Les troubles de la déglutition postintubation et trachéotomie

The presence of endotracheal or tracheostomy tube disrupts the normal physiology of swallowing. The most frequently related abnormal mechanical factors are delayed triggering of the swallowing response, reduced laryngeal elevation, reduced cough due to “desensitization” of larynx and reduced subglottic pressure. These abnormalities lead to delay in oral feeding and even aspiration pneumonia. The transglottic airflow has to be restored as soon as the patient does not need ventilation. But the difficulties of introduction of oral feeding can also be due to age, concomitant disease (e.g. COPD, neurologic diseases) or critical illness polyneuropathy. Fiberoptic endoscopic evaluation of swallowing allows an accurate diagnosis of swallowing disorders to provide safe swallow and avoid aspiration pneumonia.     

Predictors of dysphagia after spinal cord injury.

OBJECTIVE: To quantify the incidence of swallowing deficits (dysphagia) and to identify factors that predict risk for dysphagia in the rehabilitation setting following acute traumatic spinal cord injury. DESIGN: Retrospective case-control study. SETTING: Freestanding rehabilitation hospital. PATIENTS: Data were collected on 187 patients with acute traumatic spinal cord injury admitted for rehabilitation over a 4-year period who underwent a swallowing screen, in which 42 underwent a videofluoroscopic swallowing study (VFSS). MAIN OUTCOME MEASURES: VFSS was performed on patients with suspected swallowing problems. Possible antecedents of dysphagia were recorded from the medical record including previous history of spine surgery, surgical approach and technique, tracheostomy and ventilator status, neurologic level of injury, ASIA Impairment Classification, orthosis, etiology of injury, age, and gender. RESULTS: On admission to rehabilitation 22.5% (n = 42) of spinal cord injury patients had symptoms suggesting dysphagia. In 73.8% (n = 31) of these cases, testing confirmed dysphagia (aspiration or requiring a modified diet), while VFSS ruled out dysphagia in 26.2% (n = 11) cases. Logistic regression and other analyses revealed three significant predictors of risk for dysphagia: age (p < .028), tracheostomy and mechanical ventilation (p < .001), and spinal surgery via an anterior cervical approach (p < .016). Other variables analyzed had no relation or at best a slight relation to dysphagia. Tracheostomy at admission was the strongest predictor of dysphagia. The combination of tracheostomy at rehabilitation admission and anterior surgical approach had an extremely high rate of dysphagia (48%). CONCLUSION: Swallowing abnormalities are present in a significant percentage of patients presenting to rehabilitation with acute traumatic cervical spinal cord injury. Patients with a tracheostomy appear to have a substantially increased risk of development of dysphagia, although other factors are also relevant. Risk of dysphagia should be evaluated to decrease the potential for morbidity related to swallowing abnormalities.     

Cognitive-behavioral recovery in comatose patients following auditory sensory stimulation.

Nursing therapies promote recovery following severe traumatic brain injury (TBI). However, the type and dose of treatment needed to stimulate functional plasticity have not been determined. In this quasi-experimental study, the effects of a structured auditory sensory stimulation program (SSP) were examined in 12 male patients, 17-55 years old, with severe TBI. SSP was initiated 3 days after injury and continued for 7 days. Recovery was measured by comparing baseline Glasgow Coma Scale (GCS), Sensory Stimulation Assessment Measure (SSAM), Ranchos Los Amigos Level of Cognitive Functioning Scale (RLA), and Disability Rating Scale (DRS) scores to ending scores between those who received SSP and those who did not. For the intervention group a positive recovery of function trajectory was found for mean GCS, and there was a greater improvement in GCS and RLA scores between baseline and at discharge testing periods. DRS and SSAM scores at baseline and at discharge were significantly different. SSP did not affect hemodynamic or cerebral dynamic status. Early and repeated exposure to an SSP may promote arousal from severe TBI without adversely influencing cerebral dynamic status.     

