Diffuse Idiopathic Skeletal Hyperostosis (DISH)—A Rare Etiology of Dysphagia
A 72-year-old gentleman presented to the hospital with progressively worsening dysphagia to soft foods and liquids. He was diagnosed with severe pharyngeal dysphagia by modified barium swallow. A CT scan of the neck with IV contrast showed anterior flowing of bridging osteophytes from C3-C6, indicative of DISH, resulting in esophageal impingement. He underwent resection of the DISH segments. Following the surgery, a PEG tube for nutrition supplementation was placed. However, the PEG tube was removed after five months when the speech and swallow evaluation showed no residual dysphagia. DISH is a rare non-inflammatory condition that results in pathological ossification and calcification of the anterolateral spinal ligaments.
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Clinical Medicine Insights: Arthritis and
Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders 2011:4 71
Diffuse Idiopathic Skeletal Hyperostosis (DISH)—A Rare
Etiology of Dysphagia
Balakumar Krishnarasa, Abhirami Vivekanandarajah, Lucinda Ripoll, Edwin Chang and Robert Wetz
Staten Island University Hospital, Staten Island, NY, USA. Corresponding author email: firstname.lastname@example.org
Abstract: A 72-year-old gentleman presented to the hospital with progressively worsening dysphagia to soft foods and liquids. He was
diagnosed with severe pharyngeal dysphagia by modied barium swallow. A CT scan of the neck with IV contrast showed anterior
owing of bridging osteophytes from C3-C6, indicative of DISH, resulting in esophageal impingement. He underwent resection of the
DISH segments. Following the surgery, a PEG tube for nutrition supplementation was placed. However, the PEG tube was removed
after ve months when the speech and swallow evaluation showed no residual dysphagia. DISH is a rare non-inammatory condition
that results in pathological ossication and calcication of the anterolateral spinal ligaments.
Keywords: DISH, dysphagia, diffuse idiopathic skeletal hyperostosis
Krishnarasa et al
72 Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders 2011:4
Diffuse idiopathic skeletal hyperostosis (DISH) with
cervical involvement causing dysphagia is a rare
entity. It was described as an abnormal ossication
along the anterior and lateral aspects of the vertebral
column in 1950 by Forestier and Rotes-Querol.
report a case of a patient with progressive dysphagia
secondary to DISH.
A 72-year-old gentleman with coronary artery disease,
atrial brillation, hypertension, gout, and obstructive
sleep apnea presented to the hospital with progres-
sively worsening dysphagia to soft foods and liquids
for a few days. He had begun to experience dysphagia
ve years ago and had restricted his diet to mainly
soft foods and liquids. He denied fatigue, neck pain,
drooping of eye lids, difculty in breathing, hoarse-
ness, dysarthria, numbness or limb weakness. Sur-
gical history was signicant for bilateral cataract
surgeries and childhood exploratory laporotomy after
a traumatic incident. He denied a family history of
cancer. His medications included warfarin, digoxin,
atenolol, lovastatin, colchicine, hydrocholorothiaz-
ide, omeprazole, albuterol and ipratropium inhalers.
He used to smoke 1 pack per day for 40 years, but
quit 20 years ago. Esophagogastroduodenoscopy
and colonoscopy were done three years ago and
were unremarkable. Vital signs were stable and the
physical exam was unremarkable. Laboratory tests,
including an autoimmune panel were normal. CT
scan of the head was normal. A speech and swal-
low evaluation revealed dysphagia to thin liquids.
A modied barium swallow (MBS) revealed severe
pharyngeal dysphagia. CT of the neck with IV con-
trast showed anterior owing of bridging osteo-
phytes from C3-C6, indicative of DISH, causing
esophageal impingement (Fig. 1). He also had a MRI
of the neck with gadolinium that showed anterior
owing of bridging osteophytes from C3-C6 con-
sistent with diffuse idiopathic skeletal hyperostosis,
C3-C6 spinal stenosis and degenerative changes at
C3-C4 (Fig. 2). He underwent corpectomy of C4
with C3-C5 spinal fusion and resection of the C3-C6
DISH segments. Although post-operative radiologi-
cal studies showed an anatomical improvement, an
esophagram revealed residual dysphagia (Fig. 3).
He was discharged with a percutaneous endoscopic
gastrostomy (PEG) tube. Five months later, he
underwent speech and swallow evaluation, which
showed marked functional improvement and the
PEG tube was removed.
Diffuse idiopathic skeletal hyperostosis, also known as
is a non-inammatory condition
Figure 1. CT of neck with IV contrast (bone window) showing anterior ow-
ing of bridging osteophytes (arrows) from C3-C6, indicative of DISH.
Figure 2. MRI of neck with gadolinium showing anterior owing of bridg-
ing osteophytes (arrows) from C3-C6 consistent with DISH, C3-C6 spinal
stenosis and degenerative changes at C3-C4.
A rare etiology of dysphagia
Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders 2011:4 73
with pathological ossication and calcication of the
anterolateral spinal ligaments and attachment sites
of the tendons and ligaments. Ossication along
the posterior vertebral border has also been noted.
