Dysphagia Due to Ankylosing Spinal Hyperostosis in a Patient Who Regained Oral Intake Ability with Conservative Therapies

Abstract

Introduction:　We report a patient with a giant osteophyte, due to ankylosing spinal hyperostosis (ASH), causing severe dysphagia. This patient, who refused modified dysphagia diets and gastric fistula, regained oral intake ability with conservative therapies alone.

Patient:　The patient, a 84-years-old man, underwent cervical laminoplasty (C3-6) via a posterior approach for cervical spondylotic myelopathy. After the operation, severe aspiration and pharyngeal stenosis developed. However, no other treatment than the use of modified dysphagia diets had been given before the patient was transferred to our hospital. Videofluoroscopic examination of swallowing (VF) on admission showed marked anterior protrusion of a beak-like osteophyte involving the C3-6 levels, poor laryngeal elevation, lack of epiglottic retroversion, and silent aspiration.

Course:　VF was performed 3 times during hospitalization, confirming moderate improvement of the patient’s condition. However, we considered this patient to still be at extremely high risk of developing aspiration and thus repeatedly explained to him the urgent need for modified dysphagia diets. Nevertheless, the patient strongly insisted upon eating the foods of his choice; eventually, he was allowed to consume a normal diet and moderately thickened fluids on his own on condition that he maintained a sitting position with inclination of the trunk at an angle of 60°. Prior to discharge, we held a conference with the patient’s family doctor to share our concerns about the risk of aspiration at home. After discharge, home visits for rehabilitation by a speech-language pathologist from our hospital were continuously provided, once a week. At 6 months after discharge, decreased pharyngeal residue and further improvement of the swallowing reflex on VF were noted; the patient had very mild aspiration when eating in a sitting position with 60° tr unk inclination. No aspiration pneumonia developed during this 6-month period.

Discussion:　We considered dysphagia to have worsened postoperatively due to inflammation associated with the cervical spine surgery that had affected the surrounding area. The patient received only conservative therapies such as swallowing rehabilitation and administration of anti-inflammatory analgesics, but showed greater-than-expected improvement in dysphagia, thereby regaining oral intake ability. For patients with dysphagia due to ASH, it appears to be worthwhile to consider whether conservative therapies are available option prior to immediate surgical treatment.