Hi,
I would like to have your advice for the following patient.
I would like to have your advice for the following patient.
60 yr old male, has been having dysphagia and chokes on fluids and solids for about 2 yrs or more. The daughter who happens to be our nurse, says it is a pain to watch him taking food.
His X-ray neck lateral shows big osteophytes between C2-3, C3-4, C4-5, C5-6, and C5-7. The ones C4-5-6 looks like a single unit. They are big and measures almost the antero- posterior diameter of the corresponding vertebral body.
A CT done 2 yr back revealed nothing more than this. We couldn't do a Barium swallow for flimsy reasons, but it could be done about a week back, and since the software to record the same didn't work, we had to be contented by just seeing what was seen during fluoroscopy. The barium went down without any hitch, negotiating the "C" projection of the C4-5-6-7 oteophytes at the root of neck.
We sent him to our Orthopaedician, who asked for an MRI; but it couldn't be done, as he was unable to lie down for the same because of pain (Radiologist told the nurse-daughter) Hence a repeat CT was done (Is the position for CT different from MRI?), which showed no change from the previous CT.
What next? I am posting photograph of the X-ray Neck Lateral and relevant frames from a CT scan.
3 comments:
Comments received so far:
Look up DISH syndrome (diffuse idiopathic skeletal hyperostosis).
http://www.rforl.com/PDF/UK0508808.pdf
I have had several cases of this associated with severe dysphagia associated
with aspiration difficulties. My associates and I have also had 2 patients
who required tracheotomy because of upper airway obstruction. These
typically are patients whose osteophytes are substantial, fused in 2 or more
levels, and located just above the posterior commissure of the glottis.
Presumably, the retropharyngeal mass effect causes not only difficulty in
normal laryngeal excursion during swallowing, but also acts as a slope
directly into the glottis. If you combine that with an epiglottis in an
older individual that tends to rest against the posterior wall of the
pharynx, you can also have an element of airway obstruction, particularly if
they have difficulty extending their neck. Severe cases require surgical
excision of the osteophytes.
Steve Dankle
Milwaukee, Wi
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A Google search reports 4,530 English pages for dysphagia from
cervicle osteophytes.
As to osteophyte management, a right lateral neck- post esophageal
approach allows exposure then reduction by drilling similar to that
used for ear canal exostosis, e.g., hollow out the mass(es) prior to
elevating their overlying soft tissue.
Charles W Vaughan MD
Boston Un School of Medicine
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I have had only one to operate. We used a Ba tablet or other solid to demonstrate the trouble. I would not operate unless there was definite impairment that showed.
John Roediger
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Those are impressive, indeed!!
Norman J. Harris MD, FACS
Orange, California
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Do you have access to any spine surgeons? I'm fortunate to have an
orthopedic spine surgeon who will tackle these cases.
Roger Tuggle
Another comment:
I have operated on a couple of such cases, both times with a Neurosurgeon.
One lady had severe crico-pharyngeal spasm, and a large osteophyte, and on Be swallow, and Video-fluoroscopic swallow with various thickness meals, it seemed that the cricopharyngeal "bar" and the osteophyte were impinging. I didn't want to revise surgery if osteophyte removal failed, so I did a Cricopharyngeal myotomy at the same time as he knocked off the osteophyte with an Osteotome and drill.
The lady swallowed well for about 5 years, and then dysphagia recurred, as did some new neurological problems, suggesting a degenerative condition, not yet diagnosed, probably some type of Neuropathy.
The other guy had DISH syndrome (Diffuse Idiopathic Skeletal Hyperostosis) - The neurosurgeon did his osteophytes, and I decided not to do his myotomy, as his Ba swallow did not show much muscle spasm - his swallowing was no better
_______________________________________________
Mr. Stephen Kleid MB,BS FRACS
Ear Nose & Throat / Head & Neck Surgeon
Sino-Nasal & Rhinoplasty
Snoring Surgery
www.entdoc.info
www.snore.com.au
Next comment:
This looks like Forrestier's disease in which the anterior osteophytes of minimum three cervical vertebrae join up and project into the pharynx. The CT films you have show the marked projection into the pharynx. This causes dysphagia for solids mainly and odynophagia.
The treatment is surgical removal of the osteophyte by a cervical spinal surgeon. I would refer him to one now since he is obviously rather distressed by it.
Shehnaz Somjee
Otolarynglogist
Liverpool UK
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