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

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 discussed.     

Cervical Osteophytic Dysphagia: Single and Combined Mechanisms

Cervical osteophytes are common in the aging population. Dysphagia induced by cervical osteophytes, although uncommon, is an important and treatable cause of dysphagia that must be identified during the modified barium swallow. Previous authors have described osteophyte impingement as a cause for dysphagia. This report describes a case of this classic obstructive osteophytic dysphagia and one of combined osteophytic and neurogenic dysphagia. This is the first time that a combined mechanism is described in the literature.     

Approaches to the patient with aspiration and swallowing disabilities

Aspiration, or soiling of the tracheobronchial tree, can produce life-threatening pulmonary disease. Intermittent or persistent aspiration may cause symptoms including cough, intermittent fever, recurrent tracheobronchitis, atelectasis, pneumonia, and/or empyema. The pulmonary disease may be associated with weight loss, cachexia, and dehydration. In many cases the aspiration is caused by laryngeal dysfunction, allowing pulmonary contamination by swallowed material. In other cases the aspiration is caused by a dysfunction of the oral, pharyngeal, or esophageal phases of swallowing. In some cases the aspiration is caused by a combination of laryngeal and swallowing dysfunction. Geriatric patients are more likely to experience aspiration, since muscle weakness causing mechanical disability and neurologic impairment are more common in this age group. Therefore, with the ever-increasing aging of our population, these disabilities will be on the rise, with an associated increase in pulmonary disease and death. The approach to evaluation and management of these disorders must be based on an understanding of the underlying functional impairment.     

Utility of Ambulatory pH Monitoring and Videofluoroscopy for the Evaluation of Patients with Globus Pharyngeus

Globus pharyngeous is not an uncommon disorder. The precise pathophysiology remains unclear. The aim of this study was to assess the clinical value of videofluoroscopy and ambulatory pH monitoring in patients with globus pharyngeus. Twenty-three patients (11M/12F, age range = 21–74 yr, mean = 50 yr) with globus pharyngeus entered the study. Radiographic examination of the pharynx and esophagus included videofluoroscopy and static radiography. A dual probe to measure the proximal and distal intraesophageal pH was inserted for 24 h. The results of dual-probe pH monitoring were normal in all patients. Videofluoroscopic results were abnormal in 8 patients, with 5 patients having laryngeal aspiration, 2 having stasis of barium in the vallecula and pyriform sinuses, and 4 having poor pharyngeal elevation. Cervical osteophytes were found in 13 patients with a frequent location at the C5-6 level. Ambulatory pH monitoring seemed to be less helpful for the evaluation of globus pharyngeus without reflux-like symptoms. Pharyngeal dysfunction is detected in a substantial proportion of patients by videofluoroscopy and radiography.     

The surgical management of motility disorders

Surgical treatment is either the therapy of choice or a facultative procedure in various types of esophageal motility disorders. In achalasia, cardiomyotomy, frequently combined with fundoplasty, achieves good or excellent results in >80% of cases, and is, therefore, advised in cases when pneumostatic dilatation fails. Diverticulectomy and myotomy of the upper or lower esophageal sphincter are proven procedures to treat cervical and epiphrenic diverticula, leading to good/excellent results or at least an improvement in more than 95%. If, exceptionally, parabronchial diverticula require therapy, they should be excised transthoracically. Cervical myotomy is indicated in cases of cervical achalasia, when sufficient pharyngeal propulsion is preserved. In systemic diseases like scleroderma reflux induced complications may require surgical intervention in medically intractable cases. In these rather few cases, subtotal gastrectomy with a Roux-en-Y anastomosis is advised. In patients suffering from diffuse esophageal spasm or symptomatic nutcracker esophagus, extended esophageal myotomy can relieve symptoms. If a clear diagnosis is provided, about 75% of patients will have an improvement of symptoms.     

