Oropharyngeal Dysphagia in Wound Botulism

Abstract

Abstract Botulism results in a symmetric bulbar paralysis due to neuroparalytic toxins produced by Clostridium botulinum. These toxins block release of the neurotransmitter acetylcholine at the neuromuscular junction, resulting in paralysis. Several forms of botulism occur, all rare in the United States. The prominent bulbar involvement suggests oropharyngeal dysphagia is common in botulism. This article reviews the botulism literature with an emphasis on dysphagia, the swallowing signs, and clinical course in a single case of noninjection drug use wound botulism. The patient was admitted to an outside hospital with dysphagia and dysarthria 11 days after suffering a traumatic sports injury. He was later transferred to our tertiary care facility, diagnosed with wound botulism, and administered botulinum antitoxins. Repeated clinical swallow examinations were notable for decreased hyolaryngeal excursion, coughing after swallowing, and poor secretion management. Eight days after administration of botulinum antitoxins, a clinical improvement in swallow function was noted. Videofluoroscopy revealed normal oral stage function, decreased hyolaryngeal movement, reduced upper esophageal sphincter opening, pharyngeal residue, and penetration. Swallowing sensation appeared intact throughout his clinical course. An oral diet and dysphagia therapy including the use of compensatory and rehabilitative swallow techniques were recommended. During telephone follow-up one month later, the patient reported complete resolution of swallowing difficulty despite lack of compliance with the program of swallow rehabilitation.