Clinical OtolaryngologyVolume 48, Issue 4 p. 709-714 CLINICAL EXPERIENCE Incidental head and neck findings on 18F-fluorodeoxyglucose positron emission tomography-computed tomography: Diagnostic outcomes and cost analysis Jessica Ball, Corresponding Author Jessica Ball [email protected] orcid.org/0000-0002-7331-7848 Department of Otolaryngology, Head and Neck Surgery, Cambridge University Hospital, Cambridge, UK Correspondence Jessica Ball, Department of Otolaryngology, Head and Neck Surgery, Cambridge University Hospital, Hills Road, Cambridge CB20QQ, UK. Email: [email protected]Search for more papers by this authorJoseph Sinnott, Joseph Sinnott Department of Otolaryngology, Head and Neck Surgery, Great Western Hospital, Swindon, UKSearch for more papers by this authorDanial L. Fox, Danial L. Fox Department of Radiology, Musgrove Park Hospital, Taunton, Somerset, UKSearch for more papers by this authorChristopher Burgess, Christopher Burgess Department of Otolaryngology, Head and Neck Surgery, Musgrove Park Hospital, Taunton, Somerset, UKSearch for more papers by this author Jessica Ball, Corresponding Author Jessica Ball [email protected] orcid.org/0000-0002-7331-7848 Department of Otolaryngology, Head and Neck Surgery, Cambridge University Hospital, Cambridge, UK Correspondence Jessica Ball, Department of Otolaryngology, Head and Neck Surgery, Cambridge University Hospital, Hills Road, Cambridge CB20QQ, UK. Email: [email protected]Search for more papers by this authorJoseph Sinnott, Joseph Sinnott Department of Otolaryngology, Head and Neck Surgery, Great Western Hospital, Swindon, UKSearch for more papers by this authorDanial L. Fox, Danial L. Fox Department of Radiology, Musgrove Park Hospital, Taunton, Somerset, UKSearch for more papers by this authorChristopher Burgess, Christopher Burgess Department of Otolaryngology, Head and Neck Surgery, Musgrove Park Hospital, Taunton, Somerset, UKSearch for more papers by this author First published: 11 April 2023 https://doi.org/10.1111/coa.14055Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat CONFLICT OF INTEREST STATEMENT The authors declare no conflicts of interest. Open Research PEER REVIEW The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer-review/10.1111/coa.14055. DATA AVAILABILITY STATEMENT The data that supports the findings of this study is displayed in the tables within the article. There is no additional data. REFERENCES 1Rohde M, Dyrvig AK, Johansen J, Sørensen JA, Gerke O, Nielsen AL, et al. 18F-fluoro-deoxy-glucose-positron emission tomography/computed tomography in diagnosis of head and neck squamous cell carcinoma: a systematic review and meta-analysis. Eur J Cancer. 2014; 50(13): 2271–9. 2Britt CJ, Maas AM, Kennedy TA, Hartig GK. Incidental findings on FDG PET/CT in head and neck cancer. Otolaryngol Head Neck Surg. 2018; 158(3): 484–8. 3Agrawal K, Weaver J, Ul-Hassan F, Jeannon JP, Simo R, Carroll P, et al. Incidence and significance of incidental focal thyroid uptake on (18)F-FDG PET study in a large patient cohort: retrospective single-Centre experience in the United Kingdom. Eur Thyroid J. 2015; 4(2): 115–22. 4Bridndle P, Mullan D, Yap BK, Gandhi A. Thyroid incidentalomas discovered on positron emission tomography CT scanning–malignancy rate and significance of standardised uptake values. Eur J Surg Oncol. 2014; 40(11): 1528–32. 5Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid. 2015; 26(1): 1–133. 6Williams S, Kinshuck A, Williams C. Incidental head and neck findings on 18F-fluoeo-deoxy-glucose positron emission tomography computed tomography. J Laryngol Otol. 2015; 129: 898–902. 7Gobel Y, Valette G, Abgral R, Clodic C, Mornet E, Potard G, et al. Interpretation of suspected head and neck fixations seen on PET/CT in lung cancer. Eur Ann Otorhinolaryngol Head Neck Dis. 2014; 131: 217–21. 8Acton P, Zhuang H, Alavi A. Quantification in PET. Radiol Clin North Am. 2004; 42: 1055–62. 9Mabray M, Behr S, Naeger D, Flavell RR, Glastonbury CM. Predictors of pathologic outcome of focal FDG uptake in the parotid gland identified on whole body FDG PET imaging. Clin Imaging. 2015; 39(6): 1073–9. 10Lee N, Yoo I, Park S, Yoon H, Lee Y, Oh K. Significance of incidental nasopharyngeal uptake on PET/CT: patterns of benign/physiological uptake and differentiation from malignancy. Nucl Med Mol Imaging. 2015; 49: 11–8. Volume48, Issue4July 2023Pages 709-714 ReferencesRelatedInformation

