse idiopathic skeletal hyperostosis (DISH) among obese young patients – A retrospective observational study

ObjectiveDiffuse idiopathic skeletal hyperostosis (DISH) is characterized by ossification of ligaments and entheses, and most commonly affects the spinal column. The prevalence of DISH is increasing with age and is considered uncommon before the age of 50 years, with an estimated prevalence of less than 5 %. DISH is known to be highly associated with metabolic syndrome and obesity. We aim to assess the prevalence of DISH among young (≤50 yr.) patients suffering from severe obesity (BMI of 35 kg/m2 or higher). MethodsA retrospective analysis assessing chest and spine radiographs (including Computed Tomography, CT) of patients with BMI≥35 visiting the bariatric ambulatory clinic in an academic medical center from 2013 to 2022. Patients included in the analysis were 31–50 years old. Diagnosis of DISH was made according to the Resnick criteria. The prevalence of DISH was calculated. Demographic, clinical and laboratory data were collected and compared between the DISH and non-DISH groups. Results183 young (mean age: 40.4; 118 females, 64.2 %) obese (BMI median: 40.6; range 35–73) patients were included in the radiographic review. DISH was diagnosed in 33 patients (18.0 %; 95 % CI: 13.1–24.2 %) which was significantly higher than the expected 10 % (Z = 3.62, p<.001); another 8 patients (4.4 %; 95 % CI: 2.2–8.4 %) were considered as “near DISH” (not fulfilling yet the Resnick criteria) as it represents a pre-disease state. Patients diagnosed with DISH were significantly older than patients without DISH (t = 4.54, p<.001), as the prevalence of DISH increased by age (linear association=14.95, p<.001). There was a statistically significantly higher prevalence of hypertension (χ2 = 8.30, p<.004), smoking (χ2 = 4.69, p<.03) and OSA (χ2 = 6.16, p<.013) in the DISH group as compared to their non-DISH counterparts. ConclusionThe prevalence of DISH among obese young patients was 18 %, which is much higher than in the general population. Early-onset DISH should be regarded as a musculoskeletal obesity-related complication.

Is there a place for magnetic resonance imaging in diffuse idiopathic skeletal hyperostosis?

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic condition characterized by the new bone formation and enthesopathies of the axial and peripheral skeleton. The diagnosis of DISH currently relies upon the end-stage radiographic criteria of Resnick and Niwayama, in which bridging osteophytes are present over at least four thoracic vertebras. The pathogenesis of DISH is not well understood, and it is currently considered a non-inflammatory condition with an underlying metabolic derangement. However, an inflammatory component was suggested due to the similarities between DISH and spondyloarthritis (SpA) in spinal and peripheral entheseal new bone formation. Magnetic resonance imaging (MRI) is the imaging modality of choice in the diagnostic work-up and follow-up of patients with SpA, as well as in understanding its pathogenesis. The aims of the current review were to evaluate the current and future role of MRI in imaging DISH.

A case of diffuse idiopathic hyperostosis of bone (DISH) in a patient on hemodialysis.

Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory progressive disease resulting in ossification of the anterior longitudinal ligament of the spine and tendons. Herein, we describe a case of DISH in a patient on long-term hemodialysis. The patient was a 79-year-old man undergoing hemodialysis for chronic kidney disease due to diabetic nephropathy. He presented to the emergency department complaining of back pain after a slip and fall. Radiographs revealed bamboo spine-like findings, extending from the cervical to the lumbar spine. Computed tomography and magnetic resonance imaging revealed a compression fracture of thoracic vertebra 12, with abnormal ossification of the anterior longitudinal ligament. Inter-vertebral vertical osseous bridges were also observed at the cervical 7 and lumbar 2 vertebrae. There was no obvious spinal cord compression. Leukocytosis and C-reactive protein levels were not elevated and the human leukocyte type antigen HLA-B27 test was negative. Based on this finding, a diagnosis of DISH was made. In the absence of neurological findings, the patient was treated conservatively. Our findings show an overlap between the clinical features of DISH and those of hemodialysis patients, including older age, male sex, and diabetes.