Drug-induced dysphagia

Dysphagia describes the disability or problems in swallowing a wet or dry bolus properly and is normally associated with an impaired transport of the bolus. Dysphagia can be accompanied by a pain sensation in the chest mostly caused by impaction of the food bolus in the esophagus. Odynophagia describes only the status of painful swallowing without an impairment of the swallow and transport function. Drug-induced dysphagia can be caused in two different ways. First as a normal drug side effect of the pharmacological action of the drug or as a complication of the therapeutic action of the drug. The normal drug side effect is most likely in drugs that affect smooth or striated muscle function or the sensitivity of the mucosa. The drug effect on smooth muscle function that causes dysphagia can be inhibitory or excitatory. Dysphagia is a common clinical symptom in patients with reduced perception of the pharyngeal mucosa which leads to an subjective impairment of swallowing. Dysphagia caused by a complication of the therapeutic action of a drug includes viral or fungal esophagitis in patients treated with immunosuppressive drugs or cancer therapeutic agents, or antibiotics and immunological reactions to certain drugs such as erythema exsudativa multiforme or Stevens-Johnson syndrome. Second, drug-induced dysphagia can be due to medication-induced esophageal injury (MIEI). In most cases this mucosal injury appears to be the direct result of prolonged contact of a potentially caustic drug with the esophageal mucosa. This form of medication-induced esophagitis is most likely to be found in elderly patients and patients with esophageal motility disorders. The medication-induced esophageal injury is further promoted by taking the medication at bedtime without enough fluid. In conclusion, drug-induced dysphagia can be caused in many different ways. A carefully taken history in a patient, especially of the current medication, is important for the clinical diagnosis. MIEI can be prevented by concurrent ingestion of adequate amounts of fluid and avoidance of unnecessary bedtime medication, especially in elderly patients.     

Postcricoid Hemangioma: An Overlooked Cause of Dysphagia in Infants?–A Case Report

Feeding and swallowing disorders in children remain a major challenge owing to a wide differential diagnosis. Hemangioma of the upper aerodigestive tract represents one of the numerous non-neoplastic causes of dysphagia. We report two cases of postcricoid hemangioma causing inhalation and recurrent respiratory infections, treated successfully with systemic corticotherapy alone. To our knowledge, these are the second and third cases described in the literature. After a short review of the literature, the diagnostic procedures are discussed and a management strategy is proposed for this clinical entity, by far underestimated.     

Anteroposterior radiographic view of the knee. An unreliable indicator of bone damage

The clinician and/or radiologist uses standard radiographic views to assess bony changes in the joints of patients with both potential and established arthritis. Using AP (standing) views, we recorded the number of osteophytes and/or subchondral cysts seen on both nonarthritic and arthritic tibial tables and their respective plateaus. These data were compared with the number of osteophytes and/or subchondral cysts observed on "en face" views taken of the same tibial tables after they were resected from the knee joints. Not all of the osteophytes or subchondral cysts present in these tibial tables were detected with the AP view. Narrow osteophytes and those located at extreme anterior or posterior positions on a plateau were missed. Single cysts scattered across a plateau were also not seen. We found that the standard AP view gave an inaccurate measure of the amount of bone damage actually present in the tibial tables of arthritic knees.     

An Epidemiological Study of Achalasia Among the South Asian Population of Leicester, 1986–2005

Achalasia is an uncommon esophageal motility disorder of unknown etiology that predominantly affects people over the age of 50. The overall incidence in this study was 0.89 cases/10(5)/year. There was no significant difference in the proportion of South Asian women with achalasia compared to the proportion of men affected in the whole population nor between the male-to-female ratio in the patient group compared to the healthy population. Throughout the twentieth century there have been sporadic attempts to find any etiological link but to date none have been confirmed. However, there is evidence that environmental factors may be important and these are reflected in geographical differences in the distribution of the disease. In this study we were also unable to identify any triggering factor responsible for the development of achalasia.     

