Otolaryngologic manifestations of diffuse idiopathic skeletal hyperostosis


Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by formation of large cervical osteophytes that may compress the posterior wall of the aerodigestive tract. It is a rare cause of dysphagia in the elderly. The aim of this study was to investigate the various otolaryngologic manifestations of DISH. Eleven elderly patients with DISH were included in the study. All patients presented with dysphagia that was graded on the swallowing screening tool (EAT-10), and the diagnosis of DISH was based on computed tomographic criteria. The patients were subjected to otolaryngologic examination and flexible laryngoscopy. Polysomnography was used for patients with excessive daytime sleepiness for detection of obstructive sleep apnea (OSA). In addition to dysphagia of varying severity, OSA was found in nine patients, change of voice in six, globus sensation in seven, aspiration in three, and cervical pain in seven. Flexible laryngoscopy showed bulging of the posterior pharyngeal wall in all patients. DISH may be an unrecognized contributory factor to both dysphagia and OSA in the elderly. Change of voice, aspiration, globus sensation, and cervical pain are other otolaryngologic manifestations that may be encountered symptoms of the disease. An otolaryngologist should be aware of the disease that may be overlooked, and computed tomography is a confirmatory diagnostic method.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 199

This is the net price. Taxes to be calculated in checkout.

Fig. 1
Fig. 2
Fig. 3


  1. 1.

    Forestier J, Rotes-Querol J (1950) Senile ankylosing hyperostosis of the spine. Ann Rheum Dis 9:321–330

  2. 2.

    Giuffra V, Giusiani S, Fornaciari A, Villari N, Vitiello A, Fornaciari G (2010) Diffuse idiopathic skeletal hyperostosis in the Medici, Grand Dukes of Florence (XVI century). Eur Spine J 19:S103–S107

  3. 3.

    Paja L, Molnár E, Ôsz B, Tiszlavicz L, Palkó A, Coqueugniot H, Dutour O, Pálfi G (2010) Diffuse idiopathic skeletal hyperostosis—appearance and diagnostics in Hungarian osteoarcheological materials. Acta Biol Szeged 54:75–81

  4. 4.

    Resnick D, Shaul SR, Robins JM (1975) Diffuse idiopathic skeletal hyperostosis (DISH): Forestier’s disease with extraspinal manifestations. Radiology 115:513–524

  5. 5.

    Resnick D, Niwayama G (1976) Radiographic and pathologic features of spinal involvement in diffuse idiopathic skeletal hyperostosis (DISH). Radiology 119:559–568

  6. 6.

    Mader R, Sarzi-Puttini P, Atzeni F, Olivieri I, Pappone N, Verlaan J, Buskila D (2009) Extraspinal manifestations of diffuse idiopathic skeletal hyperostosis. Rheumatology 48:1478–1481

  7. 7.

    McCafferty RR, Harrison MJ, Tamas LB et al (1996) Ossification of the anterior longitudinal ligament and Forestier’s disease: an analysis of seven cases. J Neurosurg 83:13–17

  8. 8.

    Fuerderer S, Eysel-gosepath K, Schröder U, Delank K-S, Eysel P (2004) Retro-pharyngeal obstruction in association with osteophytes of the cervical spine. J Bone Joint Surg (Br) 86-B:837–840

  9. 9.

    Belafsky PC, Mouadeb DA, Rees CJ, Pryor JC, Postma GN, Allen J, Leonard RJ (2008) Validity and reliability of the eating assessment tool (EAT-10). Ann Otol Rhinol Laryngol 117:919–924

  10. 10.

    Aydin E, Akdogan V, Akkuzu B, Kirbas I (2006) Six cases of Forestier syndrome, a rare cause of dysphagia. Acta Otolaryngol 126:775–778

  11. 11.

    Srivastava S, Ciapryna N, Bovill I (2008) Diffuse idiopathic skeletal hyperostosis as an overlooked cause of dysphagia: a case report. J Med Case Rep 2:287. doi:10.1186/1752-1947-2-287

  12. 12.