Increased risk of stroke in patients with diffuse idiopathic skeletal hyperostosis: a nationwide population-based cohort study

Diffuse idiopathic skeletal hyperostosis (DISH) is frequently an incidental finding during X-ray examination. Although it has been shown to be associated with several chronic diseases, the hazard of cerebrovascular disease has seldom been explored. Our study aimed at determining the risk of stroke conferred by DISH, which is a retrospective cohort study adopting the largest medical database in Taiwan. Patients with a diagnosis of DISH at least three times from 2005 to 2010 were identified as the study group, and those in the control group were selected by matching age and gender. Patients were followed up until the end of 2015 to trace the incidence of stroke. Cox regression analysis was performed to compute the hazard ratio of stroke. Among the included 5300 patients, 1060 had a diagnosis of DISH. Significantly higher prevalence rates of stroke, hypertension, diabetes, and hyperlipidemia were noted in these patients. Overall, DISH conferred a 1.68 times higher risk of developing stroke. The significantly higher hazard ratio could be identified in both genders whether hypertension existed or not. Even in those without comorbidities, DISH still conferred a significantly higher risk of cerebrovascular disease in the future, which should never be ignored when encountered during clinical practice.

Diffuse idiopathic skeletal hyperostosis in elderly Icelanders and its association with the metabolic syndrome: the AGES-Reykjavik Study

Objective: To describe the prevalence of diffuse idiopathic skeletal hyperostosis (DISH) in a large population-based study of elderly Icelanders, with particular reference to weight-related factors and the metabolic syndrome. Method: The study population comprised 5321 participants aged 68–96 years (2276 males, mean ± sd age 76 ± 5 , and 3045 females, age 77 ± 6) from the AGES-Reykjavik Study. DISH diagnosis was based on computed tomography (CT) scans, and interpreted strictly by the Resnick criteria and additional suggestions for CT interpretation by Oudkerk et al. Radiology readings were taken by a radiology resident and sample readings by two experienced radiologists. Results: A diagnosis of DISH was made in 13.7% of males and 2.8% of females. There was no association with age, but a strong association was seen with the metabolic syndrome [odds ratio (OR) 2.12, 95% confidence interval (CI) 1.69–2.64, p = 3.9 × 10−11]. Among the components of the metabolic syndrome, the association with DISH was significant for the insulin resistance criterion (OR 1.66, 95% CI 1.32–2.01, p < 0.001) and the body mass index (BMI) criterion (OR 2.16, 95% CI 1.70–2.74, p < 0.001). Other weight-related variables (midlife BMI, weight, and abdominal circumference) showed similar associations. Conclusions: This study, which to our knowledge is the largest published study on the prevalence of DISH, shows an association with the metabolic syndrome, particularly with the insulin resistance and BMI criteria. This is analogous with previous reports linking DISH with metabolic causes. In this age category, we did not observe any increase in prevalence with age.

Comparative analysis of clinical factors associated with pedicle screw pull\u2010out during or immediately after surgery between intraoperative cone\u2010beam computed tomography and postoperative computed tomography

BackgroundNo studies to date have elucidated the clinical factors associated with pedicle screw pull-out during or immediately after surgery. The aim of this study was to assess the frequency of pedicle screw pull-out by comparing intraoperative scans obtained using cone-beam computed tomography (CBCT) with postoperative scans obtained using computed tomography (CT). We also sought to determine the incidence of pedicle screw pull-out and identify relevant risk factors.MethodsThis was a retrospective analysis of prospectively collected data for 742 pedicle screws placed in 76 consecutive patients who underwent at least triple-level posterior fixation for thoracic or lumbar spinal injury, spinal metastasis, or pyogenic spondylitis between April 2014 and July 2020. Pedicle screw pull-out distance in the axial and sagittal planes was compared between CT scans obtained 2 days postoperatively and CBCT images acquired intraoperatively. Risk factors associated with pedicle screw pull-out were investigated by multivariate logistic regression analysis.ResultsPedicle screw pull-out was seen with 58 pedicle screws (7.8%) in 26 patients (34.2%). There were significant differences in age, number of fused segments, frequency of diffuse idiopathic skeletal hyperostosis (DISH), and medical history of osteoporosis for pedicle screw pull-out. Risk factors for pedicle screw pull-out were older age (odds ratio 1.07, 95% confidence interval 1.02–1.130) and a diagnosis of DISH (odds ratio 3.35, 95% confidence interval 1.12–10.00). Several cases suggest that use of connecting rods was an important factor in intraoperative pedicle screw pull-out.ConclusionsOur findings suggest that age, number of fused segments, presence of DISH, and medical history of osteoporosis are risk factors for pedicle screw pull-out, with the greatest being older age and DISH.

