Thoracic spine osteophyte causing dysphagia

A 65-year-old man, a chronic smoker and alcoholic with a diagnosed adenocarcinoma of the antrum of the stomach, was being further investigated because of dysphagia; endoscopic examination at the referring center showed a polypoid lesion in the mid esophagus. Positron emission tomography (PET) revealed increased uptake of fluorodeoxyglucose in this esophageal lesion. The possibility of a metastasis to the esophagus from the gastric malignancy was considered. However, biopsy from the esophageal lesion revealed features of chronic inflammation. A repeat gastroscopy was done and a polypoid lesion was observed in the mid esophagus ([Fig. 1]). Histopathological examination of the biopsy specimen from this lesion again revealed features of chronic inflammation. Contrast-enhanced computed tomography (CECT) of the chest with intravenous and a positive oral contrast revealed a dilated esophagus.

Fig. 1 Polypoid lesion in the esophagus.

Radial endoscopic ultrasound examination of the esophagus revealed that the vertebral column was eroding into the posterior esophageal wall at the site of the lesion noted on endoscopy ([Fig. 2]). A repeat chest CECT, this time without oral contrast, showed that an anterior osteophyte from the thoracic vertebra was eroding into the esophagus ([Fig. 3]). It had not been possible to diagnose it in the previous CECT as during that procedure positive oral contrast was given which obscured the vertebral erosion into the esophagus ([Fig. 4]). A barium esophagogram also documented indentation of the posterior wall of the esophagus by a thoracic vertebra ([Fig. 5]).

Fig. 2 Endoscopic ultrasonography showing erosion of posterior esophageal wall by vertebra (arrow).

Fig. 3 Contrast-enhanced computed tomography showing erosion into the posterior esophageal wall by vertebra (arrow).

Fig. 4 Contrast-enhanced computed tomography with positive oral contrast in esophagus could not demonstrate the lesion in the posterior esophageal wall.

Fig. 5 Barium esophagogram showing posterior indentation of the esophagus by thoracic vertebra (arrow).

Anterior osteophytes can occasionally impinge on the anteriorly located esophagus and can cause dysphagia [1] [2] [3] [4]. This commonly involves the hypopharynx or the cervical esophagus [1] [2] [3] [4]. Involvement of the thoracic esophagus is very rare because the thoracic esophagus is a relatively mobile structure in the posterior mediastinum that can be displaced without being compressed [5].

Endoscopy_UCTN_Code_CCL_1AB_2AC_3AH

Competing interests: None

• References

• 1 Hilding DA, Tachdjian MO. Dysphagia and hypertrophic spurring of the cervical spine. N Engl J Med 1960; 263: 11-14
• 2 Resnick D, Shaul SR, Robins JM. Diffuse idiopathic skeletal hyperostosis (DISH): Forestier’s disease with extraspinal manifestations. Radiology 1975; 115: 513-524
• 3 Lin HW, Quesnel AM, Holman AS et al. Hypertrophic anterior cervical osteophytes causing dysphagia and airway obstruction. Ann Otol Rhinol Laryngol 2009; 118: 703-707
• 4 Seidler TO, Pèrez Alvarez JC, Wonneberger K et al. Dysphagia caused by ventral osteophytes of the cervical spine: clinical and radiographic findings. Eur Arch Otorhinolaryngol 2009; 266: 285-291
• 5 Underberg-Davis S, Levine MS. Giant thoracic osteophyte causing esophageal food impaction. AJR Am J Roentgenol 1991; 157: 319-320