Case Report

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: locate/ ajem

Elderly man with dysphagia and esophageal perforation from an anterior cervical osteoarthritic osteophyte

Abstract

An 85-year-old man with Multiple comorbidities presented with dysphagia and developed stridor and respiratory distress, ultimately resulting in intubation due to an anterior, cervical osteoarthritic osteophyte. The osteophyte had eroded into his esophagus and compromised his airway. To our knowledge, this is the only documented case of stridor and respiratory failure in this etiologic situation. We review the common risk factors and presenting symptom patterns for this disease and cite recommendations for diagnosis, management, and disposition in the emergency depart- ment and critical care setting. As our patient population continues to age, one must consider the rare, yet possible, osteoarthritic osteo- phyte as the etiology of dysphagia, dyspnea, or stridor.

An 85-year-old man presented to a tertiary health care center with complaint of progressive dysphagia. The patient first noticed his dysphagia with solid foods over a year ago but had noted significant worsening over the past few days. He had been unable to tolerate anything by mouth and had pain upon swallowing. He had not sought medical attention for this in the past and denied any other associated symptoms. His medical history included significant coronary artery disease with atrial fibrillation and congestive heart failure, non- Insulin-dependent diabetes, and chronic renal failure.

On initial evaluation, the patient was stable and in no acute distress. He was admitted and evaluated by gastroenterology. Given the acute worsening of symptoms as well as new-onset odynophagia, an endoscopy was performed to rule out infectious etiology. During the endoscopy, an esophageal ulcer was noted, but the study was otherwise unremarkable. The patient was taken for computed tomographic (CT) scan of the neck. Upon returning to his room, he was noted to have increased Work of breathing and stridor. Although the patient had adequate oxygen saturation, he was transferred to the intensive care unit (ICU). He was started on antibiotics and corticosteroids for presumed esophageal perforation.

Soon after the patient arrived in the ICU, the CT results returned demonstrating an anterior cervical osteophyte at C7-T1 with surrounding Free air indicative of esophageal perforation (Figs. 1 and 2). The degree of soft tissue edema around the osteophyte suggested that the perforation was caused by local inflammation secondary to the osteophyte itself. In light of this information, the patient was electively intubated using fiber optic laryngoscopy. Neurosurgery was consulted for osteophytectomy. Unfortunately, the patient’s course was complicated by myocardial infarction and Acute congestive heart failure. Ultimately, he and his family decided to defer further invasive treatments for his medical condition. The patient was extubated and died in hospice 2 days later.

Anterior, cervical osteoarthritic osteophytes are common among elderly patients. More than 75% of people 65 years and older experience cervical vertebra modification, and osteophytes are present in 20% to 30% of the general population. Osteogenesis occurs because of repetitive mechanical factors involving the cartilage- periosteum attachment and capsule-ligament traction areas, which predominantly occur in the upper thoracic and lower cervical spine [1]. Therefore, spinal osteophytes occur in the elderly, commonly at the level of the esophagus and airway. Despite their location and prevalence, most remain asymptomatic.

Symptomatic osteophytes are usually a result of long-standing pathologies such as Ankylosing spondylitis or Forestier disease, also known as Diffuse idiopathic skeletal hyperostosis [2,3]. However, there are a few cases of osteoarthritic osteophytes causing dysphagia [1,5-9]. Dysphagia related to cervical osteophytes appears progressively, initially with solids, then with fluids, and then aphagia with weight loss and alteration of the patient’s general health. It is important to note that no correlation has been reported between the size of the osteophyte and Patient symptoms, but rather between patient age and symptoms [1]. Because of numerous comorbid conditions, symptomatic osteoarthritic osteophytes often elude early diagnosis.

We cite a few, even more uncommon presentations of this disease process to demonstrate variability in presentation. Eyigor et al [4] in 2012 presented a case study of a 57-year-old man in Turkey with a large cervical osteophyte. However, his only complaint was

Fig. 1. Sagittal CT C-spine demonstrating C7-T1 osteophyte.