Spinal trauma in DISH and AS: is MRI essential following the detection of vertebral fractures on CT?

BACKGROUNDBoth ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) cause a rigid spine, but through different pathophysiology. Recent data has shown that characteristic fracture patterns may also differ following trauma since the posterior osseous and soft tissue elements are often spared in DISH. CT and MRI are important in diagnosing spine injury, but given the differences between AS and DISH, the utility of obtaining both studies in all patients warrants scrutiny. PURPOSETo assess the prevalence of posterior element injury on CT and MRI in DISH and AS patients with known vertebral body injury detected on CT; to determine whether MRI demonstrates additional injuries in neurologically intact patients presumed to have isolated vertebral body injuries on CT. STUDY DESIGNMulticenter, retrospective, case-control study. PATIENT SAMPLEDISH and AS patients presenting after spine trauma between 2007 and 2017. OUTCOME MEASURESReview of CT and MRI findings at the time of presentation. METHODSOne hundred sixty DISH and 85 AS patients presenting after spine trauma were identified from 2 affiliated academic hospitals serving as level 1 trauma and tertiary referral centers. A diagnosis of DISH or AS was verified by a board-certified emergency radiologist with 3 years of experience. Age, gender, mechanism of injury, fracture type, spine CT and MRI imaging findings, surgical intervention, and neurologic deficit were recorded. The CT and MRI studies were reviewed by the same radiologist for fracture location and type using the AO spine classification. No funding source or conflict of interest was present. RESULTSMedian age was 72 and 79 years old for the AS and DISH groups, respectively. Both were predominantly male (81%) and most presented after a low energy mechanism of injury (74% and 73%). Type C AO spine injuries were seen in 52% of AS patients but only 4% of DISH patients. In patients with known vertebral body injury on CT, additional injury to the posterior elements on CT or MRI in DISH patients was 51% versus 92% in AS patients. However, in patients with an isolated vertebral body fracture on CT and no neurological deficit, MRI identified posterior element injury in only 4/22 (18%) DISH patients compared to 5 of 7 (71%) AS patients. None of the MRI findings in the DISH patients were considered clinically important while all 5 AS patients eventually underwent operative treatment despite having no neurological deficit. Epidural hematoma on MRI was seen in 43% of AS patients as opposed to 5% of DISH patients. CONCLUSIONBased on our small sample size, CT alone may be adequate in DISH patients with isolated vertebral body fractures and no neurologic deficit, but an additional MRI should be considered in the presence of an unclear neurological exam or deficit. MRI should be strongly considered for any AS patient regardless of neurologic status.

Diffuse idiopathic skeletal hyperostosis: Etiology and clinical relevance.

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic bone-forming condition characterized by the presence of at least three bony bridges at the anterolateral spine. The aim of this review was to address the present state of pathophysiological knowledge, the clinical relevance, and diagnosis of DISH. The pathogenesis of DISH is currently unknown. The presence of DISH has been associated with older age, male sex, obesity, hypertension, atherosclerosis, and diabetes mellitus. Because the new bone forms mainly at entheseal sites, local fibroblasts, chondrocytes, collagen fibers, and calcified matrix are probably influenced by genetic, vascular, metabolic, and mechanical factors. Diagnosing the presence of DISH is of clinical importance, because the risk of a spinal fracture increases and associations with the metabolic syndrome, coronary and aortic disease, and respiratory effects are strong. Unravelling the pathogenesis of DISH can impact the field of regenerative medicine and bone tissue regeneration.

