Videofluoroscopic‐guided botulinum toxin injections for pharyngoesophageal spasm after total laryngectomy
Year: 2013
Type: article
Abstract: After total laryngectomy (TL), three methods of speech production are commonly available: esophageal, artificial (i.e., electrolarynx or equivalent), and tracheoesophageal puncture (TEP) voice. TEP is a highly successful voice restoration method for the majority of TL patients and allows for the production of intelligible, more natural sounding and fluent alaryngeal speech.1 Although success rates remain high (near 80%), there are still complications that can confound tracheoesophageal (TE) voice production. A common problem is persistent pharyngoesophageal (PE) spasm, which typically makes it difficult for the patient to initiate and/or sustain TE voice. Although management options can include neurectomy, cricopharyngeal myotomy, or dilation when a stricture is indicated, chemical denervation has become a safe, easy, and cost-efficient choice to improve voice production. This article will discuss the evaluation of patients with suspected PE spasm and the management using videofluoroscopic-guided botulinum toxin (Botox) injections. We present a safe and effective technique and recommend its use for persisting PE spasm after total laryngectomy. All patients have an initial preoperative consultation with a speech language pathologist to discuss alaryngeal voice options and swallowing rehabilitation after TL. Patients are fit with a TE prosthesis after adequate time for healing (usually 4–8 weeks) and at the discretion of the speech language pathologist. Patients are seen regularly during the initial postoperative period to evaluate voice quality and fluency. Patients who have persisting poor TE voice quality after ruling out other causes are further evaluated under videofluoroscopy. Videofluoroscopy allows for real-time imaging of speech and swallowing mechanics and is performed by the speech language pathologist and the radiologist to asses TE speech and swallowing. Patients are evaluated during TE voice production and then presented with a variety of food textures while imaged in multiple dimensions (anterior-posterior, lateral) to assess both static and dynamic phases of speaking and swallowing. PE spasm is diagnosed as the presence of a posterior or anterior remnant of the pharyngeal constrictors that is at least partially dynamic during swallowing but impedes superior air flow during TE voicing. After informed consent is obtained, Botox injections are performed in the fluoroscopy suite with the assistance of the speech language pathologist. First, the patient is asked to swallow thin barium and a lateral fluoroscopic view is obtained to confirm the PE segment spasm. The use of thin barium also outlines the upper aerodigestive structures, simplifying the identification of the PE segment. Although all patients are offered lidocaine prior to administration of Botox, it is the senior author's experience that this can be more painful than the Botox injections themselves and therefore is of little use in this setting. A 27-gauge, 1.5-inch needle is used for injection. The Botox is diluted to 25 units/mL, and 4 mL are placed in a 5-mL syringe for optimal control of administration. A lead glove is used to protect the physician's hand, and the needle is passed in the midline under fluoroscopic guidance into the PE segment. If the PE segment is long (>2 cm), the needle trajectory is adjusted in the sagittal plane such that a midline, inferior, and superior injection can be performed through the same skin puncture site (Fig. 1). If the PE segment is short (<2 cm), the needle trajectory is adjusted in the axial plane such that a midline and two lateral injections can be performed through the same skin puncture site (Fig. 2). Approximately 1 mL is slowly infiltrated per injection site, so that three injections totaling 75 U of Botox are used on each patient (Fig. 3). All patients are contacted by telephone 1 week after Botox injections to assess response and are followed for their regular cancer care or at the discretion of the speech and language pathologist. Repeat Botox injections are performed within 1 to 2 months on patients with minimal improvement. (Panel A) Videofluoroscopic image of long segment pharyngoesophageal (PE) spasm demonstrated by large white arrows. (Panel B) Schematic of Botox injection sites along the PE segment in the sagittal plane at three points (points A, B, and C) through the same skin puncture. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] (Panel A) Videofluoroscopic image of a short segment of pharyngoesophageal (PE) spasm demonstrated by a single black arrow. (Panel B) Schematic of Botox injections sites along the PE segment in the axial plane at three points (points A, B, and C) through the same skin puncture. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Videofluoroscopic images of needle placement (white arrows) during Botox injections of a long (panel A) and short (panel B) pharyngoesophageal segment. Tracheoesophageal speech has been shown to significantly improve a patient's quality of life and limit the communication impairment following total laryngectomy.2, 3 However, there are several problems that may arise that can significantly reduce the patient's ability to produce a functional TE voice. Difficulties with phonation with an appropriately placed tracheoesophageal prosthesis and well-trained patient are commonly due to PE spasm. This is believed to be caused by a reapproximation of the innervated constrictor muscles with an intact cricopharyngeus muscle. Options for improving voice after the diagnosis of PE segment spasm include esophageal dilation, pharyngeal neurectomy, cricopharyngeal myotomy, or chemical denervation. Dilation is usually more successful for relieving dysphagia due to stricture. Pharyngeal neurectomy and cricopharyngeal myotomy have good success rates, but involve an open procedure and a risk of pharyngocutaneous fistula. Given its minimally invasive, fairly inexpensive, and reversible nature, chemical denervation has become the preferred management. Although the effects of Botox are temporary (usually lasting 6–9 months), most patients do not require more than two to three repeat injections as the effect lasts longer after each injection through an unknown mechanism. There have been multiple studies reporting good success in the treatment of PE segment spasm with Botox, although none describe the technique of using fluoroscopy to aid in needle placement. Hamaker and Blom report a 79% success rate after the first injection in a 12-year study involving 62 patients with PE segment spasm.4 Fifty-five percent of these patients responded for more than 6 months. With a second or third injection, 66% were able to maintain relaxation of the pharyngeal constrictors, and no further intervention was required. Similarly, Lewin et al. reported a success rate of 65% after the first injection, which increased to 87% with one or two more injections. The average duration of response was 20.4 months (±11.1 months), with a range of 5 to 37 months.5 Figure 4 shows post-treatment videofluoroscopic images of patients with normal bolus transit after Botox injections. Videofluoroscopic images at 3 months after Botox injections demonstrating essentially normal bolus transit in patients with a long (panel A) and short (panel B) pharyngoesophageal segment. Electromyogram (EMG) has also been used to confirm needle placement for Botox injections. This technique relies on markers placed on the skin during videofluoroscopy to guide EMG needle placement.4, 5 These skin markers can be the source of error as the patient changes positions from the radiology suite to the exam room. Also, because of the individual variations of the PE segment, EMG typically does not allow for multiple sagittal or axial injections that we are able to obtain when using videofluoroscopic guidance. Therefore, we feel the main benefit of videofluoroscopy over EMG guidance is the precision (watching the needle enter the PE segment) and the ability to perform multiple directed injections. Videofluoroscopic-guided botulinum injections to treat PE spasm after total laryngectomy represent a safe and effective technique and should be considered to improve TE voice disfluency.
Source: The Laryngoscope
DOI: 10.1002/lary.23410
Authors: Matthew E. Spector, Elizabeth Callaway, Erin L. McKean, Mark E. Prince
Institutions: VA Ann Arbor Healthcare System, Ann Arbor VA Medical Center
Language: English
Topic: Voice and Speech Disorders
Subfield: Physiology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2010796390