    Johns MW (1992) Reliability and factor analysis of the Epworth Sleepiness Scale. Sleep 15:376–381

  13. 13.

    Rosen CA, Lee AS, Osborne J, Zullo T, Murry T (2004) Development and validation of the voice handicap index-10. Laryngoscope 114:1549–1556

  14. 14.

    Arffa RE, Krishna P, Gartner-Schmidt J, Rosen CA (2012) Normative values for the voice handicap index-10. J Voice 26:462–465

  15. 15.

    Banerjee D (2008) Obstructive sleep apnea: medical management. In: Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS et al (eds) Scott–Brown’s otorhinolaryngology, head and neck surgery, 7th edn. Oxford University Press, London, pp 2313–2324

  16. 16.

    Carlson ML, Archibald DJ, Graner DE, Kasperbauer JL (2011) Surgical management of dysphagia and airway obstruction in patients with prominent ventral cervical osteophytes. Dysphagia 26:34–40

  17. 17.

    Anand SS, Das G, Chakraborty DP, Saha SP, Tripathi P (2012) Diffuse idiopathic skeletal hyperostosis: a case report. Neurology Asia 17:365–368

  18. 18.

    Rotes-Querol J (1996) Clinical manifestations of diffuse idiopathic skeletal hyperostosis (DISH). Br J Rheumatol 35:1193–1196

  19. 19.

    Castellano DM, Sinacori JT, Karakla DW (2006) Stridor and dysphagia in diffuse idiopathic skeletal hyperostosis (DISH). Laryngoscope 116:341–344

  20. 20.

    Solaroglu I, Okutan O, Karakus M, Saygili B, Beskonakli E (2008) Dysphagia due to diffuse idiopathic skeletal hyperostosis of the cervical spine. Turk Neurosurg 18:409–411

  21. 21.

    Nimmons G, Van Daele DJ, Hoffman HT, Rao SS, Clark CR (2010) Multifactorial dysphagia: diffuse idiopathic skeletal hyperostosis and eosinophilic esophagitis. Laryngoscope 120:23–25

  22. 22.

    Vengust R, Mihalic R, Turel M (2010) Two different causes of acute respiratory failure in a patient with diffuse idiopathic skeletal hyperostosis and ankylosed cervical spine. Eur Spine J 19:S130–S134

  23. 23.

    Kandogan T, Sezgin Ö, Dalgiç A (2012) Diffuse idiopathic skeletal hyperostosis (DISH): a rare cause of dysphagia. Ege J Med 51:259–261

  24. 24.

    Ohki M (2012) Dysphagia due to diffuse idiopathic skeletal hyperostosis. Case Rep Otolaryngol. doi:10.1155/2012/123825

  25. 25.

    Anand V, Vikram Vel VR, Purushothaman PK, Rajesh Kumar MS (2011) Cricoarytenoid joint fixation in diffuse idiopathic skeletal hyperostosis (DISH): a case report. Indian J Otolaryngol Head Neck Surg 63:S55–S57

  26. 26.

    Verstraete WL, De Cauwer HG, Verhulst D, Jacobs F (1998) Vocal cord immobilisation in diffuse idiopathic skeletal hyperostosis (DISH). Acta Otorhinolaryngol Belg 52:79–84

Download references


We are grateful to the staff of the departments of radiology and orthopedic surgery in our institute for their assistance and contribution.

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Correspondence to Mosaad Abdel-Aziz.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (WMV 2068 kb)

Supplementary material 1 (WMV 2068 kb)

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Abdel-Aziz, M., Azab, N.A., Rashed, M. et al. Otolaryngologic manifestations of diffuse idiopathic skeletal hyperostosis. Eur Arch Otorhinolaryngol 271, 1785–1790 (2014).

Download citation


  • Dysphagia
  • Obstructive sleep apnea
  • Cervical osteophytes
  • DISH
  • Cervical pain