Clinical Communications: Adults AN UNUSUAL AND RARE CAUSE OF ACUTE AIRWAY OBSTRUCTION IN THE ELDERLY: FORESTIER’S DISEASE Walid I. Dagher, MD,* Viviane G. Nasr, MD,† Anju K. Patel, MD,* and Richard O. Wein, MD, FACS* *Department of Otolaryngology–Head and Neck Surgery and †Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts Reprint Address: Walid I. Dagher, MD, Department of Otolaryngology–Head and Neck Surgery, Tufts Medical Center, 800 Washington Street, Boston, MA 02111 , Abstract—Background: Diffuse idiopathic skeletal hy- perostosis (DISH), also known as Forestier’s disease, is an ossifying disease of unknown etiology affecting mainly elderly men. It is characterized by hypertrophic anterior vertebral osteophytes with ossification of the spinal ante- rior longitudinal ligament. Hypertrophic osteophytes can encroach on the aerodigestive tract, leading to significant swallowing and respiratory symptoms. Objective: Acute stridor and respiratory compromise requiring a surgical airway have rarely been reported in patients with DISH. This entity, although rare, should be in the differential diagnosis of acute airway obstruction, particularly in the elderly. Case Report: We describe a case of a 91-year-old patient who was transferred to the Emergency Department at Tufts Medical Center with acute stridor. A computed to- mography scan of the neck prior to transfer revealed a large anterior cervical osteophyte causing significant airway narrowing. Fiberoptic evaluation confirmed the radiologic finding of near-complete airway obstruction. The patient’s respiratory status rapidly deteriorated and he subsequently underwent an emergent awake tracheos- tomy to secure his airway. Conclusion: Given the rarity of DISH and the increase in life expectancy, clinicians should be aware of this disease entity and its potential for acute life-threatening respiratory presentation. Ó 2014 Elsevier Inc. , Keywords—stridor; acute airway obstruction; diffuse idiopathic skeletal hyperostosis; tracheostomy; Forestier’s disease INTRODUCTION Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier’s disease, was first described in 1950. It is an ossifying disease of unknown etiology affecting mainly middle-aged and elderly patients. It is characterized by hypertrophic anterior vertebral osteo- phytes with ossification of the spinal anterior longitudi- nal ligament. Hypertrophic osteophytes can encroach on the aerodigestive tract, leading to significant swallow- ing and respiratory symptoms. Although most patients with Forestier’s disease are not sufficiently distressed to merit surgery, we report a rare case of acute airway compromise necessitating an emergent tracheostomy. CASE REPORT A 91-year-old patient was transferred to the Emergency Department (ED) at Tufts Medical Center for manage- ment of his acute stridor. He had been complaining of slow deterioration of his breathing and decreased exer- cise tolerance limiting his routine daily activity. He also had progressive dysphagia, particularly to solids, and inability to take his daily medications. A computed tomography scan of the neck prior to transfer revealed a large anterior cervical osteophyte extending from C2 to C5 (Figure 1). Upon presentation to the ED, a RECEIVED: 2 April 2013; FINAL SUBMISSION RECEIVED: 14 October 2013; ACCEPTED: 17 November 2013 1 The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter http://dx.doi.org/10.1016/j.jemermed.2013.11.092