0735-6757/

Fig. 2. Coronal CT C-spine demonstrating C7-T1 osteophyte.

have alternative intubation techniques, such as fiber optic laryngos- copy, readily available.

definitive treatment is often extensive and requires a multi- disciplinary approach. Surgical intervention is deemed necessary with any respiratory compromise and when dysphagia approaches aphasia. Surgery involves a lateral cervicotomy on the side of the osteophyte, often with spinal fixation to maintain cervical stability. These patients undergo a tracheostomy to preserve their airway and also have percutaneous feeding tubes placed. In addition, experts recommend antibiotics and corticosteroids if a patient has abrupt worsening of symptoms because this may signify esophageal infection and inflammation [1]. After these interventions, patients typically have good outcomes. Carlson et al [7] in 2011 demonstrated that 100% of their patients, 8 in total, had significant improvement in dysphagia and respiratory complaints. Most returned to an unrestricted diet and were successfully decannulated after surgery.

Osteoarthric osteophytes are a rare but treatable cause of respiratory and esophageal symptoms. The clinician should be aware of this entity and consider this diagnosis in elderly patients with dysphagia or chronic upper respiratory symptoms in whom more common diagnoses have been exclude.

obstructive Sleep apnea and not dysphagia. One case of a thoracic osteophyte causing dysphagia was reported in India by Rana et al [5] in 2012, citing that thoracic osteophytes rarely cause symptoms because of the relative mobility of the esophagus in the mediastinum. A very rare case report in Greece in 2011 by Angelos and Dimitra [6] described a nonsymptomatic osteophyte causing a large abscess in the patient’s hypopharynx, manifesting in dysphagia. To our knowledge, the present case is the first patient with an osteophyte who presented with stridor in addition to dysphagia.

Diagnosis is often made after other etiologies are ruled out. Because of this, patients usually have plain films of their neck, esophagogastroduodenal fibroscopy, and transit examination com- pleted early on in their hospital course. Signs of extrinsic compression of the posterior wall of the pharynx during these studies indicate a cervical mass [7]. Cervical CT offers fast diagnosis with identification of specific cervical levels and dimensions of the osteophyte [1]. Magnetic resonance imaging is recommended for patients undergoing surgical intervention [9].

Initial management in the emergency department or ICU requires immediate attention to the patient’s airway. Airway obstruction can manifest from mass effect, ulceration, perforation, periglottic inflam- mation, and/or abscess [2,6,9]. We recommend early intubation for patients with impending respiratory failure (dyspnea, stridor, increased work of breathing), with difficult airway anticipation. One should use anesthesia and surgery (for emergent cricothyrotomy) and

Daniel Evans, DO, MPH Anthony Luizza, MD Thomas Zanders, DO Rebecca Jeanmonod, MD

St Luke’s University Hospital, Bethlehem, PA E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.11.025

References

1. Lecerf P, Malard O. How to diagnose and treat symptomatic anterior osteophytes? European Annals of Otorhinolaryngology, Head and Neck Diseases 2011;127(3): 111-6.
2. Hassard AD. Cervical ankylosing hyerostosis and airway obstruction. Laryngoscope 1984;94(7):966-8.
3. Ozkalkani MY, Katircioqlu K, Ozkalkani DT, et al. Airway management of a patient with Forestier’s disease. Journal of Anesthesia 2006;20(4):304-6.
4. Eyigor H, Selcuk OT, Osma U, et al. Cervical osteophytes: a rare cause of obstructive

   sleep apnea. Journal of Craniofacial Surgery 2012;23(5):e444-6.

   Rana SS, Bhasin DK, Rao C, et al. thoracic spine osteophyte causing dysphagia. Endoscopy 2012:44.

5. Angelos C, Dimitra A. Dysphagia due to anterior cervical osteophytes complicated by hypopharynx abscess. BMJ Case Reports 2011.
6. Carlson ML, Archibald DJ, Graner DE, et al. Surgical management of dysphagia and airway obstruction in patients with prominent ventral cervical osteophytes. Dysphagia 2011;26(1):34-40.
7. Vodicar M, Kosak R, Vengust R. Long term results of surgical treatment for symptomatic anterior cervical osteophytes: a case review series with review of the literature. Journal of Spinal disorders & Techniques May, 2011 [Epub ahead of print].
8. Kapetanakis S, Vasileiadis I, Papanas N, et al. Can a giant cervical osteophyte cause dysphagia and airway obstruction? A case report. Wien Klin Woxhenshr.