Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2014 May 6;2014(5):CD009968.
doi: 10.1002/14651858.CD009968.pub2.

Botulinum toxin for upper oesophageal sphincter dysfunction in neurological swallowing disorders

Julie Regan  1 , Anne Murphy, Mindy Chiang, Barry P McMahon, Tara Coughlan, Margaret Walshe
Affiliations

Botulinum toxin for upper oesophageal sphincter dysfunction in neurological swallowing disorders

Julie Regan et al. Cochrane Database Syst Rev. .

Abstract

Background: Adequate upper oesophageal sphincter (UOS) opening is critical to safe and efficient swallowing due to the close proximity of the UOS to the airway entrance. Many people with neurological conditions, progressive and non-progressive, present with UOS dysfunction. The consequences for the person include difficulty swallowing food with subsequent choking and aspiration (passage of material into the trachea beyond the level of the true vocal cords). Clinical complications include aspiration pneumonia, weight loss, dehydration and malnutrition. Tube feeding is often indicated but is associated with increased mortality. Quality of life is also frequently impacted. A range of interventions exist that aim to improve UOS function and swallowing. These include compensatory strategies, rehabilitation techniques, pharmacological interventions and surgery. Over the last two decades, botulinum toxin has been gaining popularity as an intervention for UOS dysfunction, with some evidence to suggest that it is successful in improving swallow function. Despite a number of studies investigating its efficacy, there is a lack of consensus regarding whether this intervention is effective in improving swallowing for individuals with UOS dysfunction associated with neurological disease.

Objectives: To establish the efficacy and safety of botulinum toxin use aimed at improving UOS dysfunction in people with swallowing difficulties (dysphagia) associated with non-progressive and progressive neurological disease.

Search methods: We searched the following electronic databases for published trials: the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (1950 to 2013); EMBASE (1980 to 2013); AMED (Allied and Complementary Medicine) (1941 to 2013); CINAHL (Cumulative Index to Nursing and Allied Health Literature) (1937 to 2013). We also searched major clinical trials registers: CCT (http://www.controlled-trials.com); Clinical Trials (http://www.clinicaltrials.gov); Chinese Clinical Trial Register (www.chictr.org); ACTR (http://www.actr.org.au/. We examined the reference lists of all potentially relevant studies to identify further relevant trials. We handsearched published abstracts of conference proceedings from both the Dysphagia Research Society and the European Society of Swallowing Disorders. Digestive Disease Week (published in Gastroenterology) was also handsearched. Additionally, we searched ProQuest Dissertations & Theses for dissertation abstracts.

Selection criteria: Only randomised controlled trials were sought.

Data collection and analysis: Independent searches were completed by JR, AM, MC and MW. Two review authors (JR and MW) independently inspected titles, abstracts and key words identified from the literature search.

Main results: No randomised controlled studies were retrieved. Twenty-nine studies were excluded, mainly on the basis of trial design.

Authors' conclusions: It was not possible to reach a conclusion on the efficacy and safety of botulinum toxin as an intervention for people with UOS dysfunction and neurological disease. There is insufficient evidence to inform clinical practice. Directions for future research are provided.

PubMed Disclaimer

Conflict of interest statement

The authors have no declaration of interest to report.

Figures

1
1
Study flow diagram.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD009968

