Forestier disease or diffuse idiopathic skeletal hyperostosis is a noninflammatory disease characterized by the presence of anterior bridging osteophytes that spare the disc and joint space of unknown etiology in elderly men, mostly at thoracic levels and asymptomatic in some cases.1–3  Spine x-ray in patients with Forestier disease shows normal bone density and the presence of extensive ossification of anterior longitudinal ligament, with bridging osteophytes in the anterior cervical and upper thoracic spine.1–3 

The accompanying images show a large tumor-like bulge of the posterior hypopharynx wall which, together with the epiglottis, completely obstructed the upper airway during the initial laryngoscopy with McGrath MAC (Medtronic, USA). With careful external laryngeal manipulation and increased force in laryngoscopy, the laryngeal view was significantly improved, which allowed endotracheal intubation. The finding was consistent with preoperative sagittal cervical spine computed tomography, which showed C3–C5 hyperostosis producing anterior laryngopharyngeal displacement, with obstruction of the airway around the epiglottis (red arrow).

Challenges in airway management of Forestier disease include: (1) limitation of mobility of the neck; (2) difficulty in lifting the epiglottis; (3) vocal cord paralysis accompanied by recurrent laryngeal nerve injury; (4) shifting and narrowing of the airway; and (5) possibility of mucosal injury. Thus, Forestier disease patients pose a greater risk of difficult laryngoscopy, even with video laryngoscopy. Considering rough external maneuvering may cause spinal cord injury, laryngeal mask airway insertion and seal may be challenging, and mask ventilation potentially may be difficult, careful fiberoptic intubation is recommended.

Competing Interests

The authors declare no competing interests.

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