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Diffuse Idiopathic Skeletal Hyperostosis Resulting in Upper Airway Obstruction and Respiratory Distress FREE TO VIEW

Michael Sutherland, DO; Saurabh Desai, MD; David Ison, MD; Thomas Roy, MD; Ryland Byrd, MD
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East Tennessee State University, Johnson City, TN

Chest. 2014;146(4_MeetingAbstracts):460A. doi:10.1378/chest.1971874
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SESSION TITLE: Miscellaneous Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Diffuse idiopathic skeletal hyperostosis (DISH) is an ossifying disease of unknown etiology. DISH primarily affects elderly men and is characterized by hypertrophic vertebral osteophytes located anteriorly. The majority of individuals with this disorder are asymptomatic. We report a patient that developed severe respiratory distress due to upper airway obstruction caused by DISH.

CASE PRESENTATION: A 71-year-old male was evaluated for dysphagia and aspiration pneumonia. While being examined he developed progressive cyanosis, stridor, and respiratory distress. He was difficult to ventilate by bag-valve mask. He was, therefore, emergently intubated by direct manual laryngoscopy. At intubation, right deviation of the trachea and a prominence of the posterior pharynx were noted. The intubation immediately relieved his distress. With his airway secured, the patient was managed on mechanical ventilation. A computerized tomogram of the neck demonstrated several large anterior osteophytes of the cervical vertebrae impinging on and compromising the tracheal lumen. The patient subsequently underwent tracheostomy and was successfully removed from mechanical ventilation. Due to comorbid illnesses, surgical removal of the osteophytes was not performed.

DISCUSSION: Little information has been reported on the complications of DISH since it was first described in 1950. This observation is probably because DISH is typically an asymptomatic disorder. When problems do arise, direct compression of adjacent structures by the osteophytes is the pathophysiologic mechanism of the complications. DISH has been reported to cause the pharyngeal symptoms of dysphagia and globus pharyngeus. It has also been implicated in obstructive sleep apnea. Respiratory distress and airway compromise are rarely reported complications of DISH of the cervical vertebrae.

CONCLUSIONS: Although DISH is a rare cause of respiratory failure it should be included in the differential diagnosis of upper airway obstruction, particularly in elderly men. Intubation may be required to secure the airway in patients with DISH. Tracheostomy may serve as a temporary intervention pending definitive surgical removal on the osteophytes. Permanent tracheostomy may be required if the more invasive procedures cannot be undertaken.

Reference #1: Matan, et. al. Management of respiratory compromise cause by cervical osteophytes: a case report and review of the literature. Spine J. 2002;2: 456-9.

Reference #2: Hassard AD. Cervical ankylosing hyperostosis and airway obstruction. Laryngoscope 1984;94: 966-8.

Reference #3: Charalampos, et. al. Hooking of the soft palate and a large cervical osteophyte: two troubles in the same airway. Am J Med Sci 2013;346(6):519-20.

DISCLOSURE: The following authors have nothing to disclose: Michael Sutherland, Saurabh Desai, David Ison, Thomas Roy, Ryland Byrd

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