ankylosing spondylitis ( as ) is a chronic systemic , inflammatory , rheumatic disease affecting primarily the sacroiliac ( si ) joints and the skeleton . other clinical manifestations include peripheral arthritis , enthesitis , and extra - articular organ involvement such as uveitis , aortitis , pericarditis , pulmonary fibrosis , and amyloidosis . dysphagia related to the musculoskeletal system is encountered frequently in cases such as diffuse idiopathic skeletal hyperostosis ( dish ) , acromegaly , hypoparathyroidism , fluorosis , ochronosis , and trauma . dysphagia in as needs to be defined , as it may lead to complications like weight loss and nutritional disorders . here , we describe a case of dysphagia in as to raise awareness of this condition . a 48-year - old male , who was being followed up for as , visited our hospital complaining of progressive dysphagia . difficulty swallowing solid foods started ~4 years prior , and for the last year , he suffered from dysphagia when swallowing both solid and liquid foods . the patient had no pain while swallowing , but did experience coughing , and had lost ~16 kg in the last 4 years . upon physical examination , cervical motion was limited in all directions ; the occiput - wall distance was 12 cm and chin - manubrium sterni distance was 7 cm . a si compression test was bilaterally positive ; the bath as disease activity index was 4.7 ; and bath as functional index was 3.9 . erythrocyte sedimentation rate was 25 mm / hour , and c - reactive protein was 19.8 mg / l ( normal range ,  5 ) . blood levels of urea , creatinine , transaminases , calcium , and alkaline phosphatase were all within normal limits . while he was negative for antinuclear antibody and rheumatoid factor , he was positive for hla - b27 . imaging studies revealed si joint ankylosis and whiskering sign in pubic bones with simple pelvic radiography ( fig . osteophytes were observed at the anterior corners of vertebra corpuses at c4 - 5 and c7-t1 levels with lateral cervical radiography ( fig . cervical computed tomography , performed to localize the osteophytes and for differential diagnosis , revealed fusion between the c5-c6-c7 corpuses with prominent osteophyte formation anteriorly on the left at the c7-t1 level . 4 ) . cervical magnetic resonance imaging ( mri ) was performed to rule out factors originating from soft tissues as causes of dysphagia . a large osteophyte formation on anterior vertebra corpuses at the c7-t1 level , which caused compression on esophagus , was defined in the cervical mri ( fig . the patient was diagnosed with severe dysphagia because he could not swallow small solid foods and he complained of coughing when swallowing liquid and solid foods . after consultation with an orthopedic surgeon , an operation for osteophyte excision was proposed , but the patient refused . diet modification , antireflux and swallowing therapy were prescribed . however , after 6 months , dysphagia had not improved . as is a systemic anti - inflammatory disease , accompanied frequently by extra - articular involvement . the presence of hla - b27 has an important role in as pathogenesis and is often concomitantly observed with environmental factors such as infection . as affects primarily vertebral joints and intervertebral disc distance , where lymphotoxic infiltration causes degeneration in the disc interspaces . ossification and autofusion progressively follow the erosion of vertebral joints . as a result , characteristic syndesmophyte formation , expansive ankylosis , and radiological bamboo spine appearance develop . in our case , there was a large anterior osteophyte on the cervical vertebra resulting from ossif ication . early diagnosis and treatment of as is key to preventing complications , such as compression of adjacent organs by vertebral deformities . initiation of swallowing therapy in the early phases and a patient treatment plan for as are equally important since most patients with cervical osteophytes can be managed conservatively . although dysphagia developed in the case reported here , it was diagnosed after 4 years of detailed anamnesis . as a consequence , the patient did not respond to conservative therapy that included diet modification , swallowing and medical therapy , and the condition progressed to a point that required surgical intervention . cervical osteophytes are common but osteophytes causing dysphagia due to compression of esophagus are unusual . abnormal osteoblast growth or activity in ligamentous regions of bone is the pathogenesis of dish . the criteria for spinal involvement in dish includes all of the following criteria : 1 ) presence of flowing calcification and ossification along the anterolateral aspect of at least four contiguous vertebral bodies , with or without associated localized pointed excrescences at the intervening vertebral body intervertebral disc junctions ; 2 ) presence of relative preservation of intervertebral disc height in the involved vertebral segment and the absence of extensive radiographic changes of degenerative disc disease ; and 3 ) absence of apophyseal joint bony ankylosis and si joint erosion , sclerosis or intra - articular osseous fusion . the case presented here did not meet the dish criteria , and involvement of the si and apophyseal joints was typical for as . dish usually begins after the age of 50 , is more common in males , and is associated with endocrine and metabolic syndromes . a similar case reported the coexistence of dish and as in a patient that developed lung aspiration due to dysphagia secondary to anterior cervical osteophytes . the patient was elderly at 80 years of age and had osteophytes in the clavicle and shoulders , as well as spinal stenosis due to dish and the posture and bamboo spine appearance suggesting as . our patient had onset of symptoms at age 25 , morning stiffness , inflammatory back pain , and a positive family history , which are all suggestive findings for as . these include direct compression of the pharynx or esophagus , tilt mechanism disorders of normal epiglottis at the laryngeal inlet due to osteophytes at c3-c4 level , inflammatory reactions in paraesophageal tissues , and cricopharyngeal spasm . in our case , an anterior osteophyte at the c7-t1 vertebrae caused dysphagia by esophageal compression . again , our case had a large osteophyte compressing the esophagus at the c7 cervical interspace , a localization not typical for dish . the patient reported here had a typical presentation of dysphagia that started mildly and progressed gradually . mild dysphagia is defined as an abnormal sensation in the pharynx while swallowing solid or liquid foods ; moderate dysphagia is defined as difficulty in swallowing of large solid foods , but easy swallowing of small amounts of liquid foods ; severe dysphagia is defined as inability to swallow small solid foods or development of cough while swallowing . conservative therapies , like diet modification and swallowing therapy , can be employed in dysphagia of mild and moderate severity ; whereas surgical therapy is employed if there is no response to the conservative measures or in cases of severe dysphagia . some studies advocate surgical intervention in the early phases of moderate dysphagia , while others propose surgery to patients who do not respond to medical therapy ( i.e. , nonsteroidal anti - inflammatory drugs , steroids , myorelaxants , antireflux drugs ) . however , he refused surgical intervention and diet modification with antireflux and swallowing therapy were prescribed . in conclusion , early diagnosis is important for conservative therapy response and should be considered when evaluating patients with as .
ankylosing spondylitis ( as ) is a chronic inflammatory rheumatological disease affecting the axial skeleton with various extra - articular complications . 
 dysphagia due to a giant anterior osteophyte of the cervical spine in as is extremely rare . 
 we present a 48-year - old male with as suffering from progressive dysphagia to soft foods and liquids . 
 esophagography showed an anterior osteophyte at c5-c6 resulting in esophageal compression . 
 the patient refused surgical resection of the osteophyte and received conservative therapy . 
 however , after 6 months there was no improvement in dysphagia . 
 this case illustrates that a large cervical osteophyte may be the cause of dysphagia in patients with as and should be included in the diagnostic workup in early stages of the disease .