Neuralgia of the superior laryngeal nerve caused by phonatory malfunctions

Clinical observations show a close relationship between neuralgia of the superior laryngeal nerve and disorders of the larynx. Neuralgia, and more minor symptoms are usually caused by hyper- and hypotonic phonatory disorders. An unphysiological compensation for glottic insufficiency causes irritation of the sensory telodendrons of the superior laryngeal nerve. As incomplete adduction of the vocal cords can often be found in patients with an autonomic laryngeal dystonia, a syndrome related to anxiety, these disturbances are often misinterpreted as "globus hystericus". However, this diagnosis does not take into account the cause and should therefore no longer be used.     

Functional disorders of the craniocervical transition and ENT symptoms--a status determination

ENT symptoms due to disorders of the cervical spine are rarely caused by pathological lesions of the cervical spine that can be demonstrated by radiography, but are mostly caused by functional disorders of the upper cervical spine. They include: globus symptoms and dysphonia; pain syndromes in the head and neck; and otoneurological disorders. ENT symptoms resolve as soon as the function of the cervical spine and vertebral joints has returned to normal.     

Anterior hyperostosis of the cervical spine: diagnostic studies and surgical therapy

BACKGROUND: Dysphagia due external compression by anterior hyperostosis of the cervical spine is rare. The diagnosis may be established by conventional X-ray of the spine, esophagogram, and CT. PATIENTS: We operated on three patients with large anterior osteophytes from C3 to C7. In two cases morphologic changes of the cervical spine were the main cause of dysphagia. One patient with progressive hypopharynx cancer had hyperostosis of cervical spine as secondary findings. RESULTS: The patients were asymptomatic, post-operatively. CONCLUSIONS: Cervical osteophytes can be detected in 20-30% of the population in asymptomatic patients. The therapeutic approach depends on the extent of dysphagic complaints. Painful dysphagia is a indication for surgery. The anterolateral extrapharyngeal approach is commonly preferred with anterior hyperostosis between C4 and C7. The transoral intrapharyngeal approach has been used in patients with hyperostosis of cervical vertebra C2/C3. Interdisciplinary orthopedic and ENT surgical treatment is without complications and yields good functional results.     

Diffuse idiopathic skeletal hyperostosis with dysphagia (a review)

Dysphagia due to cervical osteophytes is not common. However, diffuse idiopathic skeletal hyperostosis (DISH) with cervical involvement which causes dysphagia is even rarer. The otolaryngologist is not generally familiar with this entity. The diagnosis can be made by plain cervical X-ray films, a barium swallowing esophagogram and or a CT scan of the neck. When doubt still exists, further extra-axial X-ray films can be helpful. Although most patients have been treated surgically, there may be a role for conservative therapy initially, as surgery in elderly DISH patients is often morbid and even fatal. A 79-year-old patient with DISH (Forestier's disease) is reported. Non-steroidal anti-inflammatory therapy was successfully implemented. DISH is compared with other disorders of the cervical spine which may cause dysphagia.     

Operative therapy of dysphagia caused by cervical spondylophytes

This study reports two cases of anterior osteophytes that caused dysphagia leading to loss of weight and finally cachexia. The successful ablation of these osteophytes and clearance of the intravertebral spaces with ventral fusion of the cervical spine completely relieved these two patients of their swallowing difficulties.     

Cervical osteophytes causing vocal fold paralysis: case report and literature review

Objectives: To increase awareness of cervical osteophytes as an extremely rare cause of recurrent laryngeal nerve palsy; to outline the clinical approach to patients with unilateral vocal fold paralysis and to provide an update on the current management of osteoarthritis and osteophytes. Case report: An elderly man presented with right unilateral vocal fold immobility and a small phonatory gap. By a diagnosis of exclusion, a cervical osteophyte at the level of the sixth and seventh cervical vertebrae was shown to be the cause. The patient responded to speech therapy and no further intervention was required. Method: A literature review, using Medline, identified only one previously published case of vocal fold paralysis due to osteophytes secondary to osteoarthritis. Conclusion: The aetiology of unilateral paralysis of the hemilarynx must be fully investigated, as the innervating system has a protracted course, particularly on the left side. Degenerative cervical spine disease, although rare, should be considered as part of the differential diagnosis.     

