Disfagia orofaríngea secundaria a daño cerebral: diagnóstico, evolución, factores pronósticos y tratamiento con toxina botulínica

Abstract

In a previous study on oropharyngeal dysphagia after stroke and severe traumatic brain injury (TBI), all patients with clinically-suspected dysphagia were examined videofluoroscopically; some alterations was found in 87.5% of stroke patients and 90% of TBI patients, with an aspiration evidence of 66% and 62.5%, respectively. In stroke patients, altered pharyngeal security was more frequent in posterior vascular territory lesions and in patients with a history of pneumonia. No correlation was found between clinical findings and aspiration. Oral phase alterations were found in 65% of patients with neurogenic dysphagia secondary to TBI, being more prevalent in patients with a II-III score on the RLCF scale (80%); these patients also had a grater aspiration prevalence (73%). Improvement in cognitive alteration paralleled resolution of deglutition dysfunction. The initial RLCF score was the best prognostic factor in these patients. In our study on tracheal aspiration evolution in patients with oropharyngeal dysphagia after stroke and severe TBI, a significant improvement in swallowing physiology was found during follow-up, with progressive normalisation of mean oral and pharyngeal phase duration and a reduction in the number of aspirations. The most significant reduction in aspiration was observed between the 3 and 6 month controls, while no significant changes occurred between 6 months and one year. At one year of follow-up, 40% of stroke patients continued to aspirate (12% in anterior and 58% in posterior vascular territory); aspiration persisted in 23% of TBI patients. In stroke patients, aspiration persistence at the 1 year control was found to correlate significantly with the affected vascular territory, gag reflex abolition, glosso-palatal dysfunction and delay in triggering swallowing reflex at the first examination. For TBI patients, aspiration persistence at one year of evolution correlated significantly with neurological improvement severity (evaluated by RLCF and DRS scales), lingual control alteration, gag reflex abolition and delayed triggering swallowing reflex at the first examination. During follow-up, a reduction was also observed in the number of silent aspirations (at one year, no patient with aspiration was silent). In the final study, the efficacy of botulinum toxin (BTX-A) for the treatment of neurogenic dysphagia was studied in patients with upper oesophageal sphincter (UOS) opening alteration. Prior to treatment, all patients had residue in pyriform sinuses and aspiration. After BTX-A injection, both residue and aspiration decreased; at one year, aspiration persisted in only 3 patients. The manometric pattern prior to BTX-A injection showed incomplete UOS relaxation and high residual pressure. Post-treatment, improvement in relaxation and increased pharyngeal propulsion pressure were observed; these results were maintained throughout the study period. When the clinical efficacy of BTX-A injection was analysed, all but two patients were able to feed orally (normal diet or with compensations), with the majority reporting a subjective improvement in deglutition. No complications secondary to BTX-A injections were observed in this study.

Date of Award	3 Jun 2009
Original language	Undefined/Unknown
Supervisor	Fermín Mearin Manrique (Director) & Joan Monés Xiol (Director)