Varicoid Adenocarcinoma of the Esophagus: Case Report

Varicoid swellings resemble a varix, or an enlarged and convoluted vessel. Varicoid or superficial spreading carcinoma of the esophagus is a rare condition demonstrating an appearance similar to esophageal varices and as such can be misdiagnosed. In the majority of cases they tend to be squamous cell carcinomas. We present only the second reported case of a patient with varicoid adenocarcinoma of the esophagus. In the absence of chronic liver disease, we advocate that variceal lesions within the esophagus should be regarded with a high index of suspicion for possible varicoid esophageal cancer.     

Dysphagia as a Manifestation of Thyrotoxicosis: Report of ThreeCases and Literature Review

Myopathy is frequently associated with thyrotoxicosis. Skeletal muscles are predominantly involved in thyrotoxic myopathy, but dysphagia is extremely rare. We report three cases of thyrotoxicosis with dysphagia and review of the literature of the past 30 years. Most of these patients had antecedent muscle weakness before the onset of dysphagia although some suffered from a sudden onset of bulbar palsy. Either a myopathic or neuropathic pattern was found on electromyography. The incidence of oropharyngeal dysphagia was higher than that of esophageal motility dysfunction. Aspiration pneumonia occurred more accompanied by oropharyngeal dysphagia. The swallowing disorder could be resolved completely within 3 weeks after treatment for thyrotoxicosis. In light of these clinical experiences, early intensive treatment that includes antithyroid agent, beta-blocker, and Lugol solution may be necessary.     

Cartilage thickening in early radiographic knee osteoarthritis: A within‐person,between‐knee comparison

Objective

To determine whether the presence of definite osteophytes (in the absence of joint space narrowing [JSN]) on radiographs is associated with (subregional) increases in cartilage thickness in a within‐person, between‐knee cross‐sectional comparison of participants in the Osteoarthritis Initiative. Based on previous results, the external weight‐bearing medial femoral condyle (ecMF) and external weight‐bearing lateral femoral condyle (ecLF) subregions were selected as primary end points.

Methods

Both knees of 61 Osteoarthritis Initiative participants (n = 4,796) displayed definite tibial or femoral marginal osteophytes and no JSN in 1 knee, and no signs of radiographic osteoarthritis (OA) in the contralateral knee; this was confirmed by an expert central reader. In these participants, cartilage thickness was measured in 16 femorotibial subregions of each knee, based on sagittal double‐echo steady‐state with water excitation magnetic resonance images. Location‐specific joint space width from fixed‐flexion radiographs was determined using dedicated software. Location‐specific associations of osteophytes with cartilage thickness were evaluated using paired t‐tests and mixed‐effects models.

Results

Of the 61 participants, 48% had only medial osteophytes, 36% only lateral osteophytes, and 16% bicompartmental osteophytes. The knees with osteophytes had significantly thicker cartilage than contralateral knees without osteophytes in the ecMF (mean ± SD +71 ± 223 μmoles, equivalent to an increase of +5.5%; P = 0.015) and ecLF (mean ± SD +64 ± 195 μmoles, +4.1%; P = 0.013). No significant differences between knees were noted in other subregions or in joint space width. Cartilage thickness in the ecMF and ecLF was significantly associated with tibial osteophytes in the same (medial or lateral) compartment (P = 0.003).

Conclusion

The knees with early radiographic OA display thicker cartilage than (contralateral) knees without radiographic findings of OA, specifically in the external femoral subregions of compartments with marginal osteophytes.     