Incidence of Diffuse Idiopathic Skeletal Hyperostosis From a Model of Dysphagia

ObjectiveTo relate symptoms of dysphagia to Forestier–Rotes Querol disease or diffuse idiopathic skeletal hyperostosis (DISH), a disorder due to ossification in the anterior longitudinal ligament and calcifications in other entheses. Patients and methodsReview of clinical and radiological findings in 455 outpatients attended at our Center with dysphagia, for 5 years, referred from dental, trauma, neurological or primary health care. A diagnosis of DISH was established using Resnick's criteria. ResultsWe detected 51 cases with dysphagia consistent with DISH diagnostic criteria – 11.2% of subjects suffering this symptom – out of 32544 outpatients attended. An incidence of 7:100000 inhabitants per year was observed. Two cases showed significant improvement after removing the new bone in the spine. ConclusionsDISH is an ankylosing ossification between the joints, frequently systemic but showing no clinical symptoms. When symptoms manifest, neck movements and upper airways are involved, mainly dysphagia. A few cases need surgery to relieve the calcification processes.

Conservative treatment for stable low-energy thoracolumbar vertebral fractures in nonfused segments among elderly patients with diffuse idiopathic skeletal hyperostosis

Diffuse idiopathic skeletal hyperostosis (DISH) is the spontaneous osseous fusion of the spine with anterior bridging osteophytes. It is well-known that conservative treatment for vertebral fractures of fused segment among DISH spines is associated with worse clinical outcomes. However, the prognosis of conservatively treated stable vertebral fractures in neighboring nonfused segments among DISH spines is still unknown. The purpose of this study was to analyze the results of conservative treatment of stable low-energy thoracolumbar (TL) vertebral fracture in nonfused segments among patients with DISH lesions.A total of 390 consecutive patients who visited an emergency department by ambulance with spinal trauma between 2013 and 2017 were retrospectively reviewed. The diagnosis of DISH was determined based on fused spinal segments with bridging osteophytes in at least 3 adjacent vertebrae. For each case of stable TL vertebral fractures in nonfused segments of the DISH spine, we identified 2 age-, sex-, and fracture lesion-matched non-DISH controls who underwent conservative treatment for low-energy TL vertebral fractures during the same period.Of the 33 identified cases of TL fractures with DISH, 14 met our inclusion criteria. The bony union rates of the DISH group and control group were 57% and 75% at the 3-month follow-up examination (P = .38) and 69% and 100% at the 6-month follow-up examination (P = .02), respectively. Among the 13 patients with fractures below the TL junction, fused segments were not diagnosable based on the initial standard radiographs of the lumbar spine for 61.5% of patients.Although this study design was exploratory and the sample size was small, our results suggest that with conservative treatment, stable fractures in nonfused segments in the DISH spine might have a worse prognosis than ordinary osteoporotic vertebral fractures. The diagnosis of coexisting DISH lesions can be missed when only radiographs of the lumbar spine are used to determine the diagnosis.

Incidencia de la hiperostosis esquelética difusa idiopática sobre un modelo clínico de disfagia

ObjectiveTo relate symptoms of dysphagia to Forestier-Rotes Querol disease or diffuse idiopathic skeletal hyperostosis (DISH), a disorder due to ossification in the anterior longitudinal ligament and calcifications in other entheses. Patients and methodsReview of clinical and radiological findings in 455 outpatients attended at our Centre with dysphagia, for 5years, referred from dental, trauma, neurological or primary health care. A diagnosis of DISH was established using Resnick's criteria. ResultsWe detected 51 cases with dysphagia consistent with DISH diagnostic criteria – 11.2% of subjects suffering this symptom- out of 32544 outpatients attended. An incidence of 7:100000 inhabitants per year was observed. Two cases showed significant improvement after removing the new bone in the spine. ConclusionsDISH is an ankylosing ossification between the joints, frequently systemic but showing no clinical symptoms. When symptoms manifest, neck movements and upper airways are involved, mainly dysphagia. A few cases need surgery to relieve the calcification processes.

Ectopic spinal calcification associated with diffuse idiopathic skeletal hyperostosis (DISH): A quantitative micro-ct analysis.