咽宁波谱治疗贴治疗咽异感症临床观察

目的观察咽宁波谱治疗贴对咽异感症的治疗作用.方法选择治疗组60例,于天突穴粘贴咽宁治疗贴4～8次;对照组24例,于天突穴粘贴同等大小医用胶布6次.结果按有效、显效、无效进行分析,治疗组总有效率92%,显效77%,无效8%;对照组总有效率29.2%,显效4.2%,无效70.8%;两组治疗结果有显著性差异(P＜0.05).结论咽宁治疗贴用于咽异感症使用方便,疗效肯定.     

Eine atlantoaxiale Fehlbildung als seltene Ursache f��r Dysphagie und Rhonchopathie

Abnormalities of the atlantoaxial spine are very rare variants. Bony outgrowths, osteophytes, clefts and aplasia may be misinterpreted as degenerative diseases. One patient presented with intermittent dysphagia and snoring and CT and MRI scans of the cervical spine showed an accessory bone located anterior to the atlas and axis. Atlantoaxial anomalies are often incidental findings without clinical symptoms. Such changes are rarely the cause of intermittent dysphagia and snoring.     

Dysphagia caused by ventral osteophytes of the cervical spine: clinical and radiographic findings

The purpose of our study was to demonstrate the clinical and radiographic findings in patients with dysphagia and ventral osteophytes of the cervical spine due to degeneration or as a typical feature of diffuse idiopathic skeletal hyperostosis (DISH, Forestier Disease). Since 2003 we encountered 20 patients with such changes in the cervical spine causing an impairment of deglutition. A total of 12 patients had one solitary pair of osteophytes of neighboring vertebrae, 4 patients revealed two pairs and 4 patients had triple pairs of osteophytes. Thirty-two osteophytes were observed totally. A total of 14 of these arose from the right, 15 from the left side and 3 from the middle of the anterior face of the vertebra. Ten patients suffered from DISH, while ten patients revealed osteophytes as a part of a degenerative disorder of the cervical spine. The osteophytes had an average length of 19 mm maximum anterior posterior range. Most of the osteophytes (16) were found in the segments C5/6 and C6/7. Osteophytes of vertebrae C3/4/5 occurred in six cases. Only in one case C2/3 was affected. Functional endoscopic evaluation of swallowing (FEES) revealed an aspiration of thin liquids in seven patients with osteophytes arising from the anterior face of the vertebra C3/4/5 restricting the motility of the epiglottis, which seemed not to close the aditus laryngis. Retention of solids in the piriform sinus on the side obstructed by an osteophyte (C4/5) could also be repeatedly evidenced through FEES. In one case, a strong impairment of the voice because of an immobility of the right vocal cord due to mechanical obstruction by an osteophyte was the indication for surgical removal of the structure. Thus, the dysphagia of this patient was reduced and his voice turned to normal. The development of symptoms in patients with ventral osteophytes was very much related to the location of the structures. Moreover, the clinical symptoms were to some extent dependent on the size of the osteophytes, although there was no direct correlation between size of the structure and severity of the patient’s complaint.     

Diffuse idiopathic skeletal hyperostosis causing obstructing laryngeal edema

Diffuse idiopathic skeletal hyperostosis (DISH), or ankylosing hyperostosis (“Forestier’s disease”), is an ossifying diathesis of unknown etiology. Diagnosis is primarily radiologic: osseous bridging of at least four contiguous vertebral bodies, a radiolucent line between the deposited bone and the anterior vertebral surface, large osteophytes and preservation of disk height especially in the cervical and lumbar spine. Although DISH is found in 6–12% of autopsy cases, clinical features are rare and consist primarily of swallowing disorders. A case of DISH is reported in which excessively enlarged cervical osteophytes led to edema of the laryngeal inlet and consequent severe dyspnea, necessitating emergency tracheotomy. Surgical excision of the osteophytic masses resulted in relief of symptoms. Symptomatology, radiographic features and individual treatments are discussed, with the latter dependent on clinical symptoms. Received: 13 January 1997 / Accepted: 1 August 1997     

