Anterior Cervical Osteophytes Causing Dysphagia and Paradoxical Vocal Cord Motion Leading to Dyspnea and Dysphonia
A 62-year-old male patient visited our hospital with dyspnea and mild dysphagia that began approximately 4 months prior to the visit as the main symptoms. Gentle exercise, such as steps, caused difficulty of inspiration 1 month ago, but it had become worse around the time of his visit, he appeared at rest and accompanied by dysphonia. Dysphagia emerged as foreign body sensation and intermittent aspiration during a solid meal, but he did not have history of weight loss or aspiration pneumonia. Various physicians, from a pulmonologist to an otorhinolaryngologist, failed to make an accurate diagnosis and the symptoms of the patient continued to progressively deteriorate.\nThe patient did not have any particular past internal or surgical medical history other than being a smoker for the last 20 years. The patient had clear consciousness without cognitive dysfunction at the time of his visit to our hospital. In physical examination, stridor was auscultated during inhalation. There was no abnormality of the tongue and no atrophy of the body muscles. The sensory tests displayed normal findings, and normal muscular strength was observed in all muscles of the upper and lower limbs on both sides in the manual muscular strength tests along with normal findings in the deep tendon reflex tests. Fibrillation was not observed in neurological examinations, and masticatory function and gag reflex were normal without observation of particular findings, such as dysarthria in linguistic assessments. Brain magnetic resonance imaging (MRI) for intracranial pathology did not show any abnormalities. There were no abnormal findings in the electrodiagnostic studies that were screened for neuromuscular diseases such as progressive bulbar paralysis. In addition, all the enzymes related to muscular diseases, such as creatine kinase, lactate dehydrogenase, and so on, were in the normal range of the laboratory test. Pulmonary function test was performed to find the cause of dyspnea, but normal pulmonary function was observed without abnormal findings, such as obstructive or restrictive pulmonary patterns. A VFSS showed that osteophytes were severely protruding at the anterior portion of the 5th to 7th cervical spine and translocated the lower pharynx and the upper esophagus anterosuperiorly. In the oral phase, there was no abnormality except for premature bolus loss. In the pharyngeal phase, although laryngeal elevation and epiglottic closures were normal and aspiration was not observed, a lowering of food took a circuitous route around the osteophytes and the pharyngeal transit time of the solid food was delayed by 1.4 seconds. X-ray and computerized tomography (CT) scan of the cervical vertebrae were performed to verify these anterior cervical osteophytes and revealed that the formation of large osteophytes was caused by overgrowth of cortical bones of the 5th to 7th cervical vertebrae. Osteophyte in the 5th cervical spine was the most prominent and protruded 8 mm outside of the vertebral body. C-spine MRI showed anterior herniation of the intervertebral disc accompanied with a ruptured anterior longitudinal ligament, with fluid collection in the retropharyngeal space. A T2-weighted image showed high signal intensity with irregular enhancement caused by retropharyngeal irritation and inflammatory changes due to the large cervical osteophytes (). Anatomical deformities or mass-like lesions on the oropharynx and laryngopharynx were not observed in the larynx endoscopic examination. However, the paradoxical vocal cord motion, adducted vocal cords during the time of inhalation, was observed.\nBecause we did not find any possible etiology of these symptoms other than the anterior cervical osteophytes and the patient displayed a tendency of gradually aggravating dyspnea with severe anxiety and sleep disturbances, we decided to perform surgical treatments. Surgery was conducted through the anterior approach method. Removal of the anterior osteophytes and 5th to 6th cervical herniated disc were performed and interbody fixation with a bone graft was executed.\nDysphagia disappeared immediately due to relief of mechanical pressure on the larynx, but dyspnea and paradoxical vocal cord motion still remained. Accordingly, for correcting the abnormal vocal cords motion, the patient performed the breathing exercises, such as relaxation technique and diaphragmatic breathing method. Finally, the respiratory difficulties and dysphonia were gradually improved after 3 months of continuous self-treatments.