Large anterior cervical osteophytes can occur in degeneration of the cervical spine or in diffuse idiopathic skeletal hyperostosis (DISH). We present the case of an 83-year-old patient with progressive dysphagia and acute dyspnea, necessitating emergency tracheotomy. Voluminous anterior cervical osteophytes extending from C3 to C7 and narrowing the pharyngoesophageal segment by external compression and bilateral vocal fold immobility were diagnosed radiologically and by fiberoptic laryngoscopy. Surgical removal of all osteophytes led to the resolution of symptoms. Dyspnea with or without dysphagia caused by hypertrophic anterior cervical osteophytes is an uncommon entity. The exhaustive diagnostic workup proposed in the literature could be simplified by using fiberoptic laryngoscopy and dynamic videofluoroscopy. The causes, treatment, and outcome are discusse

Dulguerov, Pavel

Giger, Roland

Payer, Michael

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Case ReportAnterior Cervical Osteophytes Causing Dysphagia and Dyspnea: AnUncommon Entity RevisitedRoland Giger, MD,1,3 Pavel Dulguerov, MD,1 and Michael Payer, MD21Department of Otorhinolaryngology and Head & Neck Surgery, University Hospital of Geneva, Geneva, Switzerland; and 2Department ofNeurosurgery, University Hospital of Geneva, Geneva, SwitzerlandAbstract. Large anterior cervical osteophytes canoccur in degeneration of the cervical spine or in dif-fuse idiopathic skeletal hyperostosis (DISH). Wepresent the case of an 83-year-old patient with pro-gressive dysphagia and acute dyspnea, necessitatingemergency tracheotomy. Voluminous anterior cervi-cal osteophytes extending from C3 to C7 and nar-rowing the pharyngoesophageal segment by externalcompression and bilateral vocal fold immobility werediagnosed radiologically and by ﬁberoptic laryngos-copy. Surgical removal of all osteophytes led to theresolution of symptoms. Dyspnea with or withoutdysphagia caused by hypertrophic anterior cervicalosteophytes is an uncommon entity. The exhaustivediagnostic workup proposed in the literature could besimpliﬁed by using ﬁberoptic laryngoscopy and dy-namic videoﬂuoroscopy. The causes, treatment, andoutcome are discussed.Key words: Anterior cervical osteophytes —Dyspnea — Dysphagia — Deglutition — Deglutitiondisorders.Hypertrophic anterior cervical osteophytes (HACO)occur in degenerative disc disease, as part of thephysiologic or accelerated aging process, or in diﬀuseidiopathic skeletal hyperostosis (DISH), also knownas Forestiers disease [1, 2]. Voluminous HACO cancompress the pharyngoesophageal and the laryngo-tracheal segments causing dysphagia. The incidenceof dysphagia in patients with HACO or DISH rangedfrom 0.2% to 28% [1, 3, 4]. Dyspnea caused byHACO is less common. In a Medline search of theliterature, only 27 publications describing 37 patientssuﬀering from DISH (28 cases) or HACO (9 cases)complicated by dyspnea were found [2, 5–30]. Amale-to-female ratio of 4:1 was reported with themost frequently involved segments, in 23% of allcases, being C3/C4, C4/C5, and C5/C6.We report on one patient with large HACOthat caused chronic dysphagia and sudden and severedyspnea necessitating an emergency tracheotomy.The literature on HACO causing dyspnea with andwithout dysphagia is reviewed. Possible causes forswallowing and airway deterioration, the treatment,and the outcome are discussed. A simpliﬁed and moredirect diagnostic workup is presented.Case ReportAn 83-year-old male complained of progressive dysphagia for threemonths. Sudden and severe dyspnea, associated with life-threat-ening bronchoaspiration, required an emergency tracheotomy.Fiberoptic laryngoscopy examination revealed a retropharyngealmass bulging from the posterior hypopharyngeal wall, bilateralvocal fold immobility in an intermediate position, and pooling ofsaliva in both pyriform sinuses. A cervical computed tomography(CT) scan demonstrated large HACO from C3 to C7 and showedcompression of the hypopharynx with anterior displacement of theesophagus and larynx. Dynamic videoﬂuoroscopy conﬁrmed largeHACO that displaced the pharyngeal lumen anteriorly and directed90% of the bolus into the larynx, thereby causing serious aspiration(Fig. 1). The anterior view of the pharynx showed right-sidedCorrespondence to: Roland Giger, MD, Department of ORL andHead Neck Surgery, University Hospital of Geneva, Rue Micheli-du-Crest 24, 1211 Geneva 14, Switzerland; E-mail: gigerro@hotmail.com, roland.giger@hcuge.chDysphagia 2006: 259–263DOI: 10.1007/s00455-006-9049-0pharyngeal wall dysfunction (Fig. 2). Flexible esophagoscopy wasperformed and