Management of diffuse idiopathic skeletal hyperostosis-associated respiratory distress; when is surgical intervention necessary?

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LETTER

Hippokratia 2024, 28(2): 82

Vlastarakos PV, Sideris G, Delides A
ENT Department, Attikon University Hospital, Athens, Greece

Keywords: Diffuse idiopathic skeletal hyperostosis, DISH, osteophyte, respiratory, distress, airway, tracheotomy

Corresponding author: Petros V. Vlastarakos MD, MSc, PhD, IDO-HNS (Eng.), Assistant Professor, ENT Dept., Attikon University Hospital, 1 Rimini rd, 12462, Haidari-Athens, Greece, tel: +306977803852, e-mail: pevlast@hotmail.com, pevlast@med.uoa.gr

Dear Editor,

Diffuse idiopathic skeletal hyperostosis (DISH) is a non-inflammatory enthesopathy with an ossifying tendency towards the paraspinal muscles and ligaments and anterolateral formation of spinal osteophytes1,2. Although considered a common condition of the aging spine, DISH goes beyond a plain radiographic entity, occasionally demonstrating symptoms of interest to Ear, Nose, and Throat (ENT) surgeons, including dysphagia and airway compromise. Male gender and age over the fifth decade seem to increase the specific prevalence of DISH, whilst increased osteoblast activity leading to bony deposition may represent the underlying pathophysiologic mechanism for the inflammatory process caused by endocrine or metabolic disorders (i.e. type-2 diabetes mellitus, or obesity)1.

DISH-associated respiratory distress can occur when large osteophytes involve the cervical C2-C3 region3. The respective impairment in vocal cord movement may stem from compression of the recurrent laryngeal nerve on its route towards the intrinsic muscles of the larynx, arytenoid cartilage fixation from a protruding osteophyte causing persistent chondritis and stiffness in the cricoarytenoid joint, or vascular compression and vocal cord edema4. Selective vocal cord palsy may only occur in the first instance and result from compression of the posterior branch of the recurrent laryngeal nerve, which innervates the posterior cricoarytenoid muscle. At the same time, the adducting action of the lateral cricoarytenoid muscle innervated by the anterior branch of the recurrent laryngeal nerve remains unaffected.

Regarding the management of DISH-associated respiratory distress, surgical intervention is warranted in cases related to arytenoid cartilage fixation. Otherwise, initial treatment may consist of anti-inflammatory medication, steroids, muscle relaxants, and anti-reflux medication3. Swallowing therapy should also be considered, as the mechanical irritation of the area behind the cricoarytenoid joint from the gliding movements of the esophagus over the osteophytes during deglutition may lead to chronic inflammatory edema, local tissue reaction, and stenosis2. Functional endoscopic evaluation of swallowing may also be helpful in such cases, along with laryngeal electromyography, especially when impaired vocal cord movement is present.

Surgical management of DISH-associated respiratory distress includes management of the spine and/or laryngeal intervention. The former is performed through an anterolateral approach, which provides adequate exposure of the great vessels of the neck and the vagus nerve, thus allowing an elective osteophytectomy. Additional management may include external or endoscopic arytenoidectomy, laser chordotomy, or excision of the prolapsing edematous mucosa. Postoperative airway obstruction can develop in patients undergoing decompression surgery for DISH-associated respiratory distress, especially when preoperative laryngeal edema is present. Hence, prophylactic tracheotomy should be considered for the immediate postoperative period, taking into account related anesthetic concerns2.

Although the ENT surgeon most commonly encounters DISH-associated dysphagia, airway management remains of paramount importance. Surgical management of DISH-associated respiratory distress necessitates a team approach among ENT and Spine Surgeons. Intrinsic and extrinsic mechanisms of impaired laryngeal function should be initially determined3, considering that the respective impairment is potentially reversible following conservative treatment; hence, a watchful waiting policy may be a reasonable initial approach before aggressive surgical intervention. The anesthetic team should also be informed regarding a potentially challenging airway.

Conflicts of interest

None declared.

References

  1. Sebaaly A, Boubez G, Sunna T, Wang Z, Alam E, Christopoulos A, et al. Diffuse Idiopathic Hyperostosis Manifesting as Dysphagia and Bilateral Cord Paralysis: A Case Report and Literature Review. World Neurosurg. 2018; 111:79-85.
  2. Kim YS, Lee JJ, Chung YH, Kim ES, Chung IS. Postoperative obstructing laryngeal edema in patients with diffuse idiopathic skeletal hyperostosis of cervical spine -A report of two cases-. Korean J Anesthesiol. 2011; 60: 377-380.
  3. Castellano DM, Sinacori JT, Karakla DW. Stridor and dysphagia in diffuse idiopathic skeletal hyperostosis (DISH). Laryngoscope. 2006; 116: 341-344.
  4. Allensworth JJ, O’Dell KD, Schindler JS. Bilateral vocal fold paralysis and dysphagia secondary to diffuse idiopathic skeletal hyperostosis. Head Neck. 2017; 39: E1-E3.