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The effects of botulinum toxin injections into the cricopharyngeus muscle of patients with cricopharyngeus dysfunction associated with pharyngo-laryngeal weakness

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This prospective, open study was carried out in order to assess changes in the swallowing and dietary status after injection of Botulinum toxin A (BoNT-A) into the upper esophageal sphincter (UES) in a series of patients with cricopharyngeus (CP) muscle dysfunction associated with pharyngo-laryngeal weakness during at least 1 year follow-up after treatment. Patients who had a cricopharyngeus (CP) muscle dysfunction associated with pharyngo-laryngeal weakness and who were at risk for aspiration were included in the study. The upper border of the cricoid cartilage was identified and the CP muscle localized using a standard electromyogram (EMG). The dose of BoNT-A was determined depending on the results of EMG performed just before the injection. Outcomes were assessed by the penetration-aspiration scale (PAS), the level of residue in the pyriform sinus and the National Institute of Health-Swallow Safety Scale (NIH-SSS) on a video fluoroscopic swallowing (VFSS) assessment, the patient’s subjective impressions of their ability to swallow by the Deglutition Handicap Index (DHI), and changes in dietary status by the Functional Oral Intake Scale. Eleven patients underwent the complete assessment of swallowing function at 1, 3, 6, and 12 months. After the first set of treatment, seven patients had a good response and four did not respond. A significant decrease in the PAS score (p = 0.03), the amount of residue (p = 0.04) and the NIH-SSS score (p = 0.03) was observed 3 months after the injection in comparison with the first VFSS before the treatment. A relapse of dysphagia occurred in 3 out of the 11 treated patients; at 3 and 4 months for 2 patients with a Wallenberg syndrome, and at 11 months for a patient with cranial nerve paralysis after a surgery for a glomus tumor. Two of them underwent a second injection. One patient had a good response and remained stable for at least 1 year. The second did not respond either to the second injection or to a myotomy of the cricopharyngeal muscle. The third one is waiting for further surgery (myotomy). Therefore, at the end of the study and after a follow-up of at least 12 months, 5 patients out of the 11 enrolled had a good result. Percutaneous injection of BoNT-A into the UES can be a useful solution to improve cricopharyngeal dysfunction, despite the underlying pharyngo-laryngeal weakness.

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  1. Schneider I, Thumfart WF, Pototschnig C et al (1994) Treatment of dysfunction of the cricopharyngeal muscle with botulinum A toxin: introduction of a new, noninvasive method. Ann Otol Rhinol Laryngol 103:31–35

    PubMed  CAS  Google Scholar 

  2. Aktinson SI, Rees J (1997) Botulinum toxin for cricopharyngeal dysphagia: case reports of CT guided injection. J Otolaryngol 26:273–276

    Google Scholar 

  3. Blitzer A, Brin MF (1997) Use of botulinum toxin for diagnosis and management of cricopharyngeal achalasia. Otolaryngol Head Neck Surg 116:328–330

    Article  PubMed  CAS  Google Scholar 

  4. Dunne J, Hayes M, Cameron D (1998) Botulinum toxin A for cricopharyngeal dystonia. Lancet 342:359

    Google Scholar 

  5. Alberty J, Oelerich M, Ludwig K, Hartmann S, Stoll W (2000) Efficacy of botulinum toxin A for treatment of upper esophageal sphincter dysfunction. Laryngoscope 110:1151–1156

    Article  PubMed  CAS  Google Scholar 

  6. Ahsan SF, Meleca RJ, Dworkin JP (2000) Botulinum toxin injection of the cricopharyngeus muscle for the treatment of dysphagia. Otolaryngol Head Neck Surg 122:691–695

    Article  PubMed  CAS  Google Scholar 

  7. Haapaniemi JJ, Laurikainen EA, Pulkkinen J et al (2001) Botulinum toxin in the treatment of cricopharyngeal dysphagia. Dysphagia 16:171–175

    Article  PubMed  CAS  Google Scholar 

  8. Shaw GY, Searl JP (2001) Botulinum toxin treatment for cricopharyngeal dysfunction. Dysphagia 16:162–167

    Article  Google Scholar 

  9. Verhulst J, Amé P, Guatterie M, Barat M, Traissac L (2003) A retrospective study of 91 injections of botulinum toxin into the upper sphincter of the oesophagus. Rev Laryngol Otol Rhinol 124:315–320

    CAS  Google Scholar 

  10. Liu LW, Tarnopolsky M, Armstrong D (2004) Injection of botulinum toxin A to the upper esophageal sphincter for oropharyngeal dysphagia in two patients with inclusion body myositis. Can J Gastroenterol 18:397–399

    PubMed  Google Scholar 

  11. Zaninotto G, Marchese Ragona R, Briani C et al (2004) The role of botulinum toxin injection and upper esophageal sphincter myotomy intreating oropharyngeal dysphagia. J Gastrointest Surg 8:997–1006

    Article  PubMed  Google Scholar 

  12. Murry T, Wasserman T, Carrau RL, Castillo B (2005) Injection of botulinum toxin A for the treatment of dysfunction of the upper esophageal sphincter. Am J Otolaryngol 26:157–162

    Article  PubMed  CAS  Google Scholar 

  13. Kim DY, Park CI, Ohn SH et al (2006) Botulinum toxin type A for poststroke cricopharyngeal muscle dysfunction. Arch Phys Med Rehabil 87:1346–1351

