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Ultrasound-Guided Injection of Botulinum Toxin for Cricopharyngeal Dysphagia

Wang, Yi-Chian, MD; Shyu, Shaw-Gang, MD; Wu, Chueh-Hung, MD; Wang, Tyng-Guey, MD

American Journal of Physical Medicine & Rehabilitation: October 2018 - Volume 97 - Issue 10 - p e102–e103
doi: 10.1097/PHM.0000000000000959
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From the Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan (Y-CW, S-GS, C-HW, T-GW); and Supreme Rehabilitation Clinic, Taipei, Taiwan (Y-CW).

All correspondence should be addressed to: Chueh-Hung Wu, MD, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Zhongshan S Rd, Zhongzheng District, Taipei City 100, Taiwan.

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

This feature is a unique combination of text (voice) and video that more clearly presents and explains procedures in musculoskeletal medicine. These videos will be available on the journal’s Website. We hope that this feature will change and enhance the learning experience.

Walter R. Frontera, MD, PhD



A 68-yr-old man with right tongue squamous cell carcinoma received local excision and primary closure in 2006. The tumor progressed to T4N2M0 in 2015, and the patient received right subtotal glossectomy, segmental mandibulectomy, modified neck dissection, and free anterolateral thigh fasciocutaneous flap reconstruction in March 2015. Concurrent chemotherapy and volumetric modulated arc therapy of 6600 cGy were delivered. He was dependent on a gastrostomy tube for feeding since May 2015.

When the patient was referred to the rehabilitation department in June 2015, he could not even swallow his saliva and needed to spit out foamy oral secretion frequently. He could not cooperate with our swallow-speech pathologist because of severe neck stiffness and neck pain during any movements. He then received a protracted course of neck and chest physical therapy, intermittently disrupted by pneumonia, pain, and depression. The rehabilitation goal focused on pulmonary hygiene, cough and throat-clearing skills, saliva management, oral movement, tongue base, and pharyngeal movements. By April 2016, he had good pulmonary hygiene and could swallow approximately 50 to 100 ml of clear water in 30 mins. However, he made no further improvement in swallowing afterward, even under high motivation and good compliance to treatments including ice water stimulation, oral-pharyngeal movements, Shaker's exercise, Hawk exercise, supraglottic swallow, super supraglottic swallow, chin tuck, head tilt, and direct swallow training. Videofluoroscopic swallowing study (VFSS) was therefore arranged and showed limited hyolaryngeal excursion, poor pharyngeal effacement, marked epiglottis barium penetration, severe piriform stasis, and cricopharyngeal muscle (CPM) nonrelaxation, despite several invalid swallow attempts. In views of stagnation in his swallow function, he decided to undergo ultrasound-guided botulinum toxin injection to CPM in November 2016.

The procedure was performed by a qualified physiatrist, formally certified in musculoskeletal ultrasound training program and having more than 5000 case experiences of ultrasound-guided injection. The patient lay supine with his head rotation to right, and the probe (18–5 L linear probe; HITACHI ALOKA) was initially placed sagittal on the left neck to observe the whole pharyngeal tube. An electromyographic needle was inserted via in-plane approach. As soon as the needle tip was observed approximating the pharyngeal tube, the probe was rotated 90 degrees and placed axially at level of cricoid cartilage, where the CPM appeared as an oval-shaped circular structure, different from the upper esophagus wall, which had 5 layers.1 When the electromyographic needle was inserted via out-of-plane approach into the CPM (Fig. 1), the typical popping and clicking sounds of muscle activities were heard. Botulinum toxin type A (BOTOX, Allergan) 50 U in 1 ml 0.9% saline was then injected.



One month later, patient could drink 250 ml of liquid diet in 40 mins. Choking frequency decreased significantly. Videofluoroscopic swallowing study in January 2017 revealed much improved CPM opening (Video). Six months later, he received CPM injection again with BOTOX 100 U in 2 ml 0.9% saline. Afterward, he could drink 250 ml of liquid in 15 mins. By the time of submitting this article, the patient had received no more injection and kept gaining his weight by feeding semiliquid diet.

Cricopharyngeal muscle hypertonia, either absolute or relative, may lead to severe dysphagia. Botulinum toxin injection into the CPM has been used for reducing the muscle tone and thus facilitated food passage.2,3 Ultrasound-guided injection has several advantages, such as free from radiation exposure compared with CT guidance2 and sparing general anesthesia contrast to endoscopy guidance.3 With real-time ultrasound imaging, physician can minimize the risk of unintentional injury to the neurovascular structures. When traditional swallowing treatment failed to make progress, ultrasound and electromyography-guided CPM injection with botulinum toxin may serve as a reliable, rapid, and effective choice for treatment of cricopharyngeal dysphagia.

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1. Bhatia V, Tajika M, Rastogi A: Upper gastrointestinal submucosal lesions—clinical and endosonographic evaluation and management. Trop Gastroenterol 2010;31:5–29
2. Atkinson SI, Rees J: Botulinum toxin for cricopharyngeal dysphagia: case reports of CT-guided injection. J Otolaryngol 1997;26:273–6
3. Shaw GY, Searl JP: Botulinum toxin treatment for cricopharyngeal dysfunction. Dysphagia 2001;16:161–7
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