A 71-year-old male presented in ENT department with dysphagia for last three weeks, more to solids than liquids. He had a hard bony bulge in the posterior pharyngeal wall on palpation and hence was referred for an Orthopaedic opinion. Lateral radiograph of the cervical spine revealed diffuse ossification of the anterior longitudinal ligament. This ossification was extending almost half the width of the cervical body from its anterior body at C1 and C2 vertebra level.

1. An unusual cause of dysphagia

2. An unusual cause of dysphagia
Raju Vaishya a,
*, Vipul Vijay b
, Amit Kumar Agarwal b
a
Senior Consultant, Department of Orthopaedics, Indraprastha Apollo Hospital, New Delhi 110067, India
b
Consultant, Department of Orthopaedics, Indraprastha Apollo Hospital, New Delhi 110067, India
1. Description
A 71-year-old male presented in ENT department with
dysphagia for last three weeks, more to solids than liquids.
He had a hard bony bulge in the posterior pharyngeal wall on
palpation and hence was referred for an Orthopaedic opinion.
Lateral radiograph of the cervical spine (Fig. 1) revealed diffuse
ossification of the anterior longitudinal ligament (straight line,
Fig. 1). This ossification was extending almost half the width of
the cervical body from its anterior body at C1 and C2 vertebra
level (dashed line, Fig. 1) and there was severe narrowing of the
airway (Fig. 1, arrows).
He was diagnosed as Diffuse Idiopathic Skeletal Hyperos-
tosis (DISH) or Forestier's disease, which is characterized by
ossification of longitudinal ligaments (esp. anterior longitudi-
nal ligament) (Fig. 2, arrows) along with sparing of sacroiliac
joints (Fig. 3, arrows). It usually affects males aged greater than
50 years and is usually an incidental radiological finding and
only symptomatic lesions need specific treatment. This
patient was advised diet modification and surgical removal
of the ossified mass if the dysphagia persisted.
The most common differential of the DISH is Ankylosing
Spondylitis (AS). These two entities can be differentiated on
the basis of age at presentation and the involvement of
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x
a r t i c l e i n f o
Article history:
Received 20 August 2015
Accepted 27 August 2015
Available online xxx
* Corresponding author. Tel.: +91 9810123331.
E-mail address: raju.vaishya@gmail.com (R. Vaishya).
Fig. 1 – Lateral radiograph of the cervical spine showing
calcification of anterior longitudinal ligament (straight line)
extending in front of cervical spine (dashed line).
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3. sacroiliac (SI) joints. While AS is the disease of young with
most common onset in 2nd to a 3rd decade, DISH usually
affects population older than 50 years. The SI joints are usually
the first to be involved in AS, whereas there is a sparing of the
SI joints in DISH (1,2).
2. Learning points/take home message
Most common presentation of DISH is a radiological finding
of diffuse calcification, esp. of the anterior longitudinal
ligament, in an elderly male with sparing of SI joints.
Closest differential is Ankylosing Spondylitis, which can be
differentiated from its early age of presentation, chronic
course of pain, stiffness, and involvement of SI joints.
Conflicts of interest
The authors have none to declare.
r e f e r e n c e s
1. Tsukamoto Y, Onitsuka H, Lee K. Radiologic aspects of diffuse
idiopathic skeletal hyperostosis in the spine. Am J Roentgenol.
1977;129(5):913–918.
2. Cammisa M, De Serio A, Guglielmi G. Diffuse idiopathic
skeletal hyperostosis. Eur J Radiol. 1998;27(suppl 1):S7–S11.
Fig. 2 – Lateral radiograph of the lumbo-sacral spine
showing calcification of the anterior longitudinal ligament
(arrows).
Fig. 3 – AP radiograph of the pelvis showing the sparing of
the sacro-iliac joints (arrows).
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x2
APME-319; No. of Pages 2
Please cite this article in press as: Vaishya R, et al. An unusual cause of dysphagia, Apollo Med. (2015), http://dx.doi.org/10.1016/j.
apme.2015.08.004