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319

Case Report

Giant Thoracic lmpaction Sharon

Osteophyte

Underberg-Davis1

and Marc

Causing

phytes

cases

have

in the cervical

resulted

spine

that

from

large

impinged

anterior

neck

at the

level

of the

osteo-

on the hypopharynx

or cervical esophagus [1 -6]. Rarely, dysphagia can by osteophytes in the thoracic spine [7]. It has gested that osteophytes are more likely to cause of the cervical esophagus because the esophagus the

cricoid

cartilage,

be caused been

sug-

narrowing is fixed in

whereas

the

thoracic esophagus is a relatively mobile structure that can be displaced anteriorly or laterally without being compressed [4, 5]. Nevertheless, we recently encountered a patient who had an esophageal food impaction above a giant thoracic osteophyte associated with DISH. To our knowledge, vertebral osteophytes

have

cause of food impaction

not been described in the esophagus.

previously

Ti 0 level (Fig. iA). A single-contrast esophagogram revealed complete obstruction of the mid esophagus with barium outlining the superior border of a polypoid filling defect due to a meat bolus impacted in the esophagus above this giant osteophyte at the T9TiO level (Fig. 1 B). A small amount of aspirated barium was noted in the tracheobronchial tree. As the examination was being performed, the meat bolus dislodged spontaneously from the site of impaction and entered the stomach. The patient immediately experienced dramatic relief of symptoms. Reexamination of the esophagus revealed a smooth, extrinsic indentation on the right posterolateral wall of the esophagus caused by the osteophyte at the T9-Ti 0 level (Fig. 1 C). However, no evidence of intrinsic stricture formation was present in the

esophagus,

which

otherwise

appeared

normal,

except

for disor-

dered motility with poor primary peristalsis. The final diagnosis was a giant thoracic osteophyte causing an esophageal food impaction that resolved spontaneously during the barium study.

as a

Discussion Previous

Case Report

be caused

A 76-year-old man came to the emergency

department with acute onset of substernal dysphagia after ingesting a large piece of pork several hours earlier. His dysphagia was so severe that he was unable to swallow his saliva. The patient had experienced a similar

episode 2 years earlier that had resolved

Food

S. Levine

Dysphagia can occasionally be caused by giant vertebral osteophytes or exuberant bone formation associated with diffuse idiopathic skeletal hyperostosis (DISH). Almost all of the reported

Esophageal

spontaneously.

Plain films

of the neck and chest revealed no evidence

reports

indicate

that

dysphagia

or

thoracic spine [1 -7]. However, most patients with cervical thoracic osteophytes indenting the esophagus have esophageal symptoms. As a result, osteophytes should

or no be

logic

osteophytes

can occasionally

in the cervical

considered

by large anterior

as the cause of dysphagia

lesions

in the esophagus

(e.g.,

only when other pathotumors,

webs,

rings,

and

of a radiopaque foreign body. However, there was exuberant osteophytosis in the cervical and thoracic spine (i.e., DISH) with a giant thoracic osteophyte seen

excluded. Our patient was unusual in that he had acute onset of dysphagia due to an esophageal

extending

food

Received I

Both

anteriorly

January

authors:

2 cm from the intervertebral

24,

1 991

Department

.;

junction

at the T9-

strictures)

impaction

August

been

that

was

apparently

precipitated

by a giant

accepted after revision March 20, 1991. of Radiology,

Hospital

of the University

of Pennsylvania,

3400

S. Levine. AJR 157:319-320,

have

1991 0361-803X/91/i

572-0319

© American

Roentgen

Ray Society

Spruce

St., Philadelphia,

PA 1 91 04. Address

reprint

requests

to M.

UNDERBERG-DAVIS

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320

AND

LEVINE

AJR:157, August 1991

Fig. 1.-Giant thoracic osteophyte causing esophageal food ImpactiOn. A, Close-up view from lateral chest radiograph shows bony changes of diffuse idiopathic skeletal hyperostosis in thoracic spine with giant anterior osteophyte (arrow) at 19-110 level. B, Initial esophagogram shows complete obstruction of mid esophagus with barium outlining proximal border of impacted meat bolus (black arrows) above osteophyte (white arrows), which is seen projecting to right of esophagus. C, After spontaneous passage of meat bolus into stomach, second esophagogram in left posterior oblique projection shows smooth, extrinsic indentation on right posterolateral wall of esophagus caused by osteophyte (arrows), which is seen faintiy in this projection. Note additional osteophytes proximally

and distally.

thoracic

osteophyte impinging on the esophagus (Fig. 1). We that abnormal esophageal motility and the large size of the ingested meat bolus contributed to the impaction. Oral administration of a gas-forming agent or IV administration of glucagon can sometimes facilitate passage of the foreign body into the stomach [8]. In our patient, however, distension of the esophagus by the barium bolus caused the impacted meat to pass spontaneously from the esophagus. suspect

Food

impactions

in the

thoracic

esophagus

often

result

from a large bolus of unchewed meat lodging above an anatomic or pathologic area of narrowing, such as a lower esophageal ring or a benign or malignant stricture [8]. However, our experience indicates that giant thoracic osteophytes also Should be recognized as a rare cause of dysphagia and esophageal food impaction. An osteophyte should be suspected as the cause of obstruction when an esophagogram reveals marked hypertrophic changes in the thoracic spine at this level. Nevertheless, a second esophagogram should be obtained

after

the

impaction

has

been

relieved

in order

to

confirm that the osteophyte is impinging on the esophagus and to rule out underlying esophageal disease. In some cases, CT also may be helpful for documenting the presence of a bony mass that is encroaching on the esophagus and for excluding a neoplasm, vascular anomaly, or other extrinsic

mass lesion in the posterior mediastinum [7]. When an esophageal food impaction is caused by a giant osteophyte, the patient should be advised to chew more carefully to avoid recurrent food impactions in the future. Rarely, surgical removal of the osteophyte may be required.

REFERENCES 1 . Hilding

and hypertrophic spurring of the 11-14 2. Resnick D, Shaul 5R, Robins JM. Diffuse idiopathic skeletal hyperostosis (DISH): Forestier’s disease with extraspinal manifestations. Radiology 1975:115:513-524 cervical

DA, Tachdjian MO. Dysphagia spine. N Eng! J Med 1960;263:

3. Gamache

FW, Voorhies

AM. Hypertrophic

cervical osteophytes

dysphagia. J Neurosurg 1980;53:338-344 4. Lambert JR. Tepperman PS, Jiminez J, Newman and dysphagia. Am J Gastroenterol 1981;76:35-40 5. Deutsch EC, Schild JA, Mafee MF. Dysphagia Arch Otolaryngol 1985:111:400-402

A. Cervical and

6. Davies RP, Sage MA, Brophy BP. Cervical osteophyte Australas

Radio!

causing

spine disease

Forestier’s

disease.

induced dysphagia.

1989;33:223-225

7. Willing 5, Gammal TE. Thoracic osteophyte producing dysphagia in a case of diffuse idiopathic skeletal hypertrophy. Am J Gastroenterol 1983:78:381-383 8. Levine MS. Trauma. In: Levine MS, Philadelphia: Saunders, 1989:209-227

ed. Radiology

of the

esophagus.