脑卒中患者吞咽障碍的喂食指导与康复训练的护理

目的探讨喂食指导与吞咽功能训练护理对脑卒中患者吞咽障碍的临床效果。方法选取本院2011年4月-2012年6月收治的156例脑卒中吞咽障碍的患者,随机分为试验组（78例）和对照组（78例）,对照组采用常规治疗,试验组在对照组的基础上实施喂食指导与吞咽功能训练,治疗30d后评价治疗疗效和洼田饮水试验改善程度。结果试验组总有效率明显高于对照组,2组差异具有统计学意义（P〈0．01）。2组洼田饮水试验均较治疗前有改善,但试验组改善程度明显高于对照组,2组差异具有统计学意义（P〈0．01）。结论对急性脑卒中并发吞咽障碍患者进行喂食指导与吞咽功能训练,对改善患者吞咽困难程度有重要意义。     

Communication, swallowing and feeding in the intensive care unit patient

Background: It is not uncommon for patients requiring a period of time in the intensive care unit (ICU) to experience difficulties with communication and/or swallowing, either as a result of their illness or as a result of the treatments they receive. These difficulties can be both short term and long term and require timely and appropriate intervention in order to improve the patient’s experience and expedite recovery/rehabilitation. Aims: The purpose of this article is to provide critical care nurses with an update on aspects of communication, swallowing and feeding in the ICU. The paper will focus on each area in relation to the current evidence base and factors of ‘best practice’ (as determined by expert opinion). Implications for critical care nursing practice:

• ? Enabling communication can improve well‐being, increase compliance and reduce length of stay;
• ? Simple modes of communication, e.g. writing/gesture/pictures can be very effective;
• ? Coded eye blinking may be unreliable because of confusion with reflexive blinking;
• ? Non‐oral nutrition will generally not meet the psychological and physical needs and benefits of oral intake;
• ? Not all patients with a tracheostomy in situ will experience dysphagia; however, those considered ‘at risk’ should have their swallow assessed by an appropriately trained professional, e.g. speech and language therapist/dysphagia trained professional;
• ? An inflated tracheostomy cuff will not prevent aspiration. The decision to commence oral intake in the presence of an inflated cuff should be made as a team and take into consideration the patient’s medical and psychological status;
• ? The use of blue dye to assess the swallow carries a high false‐negative rate and cannot be relied on alone to predict either the presence or the absence of aspiration.

Conclusion: There is still much more research to be performed and evidence to be gained regarding the input into communication, swallowing and feeding in the ICU; however, a full‐team approach to these areas can have very positive effects on the patient’s experience.     

Duration of dysphagic symptoms and swallowing outcomes after thermal burn injury.

Levels of swallowing disability, patterns of dysphagia rehabilitation and swallowing outcomes on discharge were retrospectively reviewed for 30 patients with thermal burn injury (with or without inhalation injury), referred to speech pathology services for dysphagia management. The average total surface burn area of the group was 50%. All patients were mechanically ventilated for an average of 24 days, with 80% of patients requiring subsequent tracheostomy. Initial dysphagia assessment occurred approximately 20 days after admission, whereas first safe oral intake was achieved by approximately 30 days. Supplementary nutrition and hydration was necessary for all patients. The time to achieve oral intake without supplementation was 53 days. Outcome measures revealed a significant improvement in swallowing function throughout the duration of inpatient stay, with 90% of patients discharged safely tolerating a normal diet, 6.7% of patients managing soft diet consistencies, and 3.3% managing soft puree consistencies on discharge.     

Swallowing dysfunction after mechanical ventilation in trauma patients

Background

Swallowing dysfunction can occur after mechanical ventilation, leading to complications such as aspiration and pneumonia. After mechanical ventilation, authors have recommended evaluating patients with contrast studies or endoscopy to identify patients at risk for swallowing dysfunction and aspiration. The purpose of the study was to determine if a bedside swallowing evaluation (BSE) can identify patients with swallowing dysfunction after mechanical ventilation.

Methods

This is a 1-year (2008) prospective study of all adult trauma patients admitted to the intensive care unit requiring mechanical ventilation. Upon separation from mechanical, all patients received a BSE. The BSE used mental status, facial symmetry, swallow reflex, and oral ice chips and water to identify swallowing dysfunction. Patients who passed the BSE were advanced to oral intake per physician orders, whereas patients who failed the BSE were allowed nothing by mouth.

