Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
BMC Anesthesiology
Published in: BMC Anesthesiology 1/2020

Open Access 01-12-2020 | Dysphagia | Case report

Ossification of the cervical anterior longitudinal ligament is an underdiagnosed cause of difficult airway: a case report and review of the literature

Authors: Min Xu, Yue Liu, Jing Yang, Hao Liu, Chen Ding

Published in: BMC Anesthesiology | Issue 1/2020

Login to get access

Abstract

Background

Ossification of the anterior longitudinal ligament (OALL) of the cervical spine is a common, but rarely symptomatic, condition mostly observed in the geriatric population. Although the condition usually requires no intervention, it could lead to a difficult airway and compromise the patient’s safety.

Case presentation

Here, we describe the case of a 50-year-old man with cervical myelopathy and OALL that resulted in difficult endotracheal intubation after induction of anesthesia. Radiography and magnetic resonance imaging findings showed OALL, with prominent osteophytes involving four cervical vertebrae, a bulge in the posterior pharyngeal wall, and a narrow pharyngeal space. Airtraq® laryngoscope-assisted intubation was accomplished with rapid induction under sevoflurane-inhaled anesthesia.

Conclusion

Anesthesiologists should understand that OALL of the cervical spine could cause a difficult airway. However, it is difficult to recognize asymptomatic OALL on the basis of routine airway evaluation guidelines. For susceptible populations, a thorough evaluation of the airway, based on imaging studies and a history of compression symptoms, should be considered whenever possible. In case of unanticipated difficult intubation, anesthesiologists should refer to guidelines for unanticipated difficult airway management and identify OALL of the cervical spine as the cause.
Appendix
Available only for authorised users
Literature
1.
Ohara Y. Ossification of the ligaments in the cervical spine, including ossification of the anterior longitudinal ligament, ossification of the posterior longitudinal ligament, and ossification of the ligamentum flavum. Neurosurg Clin N Am. 2018;29(1):63–8.PubMed
2.
3.
Forestier J, Lagier R. Ankylosing hyperostosis of the spine. Clin Orthop Relat Res. 1971;74:65–83.PubMed
4.
Saito T, Wajima Z, Kato N, Shitara T, Inoue T, Ogawa R. Management of anesthesia in patients with the potential for difficult intubation due to ossification of anterior longitudinal ligament (OALL). Masui. 2006;55(10):1257–9.PubMed
5.
Lee HC, Andree RA. Cervical spondylosis and difficult intubation. Anesth Analg. 1979;58(5):434–5.PubMed
6.
Crosby ET, Grahovac S. Diffuse idiopathic skeletal hyperostosis: an unusual cause of difficult intubation. Can J Anaesth. 1993;40(1):54–8.PubMed
7.
Thapa D, Sinha PK, Gombar S, Gombar KK, Palta S, Sen I. Large anterior cervical osteophytes: a cause for laryngeal "BURP" failure and difficult intubation - a case report. J Anesth Clin Pharmacol. 2002;18(3):320–2.
8.
Gorback MS. Management of the challenging airway with the Bullard laryngoscope. J Clin Anesth. 1991;3(6):473–7.PubMed
9.
Togashi H, Hirabayashi Y, Mitsuhata H, Saitoh K, Shimizu R. The beveled tracheal tube orifice abutted on the tracheal wall in a patient with Forestier's disease. Anesthesiology. 1993;79(6):1452–3.PubMed
10.
Broadway JW. Forestier's disease (ankylosing hyperostosis): a cause for difficult intubation. Anaesthesia. 1994;49(10):919–20.PubMed
11.
