What surgical intervention is used for airway compromise in patients with Diffuse Idiopathic Skeletal Hyperostosis (DISH)?

Surgical Management of Airway Compromise in Diffuse Idiopathic Skeletal Hyperostosis (DISH)

For patients with airway compromise due to Diffuse Idiopathic Skeletal Hyperostosis (DISH), surgical osteophytectomy via an anterolateral approach is the most effective intervention when conservative management fails. 1, 2

Pathophysiology and Clinical Presentation

DISH is characterized by ossification of entheses, particularly affecting the cervical spine, which can lead to:

• Formation of large anterior cervical osteophytes
• Compression of the posterior pharyngeal wall
• Upper airway obstruction and respiratory distress
• Associated dysphagia in up to 28% of cases

Patients may present with:

• Sudden-onset upper airway obstruction
• Respiratory distress
• Dysphagia
• Neck pain and stiffness

Management Algorithm

Initial Airway Management

1. Acute severe obstruction:

   • Immediate airway stabilization
   • Endotracheal intubation for severe cases
   • Tracheostomy may be required as a temporary measure in emergency situations 3

2. Less severe obstruction:

   • CPAP during nighttime may be sufficient for mild cases 4
   • Careful monitoring for worsening symptoms

Conservative Management (Trial Before Surgery)

• Diet modification
• Change in head position during swallowing
• Non-steroidal anti-inflammatory drugs
• Proton pump inhibitors (e.g., pantoprazole) 5

Surgical Intervention

When conservative management fails, surgical intervention becomes necessary:

1. Preferred Surgical Approach:

   • Anterolateral surgical osteophytectomy - removal of the protruding osteophytes 2
   • This approach has shown 100% improvement in dysphagia and respiratory symptoms 2

2. Surgical Considerations:

   • Fusion after osteophytectomy using polyether ether ketone (PEEK) cage and/or plate system 5
   • Combined ENT-neurosurgical approach may be required for complex cases 4
   • Complete removal of compressive structures is essential

3. Outcomes:

   • Significant improvement in symptoms typically occurs within 6 weeks post-surgery 5
   • Successful decannulation of tracheostomy after surgery 2
   • Low recurrence rates with proper fusion technique 5

Preoperative Assessment

Prior to surgical intervention, comprehensive evaluation is essential:

• CT scan of the chest to visualize the extent of osteophytes 6
• Esophageal and laryngoscopic examinations
• Fluoroscopic swallowing study 5
• Assessment for other causes of central airway obstruction 6

Important Considerations and Pitfalls

1. Diagnostic pitfalls:

   • DISH is often underrecognized as a cause of airway obstruction 1
   • Symptoms may be mistaken for more common conditions like COPD or asthma

2. Surgical pitfalls:

   • Avoid unnecessary tracheostomy as a definitive treatment
   • Incomplete osteophyte removal may lead to persistent symptoms
   • Failure to perform fusion may result in osteophyte regrowth

3. Post-operative considerations:

   • Regular follow-up to monitor for recurrence
   • Radiographic examinations to check for pathological regrowth
   • Surveillance for swallowing function 6

Special Populations

For elderly patients or those with significant comorbidities:

• Careful risk-benefit assessment before surgical intervention
• Consider less invasive approaches when appropriate
• Balance between airway security and quality of life

In summary, while tracheostomy has historically been the most common intervention for airway compromise in DISH, surgical osteophytectomy with fusion provides better long-term outcomes and quality of life for patients who fail conservative management.