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Table of Contents
LETTERS TO EDITOR  
Year : 2022  |  Volume : 25  |  Issue : 2  |  Page : 246-247
Difficult transesophageal echocardiography probe insertion due to cervical diffuse idiopathic skeletal hyperostosis


Department of Anesthesiology, Kumamoto University Hospital, Kumamoto, Japan

Click here for correspondence address and email

Date of Submission07-Feb-2022
Date of Acceptance16-Feb-2022
Date of Web Publication11-Apr-2022
 

How to cite this article:
Kumamoto T, Araki M. Difficult transesophageal echocardiography probe insertion due to cervical diffuse idiopathic skeletal hyperostosis. Ann Card Anaesth 2022;25:246-7

How to cite this URL:
Kumamoto T, Araki M. Difficult transesophageal echocardiography probe insertion due to cervical diffuse idiopathic skeletal hyperostosis. Ann Card Anaesth [serial online] 2022 [cited 2022 May 21];25:246-7. Available from: https://www.annals.in/text.asp?2022/25/2/246/342853




To the Editor,

An 83-year-old man with hypertension and hyperlipidemia was followed for several years for aortic stenosis. He developed dyspnea during exertion and was admitted to the hospital with congestive heart failure. On admission, transthoracic echocardiography indicated severe aortic stenosis (aortic valve area 0.81 cm2, Vmax 4.35 m/s, mean pressure gradient 44.1 mmHg) with a left ventricular ejection fraction of 64%. The patient was scheduled to undergo an aortic valve replacement. He had no history of dysphagia, dysphonia, neck pain, or neck stiffness. Preoperative evaluation using transesophageal echocardiography (TEE) was not performed.

Upon arrival in the operating room, we provided general anesthesia with 5 mg of midazolam, 250 μg of fentanyl, and 50 mg of rocuronium. Endotracheal intubation was performed using a McGRATH MAC video laryngoscope (Aircraft Medical Ltd., Edinburgh, UK). We attempted to insert a TEE probe blindly; however, several attempts failed to deliver the probe into the esophagus due to unexpected resistance. We attempted to insert the probe under McGRATH MAC video laryngoscope guidance, but we could not observe the esophageal inlet due to the prominence of the posterior pharyngeal wall. We gave up inserting the probe and the surgery was performed uneventfully without a TEE. Computed tomography after surgery confirmed the presence of large anterior cervical osteophytes causing ventral displacement of the posterior pharyngeal wall [Figure 1]a, which correlated with difficult probe insertion. Radiography of the cervical spine showed extensive ossification of the anterior longitudinal ligament, which was particularly prominent at the C4–C7 vertebral level [Figure 1]b. Therefore, he was diagnosed with diffuse idiopathic skeletal hyperostosis (DISH).
Figure 1: (a) Computed tomography showing the presence of large anterior cervical osteophytes causing ventral displacement of the posterior pharyngeal wall; (b) Radiography of the cervical spine showed extensive ossification of anterior longitudinal ligament

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Although various esophageal pathologies cause difficult probe insertion and are cited as contraindications to TEE,[1] it is not well known that cervical osteophyte compression of the esophagus is associated with difficulty in probe insertion. DISH is a non-inflammatory disorder characterized by calcification and ossification of ligaments along the sides of contiguous vertebrae of the spine which induces dysphagia and dysphonia.[2] It is estimated that 3% of people over 40 years of age have DISH, but cervical spine alterations are less frequent than those of the thoracic or lumbar spine.[3] Royer et al.[4] reported a case of esophageal perforation after TEE due to compression of the esophagus by prominent thoracic vertebral osteophytes during transcatheter aortic valve implantation. Chang et al.[2] suggested that prominent cervical and thoracic vertebral osteophytes should be considered relative contraindications to TEE because direct pressure and friction by the probe against sharp vertebral osteophytes led to esophageal laceration. DISH has been reported to be associated with calcification of the aortic valves;[5] therefore, vertebral osteophytes may be relatively frequent in transcatheter aortic valve implantation and aortic valve replacement. Fortunately, there were no complications in our case. However, caution should be exercised as repeated attempts at blind TEE probe insertion as it can result in various complications. In conclusion, it is important to carefully check computed tomography before TEE to determine the severity of anterior vertebral osteophytes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D'Ambra MN, Eltzschig HK. Safety of transesophageal echocardiography. J Am Soc Echocardiogr 2010;23:1115-27.  Back to cited text no. 1
    
2.
Chang K, Barghash M, Donnino R, Freedberg RS, Hagiwara M, Bennett G, et al. Extrinsic esophageal compression by cervical osteophytes in diffuse idiopathic skeletal hyperostosis: A contraindication to transesophageal echocardiography? Echocardiography 2016;33:314-6.  Back to cited text no. 2
    
3.
Hwang JS, Chough CK, Joo WI. Giant anterior cervical osteophyte leading to dysphagia. Korean J Spine 2013;10:200-2.  Back to cited text no. 3
    
4.
Royer O, Couture ÉJ, Nicodème F, Kalavrousiotis D, Maruyama TC, Denault A, et al. Esophageal perforation with transesophageal echocardiography in an elderly patient with prominent vertebral osteophytes: A case report and a review of the literature. CASE (Phila) 2020;4:331-6.  Back to cited text no. 4
    
5.
Orden AO, David JM, Díaz RP, Nardi NN, Ejarque AC, Yöchler AB. Association of diffuse idiopathic skeletal hyperostosis and aortic valve sclerosis. Medicina (B Aires) 2014;74:205-9.  Back to cited text no. 5
    

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Correspondence Address:
Taisuke Kumamoto
Department of Anesthesiology, Kumamoto University Hospital, 1-1-1, Honjo, Chuo-ku, Kumamoto -860-8556
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.aca_29_22

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