Ranasinghe DN, Calder I. Large cervical osteophyte--another cause of difficult flexible fibreoptic intubation. Anaesthesia. 1994;49(6):512–4.PubMed
12.
Aziz ES, Thompson AR, Baer S. Difficult laryngeal mask insertion in a patient with Forestier's disease. Anaesthesia. 1995;50(4):370.PubMed
13.
Palmer JH, Ball DR. Awake tracheal intubation with the intubating laryngeal mask in a patient with diffuse idiopathic skeletal hyperostosis. Anaesthesia. 2000;55(1):70–4.PubMed
14.
Bougaki M, Sawamura S, Matsushita F, Hanaoka K. Difficult intubation due to ossification of the anterior longitudinal ligament. Anaesthesia. 2004;59(3):303–4.PubMed
15.
Naik B, Lobato EB, Sulek CA. Dysphagia, obstructive sleep apnea, and difficult fiberoptic intubation secondary to diffuse idiopathic skeletal hyperostosis. Anesthesiology. 2004;100(5):1311–2.PubMed
16.
Cesur M, Alici HA, Erdem AF. An unusual cause of difficult intubation in a patient with a large cervical anterior osteophyte: a case report. Acta Anaesthesiol Scand. 2005;49(2):264–6.PubMed
17.
Ozkalkanli MY, Katircioglu K, Ozkalkanli DT, Savaci S. Airway management of a patient with Forestier's disease. J Anesth. 2006;20(4):304–6.PubMed
18.
Montinaro A, D'Agostino A, Punzi F, Cantisani PL. Cervical anterior hyperostosis: a rare cause of dysphagia. Report of 3 cases. J Neurosurg Sci. 2006;50(3):75–7.PubMed
19.
Satomoto M, Adachi YU, Sato S. Safe intubation with a gum-elastic bougie in a patient with Forestier's disease. J Anesth. 2007;21(4):519–20.PubMed
20.
Baxi V, Gaiwal S. Diffuse idiopathic skeletal hyperostosis of cervical spine - an unusual cause of difficult flexible fiber optic intubation. Saudi J Anaesth. 2010;4(1):17–9.PubMedPubMedCentral
21.
Thompson C, Moga R, Crosby ET. Failed videolaryngoscope intubation in a patient with diffuse idiopathic skeletal hyperostosis and spinal cord injury. Can J Anaesth. 2010;57(7):679–82.PubMed
22.
Eipe N, Fossey S, Kingwell SP. Airway management in cervical spine ankylosing spondylitis: between a rock and a hard place. Indian J Anaesth. 2013;57(6):592–5.PubMedPubMedCentral
23.
Iida M, Tanabe K, Dohi S, Iida H. Airway management for patients with ossification of the anterior longitudinal ligament of the cervical spine. JA Clin Rep. 2015;1(1):11.PubMedPubMedCentral
24.
Alsalmi S, Bugdadi A, Alkhayri A, Fichten A, Peltier J. Urgent anterior cervical osteophytectomy for an asymptomatic cervical hyperostosis to overcome failed intubation. Cureus. 2018;10(3):e2400.PubMedPubMedCentral
25.
Gosavi K, Dey P, Swami S. Airway management in case of diffuse idiopathic skeletal hyperostosis. Asian J Neurosurg. 2018;13(4):1260–3.PubMedPubMedCentral
26.
Garcia Zamorano S, Garcia Del Valle YMS, Andueza Artal A, Robles Angel P, Gijon HN. Acute airway obstruction in a patient with forestier disease. Case report Rev Esp Anestesiol Reanim. 2019;66(5):292–5.PubMed
27.
Yoshimatsu Y, Tobino K, Maeda K, et al. Management of airway obstruction due to diffuse idiopathic skeletal hyperostosis in the cervical spine: a case report and literature review. Intern Med. 2019;58(2):271–6.PubMed
28.
Caminos CB, Cenoz IZ, Louis CJ, Otano TB, Esain BF, Perez de Ciriza MT. Forestier disease: an unusual cause of upper airway obstruction. Am J Emerg Med. 2008;26(9):1072.e1071–3.
29.
Demuynck K, Van Calenbergh F, Goffin J, Verschakelen J, Demedts M, Van de Woestijne K. Upper airway obstruction caused by a cervical osteophyte. Chest. 1995;108(1):283–4.PubMed
30.
