PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 29 no. 2 July – december 2014
FEATURED GRAND ROUNDS
34 PhiliPPine Journal of otolaryngology-head and neck Surgery
Diffuse idiopathic skeletal hyperostosis (DISH) is a disease characterized by massive, non-
inflammatory ossification with intensive formation of osteophytes affecting ligaments, tendons
and fascia of the anterior part of the spinal column mostly in the middle and lower thoracic regions.
However, isolated and predominant cervical spinal involvement may occur. It has predilection for
men (65%) over 50 years of age and a prevalence of approximately 15-20% in elderly patients.1
A CT scan is one of the diagnostic tools. The radiographic diagnostic criteria in the spine include:
1) osseous bridging along the anterolateral aspect of at least four vertebral bodies; 2) relative
sparing of intervertebral disc heights with minimal or absent disc degeneration; and 3) absence
of apophyseal joint ankylosis and sacroiliac sclerosis.2 We present a rare case of dysphagia over
two years duration due to DISH.
CaSe RepoRt
A 55-year-old Malay man presented with intermittent dysphagia for two years duration. He
denied foreign body ingestion, globus sensation or any laryngeal trauma, shortness of breath,
hoarseness or any neurological deficits. A solitary smooth mass on the right posterolateral
pharyngeal wall that was hard in consistency was appreciated on oropharyngeal examination.
(Figure 1) There was no significant cervical lymphadenopathy and the neurological examination
was unremarkable. Cervical Radiographs and CT scan showed marked ossification at the right
anterolateral aspect of cervical vertebral bodies C2 to C7 most probably representing a Diffuse
Idiopathic Skeletal Hyperostosis. (Figures 2, 3) He was treated conservatively with 6-monthly
follow up.
DISCuSSIon
Diffuse Idiopathic Skeletal Hyperostosis (DISH) is an ossifying diasthesis characterized by
the thickening and calcification of soft tissue (ligaments, tendons and joint capsule) resulting
in secondary formation of osteophytes. Most commonly it affects the paraspinal ligaments,
predominantly the anterior longitudinal ligament and occasionally the posterior longitudinal
ligament.2 It was first described as senile ankylosing hyperostosis of the spine by Forestier
and Rodes Querol in 1950.3 In 1970 Resnick et al. coined the term DISH for this systemic entity.
Radiologically, they established 3-diagnostic criteria which include: 1) Presence of flowing
Diffuse Idiopathic Skeletal Hyperostosis:
a Rare Cause of Dysphagia
Correspondence: Dr. Khairullah Anuar
Department of Otorhinolaryngology-Head & Neck Surgery,
Faculty of Medicine and Health Sciences,
Universiti Sains Islam Malaysia
Tingkat 13, Menara B Pesiaran MPAJ
Jalan Pandan Utama, Pandan Indah 55100 Kuala Lumpur
Malaysia
Phone: (03) 4289 2400
Fax: (03) 4289 2408
Email: drkhairul@usim.edu.my
khairullah4195@yahoo.co.nz
Reprints will not be available from the author.
The authors declared that this represents original material
that is not being considered for publication or has not been
published or accepted for publication elsewhere in full or in
part, in print or electronic media; that the manuscript has been
read and approved by the authors, that the requirements for
authorship have been met by the authors, and that the authors
believe that the manuscript represents honest work.
Disclosures: The authors signed disclosures that there are no
financial or other (including personal) relationships, intellectual
passion, political or religious beliefs, and institutional affiliations
that might lead to a conflict of interest.
Anuar Khairullah, MBChB, MS (ORL-HNS)1
Hitam Shahrul, MBBS, MMed (ORL)2
Sushil Brito –Mutuyanagam, MBBS, MS (ORL-HNS)2
1Department of Otorhinolaryngology
Head & Neck Surgery
Faculty of Medicine and Health Sciences
Universiti Sains Islam Malaysia
2 Department of Otorhinolaryngology
Ampang Hospital
Philipp J Otolaryngol Head Neck Surg 2014; 29 (2): 34-36 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 29 no. 2 July – december 2014
PhiliPPine Journal of otolaryngology-head and neck Surgery 35
FEATURED GRAND ROUNDS
Figure 1. Right posterolateral oropharyngeal mass
Figure 3a. CT scan, axial section showing large anterior osteophyte at C2 Level
ossification of anterior longitudinal ligament of at least four contiguous
vertebral bodies; 2) Preservation of intervertebral disc height; and
3) Absence of apophyseal joint ankylosis or sacroiliac joint erosion,
sclerosis or fusion.4
Cervical anterior osteophytes accompanying DISH are mostly
asymptomatic. They may present with cervical pain and stiffness. Large
osteophytes however do cause dysphagia and it is the most common
presenting complaint, affecting 17 – 28% of patients.5 Many different
mechanisms have been suggested as the cause of the dysphagia
including mass effect on the esophagus by the osteophytes and
neuropathy due to recurrent laryngeal nerve impingement.5,6 According
to LIn et al., in addition to distortion of laryngoesophageal anatomy and
functions, osteophytes of cervical vertebrae can alter the mechanics of
pharyngeal swallowing leading to secondary inflammation and edema
of mucosa and soft tissue.6 Although airway symptoms in patients with
DISH appear to be rare, clinicians should be aware of this condition and
its potential for acute respiratory complications.
