Injection of botulinum toxin A for the treatment of dysfunction of the upper esophageal sphincter

Abstract

Objective: The objective was to evaluate changes in swallow safety and dietary status after the transcutaneous injection of botulinum toxin A into the upper esophageal sphincter in a series of outpatients with dysphagia.

Study design: This was an experimental, prospective, nonrandomized study.

Methods: Patients who were at risk for aspiration and who had an unsuccessful trial of swallowing therapy were admitted to the study. All patients showed significant pooling of fluids in the postcricoid region. All patients were treated in the office; none had previous esophageal dilatation. The upper border of the cricoid cartilage was identified using standard electromyogram procedures and 100 U of botulinum toxin (Botox A) were injected. Outcomes were assessed using the penetration-aspiration scale, patients' short-term and long-term subjective impressions of their ability to swallow, and change in dietary status.

Results: Thirteen patients underwent an instrumental evaluation of swallowing function at approximately 6 months after treatment to corroborate the self-reported changes in swallowing. Of the 13 patients, 12 showed an overall improvement in their ability to take an oral diet safely as evidenced by the penetration-aspiration scale. Of the 12 patients who were on a non-oral or nearly non-oral diet, 9 resumed a normal oral diet. The remaining 3 were on an oral diet supplemented by percutaneous endoscopic gastrostomy feeding. One patient remained on a non-oral diet.

Conclusions: Injection of Botox A in the office with no additional treatments resulted in a long-term increase in swallow safety, a reduction of penetration and/or aspiration, and a reduced need for non-oral feeding. Injection of Botox A in the office should be considered when there is failure of the cricopharyngeus muscle to relax after the swallow, significant pooling in the cricopharyngeal region, and a risk for penetration and aspiration.