A man in his 40s presented with a gradual-onset, left-sided hearing loss with a whistling tinnitus and occasional sharp otalgia; examination showed a smooth mass behind the left tympanic membrane. What is your diagnosis?

A woman with a history of localized invasive ductal carcinoma of the right breast treated with wide local excision 13 years previously presented with right-sided lower motor neuron facila nerve palsy and discomfort around her right ear. What is the diagnosis?

Clinical OtolaryngologyVolume 40, Issue 2 p. 153-159 Correspondence: Our Experience Virtual reality simulation training in temporal bone surgery A. Arora, Corresponding Author A. Arora Department of Otolaryngology Head and Neck Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UKCorrespondence: Mr A. Arora, ENT Department, St Mary's Hospital, Imperial College Healthcare NHS Trust, Praed St, London W2 1NY, UK. Tel.: 07976 897 446; Fax: 207 886 1847; e-mail: asitarora@doctors.org.ukSearch for more papers by this authorA. Hall, A. Hall Department of Otolaryngology, Northwick Park Hospital, London, UKSearch for more papers by this authorJ. Kotecha, J. Kotecha Department of Otolaryngology Head and Neck Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UKSearch for more papers by this authorC. Burgess, C. Burgess Department of Otolaryngology, John Radcliffe Hospital, Oxford, UKSearch for more papers by this authorS. Khemani, S. Khemani Department of ENT, Surrey and Sussex NHS Trust, Redhill, UKSearch for more papers by this authorA. Darzi, A. Darzi Department of Biosurgery and Surgical Technology, St. Mary's Hospital, Imperial College, London, UKSearch for more papers by this authorA. Singh, A. Singh Department of Otolaryngology, Northwick Park Hospital, London, UKSearch for more papers by this authorN. Tolley, N. Tolley Department of Otolaryngology Head and Neck Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UKSearch for more papers by this author A. Arora, Corresponding Author A. Arora Department of Otolaryngology Head and Neck Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UKCorrespondence: Mr A. Arora, ENT Department, St Mary's Hospital, Imperial College Healthcare NHS Trust, Praed St, London W2 1NY, UK. Tel.: 07976 897 446; Fax: 207 886 1847; e-mail: asitarora@doctors.org.ukSearch for more papers by this authorA. Hall, A. Hall Department of Otolaryngology, Northwick Park Hospital, London, UKSearch for more papers by this authorJ. Kotecha, J. Kotecha Department of Otolaryngology Head and Neck Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UKSearch for more papers by this authorC. Burgess, C. Burgess Department of Otolaryngology, John Radcliffe Hospital, Oxford, UKSearch for more papers by this authorS. Khemani, S. Khemani Department of ENT, Surrey and Sussex NHS Trust, Redhill, UKSearch for more papers by this authorA. Darzi, A. Darzi Department of Biosurgery and Surgical Technology, St. Mary's Hospital, Imperial College, London, UKSearch for more papers by this authorA. Singh, A. Singh Department of Otolaryngology, Northwick Park Hospital, London, UKSearch for more papers by this authorN. Tolley, N. Tolley Department of Otolaryngology Head and Neck Surgery, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UKSearch for more papers by this author First published: 18 November 2014 https://doi.org/10.1111/coa.12352Citations: 16Read the full textAboutRelatedInformationPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessClose modalShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume40, Issue2April 2015Pages 153-159 RelatedInformation