Laryngologic aspects of bolus asphyxiation-bolus death

Among 12,982 forensic autopsies, 78 cases of café coronary due to bolus impaction in the larynx (bolus death) were observed from 1947 to 1988. In all cases bolus material occluded the entry to the larynx; only once was a signular occlusion of the glottis observed. The bolus frequently extended into the mouth, trachea, and bronchial tree or esophagus. In all cases small amounts of aspirated material were observed in the deeper parts of the bronchial tree. The most commonly observed bolus was not masticated meat or a meat product. In adults and the elderly the bolus was often too large to pass the physiological narrowings of the hypopharynx. It was commonly lodged above the arytenoid cartilages. Forty-five of the bolus events were observed by bystanders. In 43 of the victims vital reactions were observed by bystanders or at the autopsy. This justifies the hope that many lives could have been saved had the right diagnosis and immediate therapy been initiated. The first step should be manual extraction or use of the Heimlich maneuver; in cases of failure of both attempts, immediate tracheotomy followed by hospitalization and bronchial lavage are indicated.     

Post-mortem study of the hip joint. III. Correlations between observations.

Correlations between alterations in hip joints, described in a post-mortem study, have established the independence of limited and progressive alterations, and in addition have shown that there is a weak association between limited alterations and osteophytes and a strong one between progressive alterations and osteophytes. Nevertheless limited alterations may rarely undergo progressive damage. Cysts relate strongly to osteophytes but only moderately with progressive alterations. Limited alterations of both head and acetabulum can be subdivided. Some implications of these findings are discussed.     

Enthesopathy of the hip joint

Summary Morphologically, enthesopathy appears as dystrophic calcification or ossification of tendon insertion. In the study of the initial stages of arthrosis on necroptic material roentgenologically 158 and of these histologically 62 hip joints were investigated. A typical picture of so-called non-inflammatory enthesopathy was present in thirteen cases on the major and in three cases on the minor trochanter. Histologically, we observed enthesopathy-like changes, but to a much lesser extent in the insertions of the articular capsule. These pictures which on the X-ray resembled initial osteophytes were found seven times on the head of the femur and fourteen times on the edge of the joint acetabulum. There was no correlation to osteoarthrosis.     

Lumbar disc degeneration: association between osteophytes, end-plate sclerosis and disc space narrowing

BACKGROUND: Lumbar disc degeneration is characterised radiologically by the presence of osteophytes, end-plate sclerosis and disc space narrowing. AIM: To determine the strength of the association between increasing severity of combinations of these features in a population sample of men and women. METHODS: Men and women aged >or=50 years were recruited from a primary care-based community health index in Aberdeen, UK. Participants had lateral spinal radiographs performed according to a standard protocol. The intervertebral disc spaces (L1/2-L4/5) were evaluated for the presence of anterior osteophytes, end-plate sclerosis and disc space narrowing using a graded semiquantitative score (grade 0-3). Log linear modelling was used to determine the associations (pairwise) between increasing severity of these features, with the results expressed as beta coefficients and 95% confidence intervals (CIs). RESULTS: There were 286 men (mean age 65.3 years) and 299 women (mean age 65.2 years) with spinal radiographs, yielding a total of 2340 assessable lumbar vertebral levels. In all, 73% of vertebral levels had evidence of osteophytes, 26% of sclerosis and 37% of disc space narrowing. Increasing severity of osteophyte grade was associated with an increasing severity both of sclerosis and of disc space narrowing, whereas the severity of sclerosis was associated with the severity of narrowing. This was true at all vertebral levels. The strongest association, however, was between osteophytes and sclerosis (beta coefficient = 2.7, 95% CI 2.4 to 3.1). For sclerosis and narrowing the beta coefficient was 1.9 (95% CI 1.7 to 2.1), whereas for osteophytes and narrowing the beta coefficient was much weaker at 1.2 (95% CI 1.1 to 1.3). There was no important influence of vertebral level on any of these associations. CONCLUSION: The association between increasing severity of osteophytes and end-plate sclerosis is stronger than for other combinations of radiographic features of lumbar disc degeneration.     