percutaneous endoscopic gastrostomy was placedfor nutritional support.The patient underwent surgery with a right-sided antero-lateral cervical approach to the spine. The dissection was medial tothe carotid artery and lateral to the laryngotracheal and pharyn-goesophageal segments. A self-retaining retractor was installed,and the level of the C4/5 disc was identiﬁed by lateral ﬂuoroscopy.Large anterior osteophytes could be easily visualized and palpated,especially at the C3/4 and C6/7 levels. All osteophytes, togetherwith a calciﬁed anterior longitudinal ligament, were removed withrongeurs and a high-speed drill until the anterior spinal surfacefrom C3 to C7 was ﬂat on palpation and on lateral ﬂuoroscopiccontrol. Standard wound closure was performed.After surgery the patient was mobilized without a collar. Apostoperative lateral plain cervical spine radiograph demonstratedcomplete removal of all HACO from C3 to C7. Initial postopera-tive videoﬂuoroscopy at one month showed absence of pharyngealperistalsis and laryngeal elevation with aspiration. Three monthsafter surgery, ﬁberoptic laryngoscopy demonstrated normalmobility of both vocal folds without any bronchoaspiration andoral feeding was introduced progressively. Seven months aftersurgery, the patient had a closed tracheotomy tube for 72 h and itwas removed without further respiratory problems. The patient isstill symptom-free three years after surgery.DiscussionPathogenesis of DysphagiaPostulated explanations for the dysphagia caused byHACO include mechanical compression causingesophageal obstruction, periesophagitis and peri-pharyngitis, ﬁbrosis and adhesions with ﬁxation ofthe esophagus, cricopharyngeal spasm triggered bypressure on the esophagus, impaired epiglotticmotility, and distortion of the larynx or the laryngealcartilages [10, 12, 13, 25, 27, 30–32]. In our case,dynamic videoﬂuoroscopy showed a displacement ofthe pharyngeal lumen anteriorly by HACO. Theunilateral dysfunction of the pharyngeal wall and theFig. 1. Lateral view of dynamic videoﬂuoroscopy revealing importantanterior cervical osteophytes from C3 to C7 with a maximum at C3/4( ‹ ) and a marked cervical lordosis. Tracheal aspiration can be seen.Fig. 2. Anterior view of dynamic videoﬂuoroscopy illustratingunilateral pharyngeal wall dysfunction with residue in the right-sidepyriform sinus. The pharyngeal wall on the damaged side enables theenlargement of the pyriform sinus (›).260 R. Giger et al.: Anterior Cervical Osteophytesbilateral vocal fold immobility allowing trachealaspiration may result from damage of the pharyngealand laryngeal neural plexuses caused by compressionand/or inﬂammation. We cannot exclude directdamage of the cricoarytenoid joints as an explanationof the bilateral vocal fold immobility.Pathogenesis of DyspneaDyspnea as an additional or the only symptom ofHACO is uncommon [2, 5–30]. Possible explanationsfor dyspnea include compression, glottic inﬂamma-tion and edema, and vocal fold immobility. Dyspneacaused by a large extraluminal osteophytic mass di-rectly compressing, distorting, and ﬁnally obstructingthe airway with no evidence of associated vocal foldimmobility or soft tissue swelling has been reported in18 cases [5, 6, 8, 12, 14, 16, 18–20, 23, 24, 28–30].Mechanical irritation of the retrocricoid area causedby rolling over prominent and spiky osteophytes ateach swallow resulting in a chronic inﬂammatoryedema obstructing the larynx has been postulated asthe cause of dyspnea in ﬁve reported cases [2, 11, 17,21, 27]. Similarly, iatrogenic manipulations such astracheal intubation and respiratory infections mayincrease tissue inﬂammation and may complicatemoderate symptoms [8, 12, 19]. Unilateral or bilateralvocal fold hypomobility or immobility has been re-ported in only 14 cases of HACO with dyspnea [7, 9,10, 22, 24–26, 29]. The exact mechanism of vocal foldimmobility remains unclear, although diﬀerenthypotheses have been discussed: paresis of terminallaryngeal nerve ﬁbers, trauma to the posteriorlylocated cricoarytenoid muscles (lateral and poster-ior), and direct involvement of the cricoarytenoidjoint. All these mechanisms suppose a directmechanical eﬀect by the repeated friction of the lar-ynx over a large bony hyperostosis [7, 9, 11, 24, 28].The combination of unilateral pharyngeal wall dys-function and bilateral vocal fold immobility in ourcase could probably be explained by neural damagedue to mechanical compression.Diagnostic WorkupDiagnostic workup should exclude other causes ofdysphagia, dyspnea, and vocal fold hypo- or immo-bility. Flexible ﬁberoptic laryngoscopy will help toexclude a