Endoscopic laser cricopharyngeal myotomy is an effective treatment for cricopharyngeal dysfunction, but concern remains over the risk of serious complications following the procedure. Some authors have therefore considered endoscopic laser cricopharyngeal myotomy with mucosal repair; however, outcome data for the procedure is scanty. This study aims to identify functional outcomes in a series of patients following endoscopic laser cricopharyngeal myotomy with mucosal repair. Endoscopic laser cricopharyngeal myotomy with mucosal repair was performed on 38 subjects in two centres over a period of 33 months. Pre- and post-operative outcomes were evaluated in 32 subjects using the Sydney Swallow Questionnaire and Reflux Symptom Index. An improvement in swallowing scores was seen in 30 subjects (94%, p < 0.001). The Reflux Symptom Index improved 28 subjects (88%, p < 0.001). Mean procedure time was 58 min. One subject (2.6%) developed mediastinitis following surgery, and four experienced (12.5%) a recurrence of dysphagic symptoms. Endoscopic laser cricopharyngeal myotomy with mucosal repair is an effective treatment for cricopharyngeal dysfunction. The complication rate observed in this study was comparable or lower than previously reported studies into endoscopic laser cricopharyngeal myotomy without mucosal repair. Larger studies may be required to determine the additional benefit of mucosal repair over endoscopic laser cricopharyngeal myotomy alone.

A 56 year old woman presents with a history of fullness in her ears and reduced hearing, which has persisted for three weeks. She often hears clicking when she swallows. The eustachian tube is a cartilaginous and bony tube providing a connection between the nasopharynx and the middle ear. At rest, the eustachian tube is closed, but it opens on swallowing, yawning, sneezing, and the Valsalva manoeuvre due to contraction of palatine muscles. When the eustachian tube opens it facilitates equalisation of pressures between the external environment and the middle ear by allowing a bolus of air to pass through. Dysfunction of the eustachian tube results in development of negative pressures within the middle ear, leading to transudation of fluid and a pro-inflammatory response. Consequentially, eustachian tube dysfunction is an important component of pathology of the middle ear, particularly acute otitis media and otitis media with effusion. ### History Feeling of fullness in the ears— Eustachian tube dysfunction classically presents with a feeling of fullness in the ear, often associated with hearing loss. Eustachian tube dysfunction should be a diagnosis of exclusion as ear fullness can be the presenting feature in a wide variety of clinical entities of the external, middle, and inner ears. There is a requirement for …

Mini-ReviewTubenventilationsstörungen beim ErwachsenenRhona Sproat, Christopher Burgess, Tim Lancaster, and Pablo Martinez-DevesaRhona Sproat Ear, Nose, and Throat Department, John Radcliffe Hospital, Oxford OX3 9DU, Grossbritannien Search for more papers by this author, Christopher Burgess Ear, Nose, and Throat Department, John Radcliffe Hospital, Oxford OX3 9DU, Grossbritannien1 Search for more papers by this author, Tim Lancaster Jericho Health Centre – Primary Care, Oxford, Grossbritannien Search for more papers by this author, and Pablo Martinez-Devesa Ear, Nose, and Throat Department, John Radcliffe Hospital, Oxford OX3 9DU, Grossbritannien Search for more papers by this authorPublished Online:October 10, 2014https://doi.org/10.1024/1661-8157/a001807PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreFiguresReferencesRelatedDetails Volume 103Issue 21October 2014ISSN: 1661-8157eISSN: 1661-8165 InformationPraxis (2014), 103, pp. 1275-1277 https://doi.org/10.1024/1661-8157/a001807.© 2014Hogrefe AGPDF download