Diffuse idiopathic skeletal hyperostosis (DISH) is a non-inflammatory spondyloarthropathy identified radiographically by calcification of the ligaments and/or entheses along the anterolateral aspect of the vertebral column. The etiology and pathogenesis of calcifications are unknown, and the diagnosis of DISH is currently based on radiographic criteria associated with advanced disease. To characterize the features of calcifications associated with DISH, we used micro-computed tomographic imaging to evaluate a cohort of 19 human cadaveric vertebral columns. Fifty-three percent of the cohort (n = 10; 3 females, 7 males, mean age of death = 81 years, range 67-94) met the radiographic criteria for DISH, with calcification of four or more contiguous vertebral segments. In almost all cases, the lower thoracic regions (T8-12) were affected by calcifications, consisting primarily of large, horizontal outgrowths of bony material. In contrast, calcifications localized to the upper thoracic regions demonstrated variability in their presentation and were categorized as either "continuous vertical bands" or "discontinuous-patchy" lesions. In addition to the variable morphology of the calcifications, our analysis demonstrated remarkable heterogeneity in the densities of calcifications, ranging from internal components below the density of cortical bone to regions of hyper-dense material that exceeded cortical bone. These findings establish that the current radiographic criteria for DISH capture heterogeneous presentations of ectopic spine calcification that can be differentiated based on morphology and density. These findings may indicate a naturally heterogenous disease, potential stage(s) in the natural progression of DISH, or distinct pathologies of ectopic calcifications. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Dysphagia Due to Diffuse Idiopathic Skeletal Hyperostosis

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)

Cervical Disc Arthroplasty Combined with Interbody Fusion for the Treatment of Cervical Myelopathy with Diffuse Idiopathic Skeletal Hyperostosis

Cervical Disc Arthroplasty Combined with Interbody Fusion for the Treatment of Cervical Myelopathy with Diffuse Idiopathic Skeletal Hyperostosis

Diagnosis of diffuse idiopathic skeletal hyperostosis with chest computed tomography: inter-observer agreement

ObjectiveTo evaluate and improve the interobserver agreement for the CT-based diagnosis of diffuse idiopathic skeletal hyperostosis (DISH).MethodsSix hundred participants of the CT arm of a lung cancer screening trial were randomly divided into two groups. The first 300 CTs were scored by five observers for the presence of DISH based on the original Resnick criteria for radiographs. After analysis of the data a consensus meeting was organised and the criteria were slightly modified regarding the definition of ‘contiguous’, the definition of ‘flowing ossifications’ and the viewing plane and window level. Subsequently, the second set of 300 CTs was scored by the same observers. κ ≥ 0.61 was considered good agreement.ResultsThe 600 male participants were on average 63.5 (SD 5.3) years old and had smoked on average 38.0 pack-years. In the first round κ values ranged from 0.32 to 0.74 and 7 out of 10 values were below 0.61. After the consensus meeting the interobserver agreement ranged from 0.51 to 0.86 and 3 out of 10 values were below 0.61. The agreement improved significantly.ConclusionsThis is the first study that reports interobserver agreement for the diagnosis of DISH on chest CT, showing mostly good agreement for modified Resnick criteria.Key Points• DISH is diagnosed on fluoroscopic and radiographic examinations using Resnick criteria• Evaluation of DISH on chest CT was modestly reproducible with the Resnick criteria• A consensus meeting and Resnick criteria modification improved inter-rater reliability for DISH• Reproducible CT criteria for DISH aids research into this poorly understood entity

Brief Report: Ankylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis in Royal Egyptian Mummies of the 18th–20th Dynasties? Computed Tomography and Archaeology Studies

ObjectiveTo study the computed tomography (CT) images of royal Ancient Egyptian mummies dated to the 18th to early 20th Dynasties for the claimed diagnoses of ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) and to correlate the findings with the archaeology literature.MethodsWe studied the CT images of 13 royal Ancient Egyptian mummies (1492–1153 BC) for evidence of AS and DISH and correlated our findings with the archaeology literature.ResultsThe findings of the CT scans excluded the diagnosis of AS, based on the absence of sacroiliac joint erosions or fusion of the facet joints. Four mummies fulfilled the diagnostic criteria for DISH: Amenhotep III (18th Dynasty), Ramesses II, his son Merenptah, and Ramesses III (19th to early 20th Dynasties). The diagnosis of DISH, a commonly asymptomatic disease of old age, in the 4 pharaohs is in concordance with their longevity and active lifestyles.ConclusionCT findings excluded the diagnosis of AS in the studied royal Ancient Egyptian mummies and brought into question the antiquity of the disease. The CT features of DISH during this ancient period were similar to those commonly seen in modern populations, and it is likely that they will also be similar in the future. The affection of Ramesses II and his son Merenptah supports familial clustering of DISH. The process of mummification may induce changes in the spine that should be considered during investigations of disease in ancient mummies.

