Case report: bilateral vocal cord paralysis caused by cervical spinal osteophytes

Breathy Dysphonia, Not Just a Pain in the Neck

We describe a rare occurrence of unilateral vocal fold paralysis associated with a cervical osteophyte abutting the course of the recurrent laryngeal nerve. Trans-nasal laryngoscopy is vital in diagnosing vocal fold paralysis, but often does not provide insight into etiology. This case highlights the importance of radiographic imaging in newly diagnosed vocal fold paralysis, and underscores the principle that a diagnosis is not idiopathic until all sources have been ruled out.

Bilateral Vocal Fold Motion Impairment Associated With Diffuse Idiopathic Skeletal Hyperostosis

Objective

To describe the clinical courses and interventions of symptomatic patients with bilateral vocal fold motion impairment (BVFMI) attributed to diffuse idiopathic skeletal hyperostosis (DISH).

Study Design

Retrospective cohort study.

Setting

Single Institution Academic Health Center.

Methods

Retrospective chart review of patients ≥18 years old evaluated and treated for symptomatic BVFMI secondary to DISH between February 2021 and March 2023. A literature review was conducted.

Results

A total of 4 cases were identified. All patients were male and had symptomatic BVFMI attributed to cervical spine DISH, as seen on imaging. Symptoms ranged from life-threatening dyspnea to breathy dysphonia in addition to dysphagia. Each patient was offered surgery for DISH. Two patients underwent osteophyte removal at the C5-C6 level with improved vocal fold (VF) mobility, breathing, and voice quality. Two patients elected serial observation as voice, swallow, and airway symptoms were manageable. The literature review showed a male-dominant (100%) presentation with an average of 70 years of age. Hypertension (45%) and diabetes mellitus (36%) were the most common comorbidities. Most patients were treated surgically (55%).

Conclusion

Both surgical and conservative interventions may be considered for symptomatic relief and improvement in VF mobility on a patient-to-patient basis. Further study is warranted to investigate the etiology and treatment outcomes in these cases.

Toward diagnostic relevance of the αVβ5, αVβ3, and αVβ6 integrins in OA: expression within human cartilage and spinal osteophytes

We previously reported 18FPRGD2 uptake by the coxofemoral lining, intervertebral discs and facet joint osteophytes in OA using PET/SCAN imaging. However, the molecular mechanism by which the PRGD2 tracer interacts with joint tissues and osteophytes in OA remains unclear. As PRGD2 ligands are expected to belong to the RGD-specific integrin family, the purpose of this study was (i) to determine which integrin complexes display the highest affinity for PRGD2-based ligands, (ii) to analyze integrin expression in relevant tissues, and (iii) to test integrin regulation in chondrocytes using OA-related stimuli to increase the levels of fibrosis and ossification markers. To this end, the affinity of PRGD2-based ligands for five heterodimeric integrins was measured by competition with 125I-echistatin. In situ analyses were performed in human normal vs. OA cartilage and spinal osteophytes. Osteophytes were characterized by (immuno-)histological staining. Integrin subunit expression was tested in chondrocytes undergoing dedifferentiation, osteogenic differentiation, and inflammatory stimulation. The integrins αVβ5, αVβ3, and αVβ6 presented the highest affinity for PRGD2-based ligands. In situ, the expression of these integrins was significantly increased in OA compared to normal cartilage. Within osteophytes, the mean integrin expression score was significantly higher in blood vessels, fibrous areas, and cells from the bone lining than in osteocytes and cartilaginous zones. In vitro, the levels of integrin subunits were significantly increased during chondrocyte dedifferentiation (except for β6), fibrosis, and osteogenic differentiation as well as under inflammatory stimuli. In conclusion, anatomical zones (such as OA cartilage, intervertebral discs, and facet joint osteophytes) previously reported to show PRGD2 ligand uptake in vivo expressed increased levels of αVβ5, αVβ3, and β6 integrins, whose subunits are modulated in vitro by OA-associated conditions that increase fibrosis, inflammation, and osteogenic differentiation. These results suggest that the increased levels of integrins in OA compared to normal tissues favor PRGD2 uptake and might explain the molecular mechanism of OA imaging using the PRGD2-based ligand PET/CT.