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

References to studies excluded from this review

Ahsan 2000 {published data only}
    1. Ahsan S, Meleca R, Dworkin J. Botulinum toxin injection of the cricopharyngeus muscle for the treatment of dysphagia. Otolaryngology‐Head and Neck Surgery 2000;122(5):691‐5. - PubMed
Alberty 2000 {published data only}
    1. Alberty J, Oelerich M, Ludwig K, Hartmann S, Stoll W. Efficacy of botulinum toxin A for treatment of upper esophageal sphincter dysfunction. Laryngoscope 2000;110(7):1151‐6. - PubMed
Alfonsi 2010 {published data only}
    1. Alfonsi E, Merlo IM, Ponzio M, Montomoli C, Tassorelli C, Biancardi C, Lozza A, Martignoni E. An electrophysiological approach to the diagnosis of neurogenic dysphagia: implications for botulinum toxin treatment. Journal of Neurology, Neurosurgery, and Psychiatry 2010;81(8):54‐60. - PubMed
Aoyagi 2012 {published data only}
    1. Aoyagi Y, Tsubahara A, Seki S, Hiraoka T. The trial of lidocaine injection improves the success rate of botulinum toxin injection for dysphagia with upper esophageal sphincter (UES) dysfunction. Dysphagia 2011;26:432‐75.
Atkinson 1997 {published data only}
    1. Atkinson S, Rees J. Botulinum toxin for cricopharyngeal dysphagia: case reports of CT‐guided injection. Journal of Otolaryngology 1997;26(4):273‐6. - PubMed
Blitzer 1997 {published data only}
    1. Blitzer R, Brin MF. Use of botulinum toxin for diagnosis and management of cricopharyngeal achalasia. Otolaryngology‐Head and Neck Surgery 1997;116(3):328‐30. - PubMed
Chiu 2004 {published data only}
    1. Chiu M, Chang Y, Hsiao T. Prolonged effect of botulinum toxin injection in the treatment of cricopharyngeal dysphagia: case report and literature review. Dysphagia 2004;19(1):52–7. - PubMed
Di Pede 2012 {published data only}
    1. Pede C, Bonsangue V, Marchese Ragona R, Mion M, Masiero S. Cricopharyngeal botulinum toxin injection and rehabilitation in patients with severe oropharyngeal dysphagia from inclusion body myositis. Dysphagia 2013;28:280‐335.
Dunne 1993 {published data only}
    1. Dunne J, Hayes M, Cameron D. Botulinum toxin A for cricopharyngeal dystonia. Lancet 1993;342(8870):559. - PubMed
Haapaniemi 2001 {published data only}
    1. Haapaniemi JJ, Laurikainen EA, Pulkkinen J, Marttila RJ. Botulinum toxin in the treatment of cricopharyngeal dysphagia. Dysphagia 2001;16(3):171‐5. - PubMed
Kelly 2013 {published data only}
    1. Kelly E, Koszewski I, Jaradeh S, Merati A, Blumin J, Bock J. Botulinum toxin injection for the treatment of upper esophageal sphincter dysfunction. The Annals of Otology, Rhinology, and Laryngology 2013;122(2):100‐8. - PMC - PubMed
Kim 2006 {published data only}
    1. Kim DY, Park CI, Ohn SH, Moon JY, Chang WH, Park SW. Botulinum toxin type A for poststroke cricopharyngeal muscle dysfunction. Archives of Physical Medicine and Rehabilitation 2006;87(10):1346‐51. - PubMed
Krause 2008 {published data only}
    1. Krause E, Schirra J, Gurkov R. Botulinum toxin A treatment of cricopharyngeal dysphagia after subarachnoid haemorrhage. Dysphagia 2008;23:406‐10. - PubMed
Lee 2009 {published data only}
    1. Lee SY, Seo HG, Paik NJ. Botulinum toxin injection for dysphagia: a blinded retrospective videofluoroscopic swallowing study analysis. American Journal of Physical Medicine and Rehabilitation 2009;88(6):491‐4. - PubMed
Liu 2004 {published data only}
