Injection of botulinum toxin for the treatment of post-laryngectomy pharyngoesophageal spasm-related disorders

Abstract

Introduction Pharyngoesophageal spasm (PES) can cause dysphagia, central valve leak (CVL), and dypshonia in post-laryngectomy patients. Botulinum toxin has been used effectively for the treatment of PES, but data regarding patient-reported outcomes and efficacy for CVL are limited. We evaluated the results of botox injection for PES spasm using subjective and objective measures. Methods Data were collected prospectively (February 2010 to August 2013) on 13 patients undergoing botox injection for PES as identified by video fluoroscopy. We collected digital voice recordings, air-pressure measurements (APMs) for speech, and quality of life (QoL) data before and after the procedure: University of Washington QoL questionnaire (UW-QoL), MD Anderson Swallowing Inventory (MDADI) and the Voice Handicap Index (VHI-30). Results APMs for a sustained vowel decreased by 18% after botox injection, whereas maximum phonatory times increased by 63% (mean increase, 8 to 13 seconds). Sustained vowel amplitude decreased (mean, 87db to 83db) with an associated reduction in sustained vowel frequency (117Hz to 77Hz). MDADI scores improved by 10.2% overall, and UW-QoL scores showed an improvement in score of 7.6%. Mean scores for VHI-30 deteriorated by 2% overall but, when considering only those patients experiencing dysphonia, an improvement of 9.4% was seen. There was an overall net reduction for the CVL cohort of 12 speech valves in the year after injection. Conclusions Our series confirm the safety and objective efficacy of botox injection for PES. QoL measurements were less convincing, and this disparity between subjective and objective measurements must be considered when treating such patients.

Diagnosis and treatment of oropharyngeal dysphagia after total laryngectomy with or without pharyngoesophageal reconstruction: Systematic review

“…[36][37][38][39][40][41][42][43][44] All case series were classified as level C evidence. [45][46][47][48][49][50][51][52][53][54][55][56] None of the 44 articles met all critical appraisal criteria (Table 3). Seventeen articles fulfilled all criteria for external validity, 13,17,22,[26][27][28]30,32,35,36,[38][39][40]44,46,49,50 and six studies did not fulfill any of these criteria.…”

“…16,19,25,27,30,32,33,49,51,52,[54][55][56] Additionally, in some studies not all patients underwent the same swallowing assessment protocol. 15,36,40,44,49,53 Translation of the results to best clinical decision making is not possible in 18 studies because the methodology and results were not described in sufficient detail to warrant doing so. 14,16,19,20,26,27,30,33,34,40,46,47,[51][52][53][54][55][56] Information on the number of raters and how exams were evaluated was missing in almost all studies.…”

“…15,36,40,44,49,53 Translation of the results to best clinical decision making is not possible in 18 studies because the methodology and results were not described in sufficient detail to warrant doing so. 14,16,19,20,26,27,30,33,34,40,46,47,[51][52][53][54][55][56] Information on the number of raters and how exams were evaluated was missing in almost all studies. Only in five studies were the raters blinded 15,18,26,48,49 and only in three studies was information given on interobserver or intraobserver reliability.…”

“…14,19,33,34,42,45 Two of the included articles fulfilled all criteria for internal validity, 18,48 representing a low risk of bias. Fourteen articles met only 2-3 criteria for internal validity, 14,16,19,27,30,33,36,40,[51][52][53][54][55][56] indicating a high risk of bias. Thirty studies applied statistical analytic methods.…”

“…These omissions introduce the potential for selection and reporting bias 12. In 14 studies, extrapolation of the results to all TLE patients can be compromised due to the poor internal validity or small sample sizes (≤20 study participants) 18,19,31,[46][47][48][49][50][51][52][53][54][55][56]. The overall internal validity of 44 studies was of moderate quality.…”