    Article  PubMed  Google Scholar 

  14. Masiero S, Briani C, Marchese-Ragona R et al (2006) Successful treatment of long-standing post-stroke dysphagia with botulinum toxin and rehabilitation. J Rehabil Med 38:201–203

    Article  PubMed  Google Scholar 

  15. Suzukia Y, Sano N, Shinonaga C et al (2007) Successful botulinum toxin treatment of dysphagia in a spinal muscular atrophy type 2 patients. Brain Dev 29:662–665

    Article  PubMed  Google Scholar 

  16. Krause E, Schirra J, Gürkov R (2008) Botulinum toxin a treatment of cricopharyngeal dysphagia after subarachnoid hemorrhage. Dysphagia 23:406–410

    Article  PubMed  Google Scholar 

  17. Sewell RK, Bauman NM (2005) Congenital cricopharyngeal achalasia: management with botulinum toxin before myotomy. Arch Otolaryngol Head Neck Surg 131:451–453

    Article  PubMed  Google Scholar 

  18. Ertekin C, Aydogdu I (2002) Electromyography of human cricopharyngeal muscle for the upper oesophageal sphincter. Muscle Nerve 26:729–739

    Article  PubMed  Google Scholar 

  19. Woisard V, Andrieux MP, Puech M (2006) Validation of a self-assessment questionnaire for swallowing disorders (Deglutition Handicap Index). Rev Laryngol Otol Rhinol (Bord). 127:315–325

    CAS  Google Scholar 

  20. Woisard V, Lepage B (2010) The “Deglutition Handicap Index” a self-administrated dysphagia-specific quality of life questionnaire: temporal reliability. Rev Laryngol Otol Rhinol (Bord) 131:19–22

    CAS  Google Scholar 

  21. Crestani S, Moerman M, Woisard V (2011) The “Deglutition Handicap Index” a self-administrated dysphagia-specific quality of life questionnaire: sensibility to change. Rev Laryngol Otol Rhinol (Bord) 132(1):3–7

    Google Scholar 

  22. Speyer R, Heijnen BJ, Baijens LW, Vrijenhoef FH, Otters EF, Roodenburg N, et al (2011) Quality of life in oncological patients with oropharyngeal dysphagia: validity and reliability of the Dutch version of the MD Anderson Dysphagia Inventory and the Deglutition Handicap Index. Dysphagia [Internet]. 2011 Jan 29 [cited 2011 aug 28];Available from:

  23. Crary MA, Carnaby Mann GD, Groher ME (2005) Initial psychometric assessment of a Functional Oral Intake Scale for dysphagia in stroke patients. Arch Phys Med Rehabil 86:1516–1520

    Article  PubMed  Google Scholar 

  24. Rosenbek JC, Robbins JA, Poeckeer EB et al (1996) A penetration-aspiration scale. Dysphagia 11:93–98

    Article  PubMed  CAS  Google Scholar 

  25. Elmstähl S, Bulow M, Ekberg O et al (1999) Treatment of dysphagia improves nutritional conditions in stroke patient. Dysphagia 14:61–66

    Article  PubMed  Google Scholar 

  26. Humbert IA, Poletto CJ, Saxon KG, Kearney PR, Crujido L, Wright-Harp W et al (2006) The effect of surface electrical stimulation on hyo-laryngeal movement in normal individuals at rest and during swallowing. J Appl Physiol 101:1657–1663

    Article  PubMed  Google Scholar 

  27. Ludlow CL, Humbert I, Saxon K, Poletto C, Sonies B, Crujido L (2007) Effects of surface electrical stimulation both at rest and during swallowing in chronic pharyngeal Dysphagia. Dysphagia 22(1):1–10

    Article  PubMed  Google Scholar 

  28. Fuller SC, Leonard R, Aminpour S, Belafsky PC (2009) Validation of the pharyngeal squeeze maneuver. Otolaryngol Head Neck Surg 140(3):391–394

    Article  PubMed  Google Scholar 

  29. Pankaj J, Ravich WJ, Hendrix RT et al (1996) Botulinum toxin for Achalasia: long term outcome and predictors of response. Gastroenterol 110:1410–1415

    Article  Google Scholar 

  30. Blitzer A, Crumley RL, Dailey SH, Ford CN, Floeter MK, Hillel AD et al (2009) Invited Article: Recommendations of the Neurolaryngology Study Group on Laryngeal Electromyography. Otolaryngol Head Neck Surg 140:782–793

    Article  PubMed  Google Scholar 

  31. Prosiegel M, Höling R, Heintze M et al (2005) The localization of central pattern generators for swallowing in humans—a clinical-anatomical study on patients with unilateral paresis of the vagal nerve, Avellis’ syndrome, Wallenberg’s syndrome, posterior fossa tumours and cerebellar hemorrhage. Acta Neurochir Suppl 93:85–88

    Article  PubMed  CAS  Google Scholar 

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Correspondence to Virginie Woisard-Bassols.

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Woisard-Bassols, V., Alshehri, S. & Simonetta-Moreau, M. The effects of botulinum toxin injections into the cricopharyngeus muscle of patients with cricopharyngeus dysfunction associated with pharyngo-laryngeal weakness. Eur Arch Otorhinolaryngol 270, 805–815 (2013).

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