    1. Liu L, Tarnopolsky M, Armstrong D. Injection of botulinum toxin A to the upper esophageal sphincter for oropharyngeal dysphagia in two patients with inclusion body myositis. Canadian Journal of Gastroenterology 2004;18(6):397‐9. - PubMed
Masiero 2006 {published data only}
    1. Masiero S, Briani C, Marchese‐Ragona R, Giacometti P, Costantini M, Zaninotto G. Successful treatment of long‐standing post‐stroke dysphagia with botulinum toxin and rehabilitation. Journal of Rehabilitation Medicine 2006;38(3):201‐3. - PubMed
Murry 2005 {published data only}
    1. Murry T, Wasserman T, Carrau RL, Castillo B. Injection of botulinum toxin A for the treatment of dysfunction of the upper esophageal sphincter. American Journal of Otolaryngology 2005;26(3):157‐62. - PubMed
Parameswaran 2002 {published data only}
    1. Parameswaran MS, Soliman AM. Endoscopic botulinum toxin injection for cricopharyngeal dysphagia. Annals of Otology, Rhinology and Laryngology 2002;111(10):871‐4. - PubMed
Rees 2010 {published data only}
    1. Rees C, French C, Butler S, Hickman M, Wright S. Cricopharyngeal botulinum toxin injection with dilation for globus pharyngeus. Dysphagia (Dysphagia Research Society Conference, 2010) 2010;25:354‐98.
Restivo 2006 {published data only}
    1. Restivo DA, Marchese‐Ragona R, Lauria G, Squatrito S, Gullo D, Vigneri R. Botulinum toxin treatment for oropharyngeal dysphagia associated with diabetic neuropathy. Diabetes Care 2006;29(12):2650‐3. - PubMed
Restivo 2011 {published data only}
    1. Restivo DA, Marchese‐Ragona R, Patti F, Solaro C, Maimone D, Zappalá G, et al. Botulinum toxin improves dysphagia associated with multiple sclerosis. European Journal of Neurology 2011;18(3):486‐90. - PubMed
Restivo 2013 {published data only}
    1. Restivo D, Casabona A, Nicotra A, Zappia M, Elia M, Romano M, et al. ALS dysphagia pathophysiology Differential botulinum toxin response. Neurology 2013;80(7):616‐20. - PubMed
Schneider 1994 {published data only}
    1. Schneider I, Thumfart WF, Pototschnig C, Eckel HE. Treatment of dysfunction of the cricopharyngeal muscle with botulinum A toxin: introduction of a new, noninvasive method. The Annals of Otology, Rhinology, and Laryngology 1994;103(1):31‐5. - PubMed
Shaw 2001 {published data only}
    1. Shaw G, Searl J. Botulinum toxin treatment for cricopharyngeal dysfunction. Dysphagia 2001;16:161‐7. - PubMed
Sjogren 2011 {published data only}
    1. Sjogren. European Society of Swallowing Disorders. 2011.
Terre 2008 {published data only}
    1. Terre R, Valles M, Panades A, Mearin F. Long‐lasting effect of a single botulinum toxin injection in the treatment of oropharyngeal dysphagia secondary to upper esophageal sphincter dysfunction: A pilot study. Scandinavian Journal of Gastroenterology 2008;43:1296‐303. - PubMed
Terré 2013 {published data only}
    1. Terré R, Panadés A, Mearin F. Botulinum toxin treatment for oropharyngeal dysphagia in patients with stroke. Neurogastroenterology and Motility 2013;24(11):896‐e702. - PubMed
Woisard‐Bassols 2013 {published data only}
    1. 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. European Archives of Oto‐Rhino‐Laryngology 2013;270(3):805‐15. - PubMed
Zanninoto 2004 {published data only}
    1. Zaninotto G, Marchese Ragona R, Briani C, Costantini M, Rizzetto C, Portale G. The role of botulinum toxin injection and upper esophageal sphincter myotomy in treating oropharyngeal dysphagia. Journal of Gastrointestinal Surgery 2004;8(8):997‐1006. - PubMed