The etiology of DISH is still unclear, however according to
Calisanellerr et al. it may be associated with excessive mechanical
stress, hyperlipidaemia, increased levels of insulin with or without
diabetes mellitus, increased levels of insulin-like growth factor-1
and hyperuricaemia.7 A positive HLA–B8 has also been reported
and hypervascularity may also play a role in the etiopathogenesis of
DISH.7,8,9
Differential diagnosis of DISH includes ankylosing spondylitis,
spondylosis deformans, osteoarthritis and esophageal malignancies
where it should be considered when the dysphagia cannot be explained
by small anterior osteophytes.5
Figure 3B. CT scan, bone window at same level, showing the large anterior osteophytes
Figure 2. Lateral neck X-ray showing the osteophytes
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 29 no. 2 July – december 2014
FEATURED GRAND ROUNDS
36 PhiliPPine Journal of otolaryngology-head and neck Surgery
ReFeRenCeS
1. Weinfeld RM, Olson PN, Maki DD, Griffiths HJ. The prevalence of diffuse idiopathic skeletal
hyperostosis (DISH) in two large American Midwest metropolitan hospital populations. Skeletal
Radiol 1997 Apr; 26(4):222–225.
2. Goh PY, Dobson M, Iseli T, Maartens NF. Forestier’s disease presenting with dysphagia and
dysphonia. J Clin Neurosci. 2010 Oct; 17(10):1336-1338.
3. Forestier J, Rotes-Querol J. Senile ankylosing hyperostosis of the spine. Ann Rheum Dis 1950
Dec; 9(4 ):321–330.
4. Resnick D, Niwayama G. Radiographic and pathologic features of spinal involvement in diffuse
idiopathic skeletal hyperostosis (DISH). Radiology 1976 Jun; 119(3): 559–568.
5. Kos MP, Van Royen BJ, David EF, Mahieu HF. Anterior cervical osteophytes resulting in severe
dysphagia and aspiration: two case reports and literature review. J Laryngol Otol. 2009 Oct;
123(10):1169-1173.
6. Lin HW, Quesnel AM, Holman AS, Curry WT Jr., Rho MB. Hypertrophic anterior cervical
osteophytes causing dysphagia and airway obstruction. Ann Otol Rhinol Laryngol 2009 Oct;
118(10);703-707.
7. Calisaneller T, Ozdemir O, Tosun E, Altinors N. Dysphagia due to diffuse idiopathic skeletal
hyperostosis. Acta Neurochir 2005; 147: 1203–1206.
8. Denko CW, Boja B, Moskowitz RW. Growth promoting peptides in osteoarthritis and diffuse
idiopathic skeletal hyperostosis – insulin, insulin-like growth factor-I, growth hormone . J
Rheumatol 1994; 21(9): 725–730.
9. Miedany YM, Wassif G, Baddini M. Diffuse idiopathic skeletal hyperostosis (DISH): is it of
vascular etiology? Clin Exp Rheumatol 2000; 18(2): 193–200.
10. Troyanovich SJ, Buettner M. A structural chiropractic approach to the management of diffuse
idiopathic skeletal hyperostosis. J Manipulative Physiol Ther.2003 Mar-Apr; 26(3):202-206.
11. Carlson ML, Archibald DJ, Graner DE, Kasperbauer JL. Surgical management of dysphagia and
airway obstruction in patients with prominent ventral cervical osteophytes. Dysphagia. 2011
Mar; 26(1): 34-40.
Treatment can be divided into conservative treatment with dietary
modification, swallowing therapy sessions and analgesia for early
stages of mild dysphagia. Chiropractic treatment and acupuncture
are popular alternatives among patients. The benefit of chiropractic
therapy may lie in its role in increasing range of movement of the spine
and providing pain relief.10 When conservative treatment fails, surgical
interventions such as osteophytectomy, tracheotomy and feeding tube
insertion are indicted. Surgical excision via perioral transpharyngeal
route for C1 and C2 vertebrae or anterior cervical approach for C3 to C7
vertebrae is preferred.6,11 The aim of the surgery is to provide satisfactory
decompression of the esophagus.6 Recent studies have shown
that patients treated surgically with osteophytectomy had marked
improvement if not complete resolution of their upper aerodigestive
disturbances.11 It should be remembered that surgical interventions
harbor the risk of recurrent laryngeal nerve injury, Horner’s syndrome,
cervical instability, persistent symptoms and recurrence.11
Dysphagia caused by diffuse idiopathic skeletal hyperostosis is an
uncommon entity. Radiological evaluation specifically CT scans are
diagnostic and can rule out other possible causes of oropharygeal mass.
Surgical decompression may relieve the dysphagia when conservative
treatments fail.