The management of the lateral neck in metastatic differentiated thyroid cancer (DTC) varies widely. Most groups advocate dissection of nodal levels II–IV but many perform a more extensive dissection. We aimed to asses whether there was any evidence for a modified radical neck dissection over a selective neck dissection by looking at the extent to which DTC metastases to levels I and V. We performed a review of the current literature including adult and paediatric patients who underwent a lateral neck dissection for metastatic DTC. The primary endpoint was histological confirmation of metastases in nodal levels I and V. 650 abstracts were identified and reviewed. 23 papers were included in the study. The incidence of level V metastases during routine level V dissection in patients with DTC is 20 % and the incidence of level I metastases during routine level I dissection in patients with DTC is 8 %. Histologically proven metastases were found in 22.5 % of level V neck dissection of which 2.5 % were pre-operatively suspected of metastases. 20 % had histologically proven metastases to level I of which 12 % were pre-operatively suspected of metastases. Our study has shown a 20 % incidence of level V metastases in the N+ neck suggesting that level V should be part of a planned neck dissection. Evidence is lacking for routine dissection of level I. A future prospective study is required to asses the question of risk factors for lateral nodal metastases, recurrence and survival.

The terms rhinitis and sinusitis have been superseded by rhinosinusitis, which represents the understanding that the two conditions usually coexist. Rhinosinusitis can be subdivided into acute and chronic. Acute rhinosinusitis (ARS) presents an enormous burden in primary care. It is estimated that around 1–2% of visits to a GP in Europe are for symptoms of ARS.1ARS is seen across a wide spectrum of ages, but is less common in the paediatric group due to the relative immature development of the sinuses in children (maxillary and ethmoidal sinuses develop during gestation, whereas the frontal and sphenoid sinuses begin to develop at the age of 3 years but are not fully developed until late adolescence). A consequence of patients presenting to primary care is the associated high pharmacy costs. Ashworth et al found that a prescription for antibiotics was given in 92% of patients with symptoms of ARS.2This article provides a summary of the current best evidence for the management of ARS in primary care and highlights the recent guidelines provided by the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS2012).3The paranasal sinuses are lined by pseudostratified ciliated columnar epithelia containing basal cells, columnar cells, and mucus-secreting goblet cells. Secretions aid humidification, olfaction, and filtration. Cilia are crucial to mucus clearance. The cilia can be damaged by smoking, chronic nasal disease, or genetic predisposition such as primary cilia dyskinesia. When the clearance of mucus from the paranasal sinuses to the meati of the nose is interrupted, mucus trapping can occur with increased risk of infection.Viral causes of the common cold include respiratory syncytial virus (RSV), rhinovirus, parainfluenza, and influenza with rhinovirus being the most common. The commonest organisms in acute bacterial rhinosinusitis (ABRS) include Streptococcus pneumonia (41%) and Haemophilus influenza (35%). Other causes include …

Objectives: To establish the diagnostic adequacy of ultrasound-guided fine needle aspiration cytology samples at the East Berkshire neck lump clinic, and to perform a cost-benefit analysis related to the hypothetical addition of an on-site cytology technician (required to review fine needle aspiration specimen adequacy).Method: The adequacy of all ultrasound-guided fine needle aspiration procedures was reviewed from 1 January to 30 June 2011. These results were used in the cost-benefit analysis related to on-site cytology assessment.Results: Of the 307 ultrasound-guided fine needle aspiration cytology procedures performed over 6 months, 67 (22 per cent) were reported to be non-diagnostic. Operator experience was found to correlate significantly with diagnostic adequacy (p<0.001). Only 5 per cent of all fine needle aspirations were initially non-diagnostic but diagnostic on repeat sampling. This suggests that the financial and time costs of on-site fine needle aspirate adequacy assessment would outweigh any benefit.Conclusion: In this series, the experience of individuals performing fine needle aspirations was the most important factor related to adequacy.

An 85 year old woman with mild dementia presented to the emergency department with a 36 hour history of sore throat …

We present a case of an 81-year-old man who was diagnosed with a necrotising (malignant) otitis externa (NOE). Initial biopsies from the external auditory canal showed scanty squamous epithelium but no evidence of malignancy. Despite an initial improvement on intravenous antibiotics and subsequent discharge from hospital, the patient returned with worsening otalgia. Following readmission to the hospital, intravenous antibiotics were restarted. Despite this, the patient developed a lower motor neurone palsy of cranial nerve VII on the ipsilateral side of the pain. He was taken to the theatre for an exploration of the left mastoid with further biopsies. Adenocarcinoma was diagnosed histologically and the patient was started on palliative radiotherapy. This case adds to the known literature on metastatic disease in the temporal bone and highlights the need to exclude malignancy in cases of NOE.

