Abstract
Objective: To evaluate botulinum toxin treatment of hyperactive upper esophageal sphincter after first-time brainstem stroke. Design: A retrospective study. Subjects: Twelve patients with long standing dysphagia after brainstem vascular injury admitted to the rehabilitation department of a medical centre. Methods: All patients underwent clinical examination, videofluoroscopic study of swallowing and electromyography. Botulinum toxin was injected percutaneously under electromyographic guide. Outcomes were measured after two weeks and through a long follow up programme, which ranged from two to ten years. Results: A total of 75% of patients (9 of 12) had favourable outcomes. Two patients showed long lasting functional benefits after only one botulinum toxin injection, while seven patients required further treatments to maintain an adequate oral intake. In seven cases it was possible to remove percutaneous endoscopic gastrostomy. No relevant complications were observed. Conclusion: Botulinum toxin can improve severe dysphagia with elective hyperactivity of the upper esophageal sphincter in patients with or without unilateral paresis of the inferior constrictor muscle and in absence of a nuclear involvement of the IXth and Xth cranial nerves. The outcome could be unsatisfactory in the cases of oral phase involvement, bilateral lesion of the inferior constrictor muscle and when there is velopharyngeal insufficiency.
Highlights
Dysphagia is a severe and debilitating disorder often consequence of brainstem stroke [1]
Among patients with a medullary infarction, dysphagia is more common if the lesion is at the upper or middle and dorsolateral medullary level [1] and persistent deglutition disorders are often associated with lower brainstem lesions [3,4,5]
Dysphagia can be characterized by pharyngeal dysmotility, velopharyngeal insufficiency, pharyngeal asymmetry and incomplete relaxation of the upper esophagus sphincter (UES) that can lead to retention of food materials in the pharynx and aspiration into the larynx and trachea
Summary
Dysphagia is a severe and debilitating disorder often consequence of brainstem stroke [1]. Among patients with a medullary infarction, dysphagia is more common if the lesion is at the upper or middle and dorsolateral medullary level [1] and persistent deglutition disorders are often associated with lower brainstem lesions [3,4,5]. The medullary stroke syndromes can have various swallowing impairments In such cases, dysphagia can be characterized by pharyngeal dysmotility, velopharyngeal insufficiency, pharyngeal asymmetry and incomplete relaxation of the upper esophagus sphincter (UES) that can lead to retention of food materials in the pharynx and aspiration into the larynx and trachea. After the acute brainstem stroke phase, dysphagia tends to recover, there are only a few patients with persistent and severe dysphagia and not all of them have hyperactivity of UES. Swallowing disorders caused by brainstem stroke show different clinical and videofluoroscopic characteristics in respect to hemispheric lesions [6]
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