Abstract
Background: Botulinum toxin type A (BoNT-A) has been used in treating dysphagia due to spasticity of upper oesophageal sphincter (UES). However, the doses commonly injected could result ineffective. A case of dysphagia treated successfully by high dosage of BoNT-A is described. Case report: A 50 year-old male subject with tetraparesis and dysphagia due to severe spasticity of UES following encephalitis. No bolus transit was observed to videofluoroscopy (VS). Because of severe UES spasticity, it was not possible to perform oesophageal manometry. Growing BoNT-A dosage of 10 U (Botox) and 100 U (Xeomin) injected into cricopharingeal muscle (CM) had no benefit. Since negative effect of previous doses, BoNT-A (Xeomin) high dosage of 200 U was injected into CM. After neurotoxin injections,VS showed significant dysphagia improvement lasting eight months. Transient paresis of the right vocal cord occurred. A second BoNT-A injection session with same dosage and modalities was performed efficaciously. Conclusion: High dose of 200 U of BoNT-A (Xeomin) was efficacious and safe in treating refractory dysphagia due to severe spasticity of UES. High dosage of neurotoxin should be considered when common doses were ineffective
Highlights
Dysphagia is a dysfunction in normal swallowing characterized by a condition that the food including solids or liquids are not being swallowed correctly
One of the most important structures involved in normal swallowing is the Upper Esophageal Sphincter (UES) which is predominantly regulated by Cricopharyngeus Muscle (CM) action
Botulinum toxin type A (BoNT-A) has been widely reported as efficacious therapeutic medical tool for the treatment of dysphagia due to the spasticity of cricopharingeal muscle (CM) [6,7,8]
Summary
Dysphagia is a dysfunction in normal swallowing characterized by a condition that the food including solids or liquids are not being swallowed correctly. Pharyngeal, and oesophageal phase characterize the normal swallowing, all of which can be affected resulting in dysphagia. It can follow a huge of disturbances including oropharyngeal, neurological diseases, and postsurgical disorders. VS with modified barium swallowing, and oesophageal manometry were used to assess the dysphagia before and 2 weeks after BoNT-A injections. Before BoNT-A treatment, VS showed no passage of barium into the oesophagus with occasional pharyngeal reflux due to severe UES spasticity (Figure 1). He gained almost complete oral feeding that persisted for nearly eight months At this time, a second BoNT-A injection session with same dosage and modalities was performed that maintained the swallowing benefit previously obtained. No side effect was observed, apart mild pain in the site of inoculation
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