Diffuse Idiopathic Skeletal Hyperostosis: A Case with Dysphonia, Dysphagia and Myelopathy

BACKGROUND Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by the ossification of soft tissues, primarily the ligaments and enthesis. Exuberant osteophyte formation of the anterior longitudinal ligament of the spine is usually found. Among the reported complications of cervical osteophyte, dysphagia is the most frequent symptom, and dysphonia is rare. CASE REPORT A 66-year old male was suffering from progressive dysphonia, dysphagia, and myelopathy. Anterior cervical osteophytes and ossification of the posterior longitudinal ligament (OPLL) was shown on x-ray and computed tomography (CT). He was diagnosed with DISH and the osteophytes were resected. The patient's symptoms gradually improved. CONCLUSIONS DISH may induce varying symptoms and surgical intervention is a good way to relieve these symptoms. We rarely see the symptoms of dysphonia, but we should consult with other professionals, such as otolaryngologist and dietician, when treating DISH patients.

[Adjacent segment degeneration following spinal fusion of vertebral fractures in paraplegic patients]

The effects of adjacent segment degeneration (ASD) after spinal fusion of vertebral fractures have previously not been demonstrated in patients with trauma-related paraplegia. The aim of this study was to evaluate the role of ASD in patients with paraplegia caused by vertebral fractures and to observe whether there is a difference between unilateral or combined spinal fusion in long-term results regarding the degeneration of cranial or caudal adjacent spinal segments. A total of 111 paraplegic patients with an average age of 45 years who underwent spinal fusion of vertebral fractures were observed in a retrospective longitudinal study with a follow-up period of 4 years. Conventional X‑ray images and magnetic resonance imaging (MRI) scans were used to assess the ASD in the adjacent free vertebral segments cranial and caudal to the spinal fusion using the following elements: ventral spondylophytes, intervertebral space, intervertebral disc signal in MRI, posterior spondylophytes, facet joint arthrosis, bone bridging and ossification of the anterior longitudinal ligament. Additionally, the classification by the American Spinal Injury Association (ASIA) impairment scale and spinal cord independence measure version 3 score were surveyed. The 4‑year incidence of radiographically detectable ASD was 3-12 % in this study. The majority of ASDs were observed in the cranial segments adjacent to the interbody fusion. The dorsoventral spinal fusion showed the least effects on the adjacent segments. In conclusion, a concept of prompt surgery using short dorsoventral segment fusion carried out by an interdisciplinary paralysis center is recommended. The role of natural degeneration processes and whether they are influenced by iatrogenic manipulation through the vertebral stabilization is unclear. For this reason it is important to further investigate strategies for ASD reduction in the future to ensure the best possible treatment success including the lowest degree of additional impairments for this special patient group.

Symptomatic dyspnoea addressed by excision of ossified anterior longitudinal ligament

Ossification of the anterior longitudinal ligament (OALL) in cervical spine is known to cause dysphagia. However, dyspnoea and obstructive sleep apnoea (OSA) due to OALL is a rare entity. A 50-year-old man presented to our clinic 2 years after anterior cervical discectomy and fusion (ACDF) with complaints of dysphagia, dyspnoea and difficulty in sleeping supine. The clinico-neurological examination of patient was normal without any long tract signs. The diagnosis of OALL was made on plain lateral radiographs. Ultrasonic bone cutter was used to convert sessile osteophyte mass into a pedunculated mass. It was then disconnected from the anterior aspect of vertebral bodies with a chisel. The patient showed immediate relief from dysphagia and OSA. Dyspnoea improved over a week and the postoperative change in voice responded well to speech therapy. To the best of our knowledge, this is the first report of dyspnoea due to OALL after ACDF.

Cervical Hyperostosis Leading to Dyspnea, Aspiration and Dysphagia: Strategies to Improve Patient Management

Diffuse idiopathic skeletal hyperostosis (DISH) is a rare but well known cause of dysphagia. In very few cases aspiration and dyspnea are described as a clinical manifestation. An 82-year-old man presented himself in our clinic with severe dyspnea, aspiration, and pneumonia. After performing a microlaryngoscopy an emergency tracheotomy became necessary. In laryngoscopy a severe bulging of the posterior oropharyngeal and hypopharyngeal wall was detected. The glottis area was not observable and immobilisation of the right vocal cord could be detected. The CT showed anterior osteophytes and ossification of the anterior longitudinal ligament from C2-C7. We performed a panendoscopy in order to explore the upper aerodigestive area. Postoperatively an emergency tracheotomy was needed due to the development of laryngeal edema. The osteophytes were removed in cooperation with the department of orthopaedics. Three months postoperative the patient had no dyspnea or dysphagia, so the tracheotomy could be closed. Cervical hyperostosis is commonly described in elderly patients and usually presenting without symptoms, therefore a surgical treatment is usually not necessary. Nevertheless it can lead to severe morbidity and dyspnea with airway obstruction. Therefore it is essential that cervical hyperostosis is recognized early enough and appropriate treatment is initiated. Flexible endoscopy should be preferred over direct panendoscopy because it could lead to life-threatening edema and a prophylactic tracheostomy should be strongly considered in patients that present with severe dyspnea.

