A 75-year-old male patient visited the hospital complaining of dysphagia and weight loss (as much as 5 kg) that had occurred 3 months prior to this visit. Twenty years earlier, he had a received craniotomy on the left frontal parietal region because of traumatic subdural hemorrhage from falling and had recovered without sequelae. He had taken drug treatment for hypertension, but has no difficulty in daily living activity. For his dysphagia, he complained of more difficulties in swallowing solid foods rather than liquid foods and this was gradually progressing. Seven months after the onset of dysphagia, he was hospitalized, at which time he could only take small amounts of liquid foods instead of regular meals and his weight loss during 10 months since the onset of dysphagia was approximately 10 kg. The patient did not complain of speech disturbance or dyspnea and both movements of the tongue and gag reflex were normal. On his brain MRI scan, partial encephalomalacia was observed on the lesion where the left frontal parietal craniotomy had performed and left inferior temporal gyrus; this was not different compared with a prior brain MRI scan, and any additional lesions which might induce dysphagia was not observed. An endoscopic examination was performed with suspicion of a pharyngolaryngeal tumor, but no abnormal findings were detected. There were also no abnormal results in routine blood and tumor marker tests. As excessive osteophytosis on the anterior part of the cervical vertebrae from C3^rd to C6^th levels were observed in the cervical plain radiograph, a 3D cervical CT was performed and the identified posterior part of the pharyngolaryngeal cavity was compressed and narrowed by osteophytes from C2^nd to C7^th vertebrae levels (Fig. 1). As the dysphagia by anterior cervical osteophytes was suspected, a VFSS (Video Fluroscopic Swallowing Study) was performed (Fig. 2). Findings revealed that a movement of the epiglottis displayed an abnormal recurvation by osteophytes, with at least 50% of food remaining in the epiglottic valleculae. Pyriform sinuses were observed in all tested materials, and asymptomatic aspiration was shown as 8 points of the PAS (Penetration-Aspiration Scale) in 2 cc of diluted barium swallowing test. After the above examinations, an electronic stimulator, VitalStim® (Chaltanooga group, Austin, USA), was conducted one hour a day for 10 days. The treatment sessions were completed in two weeks. The electronic stimulation used a 2-channel form with an alternating current, wherein one of the electrical pads of the first channel was attached between the musculus biventer mandibulae muscle and hyoid bone and another electrical pad was attached between the hyoid bone and thyroid cartilage. The electrical pad of the second channel was attached between the thyroid and cricoid cartilages and vertically to the inferior part of the cricoid cartilage. A week after completing the electronic stimulation treatment, a VFSS was performed, where it was found that aspiration and nasal regurgitation had disappeared and the remaining amount of food shown in the epiglottic valleculae and pyriform sinuses were reduced to below 10%. Thus, it was possible to change his diet from liquid form to regular meals. After one month, however, dysphagia began to progress again and aspiration pneumonia had developed, which required hospitalization. Compared with previous findings, VFSS results revealed an increase in the amount of retention of contrast in the epiglottic valleculae and pyriform sinuses by 10-50% and the movement of epiglottis had decreased in all tested materials. It was suggested that his symptoms has worsened compared to previous findings. Due to persistent dysphagia, his diet was changed back to liquid food. He also received consultation in our department of neurosurgery for operation due to severe general weakness caused by insufficient nutrition. Next, he decided to have an operation after 2 year 7 months since the onset of dysphagia. Osteophytes cervical vertebrae from C2^nd to C7^th levels were removed via an anterior approach (Fig. 1). After the operation, he recovered without any side effects and 1 month later, VFSS was performed. Based on the nasal reflux that had been observed in the swallowing water test disappeared and food remaining in the epiglottic valleculae and pyriform sinuses were below 10%. In spite of the formation of the inner wall membrane, the remaining food was removed by chin tuck and repetitive swallowing. It was determined that the epiglottic motion had improved and the remainder in the epiglottic valleculae and pyriform sinus had reduced remarkably (Fig. 2). The patient was able to return to a general diet, had gained approximately 6kg of weight, and was satisfied with his postoperative improvement of symptoms in spite of having subjective dysphagia for waterless biscuits.

A 62 year-old male patient visited our department of neurosurgery, complaining of dysphagia and limited movement range of the cervical vertebrae that has occurred for 7 months. He was diagnosed as having hypertension 3 years before and receiving medication. He felt no discomfort when taking a meal, but complained of difficulties in swallowing a tablet. There was no language disorder or dyspnea. During a physical examination, both motion and gag reflux of his tongue were normal. As an imaging test, a 3D cervical CT was performed and the posterior part of the pharyngolaryngeal cavity was compressed by an anterior bony spur of the 3^rd-6^th cervical vertebrae (Fig. 3). VFSS findings had determined that there was a remainder of 10-50% in the epiglottic valleculae and pyriform sinuses due to motor abnormality of the cricopharyngeal muscle caused by an anterior bony spur on the cervical vertebrae with the height of upper esophageal sphincter in swallowing cookies. In a swallowing test involving 10 cc of water, vocal cord penetration was shown, but it was removed spontaneously (Fig. 3). The bony spur on the 4^th-6^th cervical vertebrae with anterior approach was removed. VFSS findings performed 2 weeks after the operation suggested that there was no remarkable change in the remainder of the epiglottic valleculae that was shown in swallowing cookies, but the remainder of the pyriform sinuses decreased dramatically, and the phenomenon of vocal cord penetration that had appeared during the water swallowing test also disappeared (Fig. 3). The patient reported a reduction in the number of feeling difficulties in taking tablet after surgery, but a complete improvement of the symptoms was not shown.

After complaining of dysphagia, a 61-year-old male patient was operated under the diagnosis of diffuse idiopathic hyperostosis on the 2^nd-5^th cervical vertebra, and had since experienced symptoms improvement. However, his dysphagia began to progress again to being able to swallow only liquid food since approximately May, 2010. He was hospitalized in our department of orthopedics with 170 cm height, 46.8 kg of weight, and 16.18 of BMI. His medical history was unremarkable. In imaging tests performed after hospitalization, diffuse idiopathic hyperostosis on the 1^st-3^rd cervical vertebrae and anterior bony spur ranging from the 2^nd cervical vertebrae to the 1^st thoracic vertebrae were found (Fig. 4). VFSS findings showed that there was normal swallowing reflex in the pharyngeal phase, but because of an anterior bony spur on the 2^nd-4^th cervical vertebrae, there was an epiglottic recurvation disorder. There was also a remainder of 10-50% in the pyriform sinuses and with an increase of sample viscosity, not only did the amount of remainder in the pyriform sinuses increase but his complaint for the feeling of sticking in his throat got similarly worse. In addition, asymptomatic aspiration was observed in 5 cc of a diluted barium test (Fig. 4). Next, there was removal of the osteophyte on the 2^nd, 3^rd, 4^th, and 5^th cervical vertebrae discectomy, and fixation of the 3^rd and 4^th cervical vertebrae with an anterior approach for the improvement of dysphagia (Fig. 4). One month after the operation, VFSS findings determined that no aspiration was observed, the amount of remainder in the pyriform sinuses had decreased, but the amount of remainder increased with an increase of sample viscosity. Sinse abnormal movement of the epiglottis still remained, a 10-time application of VitalStim® was performed. After electric stimulation treatment, VFSS findings determined that the amount of remainder in the pyriform sinuses after swallowing was reduced and aspiration that had previously been observed had disappeared. He was able to have regular meals and improvement on symptoms of dysphagia increased by 80% compared with preoperative conditions.