Results

A total of 345 patients were included; 54 died before separation from mechanical ventilation and were excluded. The remaining 291 patients underwent BSE after separation from mechanical ventilation, with 143 (49%) passing and 148 (51%) failing. Patients who failed the BSE required mechanical ventilation longer than those who passed (14 ± 13 vs 5 ± 20 days, P = .001). In addition, only 23% of patients extubated within 72 hours failed the BSE, whereas 78% of those intubated more than 72 hours failed the BSE (P < .001). All patients who passed the BSE were discharged from the hospital without a clinical aspiration event. Independent risk factors for failure of BSE included tracheostomy, older age, prolonged mechanical ventilation, delirium tremens, traumatic brain injury, and spine fracture. Three (2%) patients who failed the BSE had a clinical aspiration event despite taking nothing by mouth.

Conclusions

A simple BSE can be used to identify patients at risk for swallowing dysfunction after mechanical ventilation. More importantly, BSE can safely clear patients without swallowing dysfunction, avoiding costly and time-consuming contrast studies or endoscopic evaluation.     

Heparin lock for nighttime intravenous fluid management in a dysphagic patient

Dysphagia, with its inherent risk of aspiration, is a clinical problem frequently encountered in patients with brain injury from trauma or cerebrovascular accident. The use of nasogastric tubes and intravenous lines for nutrition and hydration can be cumbersome and uncomfortable for the patient, and can interfere with rehabilitation therapy. With the advent and increased use of video- and cinefluoroscopy to evaluate swallowing, the type of dysphagia can be defined more readily. This article describes the use of a heparin lock at night to provide fluids intravenously to a patient who could swallow solid or semisolid food, but aspirated thin liquids. This approach insured adequate hydration while keeping the patient free of parenteral lines and nasogastric tubes during therapy. This technique was continued for 3 1/2 weeks until the patient's dysphagia improved and a full oral diet could be resumed. The authors recommend the use of nighttime intravenous feeding via a heparin lock as an option for managing this subset of dysphagic patients in a rehabilitation setting.     

Association Between the Swallowing Reflex and the Incidence of Aspiration Pneumonia in Patients With Dysphagia Admitted to Long-term Care Wards: A Prospective Cohort Study of 60 Days

ObjectiveTo investigate the association between the Simple Swallowing Provocation Test (SSPT) and the incidence of aspiration pneumonia in patients with dysphagia in long-term care (LTC) wards.DesignThe study design was a prospective cohort study. Participants were followed for 60 days from admission.SettingLTC wards.ParticipantsStudy participants were patients with dysphagia aged ≥65 years who were admitted to LTC wards between August 2018 and August 2019. In total, 39 participants were included in the analysis (N=39; 20 male, 19 female; mean age, 83.8±8.5y). Participants were divided into 2 groups based on SSPT results: normal swallowing reflex (SSPT normal group) and abnormal swallowing reflex (SSPT abnormal group). The covariates were age and sex, primary disease, history of cerebrovascular disease, Glasgow Coma Scale, body mass index, Geriatric Nutritional Risk Index, the Mann Assessment of Swallowing Ability, Food Intake Level Scale, FIM, and Oral Health Assessment Tool.InterventionsNot applicable.Main Outcome MeasuresThe outcome was the incidence of aspiration pneumonia during the first 60 days of hospitalization, and the predictive factor was SSPT: 0.4 mL.ResultsThe incidence of aspiration pneumonia was 33.3% in the SSPT normal group and 76.2% in the SSPT abnormal group. The φ coefficient (a measure of association for 2 binary variables) was 0.43, the risk ratio (the ratio of the probability of an outcome in an exposed group to the probability of an outcome in an unexposed group) was 2.29, and the 95% confidence interval was 1.14-4.58 for the SSPT abnormal group.ConclusionsOur findings suggest that the SSPT provides a valid index for the development of aspiration pneumonia in older patients with dysphagia admitted to LTC wards.     