Uncommon and rare causes of vocal fold paralysis detected via imaging

BACKGROUND

Cross-sectional imaging can be used to trace the course of the vagus nerve and its laryngeal branches to detect many of the causes of vocal fold paralysis. The most frequent aetiologies are surgical injury and tumoural involvement of the recurrent laryngeal nerve anywhere along its course.

METHOD

This review article focuses on the uncommon and rare causes of vocal fold paralysis that have been detected or diagnosed on cross-sectional imaging.

RESULTS AND CONCLUSION

Uncommon causes included a tortuous oesophagus, tracheal diverticulum, cervical osteophytes and cardiovocal syndrome. These examples are presented with clinical case histories and radiological appearances, and are discussed in the context of the current literature.

Dysphagia due to Diffuse Idiopathic Skeletal Hyperostosis

Diffuse idiopathic skeletal hyperostosis (DISH) is usually asymptomatic. However, rarely, it causes dysphagia, hoarseness, dyspnea, snoring, stridor, and laryngeal edema. Herein, we present a patient with DISH causing dysphagia. A 70-year-old man presented with a 4-month history of sore throat, dysphagia, and foreign body sensation. Flexible laryngoscopy revealed a leftward-protruding posterior wall in the hypopharynx. Computed tomography and magnetic resonance imaging revealed a bony mass pushing, anteriorly, on the posterior hypopharyngeal wall. Ossification included an osseous bridge involving 5 contiguous vertebral bodies. Dysphagia due to DISH was diagnosed. His symptoms were relieved by conservative therapy using anti-inflammatory drugs. However, if conservative therapy fails and symptoms are severe, surgical treatments must be considered.

Diffuse idiopathic skeletal hyperostosis of the cervical spine: an underestimated cause of dysphagia and airway obstruction

BACKGROUND CONTEXT

Diffuse idiopathic skeletal hyperostosis (DISH) is a common but underdiagnosed condition relating to ossification of spinal ligaments that can cause compression of the esophagus and trachea. According to case reports, dysphagia or airway obstruction resulting from DISH is a rare occurrence.

PURPOSE

This study was intended to identify all published cases of dysphagia and/or airway obstruction resulting from DISH to increase the epidemiologic/clinical knowledge of these related conditions.

STUDY DESIGN

A systematic review of the literature was performed.

METHODS

The articles resulting from the systematic PubMed/EMBASE search of the literature were closely read, and predefined parameters were scored.

RESULTS

The search yielded a total of 118 articles (95 case reports and 23 case series) describing 204 patients with dysphagia and/or airway obstruction resulting from DISH. The number of cases demonstrated a steady increase from 1980 to 2009. This might be a real effect not ascribable to publication bias or expansion of the medical literature alone.

CONCLUSIONS

Diffuse idiopathic skeletal hyperostosis as a cause of dysphagia and/or airway obstruction may be an increasing and underappreciated phenomenon. Diffuse idiopathic skeletal hyperostosis should be included in the differential diagnosis of dysphagia and airway obstruction.

[Persistent dysphagia and mechanical glottic paralysis. Complications of a ventral fracture spondylodesis with Forestier's disease]

Persistent dysphagia after ventral instrumentation of a patient with a cervical spine fracture and diffuse idiopathic skeletal hyperostosis (DISH, or Forestier's disease) is a rare but dramatic complication. In this case report some pathogenetic factors are discussed. Accurate resection of the spondylophytes should be considered to avoid a ventral protrusion of the plate.

A case of obstructive sleep apnoea with anterior cervical osteophytes

Osteophytes of the cervical spine are usually seen in elderly adults. When prominent, they have been blamed for dysphagia, cough, dysphonia and dyspnoea. This paper reports on an obstructive sleep apnoea (OSA) patient with cervical spinal osteophytes, one cause of airway obstruction. A 75-year-old male complained of pronounced snoring. The diagnosis was mild OSA, apnoea hypopnoea index was 9.4. Patient reported no restrictions in neck movements, experiences of neck pain or neck trauma. Previously, patient underwent a tonsillectomy due to discomfort in the pharyngeal region. A lateral cephalometric image was taken to observe airway before oral appliance therapy. The image revealed the presence of large osteophytes or sclerotic enthesopathy, lying on anterior surfaces from the fourth to seventh cervical vertebrae. A computed tomography (CT) image revealed the relationship of airway position to the spine. In the reconstructed three-dimensional (3D) image, the airway appeared displaced to the right of the craniomandiblar bone, with the hyoid bone similarly displaced in a manner to that of the airway. The spine also appeared displaced to the left side ofcraniomandiblar bone. Additionally, the 3D image revealed calcification of the stylohyoideum ligament and ligamentum nuchae. This present case highlights the necessity of CT examination for OSA patients. There were several ligament calcifications in the head and neck region. Cervical spine osteophytes, as a component of Forestier's or cervical spine disease, have been associated with dysphagia and dysphonia. It was reported that bilateral vocal cord paralysis was caused by osteophytes compressing the post-cricoid area of larynx.

