Correspondence

Botulinum Toxin for Cricopharyngeal Dysfunction in Parkinson's Disease

N Engl J Med 2002; 346:1174-1175April 11, 2002

Article

To the Editor:

Dysphagia occurs in more than 50 percent of patients with Parkinson's disease.1 Although all the phases of swallowing can be involved, dysphagia due to hyperactivity of the upper esophageal sphincter is the prevalent abnormality.1

Dysphagia does not respond to dopaminergic therapy.1 Surgical myotomy of the cricopharyngeal muscle is the treatment of choice for hyperactivity of the upper esophageal sphincter due to neurologic disorders,2 including Parkinson's disease.3 However, cricopharyngeal myotomy requires general anesthesia and is not always effective.2

Botulinum neurotoxin type A has been used to treat dysphagia.4,5 We describe its use in four patients (three men and one woman; age range, 58 to 72 years) with Parkinson's disease and dysphagia. In these patients, dysphagia for solid food had progressed to dysphagia for liquids, and the diet had become confined to semiliquid meals. The mean duration of dysphagia was 5.9 years.

All the patients were receiving levodopa and decarboxylase inhibitors, but there was no improvement of the dysphagia. Videofluoroscopic studies showed a reduction of pharyngeal clearance and incomplete cricopharyngeal opening. Electromyographic studies of both the cricopharyngeal and the pharyngeal inferior constrictor muscles showed abnormal tonic hyperactivity of the former.

To evaluate the possible efficacy of cricopharyngeal myotomy, we decided to treat the cricopharyngeal muscle with botulinum neurotoxin type A. After the patients had given written informed consent and the local ethics committee had approved the treatment, both cricopharyngeal muscles were percutaneously injected with botulinum neurotoxin type A (Dysport, Ipsen, Wrexham, United Kingdom; 30 units per muscle) under electromyographic control. Forty-eight hours later, all patients had remarkable improvement in swallowing. Clinical, electromyographic, and videofluoroscopic examinations were performed 8, 16, 20, and 22 weeks after the injection. At eight weeks, all the patients were able to swallow. Videofluoroscopic and electromyographic studies showed normal swallowing and coordination between the cricopharyngeal and inferior constrictor muscles and a marked reduction in cricopharyngeal hyperactivity. The improvement persisted at 16 and 20 weeks in all four patients and disappeared in three of them at 22 weeks. All patients gained 5 to 8 kg in body weight.

Given its safety and effectiveness, we propose that treatment with botulinum neurotoxin type A may be a successful alternative to invasive procedures or may be a useful tool for identifying patients who might benefit from surgical myotomy.

Domenico A. Restivo, M.D., Ph.D.
Agostino Palmeri, M.D., Ph.D.
University of Catania, 95125 Catania, Italy
darestivo@eudoramail.com

Rosario Marchese-Ragona, M.D.
University of Padua, 35100 Padua, Italy

5 References

1. 1

   Hunter PC, Crameri J, Austin S, Woodward MC, Hughes AJ. Response of parkinsonian swallowing dysfunction to dopaminergic stimulation. J Neurol Neurosurg Psychiatry 1997;63:579-583
   CrossRef | Web of Science | Medline

2. 2

   McKenna JA, Dedo HH. Cricopharyngeal myotomy: indications and technique. Ann Otol Rhinol Laryngol 1992;101:216-221
   Web of Science | Medline

3. 3

   Born LJ, Harned RH, Rikkers LF, Pfeiffer RF, Quigley EM. Cricopharyngeal dysfunction in Parkinson's disease: role in dysphagia and response to myotomy. Mov Disord 1996;11:53-58
   CrossRef | Web of Science | Medline

4. 4

   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. Ann Otol Rhinol Laryngol 1994;103:31-35
   Web of Science | Medline

5. 5

   Restivo DA, Marchese Ragona R, Staffieri A, de Grandis D. Successful botulinum toxin treatment of dysphagia in oculopharyngeal muscular dystrophy. Gastroenterology 2000;119:1416-1416
   CrossRef | Web of Science | Medline

Citing Articles (15)

Citing Articles

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   David Salat-Foix, Oksana Suchowersky. (2012) The management of gastrointestinal symptoms in Parkinson’s disease. Expert Review of Neurotherapeutics 12:2, 239-248
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2. 2

   Ronald F. Pfeiffer. 2011. Gastrointestinal and Swallowing Disturbances in Parkinson's Disease. , 257-273.
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3. 3

   D. A. Restivo, R. Marchese-Ragona, F. Patti, C. Solaro, D. Maimone, G. Zappalá, A. Pavone. (2011) Botulinum toxin improves dysphagia associated with multiple sclerosis. European Journal of Neurology 18:3, 486-490
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4. 4

   Ronald F. Pfeiffer. (2011) Gastrointestinal dysfunction in Parkinson’s disease. Parkinsonism & Related Disorders 17:1, 10-15
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5. 5

   W. H. Oertel, A. Berardelli, B. R. Bloem, U. Bonuccelli, D. Burn, G. Deuschl, E. Dietrichs, G. Fabbrini, J. J. Ferreira, A. Friedman, P. Kanovsky, V. Kostic, A. Nieuwboer, P. Odin, W. Poewe, O. Rascol, C. Sampaio, M. Schüpbach, E. Tolosa, C. Trenkwalder. 2010. Late (Complicated) Parkinson's Disease. , 237-267.
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6. 6

   Emilia Michou, Shaheen Hamdy. (2010) Dysphagia in Parkinson’s disease: a therapeutic challenge?. Expert Review of Neurotherapeutics 10:6, 875-878
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7. 7

   Michela Barichella, Emanuele Cereda, Gianni Pezzoli. (2009) Major nutritional issues in the management of Parkinson's disease. Movement Disorders 24:13, 1881-1892
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8. 8

   Laura W. J. Baijens, Renée Speyer. (2009) Effects of Therapy for Dysphagia in Parkinson’s Disease: Systematic Review. Dysphagia 24:1, 91-102
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9. 9

   Mieke BJ Moerman. (2006) Cricopharyngeal Botox injection: indications and technique. Current Opinion in Otolaryngology & Head and Neck Surgery 14:6, 431-436
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10. 10

    Alan Diamond, Joseph Jankovic. (2006) Treatment of advanced Parkinson’s disease. Expert Review of Neurotherapeutics 6:8, 1181-1197
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11. 11

    Harsha Vittal, Pankaj Jay Pasricha. (2006) Botulinum toxin for gastrointestinal disorders: Therapy and mechanisms. Neurotoxicity Research 9:2-3, 149-159
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12. 12

    D. A. Restivo, R. Marchese–Ragona. (2006) Botulinum toxin treatment for oropharyngeal dysphagia due to tetanus. Journal of Neurology 253:3, 388-389
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13. 13

    Rosario Marchese-Ragona, Gino Marioni, Domenico A. Restivo, Alberto Staffieri. (2005) Solving dysphagia due to cricopharyngeal muscle dysfunction with botulinum toxin. European Archives of Oto-Rhino-Laryngology 262:3, 250-251
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14. 14

    D. Gui, S. Rossi, M. Runfola, S. C. Magalini. (2003) Botulinum toxin in the therapy of gastrointestinal motility disorders. Alimentary Pharmacology and Therapeutics 18:1, 1-16
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15. 15

    Ronald F Pfeiffer. (2003) Gastrointestinal dysfunction in Parkinson's disease. The Lancet Neurology 2:2, 107-116
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