Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

: 2003  |  Volume : 13  |  Issue : 1  |  Page : 79--80

Forestier disease - an unusual cause of dysphagia

SG Iyer, P Saxena, GL Sharma, UD Saxena 
 M-601-Dharma Apartments, Patparganj, I.P. Extension, Delhi-110092, India

Correspondence Address:
S G Iyer
M-601, Dharma Apartments, Patparganj, I.P. Extension, Delhi-110092

How to cite this article:
Iyer S G, Saxena P, Sharma G L, Saxena U D. Forestier disease - an unusual cause of dysphagia.Indian J Radiol Imaging 2003;13:79-80

How to cite this URL:
Iyer S G, Saxena P, Sharma G L, Saxena U D. Forestier disease - an unusual cause of dysphagia. Indian J Radiol Imaging [serial online] 2003 [cited 2020 Sep 21 ];13:79-80
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 Case report

A sixty year old man was referred to us from the department of ENT with a request for a barium swallow examination. The man was apparently alright six months back, at the time of presentation, he complained of difficulty in swallowing, but no pain on attempting to do so. He was a known case of diabetes mellitus but was otherwise normal in all respects. Plain skiagrams of his lumber spine [Figure 2] and sacroiliac joints [Figure 3] were also obtained. Flowing ossification of the anterior longitudinal ligaments joining four cervical [Figure 1] and four lumbar vertebrae on their anterior aspects were seen. A peg like osteophyte protruding from his fourth cervical vertebra was identified as the cause for his dysphagia- this was confirmed on fluoroscopy. The sacroiliac joints were found to be normal.


Forestier Disease or Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a rheumatic abnormality characterized by exuberant proliferation of bone at osseous sites of ligamentous and tendinous attachments throughout the body. A higher prevalence is found among diabetics [1]. The incidence of DISH increases with age, being most common in the middle aged and elderly, and develops more frequently in men.

Recent investigations support the hypothesis that Growth Hormone and Insulin may act as bone growth promoting factors in patients with DISH [2].

 Imaging findings in DISH include

Spine- The most common site of involvement is the mid to lower thoracic spine. Lower cervical spine abnormalities are also common and include posterior alterations (e.g., posterior spinal osteophytes, ossification within the nuchal ligament and the posterior longitudinal ligament) in addition to the more common anterior longitudinal ligament (ALL) calcification. Spinal involvement is based on the following three strict radiographic criteria, which aid in distinguishing DISH from Osteoarthritis of the spine and Ankylosing spondylitis [3]:

1. Flowing ossification of the anterolateral aspect of at least four contiguous vertebral bodies.

2. Relative preservation of the disc height in the involved segments and absence of radiographic changes associated with disc degenerative disorder.

3. Absence of sacroilitis and facet ankylosis.

The most common site of involvement is the mid to lower thoracic spine where the new anterolateral bone formation is more often on the right, apparently because of the pulsating descending thoracic aorta on the left. Cervical spine abnormalities are also common and often include posterior alterations such as ossification of the nuchal ligament or the posterior longitudinal ligament, in addition to the more common anterior bone deposition.

Sacroiliac joints- The synovial portion, or lower two-thirds is not commonly affected; however the upper third may become blurred or indistinct. The superior and inferior portions of the joints may be bridged by para articular ligamentous calcification.

Extraspinal enthesopathy- The typical sites of involvement include the pelvis, calcaneus and the patella. The enthesopathic changes that ensue are purely productive and there is no erosive activity. These are initially visualized radiographically by roughening of the bone and later by extensive proliferation.

The clinical complaints of mild pain and stiffness that are associated with the majority of patients with DISH are much less remarkable than the extensive radiographic changes seen. The rare modes of presentation include dyspnoea, hoarseness, dysphagia, aspiration pneumonia, myelopathies, peripheral nerve entrapment, or tendonitis [4],[5],[6].


1Forgacs S S: Diabetes mellitus and rheumatic disease, Clin. Rheum Dis 12: 279, 1986.
2Vezyroglow G et al: A metabolic syndrome in Diffuse idiopathic skeletal hyperostosis. A controlled study, J Rheumatol 23:672, 1996.
3Resnick D, Niwayama G: Radiographic and pathologic features of spinal involvement in Diffuse idiopathic skeletal hyperostosis (DISH), Radiology 119:559, 1976.
4Karlins N L, Yagan R: Dyspnoea and hoarseness. A complication of Diffuse idiopathic skeletal hyperostosis, Spine 16:235, 1991.
5Warnick C, Sherman M S, Lesser R W: Aspiration pneumonia due to diffuse cervical hyperostosis, Chest 98:763, 1990.
6Wilson F M, Jaspan T: Thoracic spinal cord compression caused by Diffuse idiopathic skeletal hyperostosis (DISH), Clin Radiol 42:133, 1990.