Additional references

Alfonso 2010
    1. Alfonsi E, Merlo I, Ponzio M, Montomoli C, Tassorelli C, Biancardi C, et al. An electrophysiological approach to the diagnosis of neurogenic dysphagia; implications for botulinum toxin treatment. Journal of Neurology, Neurosurgery, and Psychiatry 2010;81(1):54‐60. - PubMed
Ali 1996
    1. Ali GN, Wallace KL, Schwartz R, DeCarle DJ, Zagami AS, Cook IJ. Mechanisms of oral‐pharyngeal dysphagia in patients with Parkinson's disease. Gastroenterology 1996;110(2):383‐92. - PubMed
Bian 2009
    1. Bian RX, Choi IS, Kim JH, Han JY, Lee SG. Impaired opening of the upper esophageal sphincter in patients with medullary infarctions. Dysphagia 2009;24(2):238‐45. - PubMed
Butler 2009
    1. Butler SG, Stuart A, Castell D, Russell GB, Koch K, Kemp S. Effects of age, gender, bolus condition, viscosity, and volume on pharyngeal and upper esophageal sphincter pressure and temporal measurements during swallowing. Journal of Speech Language and Hearing Research 2009;52(1):240. - PubMed
Colton‐Hudson 2002
    1. Colton‐Hudson A, Koopman WJ, Moosa T, Smith D, Bach D, Nicolle M. A prospective assessment of the characteristics of dysphagia in myasthenia gravis. Dysphagia 2002;17(2):147‐51. - PubMed
Consort 2010
    1. Schulz KF, Altman DG, Moher D, for the CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:698‐702.
Cook 1989
    1. Cook IJ, Dodds WJ, Dantas RO, Massey B, Kern MK, Lang IM, et al. Opening mechanisms of the human upper esophageal sphincter. American Journal of Physiology 1989;257(5 pt 1):G748–59. - PubMed
Cook 2000
    1. Cook IJ. Diagnosis and management of cricopharyngeal achalasia and other upper esophageal sphincter opening disorders. Current Gastroenterology Reports 2000;2:191‐5. - PubMed
Costa 2005
    1. Costa J, Espírito‐Santo C, Borges A, Ferreira JJ, Coelho M, Moore P, et al. Botulinum toxin type B for cervical dystonia. Cochrane Database of Systematic Reviews 2005, Issue 1. [DOI: 10.1002/14651858.CD004315.pub2] - DOI - PubMed
Ertekin 2002
    1. Ertekin C, Aydogdu I. Electromyography of human cricopharyngeal muscle of the upper esophageal sphincter. Muscle & Nerve 2002;26(6):729‐39. - PubMed
Fuster Torres 2007
    1. Fuster Torres MA, Aytes LB, Escoda CG. Salivary gland application of botulinum toxin for the treatment of sialorrhea. Medicina Oral Patologia Oral Y Cirugia Bucal 2007;12(7):E511‐7. - PubMed
Hatlebakk 1998
    1. Hatlebakk JG, Castell JA, Spiegel J, Paoletti V, Katz PO, Castell DO. Dilatation therapy for dysphagia in patients with upper esophageal sphincter dysfunction–manometric and symptomatic response. Diseases of the Esophagus 1998;11(4):254–9. - PubMed
Heinen 2006
    1. Heinen F, Molenaers G, Fairhurst C, Carr L, Desloovere K, et al. European consensus table 2006 for botulinum toxin for children with cerebral palsy. European Journal of Paediatric Neurology 2006;10:215‐25. - PubMed
Higgins 2011
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.
Higo 2001
    1. Higo R, Tayama N, Watanabe T, Niimi S. Abnormal elevation of resting pressure at the upper esophageal sphincter of Parkinson’s disease patients. European Archives of Otorhinolaryngology 2001;258:552‐6. - PubMed
Higo 2002
    1. Higo R, Tayama N, Watanabe T, Nitou T. Videomanofluorometric study in amyotrophic lateral sclerosis. Laryngoscope 2002;112(5):911–7. - PubMed
Hiss 2005
    1. Hiss SG, Huckabee ML. Timing of pharyngeal and upper esophageal sphincter pressures as a function of normal and effortful swallowing in young healthy adults. Dysphagia 2005;20(2):149‐56. - PubMed
Hu 2010
    1. Hu HT, Shin JH, Kim JH, Park JH, Sung KB, Song HY. Fluoroscopically guided balloon dilation for pharyngoesophageal stricture after radiation therapy in patients with head and neck cancer. American Journal of Roentgenology 2010;194(4):1131. - PubMed
