xRead - Swallowing Disorders in the Adult Patient (October 2024)

The Laryngoscope © 2024 The Author(s). The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.

Botulinum Toxin Injection for Retrograde Cricopharyngeal Dysfunction: A Prospective Cohort Study

Can Doruk, MD ; Evan L. Kennedy, MS, CCC-SLP ; Courtney Tipton, MD ; Yassmeen Abdel-Aty, MD; Michael J. Pitman, MD

Objectives: Retrograde Cricopharyngeal Dysfunction (RCPD) is treated by botulinum toxin (BTX) injection into the cricopharyngeus. This prospective study compares the effectiveness and side effects of operating room (OR) and in-of fi ce (IO) injections. Methods: Patients over 18 years of age with inability to burp, abdominal, thoracic, or cervical gurgling sounds, bloating, and excessive fl atulence were diagnosed with RCPD and included in the study. Injections were performed in the OR (80U) or IO (30U) by the senior author. An RCPD questionnaire quantifying major and minor symptoms on a Likert scale, Eating Assess ment Tool-10 (EAT-10), and Generalized Anxiety Score 7 (GAD-7), were completed preinjection; at 1, 2, and 3 weeks; and 3 months postoperatively. Linear mixed models were used to analyze effects of BTX injection on RCPD symptoms, the EAT-10, and the GAD-7. Results: 108 (55 M/53F) patients completed the pretreatment survey, 53 (31 OR vs. 22 IO) completed the 3-week follow-up, and 36 (22 OR vs. 14 IO) completed the 3-month questionnaire. Average posttreatment RCPD scores were signi fi cantly lower in both groups at 3 weeks and 3 months ( p < 0.0001), There was no difference between IO or OR ( p = 0.4924). GAD-7 scores were signi fi cantly lower in both groups at week 3 ( p = 0.0018) and month 3 ( p = 0.0012). Postinjection EAT-10 scores were signi fi cantly higher in OR compared with IO ( p = 0.0379). Conclusion: OR and IO injections are equally effective in the treatment of RCPD. Postinjection dysphagia is more severe after the OR injections which may be related to higher doses of BTX used. General anxiety levels decrease with treatment. KeyWords: botulinum toxin injection, in-of fi ce procedures, laryngology, retrograde cricopharyngeal dysfunction. Level of Evidence: 2 Laryngoscope , 00:1 – 6, 2024

INTRODUCTION The inability to burp and associated symptoms of gurgling noise in the chest, severe episodic chest pain and inability to vomit with no de fi nite treatment was fi rst described by Kahrilas et al. in 1987. 1 In 2019, Bastian et al. published results of 51 patients treated with Botuli num Toxin (BTX) injections and codi fi ed the disease as Retrograde Cricopharyngeal Dysfunction (RCPD). 2 The diagnosis of RCPD is made clinically without need for This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distri bution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. From the Center for Voice and Swallowing, Department of Otolaryngology-Head & Neck Surgery ( C . D ., E . L . K ., C . T ., Y . A .- A ., M . J . P .), Columbia University Irving Medical Center, New York, New York, U.S.A.; Department of Otolaryngology-Head & Neck Surgery ( C . D .), Istanbul Demiroglu Bilim University, Istanbul, Turkey; and the Department of Otolaryngology-Head & Neck Surgery ( Y . A .- A .), University of South Florida Morsani College of Medicine, Tampa, Florida, U.S.A. Editor ’ s Note: This Manuscript was accepted for publication on June 07, 2024. The authors have no funding, fi nancial relationships, or con fl icts of interest to disclose. Meetings: This study will be presented as a Podium Presentation at the 104th Annual Meeting of the American Bronchoesophagological Asso ciation, Chicago, IL, U.S.A., May 15 – 19, 2024. Send correspondence to Can Doruk, Department of Otolaryngology – Head and Neck Surgery, Istanbul Demiroglu Bilim Uni versity, Esentepe, Büyükdere Cd. No:120, 34394 Sisli/ _ Istanbul, Turkey. Email: can.doruk@istanbul.edu.tr

additional testing by the presence of four major symp toms: inability to belch, abdominal bloating, abdominal, thoracic, or cervical gurgling noises, and excessive fl atu lence. 2 Millet et al. qualitatively interviewed 13 patients with RCPD and found that patients with RCPD tend to have increased anxiety, social isolation and loss of productivity. 3 The current most utilized treatment of RCPD is direct visualization and BTX injection of the cricopharyngeus muscle (CP) under general anesthesia. To date, no uniform treatment protocol exists; thus, the dosing is dependent on the provider ’ s preferences. Publi shed literature indicates an 88.2% – 100% short-term suc cess rate with 80% prolonged effectiveness using variable doses (50 – 100 U) of BTX. 2,4 – 6 Posttreatment dysphagia rates are reported at 40% – 66% lasting 1 – 4weeks. 5,7 Recently, two different methods for in-of fi ce (IO) BTX injections have been described. 7,8 The trans cricoid (TCric-IO) approach was described by Wajsberg et al. with short-term success rates of 100%, post treatment dysphagia rates of 56.6%, and other complica tion (hoarseness and noisy breathing) rates of 38.9% at initial follow-up using 50 – 75U BTX. 8 The lateral tran scervical (TCerv-IO) technique was described by two authors from this study group, which is less effective but also less invasive than TCric-IO approach with short term success rates of 64.9%, dysphagia rates of 46%, and other complication rates of 5%. 7

DOI: 10.1002/lary.31591

Laryngoscope 00: 2024

Doruk et al.: Botulinum Toxin Injection for RCPD 1