Dynamic imaging in diagnosis of dysphagia and globus sensation

BACKGROUND: Videofluoroscopy has gained high significance for the evaluation of deglutition disorders. Imaging alone cannot clarify whether the subjective symptom is represented morphologically or whether it is the substrate of a functional disorder. METHOD: The videofluoroscopies of 101 patients with dysphagia (n = 55) and globus pharyngitis (n = 46) were evaluated. Morphologic abnormalities were registered as well as sequential movement patterns. These data were compared with clinical and endoscopic findings. RESULTS: In 87% of the dysphagia and 74% of the globus patients videofluoroscopy revealed pathologic findings. Functional disorders were seen significantly more often than morphologic abnormalities. Highest incidence was found for cricopharyngeal dyskinesia (42%). Hypopharyngeal pouches and degeneration signs of the cervical spine with bolus impression less than 40% are common but functionally not important. Additional esophago-gastroduodenoscopy was pathological in 83% in the dysphagia group and 96% in the globus group. CONCLUSION: Videofluoroscopy is indispensable for the differential diagnosis of dysphagia and globus sensation, especially for the detection of functional disorders in the pharyngoesophageal segment thus documenting the dynamic aspect of deglutition. Videofluoroscopy should be completed by a gastroenterologic examination in order to improve diagnosis.     

An accessory retropharyngeal bone as a rare cause of dysphagia

A 77-year-old woman had a history of several-years of dysphagia. On presentation, a submucosal mass impinging on the left oropharynx was present. CT-scans showed a bony structure isolated from the cervical column. The patient underwent complete surgical resection using a transoral approach. Histological examination confirmed the radiological finding; a new formation of bone surrounded by cartilage with hematopoieses in the bone marrow. Recovery was complete within 2 weeks. Dysphagia due to cervical spine osteophytes, Forestier's disease or progressive ossifying fibrodysplasia is well known. This case adds an isolated retropharyngeal bone formation as a rare cause of dysphagia to the literature.     

Otolaryngologic manifestations of diffuse idiopathic skeletal hyperostosis

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by formation of large cervical osteophytes that may compress the posterior wall of the aerodigestive tract. It is a rare cause of dysphagia in the elderly. The aim of this study was to investigate the various otolaryngologic manifestations of DISH. Eleven elderly patients with DISH were included in the study. All patients presented with dysphagia that was graded on the swallowing screening tool (EAT-10), and the diagnosis of DISH was based on computed tomographic criteria. The patients were subjected to otolaryngologic examination and flexible laryngoscopy. Polysomnography was used for patients with excessive daytime sleepiness for detection of obstructive sleep apnea (OSA). In addition to dysphagia of varying severity, OSA was found in nine patients, change of voice in six, globus sensation in seven, aspiration in three, and cervical pain in seven. Flexible laryngoscopy showed bulging of the posterior pharyngeal wall in all patients. DISH may be an unrecognized contributory factor to both dysphagia and OSA in the elderly. Change of voice, aspiration, globus sensation, and cervical pain are other otolaryngologic manifestations that may be encountered symptoms of the disease. An otolaryngologist should be aware of the disease that may be overlooked, and computed tomography is a confirmatory diagnostic method.     

Update oropharyngeal dysphagia part 2: etiology and therapy

Oropharyngeal dysphagia is a common problem, especially in the elderly. There is a wide range of causes: neurological disorders (such as stroke), osteophytes of the cervical spine, malignancies of the head and neck, as a consequence of radiotherapy or side effect from medication or simply "dysphagia of aging". Where oral feeding is sufficiently impaired then this route may have to be bypassed by percutaneous enteral gastrostomy. When aspiration is a risk, then a cuffed tracheostomy tube may be required. Individual needs must be addressed, usually, and best, by a multidisciplinary team.     

Akzessorischer retropharyngealer Knochen

A 77-year-old woman had a history of several-years of dysphagia. On presentation, a submucosal mass impinging on the left oropharynx was present. CT-scans showed a bony structure isolated from the cervical column. The patient underwent complete surgical resection using a transoral approach. Histological examination confirmed the radiological finding; a new formation of bone surrounded by cartilage with hematopoieses in the bone marrow. Recovery was complete within 2 weeks. Dysphagia due to cervical spine osteophytes, Forestier’s disease or progressive ossifying fibrodysplasia is well known. This case adds an isolated retropharyngeal bone formation as a rare cause of dysphagia to the literature.     