Malignancy-induced secondary achalasia

Secondary achalasia refers to the development of clinical, radiographic, and manometric findings of achalasia as a result of (i.e., secondary to) another underlying disorder. A variety of malignancies have been associated with secondary achalasia. Adenocarcinoma of the esophagogastric junction accounts for the majority of cases of malignancy-induced achalasia, however, noncontiguous tumors may also cause this disorder. Although rare, malignancy-induced achalasia will occasionally be encountered by gastroenterologists and gastrointestinal radiologists who see patients with dysphagia and/or achalasia. Since treatment is aimed at the underlying neoplasm, it is important to recognize this disorder. Three clinical features suggest the possibility of malignancy as a cause of achalasia: 1) short duration of dysphagia (<1 year); 2) significant weight loss (>15 pounds); and 3) age >55 years. The presence of any of these should at least raise a suspicion of malignancy. Diagnosis may not be evident on routine esophagrams and endoscopy, and requires clinical suspicion for further evaluation with thoraco-abdominal CT scanning and endoscopic ultrasonography.     

The distribution, determinants, and clinical correlates of vertebral osteophytosis: a population based survey

OBJECTIVE: Vertebral osteophytes are a characteristic feature of intervertebral disc degeneration. There are, however, few population data concerning the occurrence of and clinico-biological correlates of vertebral osteophytes in both the dorsal and lumbar spine. Our purpose was to determine the frequency and distribution of anterior osteophytes in the thoracic and lumbar spine, and their relationship with both various putative risk factors, including physical activity and obesity, and self-reported back pain. METHODS: Men and women aged 50 years and over were recruited from primary care based registers in 5 UK centers. They were invited to attend for an interviewer administered lifestyle questionnaire, assessment of height and weight, and lateral spinal radiographs. Lateral spinal radiographs were evaluated by a single observer for the presence of osteophytes from T4 to L5 using a semiquantitative score (grade): 0 = none, 1 = doubtful, 2 = mild, 3 = moderate, 4 = severe. Based on these data 2 summary statistics were derived: the maximum osteophyte grade at any vertebral level (MAX), and the sum of the osteophyte grades at the individual vertebral levels (TOT). RESULTS: In total, 681 women, mean age 63.3 years, and 499 men, mean age 63.7 years, were studied; 84% of men and 74% of women had at least one vertebral level with a grade 1 or higher osteophyte. Both the sum of the individual grades (TOT) and the proportion of subjects with MAX > or =2 were greater in men than in women in both the dorsal and lumbar spine, and both increased with age. The pattern of spinal involvement was similar in the sexes, with osteophytes occurring most frequently at T9-10 and L3. Increasing body mass index was associated with more frequent osteophytes at both dorsal and lumbar spine, although the relationship was stronger at the dorsal spine. Heavy physical activity, particularly in young adult life, was associated with osteophytosis in men. Self-reported back pain, both ever and in the past year, was linked with lumbar osteophytes in men. CONCLUSION: The distribution within the spine in our study and the relationship with heavy physical activity points to mechanical factors being important in pathogenesis of vertebral osteophytosis. Prospective studies are needed to explore the types of physical activity that increase susceptibility to vertebral osteophytosis. In men, osteophytes affecting the lumbar spine are associated with back pain.     

Extrinsic Esophageal Compression by Cervical Osteophytes in Diffuse Idiopathic Skeletal Hyperostosis: A Contraindication to Transesophageal Echocardiography?

Contraindications to transesophageal echocardiography (TEE) include various esophageal pathologies, but compression of the esophagus by vertebral osteophytes is not listed in the current American Society of Echocardiography guidelines. We report a case of diffuse idiopathic skeletal hyperostosis (DISH) in an 81‐year‐old man who had incidentally been found to have extrinsic esophageal compression by cervical osteophytes prior to a proposed TEE. The incidence of esophageal perforation in patients with DISH and vertebral osteophytes is not well documented. We believe these patients are at increased risk of esophageal perforation during TEE, and thus, TEE may be relatively contraindicated in patients with DISH.