[Dysphagia] Botox to assist with mastication/swallowing

[Tara.Moore at chw.edu (Moore, Tara - SJHMC)]

I have a 22 year-old patient who suffered anoxic brain injury a few years
ago secondary to cardia arrest. He has had a PEG tube since the accident and
has, "a severe-profound oropharyngeal dysphagia characterized by (per MBSS
01/23/06), severely decreased initiation (as expected with anoxic brain
injury), severely decreased mastication with open mouth posture and anterior
leakage, inability to move bolus posteriorly, gradual premature spillage to
the valleculae, occasional triggering of pharyngeal swallow with minimal
passage of material, no penetration, mild residue throughout the pharyngeal
recessess." He has hx of pneumonia x2 b/w June 2005 and December 2005.

OP dysphagia therapy over the last four months has focused on increasing
voltional dry swallows, increasing lingual control/movement, increasing
one-step commands for oral musculature, increasing frequency of swallows and
the timeliness of swallow, and increasing oral sensitivity. He has much
improved superior/anterior laryngeal movement and a strong phayngeal
swallow...problem is I cannot improve his open mouth posturing so he leaks
all po trials anteriorly. In addition - it is much harder to swallow with
open mouth posturing.  He has significant dystonia...and I've noticed with
cold stimuli (e.g., lemon glycerin swabs) lingual tone kicks in. His jaw is
very tight and appears to be spastic as well. It appeared to get better with
massage I trained his caregiver with - but I think the care is inconsistent.
The patient gets Botox BUE every few months and has previously gotton Botox
in BLE as well...has anyone ever considered Botox for muscles of
mastication? I've never heard of this...but thought it may work with
dystonia? The masseter, the temporalis, the medial pterygoid, and the
lateral pterygoid? Any other ideas?

Any input is greatly appreciated....I'm running out of ideas! :)

Tara C. Moore, MS, CCC-SLP
Speech/Language Pathologist
St. Joseph's Hospital and Medical Center
Outpatient Rehabilitation
114 W. Thomas Rd. 
Phoenix, AZ 85013
(P) 602-406-6494
(F) 602-406-4105
tara.moore at chw.edu