While etiology of DISH remains unknown, various
hypotheses were proposed relating to mechanical
factors, diet, metabolic conditions and environmental
Specically, mechanical factors leading
to ligament stretching, high uoride levels in water,
excess of vitamin A, long term isotretinoin therapy,
and metabolic conditions that produce increased
insulin-like growth factor-1 to stimulate osteoblasts
have been documented as potential causative factors.
While some conrmation came from clinical stud-
ies, there were conicting results reported as well.
The pathogenesis of DISH has been explained as an
enthesopathy due to pathological osteoblast differen-
tiation and ossication.
Prevalence is higher in men
(typically in their 60s) than women.
increases with age and varies by population.
Symptoms of DISH depend on the localization
and involvement of adjacent structures. Patients
may experience neck, thoracic spine, lumbar spine
and/or extremity pain and disability. Spinal morning
stiffness is experienced by the majority of patients.
Dysphagia and symptoms pertaining to the knee,
shoulder and elbow are less common. Dysphagia,
odynophagia, foreign body sensation, stridor,
obstructive sleep apnea, and aspiration of solids and
liquids may occur when large anterior osteophytes
of the cervical spine impinge or displace the adja-
cent structures of the gastrointestinal and respiratory
Dysphagia is usually progressive and greater
for solids than liquids. The osteophytes arising from
the C5-C6 level frequently cause dysphagia, followed
Stridor may be a rare manifestation of the
large C2-C3 anterior osteophyes, while point pres-
sure between osteophytes and the posterior cricoid
cartilage results in hypopharyngeal ulceration caus-
Spinal cord compression can hap-
pen in patients with posterior ligament ossication
and this may lead to myelopathy and radiculopathy.
All these symptoms can manifest due to mechani-
cal obstruction, inammation in the immediate sur-
rounding of the osteophytes or spasm due to pain.
Presumably, a summation of all these factors plays
a role in producing the symptoms. Physical ndings
include decrease range of spinal motion, particularly
when the thoracic segment is involved, and palpable
nodules when the appendicular skeleton is involved.
Neurological ndings may be elicited when poste-
rior ligament calcication involves the spinal cord.
Differential diagnoses for DISH include Ankylosing
spondylitis (AS) and Spondylosis deformans (SD).
There are spurs seen in the region of the cervical
and lumbar spine similar to DISH but involvement
of the anterior longitudinal ligament in the thoracic
region is not seen in SD. AS is more common in
males than females and there is an association with
ligamentous ossication and syndesmophytes simi-
lar to DISH but the anterior longitudinal ligament is
not involved and the bony bridges involve the outer
margin of the annulus brosis. In addition, erosions
and bony ankylosis of the sacroiliac and apophy-
seal joints are seen in AS. Radiological imaging of
the spine will show squaring of the vertebrae also
known as “bamboo spine.” Other conditions that
may be associated with DISH include gout,
Evaluation of progressive dysphagia
should include speech and swallow evaluation,
Figure 3. Post-operative esophagram showing residual dysphagia (arrow)
[uid entering esophagus and trachea] and anatomical correction of
Krishnarasa et al
74 Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders 2011:4
barium swallow studies, motility studies, otolaryn-
gologic examination, and other radiological studies,
which include CT and MRI of the head and neck.
Endoscopy should be utilized with caution as this
may cause perforation of esophagus.
is placed on diagnostic imaging to diagnose DISH.
The radiological ndings of DISH may occur in the
absence of clinical symptoms. Resnick and Utsinger
proposed radiographic criteria for the diagnosis of
The Resnick radiographic criteria for the
diagnosis of DISH include: (a) the presence of ow-
ing ossication and calcication along the antero-
lateral aspect of at least four contiguous vertebral
bodies, (b) the preservation of intervertebral disk
heights in the involved vertebrae, (c) the absence of
apophyseal joint bony ankylosis and sacroiliac joint
Extra-spinal ossication in DISH may
occur at ligamentous attachments and para-articular
There are no specic laboratory abnor-
malities that have been associated with DISH.
Treatment of DISH depends on the presence of
symptoms. Physical activity and physical therapy
with heat can give symptomatic relief in patients with
DISH. The pain associated with DISH is treated simi-
lar to patients with osteoarthritis. Dysphagia, radicu-
lopathy, myelopathy, recurrent laryngeal nerve palsy,
and stridor need surgical intervention.
DISH is an uncommon etiology of dysphagia, which
is a common symptom. There have been other case
reports that have described dysphagia as a manifesta-
tion of DISH.
Although a rare cause of dysphagia,
DISH can cause considerable morbidity in the geri-
atric population. Keeping this clinical entity in the
differential diagnosis is important in arriving at the
Author(s) have provided signed conrmations to the
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and ethical obligations in respect to declaration of
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torship, and compliance with ethical requirements in
respect to treatment of human and animal test subjects.
If this article contains identiable human subject(s)
author(s) were required to supply signed patient con-
sent prior to publication. Author(s) have conrmed
that the published article is unique and not under con-
sideration nor published by any other publication and
that they have consent to reproduce any copyrighted
material. The peer reviewers declared no conicts of
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A rare etiology of dysphagia
Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders 2011:4 75