Clinical OtolaryngologyVolume 37, Issue 3 p. 246-246 CORRESPONDENCE: LETTERS Response to Lieder and Wilson C.A. Burgess, C.A. Burgess Wexham Park Hospital, SloughSearch for more papers by this authorO.T. Dale, O.T. Dale Northampton General Hospital NorthamptonSearch for more papers by this authorR. Almeyda, R. Almeyda John Radcliffe Hospital, OxfordSearch for more papers by this authorR.J. Corbridge, R.J. Corbridge Royal Berkshire Hospital, Reading, UK. E-mail: [email protected]Search for more papers by this author C.A. Burgess, C.A. Burgess Wexham Park Hospital, SloughSearch for more papers by this authorO.T. Dale, O.T. Dale Northampton General Hospital NorthamptonSearch for more papers by this authorR. Almeyda, R. Almeyda John Radcliffe Hospital, OxfordSearch for more papers by this authorR.J. Corbridge, R.J. Corbridge Royal Berkshire Hospital, Reading, UK. E-mail: [email protected]Search for more papers by this author First published: 19 June 2012 https://doi.org/10.1111/j.1749-4486.2012.02505.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. References 1 Kelly I.P., Attwood S.E., Quilan W. et al. (1995) The management of impalement injury. Injury 26, 191– 193 2 Ferreira P.C., Santa-Comba A., Barbosa R.F. et al. (2004) Cervical impalement injury. J. Craniofac. Surg. 15, 851– 854 3 Rhee P., Kuncir E.J., Johnson L. et al. (2006) Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. J. Trauma 61, 1166– 1170 4 Lustenberger T., Talving P., Lam L. et al. (2011) Unstable cervical spine fracture after penetrating neck injury: a rare entity in an analysis of 1,069 patients. J. Trauma 70, 870– 872 5 Connell R.A., Graham C.A. & Munro P.T. (2003) Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma? Injury 34, 912– 914 Volume37, Issue3June 2012Pages 246-246 ReferencesRelatedInformation

Clinical OtolaryngologyVolume 37, Issue 4 p. 331-332 CORRESPONDENCE: LETTERS Response to Harris and Oakley C.A. Burgess, C.A. Burgess Wexham Park Hospital, SloughSearch for more papers by this authorO. Dale, O. Dale Northampton General Hospital NorthamptonSearch for more papers by this authorR. Almeyda, R. Almeyda John Radcliffe Hospital, OxfordSearch for more papers by this authorR. Corbridge, R. Corbridge The Royal Berkshire Hospital, Reading, UK. E-mail: chris.burgess@doctors.org.ukSearch for more papers by this author C.A. Burgess, C.A. Burgess Wexham Park Hospital, SloughSearch for more papers by this authorO. Dale, O. Dale Northampton General Hospital NorthamptonSearch for more papers by this authorR. Almeyda, R. Almeyda John Radcliffe Hospital, OxfordSearch for more papers by this authorR. Corbridge, R. Corbridge The Royal Berkshire Hospital, Reading, UK. E-mail: chris.burgess@doctors.org.ukSearch for more papers by this author First published: 28 August 2012 https://doi.org/10.1111/j.1749-4486.2012.02530.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume37, Issue4August 2012Pages 331-332 RelatedInformation