Dysphagia caused by neurogenic deglutition disorders and diffuse idiopathic skeletal hyperostosis (DISH)

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH) may lead to dysphagia caused by osteophytes of the cervical spine. Osteophytes can be resected transorally or transcervically, but operative ablation should not be indicated generously because of the threat of severe complications. PATIENT: A fifty-year-old man with dysphagia and loss of weight of 15 kg in the last three months is presented. He also suffered from a brain damage during infancy which caused grand-mal-seizures. One seizure lead to cardiac arrest which required cardio-pulmonary resuscitation and subsequent tracheostomy. A spheric tumor of the posterior pharyngeal wall could be seen endoscopically, it appeared radiologically as an osteophytic formation of the segments C (3) - C (5). Ossification of the anterior longitudinal ligament was also seen. Diagnosis of DISH was made on the basis of these results. Contrast imaging of the esophagus and videofluoroscopy showed aspiration in terms of neurogenic disorders. The patient received a percutaneous gastrostomy after his case was discussed with neurologic and orthopaedic colleagues, because a causal therapy of the combined disease seemed to be impossible. CONCLUSION: Dysphagia in the presented case was caused by a combination of neurogenic deglutition disorders and oropharyngeal obstruction through osteophytes. Surgical removal of the osteophytes was not indicated because it would have put the patient at a certain risk, but only a part of the underlying problem would have been removed. Symptomatic therapy with a gastrostomy secures normocaloric diet. The patient's weight remained stable and he can follow his habitual daily routine.     

Pharyngeal perforation: a late complication of cervical spine surgery

Anterior cervical spine fusion and stabilization is a well-recognized procedure for a number of cervical spine disorders. Unfortunately, the complex anatomy of the cervical spine means that these procedures are not without complications. Pharyngo-oesophageal perforation is a rare but potentially life-threatening complication of cervical spine surgery and may present intra-operatively, in the immediate post-operative period or many years later. We present the case of a gentleman with ankylosing spondylitis who presented with a pharyngeal perforation and fistula five years after cervical spine surgery.     

Swallowing disorders among patients with diffuse idiopathic skeletal hyperostosis

Conclusion: Diffuse idiopathic skeletal hyperostosis (DISH) is a cause of swallowing disorders in elderly, and otolaryngologists should be aware of the disease on dealing with old patients complaining of dysphagia. The condition may be treated conservatively in most patients; however, surgical reduction of cervical osteophytes may be needed in severe cases.

Objective: Large cervical osteophytes may cause dysphagia; they compress the pharynx leading to mechanical impairment of swallowing. DISH is characterized by ossification of the anterior longitudinal spinal ligament with formation of osteophytes. The aim was to investigate swallowing disorders among patients with DISH.

Method: The study included 139 patients with DISH. Their swallowing was evaluated using the eating assessment tool (EAT-10), and patients with swallowing disorders were subjected to fiber-optic endoscopic evaluation of swallowing (FEES), they received conservative treatment for 6 months. Patients were assessed again after treatment using the same measures that were employed before treatment.

Results: Twenty-three patients (16.5%) demonstrated swallowing disorder, and FEES showed residues of food in the pharynx after swallow in all of them. Significant overall improvement after conservative treatment was achieved, with two patients resuming their normal regular diet. However, one patient demonstrated no improvement, and he needed surgical reduction of his large cervical osteophytes.     

Therapy of functional disorders of the craniovertebral joints in vestibular diseases]

Cervicogenic vertigo is caused by functional disorders of the craniovertebral joints. Improvement of vertigonous symptoms by chiropractic treatment was often described. The therapeutic effect of chiropractic treatment in 28 patients with vertigo and purely functional disorders of the upper cervical spine or with a combination of functional disorders of the upper cervical spine and the labyrinth was evaluated. Improvement of vertigonous symptoms on patients with purely functional disorders of the craniovertebral joints as well as on patients with combined functional disorders of the craniovertebral joints and labyrinth could be seen. Two of the 28 patients showed persistent relief of symptoms and normalisation of cervical motility whereas the vestibular deficit persisted. One patient with persistent vestibular dysfunction showed recurrent malfunction of the upper cervical spine and vertigo. In our opinion chiropractic treatment is mandatory for the therapy of patients with vestibular affections and functional disorders of the craniovertebral joints.