tumor and to estimate the vocal foldmobility and eventual inﬂammation. A lateral plaincervical radiograph shows anterior osteophytes.A CT scan with sagittal reconstruction demon-strates the craniocaudal and anteroposterior extent ofcervical osteophytes and the location and degree ofpharyngoesophageal and laryngotracheal compres-sion. Magnetic resonance imaging may revealinﬂammatory lesions [2, 5–30]. Flexible esophagos-copy and bronchoscopy were proposed to evaluatethe lower aerodigestive tract [8, 15, 23, 25, 26].Dynamic videoﬂuoroscopy is the main tool forinvestigating swallowing functions and shows therelationship between swallowing pathology andosteophyte size [31]. Finally, the literature and theexperience with our case report let us conclude thatﬁberoptic laryngoscopy that conﬁrms the bulge in theposterior pharyngeal wall and the laryngeal abnor-malities, such as edema of the laryngeal mucosa andvocal fold hypo- or immobility, in combination withdynamic videoﬂuoroscopy that shows the swallowingdisorders in relation to the HACO would be suﬃcientand most helpful in establishing the diagnosis.TherapyThe literature points out that treatment of HACO-induced dysphagia should depend on the nature andseverity of the disease. Sedation, antibiotics, anti-inﬂammatory drugs, steroids, and muscle relaxantswith an appropriate soft diet have been used suc-cessfully [32]. However, there is no doubt that in caseswith prominent respiratory symptoms, the oﬀendingbony mass and spurs have to be removed with sur-gery to avoid further complications and respiratoryfailure [7]. As observed in our case report and in thereviewed literature, dysphagia is almost always apreexisting symptom that appears several monthsbefore the occurrence of dyspnea [2, 5–30]. Whichpatient will develop dyspnea is unclear.OutcomeThe prognosis for the restoration of swallowing isgood. Every case in our literature review that hadundergone surgery showed improvement of the dys-phagia [2, 5–30]. However, the prognosis for therestoration of respiration and vocal fold mobilityremains unclear [2, 5–30]. Sixteen of the 17 patientswith dyspnea caused by posterior pharyngeal bulgingwith and without laryngeal edema with no signs ofvocal fold hypo- or immobility showed improvementof respiration within one month after surgery. Only 5of the 12 patients with dyspnea caused by posteriorpharyngeal bulging with and without laryngeal ede-ma and vocal fold hypo- or immobility showedimprovement of respiration and vocal fold mobilitywithin one month after surgery. The other ﬁvepatients, including our case, showed slow improve-ment in respiration and vocal fold mobility in theR. Giger et al.: Anterior Cervical Osteophytes 261months right after surgery, while in two patients noresolution of dyspnea and vocal fold immobility wasobserved. In nine patients, no further treatment wasperformed. These ﬁndings let us conclude that pa-tients with mechanical burden with or withoutmucosal edema causing dyspnea probably have abetter prognosis and faster restoration of respirationafter surgery than patients with additional vocal foldhypo- or immobility, which is probably a sign ofacute and chronic inﬂammation followed by tissueﬁbrosis and/or neurologic damage.ConclusionsHypertrophic anterior cervical osteophytes (HACO)constitute an uncommon cause of dyspnea in com-bination with dysphagia. Large HACO may lead tolife-threatening dyspnea with or without dysphagiaby diﬀerent mechanisms: (1) mechanical compressionof the upper aerodigestive tract and (2) mechanicaltissue irritation that induces inﬂammation, edema,ﬁbrosis, ankylosis, and compression of neurologicstructures (vagus nerve, pharyngeal and laryngealbranches of the vagus nerve, recurrent laryngealnerve) compromising laryngeal or vocal fold mobilityand esophageal peristalsis. Clinical examination byﬁberoptic laryngoscopy that conﬁrms the bulge in theposterior pharyngeal wall and the laryngeal signs ofdyspnea such as edema of the laryngeal mucosa andvocal fold hypo-/immobility, in combination withdynamic videoﬂuoroscopy that shows the swallowingdisorders in relation to the HACO, would be suﬃ-cient and most helpful in establishing the diagnosis.Surgical removal of all HACO seems to be successfultreatment in most cases.References1. 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Anterior Cervical Osteophytes Causing Dysphagia and Dyspnea: An Uncommon Entity Revisited

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Anterior Cervical Osteophytes Causing Dysphagia and Dyspnea: An Uncommon Entity Revisited

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