BACKGROUND:Although relatively uncommon, penetrating neck trauma has the potential for serious morbidity and an estimated mortality of up to 6%. The assessment and management of patients who have sustained a penetrating neck injury has historically been an issue surrounded by significant controversy. OBJECTIVES OF REVIEW: To assess recent evidence relating to the assessment and management of penetrating neck trauma, highlighting areas of controversy with an overall aim of formulating clinical guidelines according to a care pathway format.TYPE OF REVIEW:Structured, non-systematic review of recent medical literature.SEARCH STRATEGY:An electronic literature search was performed in May 2011. The Medline database was searched using the Medical Subject Headings terms 'neck injuries' and 'wounds, penetrating' in conjunction with the terms 'assessment' or 'management'. Embase was searched with the terms 'penetrating trauma' and 'neck injury', also in conjunction with the terms 'assessment' and 'management'. Results were limited to articles published in English from 1990 to the present day.EVALUATION METHOD:Abstracts were reviewed by the first three authors to select full-text articles for further critical appraisal. The references and citation links of these articles were hand-searched to identify further articles of relevance.RESULTS:147 relevant articles were identified by the electronic literature search, comprising case series, case reports and reviews. 33 were initially selected for further evaluation.CONCLUSIONS:Although controversy continues to surround the management of penetrating neck trauma, the role of selective non-operative management and the utility of CT angiography to investigate potential vascular injuries appears to be increasingly accepted.

Far from being the preserve of the great and the good, or gracing only high-grade churches such as abbeys or cathedrals, chantries ordinarily had a more humdrum character and expression. Most were of temporary duration, sited at existing altars in parish churches, and founded by the more middling sort — wealthier parishioners in either town or countryside. This essay dwells on the chantries established by men and women in Bristol in the century and more before the Reformation, and seeks particularly to place what was nonetheless still a relatively ambitious post obit arrangement into its supporting context — be this either the particular parish in which the service was to function or the circumstances of the founder's family. Rather than conceiving of chantries as relatively self-interested provisions, profiting only their founders, the following argues that these arrangements supported priests whose presence was intended primarily to benefit the broader community. As well as seeking to identify the contribution made by such undertakings, this essay explores the strategies employed both by families and by the parish community, each often assisting the other, to establish and sustain the highly valued auxiliary priests that chantries entailed.

Figure 1. A: Preopera tive lateralcervical spine x-ray shows the massive anterior osteophytes at C2 and C3 and ossification of the anterior longitudinal ligament at caudal levels. B: Preoperative MRI confirms extensiveossifica tionoftheanteriorlongitudinalligamentacrossmultiplecontiguousvertebraewithrelative preservation of the intervertebral disc height and /JO evidenceof degenerative or ankylosing spine disease. Thesefindingsfulfill the criteria for a diagnosis of DISH. The spinal CIl nal is /JOt affected. A 72-year-old man B was referred to the Department of Neurosurgery at the John Radcliffe Hospital for surg ical managem ent of dysphagia, the underlying cause of which had eluded diagno sis for almost 10 years. At his initial presentation nearly a decade earlier, he had reported symptoms of high dysph agia for solid foods and episodes of coughing and chokin g during meals. Findings on the physical examination at that tim e were normal, and a barium swallow test detected no obvious abnormality. A provi sional diagnosis of mild neuromuscular incoo rdination of the pharynx was made. Over a number of years, the patient's symptoms pro gressed. A videofluoroscopic swallow examination demonstrated a delayed and incon sistent cough reflex, evidence of silent aspiratio n, and pooling of secretio ns in the valleculae and piriform sinuses. In the cervical spine, an x-ray showed large anterior osteophytes at C2 and C3 (figure 1, A). These osteophytes were fou nd to int errupt bolus flow and impe de the action of ph aryngeal constrictors. Magnetic resonance imaging (MRI) (figure 1, B) and computed tom ography of the cervical spine confirmed an underlying diagno sis of diffuse idiop ath ic skeletal hyperostosis (DISH) . Surg ical excision of the osteophytes was achieved via an anterior cervical approach. At the 3-mo nth followup, the patient repo rted a significant reduction of his dysph agia. Postoperative cervical xrays confirmed that a satisfactory decompression of th e ph arynx had been accomplished (figure 2). Also known as Forestier disease, DISH is estima ted to affect about 10% of th e popul ation. I It is more common in men, and its prevalence increases with age (35% in men olde r than 70 years); it is also more severe in men.' In some cases DISH is asymptomatic, and the