Botulinum Toxin A Treatment of Cricopharyngeal Dysphagia After Subarachnoid Hemorrhage
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Elevated muscular tone associated with spastic syndromes can cause excessive contractility at the upper esophageal sphincter and impede swallowing. A 47-year-old male patient with spasticity predominantly of the lower extremities after a subarachnoid hemorrhage suffered from severe dysphagia and chronic salivary aspiration. He was dependent on a cuffed tracheostomy tube and a percutaneous enterogastric feeding tube. Barium swallow and esophageal manometry revealed cricopharyngeal spasm, while laryngeal elevation and pharyngeal contractility were well preserved. We endoscopically injected 180 MU botulinum toxin A into the cricopharyngeus muscle. Two days post injection, swallowing function had improved and oral nutrition was possible. This improvement lasted for six weeks. After another injection 8 weeks later, an undesired diffusion into the hypopharynx occurred and manometry showed diminished contractility without amelioration of dysphagia. Botulinum toxin therapy of cricopharyngeal spasm improves swallowing function in a subgroup of patients with spastic syndromes. The therapeutic effect is of limited duration. Toxin diffusion into the pharynx should be avoided. Manometry is useful in planning and monitoring the therapy.
KeywordsBotulinum toxin Dysphagia Upper esophageal sphincter Manometry Spasticity Deglutition Deglutition disorders
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