Management of Airway Obstruction due to Diffuse Idiopathic Skeletal Hyperostosis in the Cervical Spine: A Case Report and Literature Review

Abstract

Diffuse idiopathic skeletal hyperostosis (DISH) is a relatively common progressive noninflammatory entheses disease. Patients are often asymptomatic or are undiagnosed due to minor chronic symptoms. We herein report a rare case in which the primary symptom was sudden-onset upper airway obstruction due to exuberant osteophytosis in the cervical spine. Treatment was successful with careful airway management and surgical osteophyectomy. Most DISH cases in the literature with airway obstruction have been managed with tracheotomy. However, the safety and necessity of this approach remain questionable. We herein discuss the possibility of conservative management as a choice of airway control. Airway obstruction due to DISH may be underrecognized. This highlights the importance of including DISH in the differential diagnosis of airway obstruction. In addition, a detailed evaluation and personalized care for each individual case is essential.

Ossification of the cervical anterior longitudinal ligament is an underdiagnosed cause of difficult airway: a case report and review of the literature

“…Of these, 34 full-text articles were evaluated, and 23 papers were potential candidates. One article was excluded because the full text could not be found [7], leaving 22 articles (summarized in Table 1) [5,6,[8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]. The excluded articles are presented in the appendix.…”

“…Among the patients included, the most commonly involved cervical vertebrae were C3-C4, followed by C4-C5 and C5-C6, leading to dysphagia and airway obstruction, possibly due to excessive activity. Six patients had no symptoms before intubation [5,6,10,12,14,21], and the rest of the patients had symptoms such as dysphagia, dysphonia, dyspnea, airway obstruction, or restricted motion of the neck [8,9,11,13,[15][16][17][18][19][20][22][23][24][25][26][27]. Awake intubation was chosen for 10 patients [5, 11, 13-15, 20, 22-25], and rapid induction was chosen for 7 patients [6,8,9,16,17,21,23]; fiberscope-assisted intubation was cited as the optimal choice in 13 articles [11, 13-15, 18, 20-27]; other cases favored the direct laryngoscope [5,6,9,16,17,19,23] or the intubating laryngeal mask [13,21].…”

“…Awake intubation was chosen for 10 patients [5, 11, 13-15, 20, 22-25], and rapid induction was chosen for 7 patients [6,8,9,16,17,21,23]; fiberscope-assisted intubation was cited as the optimal choice in 13 articles [11, 13-15, 18, 20-27]; other cases favored the direct laryngoscope [5,6,9,16,17,19,23] or the intubating laryngeal mask [13,21]. A small-sized endotracheal tube was selected for 4 patients [6,17,25,27], while a nasotracheal tube was selected for 2 patients [11,22]. The majority of patients required multiple endotracheal intubation attempts, and four patients could not undergo the surgery because of intubation failure [5,14,15,18].…”

Forestier Disease and Airway Management

“…F orestier disease or diffuse idiopathic skeletal hyperostosis is a noninflammatory disease characterized by the presence of anterior bridging osteophytes that spare the disc and joint space of unknown etiology in elderly men, mostly at thoracic levels and asymptomatic in some cases. [1][2][3] Spine x-ray in patients with Forestier disease shows normal bone density and the presence of extensive ossification of anterior longitudinal ligament, with bridging osteophytes in the anterior cervical and upper thoracic spine. [1][2][3] The accompanying images show a large tumor-like bulge of the posterior hypopharynx wall which, together with the epiglottis, completely obstructed the upper airway during the initial laryngoscopy with McGrath MAC (Medtronic, USA).…”

“…[1][2][3] Spine x-ray in patients with Forestier disease shows normal bone density and the presence of extensive ossification of anterior longitudinal ligament, with bridging osteophytes in the anterior cervical and upper thoracic spine. [1][2][3] The accompanying images show a large tumor-like bulge of the posterior hypopharynx wall which, together with the epiglottis, completely obstructed the upper airway during the initial laryngoscopy with McGrath MAC (Medtronic, USA). With careful external laryngeal manipulation and increased force in laryngoscopy, the laryngeal view was significantly improved, which allowed endotracheal intubation.…”