No more DISHes, doctor? DISH as a cause of dysphagia

Clinical History

A 66-year-old gentleman who had experienced difficulty in swallowing solid food for the past two months, presented for evaluation.

Imaging Findings

This gentleman presented to his general practitioner with a difficulty in swallowing solid food, which he had experienced for the past two months. He felt food sticking in the region of the cervical pharynx. There was no history of weight loss or odynophagia. The physical examination was unremarkable. There were no thyroid masses, goiter or lymph nodes palpable. A barium swallow test which was performed showed no mucosal abnormality in the esophagus. There was no stenosing lesion or obstructing lesion to account for the dysphagia for solids. However, a diffuse idiopathic skeletal hyperostosis between C3 and C7 in the form of bridging osteophytes and an ossification of the anterior longitudinal ligament were seen at the regions where the patient complained of dysphagia.

Discussion

DISH or diffuse idiopathic skeletal hyperostosis is a less well-recognized cause of cervical pharyngeal dysphagia. Occurring in 2.4%–5.4% of the population above 40 years of age, with 11.2% of them being above 70-year-old, DISH is characterized by the ligamentous ossification of the anterolateral spine. A key feature of DISH is the preservation of the intervertebral disc height and the relative lack of degenerative disease. Clinically it may manifest as dysphagia, hoarseness, food impaction and even stridor in severe cases. Although the etiology of DISH is unknown, there have been positive correlations with diabetes, hypertension, a greater body mass index, gout and Dupuytren’s contracture. Dysphagia due to DISH is hypothesized to be secondary to the following conditions: 1. giant osteophytes impinging the esophagus and obstructing the passage of food bolus; 2. peri-esophageal inflammation and edema of soft tissues around large osteophytes, inducing obstruction, pain and spasm; and 3. impingement of small osteophytes on the relatively immobile cricoid cartilage. Complications from DISH include fractures of the cervical spine after minor injury. Ankylosis of the cervical spine results in easy fractures which are transverse in nature, contrary to the usual compression fractures. This is due to the reduced dissipation of forces applied to the ankylosed spine. The diagnosis of DISH has a particular significance in cases requiring procedures such as endotracheal intubation or rigid endoscopy, due to the presence of large osteophytes impinging on adjacent soft-tissue structures. The treatment of DISH is mainly conservative, and includes the use of non-steroidal anti-inflammatory drugs, analgesics, muscle relaxants, anti-reflux regimes and diet modification. Failing this, surgery for the palliation of the symptoms of dysphagia is selectively undertaken via cervical osteophytectomy. The awareness of this easily diagnosed radiological condition provides the clinician with an etiology for dysphagia and allows him to treat the patient appropriately and predict possible complications which may arise from this condition.

Differential Diagnosis List

Final Diagnosis

Diffuse idiopathic skeletal hyperostosis.

URL:	https://www.eurorad.org/case/3174
DOI:	10.1594/EURORAD/CASE.3174
ISSN:	1563-4086