Jankovic 1991
    1. Jankovic J, Brin MF. Therapeutic uses of botulinum toxin. The New England Journal of Medicine 1991;324:1186–94. - PubMed
Kahrilas 1991
    1. Kahrilas P, Logemann J, Krugler C, Flanagan E. Volitional augmentation of upper esophageal sphincter opening during swallowing. American Journal of Physiology 1991;260:G450‐6. - PubMed
Kelly 2000
    1. Kelly JH. Management of upper esophageal sphincter disorders: indications and complications of myotomy. American Journal of Medicine 2000;108 Suppl 4a:43S‐6S. - PubMed
Kos 2010
    1. Kos MP, David EF, Klinkenberg‐Knol EC, Mahieu HF. Long‐term results of external upper esophageal sphincter myotomy for oropharyngeal dysphagia. Dysphagia 2010;25(3):169‐76. - PMC - PubMed
Leow 2010
    1. Leow L, Huckabee ML, Anderson T, Beckert L. The impact of dysphagia on quality of life in ageing and Parkinson’s disease as measured by the Swallowing Quality of Life (SWAL‐QOL) Questionnaire. Dysphagia 2010;25(2):216‐20. - PubMed
Martino 2005
    1. Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke 2005;36(12):2756. - PubMed
McCulloch 2010
    1. McCulloch TM, Hoffman MR, Ciucci MR. High‐resolution manometry of pharyngeal swallow pressure events associated with head turn and chin tuck. The Annals of Otology, Rhinology, and Laryngology 2010;119(6):369. - PMC - PubMed
Moerman 2006
    1. Moerman MB. Cricopharyngeal botox injection: indications and technique. Current Opinion in Otolaryngology & Head and Neck Surgery 2006;14(6):431–6. - PubMed
Oh 2008
    1. Oh TH, Brumfield KA, Hoskin TL, Kasperbauer JL, Basford JR. Dysphagia in inclusion body myositis: clinical features, management, and clinical outcome. American Journal of Physical Medicine & Rehabilitation 2008;87(11):883. - PubMed
Restivo 2002
    1. Restivo DA, Palmeri A, Marchese‐Ragona R. Botulinum toxin for cricopharyngeal dysfunction in Parkinson's disease. The New England Journal of Medicine 2002;346(15):1174‐5. - PubMed
Shaker 1997
    1. Shaker R, Kern M, Bardan E, Taylor A, Stewart ET, Hoffman RG, et al. Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. American Journal of Physiology 1997;272:G1518‐22. - PubMed
Shaker 2002
    1. Shaker R, Easterling C, Kern M, Nitschke T, Massey B, Daniels S, et al. Rehabilitation of swallowing by exercise in tube‐fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology 2002;122(5):1314‐21. - PubMed
Singh 2005
    1. Singh S, Hamdy S. The upper oesophageal sphincter. Neurogastroenterology & Motility 2005;17:3‐12. - PubMed
Sivarao 2000
    1. Sivarao DV, Goyal RK. Functional anatomy and physiology of the upper esophageal sphincter. American Journal of Medicine 2000;108(4a):27S‐37S. - PubMed
Smithard 1996
    1. Smithard DG, O’Neill PA, Parks C, Morris J, Wyatt R, England R, et al. Complications and outcome after acute stroke: does dysphagia matter?. Stroke 1996;27:1200‐4. - PubMed
Steinhagen 2009
    1. Steinhagen V, Grossman A, Benecke R, Walter U. Stroke patients swallowing disturbance pattern relates to brain lesion location in acute stroke patients. Stroke 2009;40:1903‐6. - PubMed
Wada 2012
    1. Wada S, Tohara H, Lida T, Inoue M, Sato M, Ueda K. Jaw‐opening exercise for insufficient opening of upper esophageal sphincter. Archives Physical Medical Rehabilitation 2012;93:1995‐9. - PubMed
Zaninnotto 2004
    1. Zaninotto G, Marchese Ragona R, Briani C, Costantini M, Rizzetto C, Portale G. The role of botulinum toxin injection and upper esophageal sphincter myotomy in treating oropharyngeal dysphagia. Journal of Gastrointestinal Surgery 2004;8(8):997‐1006. - PubMed

Publication types

MeSH terms