Matan AJ, Hsu J, Fredrickson BA. Management of respiratory compromise caused by cervical osteophytes: a case report and review of the literature. Spine J. 2002;2(6):456–9.PubMed
31.
Lin HW, Quesnel AM, Holman AS, Curry WT Jr, Rho MB. Hypertrophic anterior cervical osteophytes causing dysphagia and airway obstruction. Ann Otol Rhinol Laryngol. 2009;118(10):703–7.PubMed
32.
Varsak YK, Eryilmaz MA, Arbag H. Dysphagia and airway obstruction due to large cervical osteophyte in a patient with ankylosing spondylitis. J Craniofac Surg. 2014;25(4):1402–3.PubMed
33.
Bird JH, Biggs TC, Karkos PD, Repanos C. Diffuse idiopathic skeletal hyperostosis as an acute airway presentation requiring urgent tracheostomy. Am J Emerg Med. 2015;33(5):737.e731–2.
34.
Hoey AW, Dusu K, Gane S. Diffuse idiopathic skeletal hyperostosis (DISH): an unusual cause of airway obstruction. BMJ Case Rep. 2017;2017:bcr2017219635.PubMedPubMedCentral
35.
Psychogios G, Jering M, Zenk J. Cervical hyperostosis leading to dyspnea, aspiration and dysphagia: strategies to improve patient management. Front Surg. 2018;5:33.PubMedPubMedCentral
36.
Boachie-Adjei O, Bullough PG. Incidence of ankylosing hyperostosis of the spine (Forestier's disease) at autopsy. Spine. 1987;12(8):739–43.PubMed
37.
Frerk C, Mitchell VS, McNarry AF, et al. Difficult airway society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827–48.PubMedPubMedCentral
38.
Resnick D. Degenerative diseases of the vertebral column. Radiology. 1985;156(1):3–14.PubMed
39.
Denko CW, Malemud CJ. Body mass index and blood glucose: correlations with serum insulin, growth hormone, and insulin-like growth factor-1 levels in patients with diffuse idiopathic skeletal hyperostosis (DISH). Rheumatol Int. 2006;26(4):292–7.PubMed
40.
Kiss C, Szilagyi M, Paksy A, Poor G. Risk factors for diffuse idiopathic skeletal hyperostosis: a case-control study. Rheumatology (Oxford). 2002;41(1):27–30.
41.
Wang JM, Ma EL, Wu QP, Tian M, Sun YY, Lin J, et al. Effectiveness and safety of a novel approach for management of patients with potential difficult mask ventilation and tracheal intubation: a multi-center randomized trial. Chin Med J. 2018;131(6):631–7.PubMedPubMedCentral
Metadata
Title
Ossification of the cervical anterior longitudinal ligament is an underdiagnosed cause of difficult airway: a case report and review of the literature
Authors
Min Xu
Yue Liu
Jing Yang
Hao Liu
Chen Ding
Publication date
01-12-2020
Publisher
BioMed Central
Published in
BMC Anesthesiology / Issue 1/2020
Electronic ISSN: 1471-2253
DOI
https://doi.org/10.1186/s12871-020-01077-9

Other articles of this Issue 1/2020

BMC Anesthesiology 1/2020 Go to the issue

Research article

A nationwide survey of intraoperative management for one-lung ventilation in Taiwan: time to accountable for diversity in protective lung ventilation

Research article

LMA Gastro™ airway is feasible during upper gastrointestinal interventional endoscopic procedures in high risk patients: a single-center observational study

Research article

Fluid expansion improve ventriculo-arterial coupling in preload-dependent patients: a prospective observational study

Research article

Troponin I as a mortality marker after lung resection surgery – a prospective cohort study

Research article

Retrospective evaluation of pain in patients with coccydynia who underwent impar ganglion block

Research article

Airway management in children with hemifacial microsomia: a restropective study of 311 cases