Diagnosing Dysphagia in Forestier Syndrome: A Dynamic Digital Radiology Application

Diffuse idiopathic skeletal hyperostosis (DISH), or Forestier's disease, is a non-inflammatory condition characterized by the calcification and ossification of spinal ligaments and entheses, especially the anterior longitudinal ligament. Its prevalence increases with age and it is more common in males. The term DISH usually refers to the imaging aspects of this condition, while "Forestier's disease" is used for the clinical correlates of the condition, especially the development of dysphagia. Diagnosis is usually made with conventional radiography, based on the Resnick and Niwayama criteria: flowing osteophytes over at least four contiguous vertebral bodies, the preservation of intervertebral disk space, absent facet and costovertebral joint ankylosis, and absent sacroiliac joint abnormalities. A "melted candle wax" appearance along the spine is typical of the advanced disease. Large anterior osteophytes in the cervical spine lead not only to stiffness and chronic neck pain, but also to compressive symptoms such as dysphagia, dysphonia, and even airway compromise. Digital Dynamic Radiography (DDR), thanks to a flat-panel detector system, captures high-temporal resolution sequential low-dose radiographs at high frame rates in dynamic motion studies to provide functional information. We report the case of a 50-year-old female patient diagnosed with Forestier's disease. Cervical radiography showed coarse anterior osteophytes and calcifications typical of DISH. The patient complained about persistent cervical pain and significant dysphagia. To investigate the underlying mechanism, a DDR with barium oral administration was performed. The examination confirmed the mechanical narrowing of the pharyngeal lumen caused by bulky anterior osteophytes. Given the severity of the symptoms, the patient underwent a surgical resection of the osteophytic and calcified components, with a subsequent improvement of swallowing function. This case highlights how DDR provides functional and morphological information in patients with dysphagia related to cervical DISH.