[Anterior spondylosis of the cervical spine causing dyspnea and sleep disturbance]

BACKGROUND

Cervical osteochondrosis is a rare differential diagnosis leading to dysphagia, inspiratory stridor and obstructive sleep apnea syndrome (OSAS).

PATIENTS AND METHODS

We report six cases of patients with episodes of neck pain (n=6), pain reflected to the arm (n=1), sleep apnea (n=5), inspiratory stridor (n=3) and/or unclear dysphagia (n=6), who presented between 2000 and 2003 at the Römerwallklinik Mainz and the university hospitals of Mainz and Cologne. None of these patients had symptoms of spinal or radicular compression. All underwent otorhinolaryngological and radiological examination followed by excision of anterior spondylophytes and intervertebral fusion. One patient required immediate tracheotomy due to perforation of the pharyngeal wall associated with severe supraglottic swelling.

RESULTS

All patients were free of inspiratory stridor postoperatively. Symptoms of dysphagia disappeared in four patients and were reduced in two. Three of five patients were free of apnea. OSAS had improved in two. Neck pain was eliminated in four cases and markedly improved in two cases.

CONCLUSIONS

In case of symptoms of pharyngeal compression and OSAS, a vertebragenic cause should be considered.

Osteophytes: relevance and biology

OBJECTIVE

Osteophytes are common features of osteoarthritis. This review summarizes the current understanding of the clinical relevance and biology of osteophytes.

METHOD

This review summarizes peer-reviewed articles published in the PubMed database before May 2006. In addition this review is supplemented with own data and theoretical considerations with regard to osteophyte formation.

RESULTS

Osteophytes can contribute both to the functional properties of affected joints and to clinical relevant symptoms. Osteophyte formation is highly associated with cartilage damage but osteophytes can develop without explicit cartilage damage. Osteophytes are mainly derived from precursor cells in the periosteum and growth factors of the TGFbeta superfamily appear to play a crucial role in their induction.

CONCLUSION

Osteophyte formation is an integral component of OA pathogenesis and understanding the biology of osteophyte formation can give insights in the disturbed homeostasis in OA joints.

Radiology findings in adult patients with vocal fold paralysis

AIM

To compile imaging findings in patients with vocal fold paralysis.

MATERIALS AND METHODS

A retrospective analysis of the medical charts of 100 consecutive patients, admitted to our department with vocal fold paralysis was undertaken. After laryngoscopy, patients were referred for radiological work-up depending on their clinical history and clinical findings. Ultrasound of the neck and/or contrast-enhanced spiral computed tomography (CT) of the neck and mediastinum was performed, extending to include the whole chest if necessary. In one patient, CT of the brain and in two patients, magnetic resonance angiography was undertaken. Analysis of the clinical and radiological data was performed to assess the most frequent causes for vocal fold paralysis.

RESULTS

In 66% of patients, the paralysis was related to previous surgery. Thirty-four percent of cases were labelled idiopathic after clinical examination. After imaging and follow-up, only 8% remained unexplained. Nine patients suffered from neoplasms, four from vascular disease, and 12 from infections. One patient developed encephalomyelitis disseminata on follow-up.

CONCLUSION

Thorough radiological work-up helps to reduce the amount of idiopathic cases of vocal fold paralysis and guides appropriate therapy.

Bilateral vocal cord paralysis secondary to esophageal compression

Bilateral vocal cord paralysis is most commonly caused by trauma, malignancy, and neurologic disorders. Cases secondary to esophageal compression of the recurrent laryngeal nerves are rare. We report a patient admitted with an exacerbation of achalasia who developed acute respiratory distress from bilateral immobile vocal cords. Imaging studies revealed impressive dilation of the cervical esophagus causing compression of both recurrent laryngeal nerves. After securing the airway and decompression of the esophagus, mobility of the vocal cords returned within 1 week. This case shows the importance of a careful airway workup in patients with esophageal distention. Early decompression may prevent permanent recurrent laryngeal nerve injury and airway obstruction.