Otolaryngologic manifestations of diffuse idiopathic skeletal hyperostosis

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by formation of large cervical osteophytes that may compress the posterior wall of the aerodigestive tract. It is a rare cause of dysphagia in the elderly. The aim of this study was to investigate the various otolaryngologic manifestations of DISH. Eleven elderly patients with DISH were included in the study. All patients presented with dysphagia that was graded on the swallowing screening tool (EAT-10), and the diagnosis of DISH was based on computed tomographic criteria. The patients were subjected to otolaryngologic examination and flexible laryngoscopy. Polysomnography was used for patients with excessive daytime sleepiness for detection of obstructive sleep apnea (OSA). In addition to dysphagia of varying severity, OSA was found in nine patients, change of voice in six, globus sensation in seven, aspiration in three, and cervical pain in seven. Flexible laryngoscopy showed bulging of the posterior pharyngeal wall in all patients. DISH may be an unrecognized contributory factor to both dysphagia and OSA in the elderly. Change of voice, aspiration, globus sensation, and cervical pain are other otolaryngologic manifestations that may be encountered symptoms of the disease. An otolaryngologist should be aware of the disease that may be overlooked, and computed tomography is a confirmatory diagnostic method.

Diffuse Idiopathic Skeletal Hyperostosis in Psoriatic Arthritis

To determine the prevalence of diffuse idiopathic skeletal hyperostosis (DISH) in patients with psoriatic arthritis (PsA) and to identify the features associated with its occurrence. Patients were recruited from the University of Toronto PsA observational cohort initiated in 1978. All patients fulfilled the CASPAR criteria. Radiographs of peripheral joints and spine were obtained every 2 years. DISH was defined as flowing bony bridges in at least 4 contiguous thoracic vertebrae. Each PsA patient with DISH was matched by sex to 3 PsA patients without DISH. Demographics, disease characteristics, and radiographic features were compared using McNemar test, Fisher's exact test, chi-square test, and paired t test as appropriate. Logistic regression analyses models with stepwise regression were conducted. DISH was observed in 78 (8.3%) of 938 patients with PsA. Patients with DISH were older and had longer disease duration, higher body mass index (BMI), and higher uric acid levels. Diabetes and hypertension were more prevalent in patients with DISH than in those without. The severity of radiographic damage to peripheral joints was also greater in patients with DISH. The presence of inflammatory back pain, HLA-B*27 allele, and sacroiliitis was similar in both groups. Patients with DISH had more syndesmophytes and calcaneal spurs. Older age, higher BMI, and the presence of radiographic damage to peripheral joints were associated with DISH in multivariate analysis. The diagnosis of DISH is possible in the presence of axial PsA. DISH was associated with known DISH-related factors including older age and high BMI, as well as the presence of radiographic damage to peripheral joints.

Incidental Findings of Massive Heel Spurs in a Veteran with a Variant of Psoriatic Arthritis

A middle-aged man presented for left foot diabetic ulcer care. Pedal radiographs were negative for signs of osteomyelitis. However, asymptomatic incidental osseous findings demonstrated significant plantar and posterior calcaneal spurring possibly consistent with diffuse idiopathic skeletal hyperostosis (DISH). A differential of DISH, psoriatic arthritis, Reiter's, and ankylosing spondylitis was developed. Subsequent spinal imaging and laboratory work-up did not satisfy the diagnostic criteria for DISH. This case illustrates radiographic changes characteristic of multiple seronegative arthropathies. On initial presentation a diagnosis of DISH was most likely, but with further imaging studies a diagnosis of a variant of psoriatic arthritis may be more correct.