title: The role of botulinum toxin injection and upper esophageal sphincter myotomy in treating oropharyngeal dysphagia.
abstract: The aims of this study were to assess the efficacy and safety of botulinum toxin (BoTox) injection in the cricopharyngeus muscle (CP) and CP myotomy in patients with oropharyngeal dysphagia (OPD) and to identify factors predicting the outcome of these treatments. The study involved patients with persistent OPD despite 2-6 months of rehabilitation, who all underwent clinical evaluation, esophageal manometry, upper gastrointestinal endoscopy, and videofluoroscopy (VFS). Patients received 5-10 BoTox units injections in the CP, identified by electromyography. Surgical myotomy of the upper esophageal sphincter was performed when dysphagia persisted after two BoTox injections. After treatment, patients were reevaluated with clinical interviews and VFS. The study population included 21 patients (15 mean and 6 women; median age, 68 years), classified into three groups, based on the etiology of their OPD: eight (38%) had central nervous system abnormalities, five (24%) had peripheral nerve disease, and eight (38%) were classified as idiopathic. The median time since the onset of dysphagia was 18 months. Thirteen of 21 patients (62%) needed supplemental/total gastrostomy feeding, and 5 of 21 (24%) had tracheostomy. One patient died, on posttreatment day 7, due to massive aspiration. No other BoTox-related complications were observed. After BoTox injection, dysphagia improved in 9 of 21 (43%) patients. Severely altered VFS findings and CP incoordination or low activity predicted BoTox failure at multivariate analysis. Dysphagia improved in 8 of 11 (72.7%) patients who failed to respond to BoTox and underwent myotomy. A mild impairment of VFS findings and a higher pressure of pharyngeal contractions best predicted response to BoTox with or without myotomy. BoTox injection can be used as the first therapeutic option in patients with OPD: it is safe and simple and relieves dysphagia in 43% of cases. If BoTox fails, CP myotomy can be offered to patients with preserved oral and tongue activity at VFS and an intact bolus propulsion ability on manometry.
authors.affiliation: Department of Medical and Surgical Sciences, Clinica Chirurgica 3, University of Padova School of Medicine, Padova, Italy. giovanni.zaninotto@unipd.it
authors.forename: Giovanni
authors.initials: G
authors.lastname: Zaninotto
authors.forename: Rosario
authors.initials: R
authors.lastname: Marchese Ragona
authors.forename: Chiara
authors.initials: C
authors.lastname: Briani
authors.forename: Mario
authors.initials: M
authors.lastname: Costantini
authors.forename: Christian
authors.initials: C
authors.lastname: Rizzetto
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Portale
authors.forename: Lia
authors.initials: L
authors.lastname: Zanetti
authors.forename: Stefano
authors.initials: S
authors.lastname: Masiero
authors.forename: Michela
authors.initials: M
authors.lastname: Costantino
authors.forename: Loredana
authors.initials: L
authors.lastname: Nicoletti
authors.forename: Alessandro
authors.initials: A
authors.lastname: Polidoro
authors.forename: GianPiero
authors.initials: G
authors.lastname: Feltrin
authors.forename: Corrado
authors.initials: C
authors.lastname: Angelini
authors.forename: Ermanno
authors.initials: E
authors.lastname: Ancona
authors.forename: Diego
authors.initials: D
authors.lastname: Guidolin
authors.forename: Anna R
authors.initials: AR
authors.lastname: Parenti
mesh_terms: D000368:Aged; D001905:Botulinum Toxins / Q000008:administration & dosage*; D016022:Case-Control Studies; D003679:Deglutition / Q000502:physiology; D003680:Deglutition Disorders / Q000503:physiopathology / Q000628:therapy*; D004576:Electromyography; D049631:Esophageal Sphincter, Upper / Q000601:surgery; D005260:Female; D005471:Fluoroscopy; D006801:Humans; D008297:Male; D008365:Manometry; D009960:Oropharynx; D010608:Pharyngeal Diseases / Q000503:physiopathology / Q000628:therapy*; D016896:Treatment Outcome
chemical_list: D001905:Botulinum Toxins