Vagal nerve magnetic stimulation for post-traumatic cricopharyngeal achalasia with bilateral vocal cord paralysis: A case report.

Abstract

Rationale: Post-traumatic dysphagia is a severe complication of traumatic brain injury, particularly in cases involving medullary damage. The rare combination of cricopharyngeal achalasia and bilateral vocal cord paralysis presents substantial challenges, with profound swallowing dysfunction and increased aspiration risk. Current treatments primarily target cricopharyngeal dysfunction but lack effective solutions for concurrent vocal cord paralysis, highlighting the need for innovative therapeutic strategies.

Patient concerns: A 15-year-old male presented with severe dysphagia, confirmed as upper esophageal sphincter (UES) dysfunction and bilateral vocal cord paralysis. The patient exhibited severe aspiration (grade V water swallowing test, penetration aspiration scale: score of 7) and elevated UES residual pressure (28.2 mm Hg, normal < 12.0 mm Hg).

Diagnoses: Post-traumatic neurogenic dysphagia with cricopharyngeal achalasia and bilateral vocal cord paralysis secondary to medullary damage.

Interventions: An individualized protocol combining vagus nerve magnetic stimulation (VNMS) and conventional rehabilitation was implemented. VNMS targeted the left vagus nerve using 5 Hz stimulation at 80% resting motor threshold, while rehabilitation included pulmonary exercises, balloon dilation therapy, and tongue base pressure training.

Outcomes: Substantial improvements were observed. UES residual pressure decreased from 28.2 mm Hg to 2.7 mm Hg, penetration aspiration scale score improved from 7 to 2, and the functional oral intake scale increased from level 1 to level 6, enabling oral feeding and removal of the tracheostomy and gastric tube. No adverse events were reported.

Lessons: This case highlights the potential of VNMS as a noninvasive and effective treatment for complex post-traumatic brain injury dysphagia involving cricopharyngeal achalasia and bilateral vocal cord paralysis. By addressing dual swallowing-related pathologies, VNMS offers a promising therapeutic approach in neurorehabilitation. Further research is warranted to validate these findings and explore broader clinical applications.