Repeatedly Successful Closure of the Larynx for the Treatment of Chronic Aspiration with the Use of Botulinum Toxin A

Abstract

Botulinum toxin A was used preoperatively to temporarily paralyze the intrinsic laryngeal muscles to hinder movements during the healing period after operation. In addition, toxin was injected into the cricopharyngeal muscle to allow a better passive drainage of the saliva into the esophagus. We treated six patients. Three suffered from chronic aspiration problems after multiple lower cranial nerve lesions, and three patients were apallic (after stroke and major brain injury). Two weeks before scheduled operation, we injected the toxin into the posterior cricoarytenoid muscles, the aryepiglottic muscles, and the vocalis muscle on both sides, as well as the cricopharyngeal muscle. The amount of injected toxin varied between 1.0 and 1.4 mL, equal to 200 to 280 units of botulinum toxin A (Dysport). After a complete palsy of these muscles (controlled by direct electromyography), a closure of the larynx was performed. After laminotomy and exposure of the intralaryngeal structures, the false vocal cords were mobilized and adapted with sutures. Because involuntary movements of the intralaryngeal musculature were absent, primary healing without complications occurred in all cases. Aspiration and related complications disappeared in all patients. In addition, the intensity of patient care could be considerably reduced. Preoperative use of botulinum toxin A allows sufficient laryngeal closure. This procedure is especially useful in the treatment of children and young adults, preserving the ability of later speech rehabilitation because of the return of voluntary movements of the intrinsic laryngeal muscles 6 months after the injection. Furthermore, this technique, as minimal surgical intervention, can be performed in high-risk patients.

Dysphagia

“…These include patients who have dysphagia associated with neuromyopathy associated with multiple cerebral infarctions [30], oculopharyngeal muscular dystrophy [31], cricopharyngeal spasm [32,33•], dysphagia associated with esophageal diverticuli [34], Zenker's diverticulum [35], and into the larynyx for chronic aspiration [36].…”

‘Steam-boat’ supraglottic laryngoplasty for treatment of chronic refractory aspiration: a modification of Biller's technique

“…The supraglottic closure in this situation is subjected to a high risk of dehiscence, as the integrity of the mucosal tube is maintained only by two thin layers of epiglottic mucosa. One report suggests that intact laryngeal musculature may also cause dehiscence of the supraglottic and glottic closure 13 . To our knowledge, we are the first group to report the use of a tubed supraglottic laryngoplasty to treat intractable aspiration in Chinese patients.…”

Botulinum toxin: Adjunctive treatment for posterior glottic synechiae

“…Botulinum toxin has been used safely and effectively to control symptoms of patients with disorders of neural origin 1 and voice disorders 2,7,8 . Preoperative botulinum toxin injection has been used to temporarily paralyze the intrinsic laryngeal muscles to hinder movement during the healing period after operation 9 . The short‐lasting effects of botulinum toxin, ranging from 3 to 4 months, is a relative disadvantage.…”