Swallowing in individuals with disorders of consciousness: A cohort study

BackgroundAfter a period of coma, a proportion of individuals with severe brain injury remain in an altered state of consciousness before regaining partial or complete recovery. Individuals with disorders of consciousness (DOC) classically receive hydration and nutrition through an enteral-feeding tube. However, the real impact of the level of consciousness on an individual's swallowing ability remains poorly investigated.ObjectiveWe aimed to document the incidence and characteristics of dysphagia in DOC individuals and to evaluate the link between different components of swallowing and the level of consciousness.MethodsWe analyzed clinical data on the respiratory status, oral feeding and otolaryngologic examination of swallowing in DOC individuals. We analyzed the association of components of swallowing and participant groups (i.e., unresponsive wakefulness syndrome [UWS] and minimally conscious state [MCS]).ResultsWe included 92 individuals with DOC (26 UWS and 66 MCS). Overall, 99% of the participants showed deficits in the oral and/or pharyngeal phase of swallowing. As compared with the MCS group, the UWS group more frequently had a tracheostomy (69% vs 24%), with diminished cough reflex (27% vs 54%) and no effective oral phase (0% vs 21%).ConclusionAlmost all DOC participants had severe dysphagia. Some components of swallowing (i.e., tracheostomy, cough reflex and efficacy of the oral phase of swallowing) were related to consciousness. In particular, no UWS participant had an efficient oral phase, which suggests that its presence may be a sign of consciousness. In addition, no UWS participant could be fed entirely orally, whereas no MCS participant orally received ordinary food. Our study also confirms that objective swallowing assessment can be successfully completed in DOC individuals and that specific care is needed to treat severe dysphagia in DOC.     

中重型颅脑损伤患者的康复治疗

目的 :研究中重型颅脑损伤患者综合康复治疗效果及影响因素。方法 :6 4例中重型颅脑损伤患者采用综合康复措施进行治疗 ,并运用Glasgow昏迷量表 (GCS)、简易精神状态检查量表 (MMSE)、平衡功能量表、运动功能 (Fugl Meyer)量表及日常生活活动能力 (ADL)进行疗效评定。结果 :6 4例患者平均治疗 12 0d ,其认知功能、平衡功能、运动功能及ADL均有明显改善。ADL的恢复主要受损伤程度和治疗时间的影响 (P <0 .0 5 ) ,认知功能的恢复与GCS和病程有关 (P <0 .0 5 )。结论 :中重型颅脑损伤患者ADL及认知能力恢复受颅脑损伤程度影响 ,综合康复治疗可降低颅脑损伤的残疾率 ,提高ADL。     

Hyoid-complex elevation and stimulation technique restores swallowing function in patients with lateral medullary syndrome:Two case reports

BACKGROUND A swallowing disorder may occur following a brainstem stroke,especially one that occurs in the swallowing centers.Lateral medullary syndrome(referred to as LMS),a rare condition in which a vascular event occurs in the territory of the posterior inferior cerebellar artery or the vertebral artery,has been reported to lead to more severe and longer lasting dysphagia.CASE SUMMARY We report two patients with dysphagia due to LMS and propose a novel technique named hyoid-complex elevation and stimulation technique(known as HEST).The two patients had no other functional incapacity back into life,but nasogastric feeding was the only possible way for nutrition because of severe aspirations.Swallowing function was evaluated by functional oral intake scale,modified water swallow test,surface electromyographic signal associated with video fluorography swallowing study to assess the situation of aspiration,pharyngeal residue,pharyngeal peristalsis,upper esophageal opening and the ability of deglutition.Both patients were treated with the HEST method for dysphagia and recovered quickly.CONCLUSION HEST is effective for shortening the in-hospital time and improving the quality of life for patients with dysphagia who suffer from LMS and likely other strokes.     

Dysphagia in patients with brainstem stroke: incidence and outcome

OBJECTIVE: This study was conducted to delineate the incidence and outcome of dysphagia among hospitalized patients who were referred for rehabilitation because of brainstem stroke. DESIGN: We retrospectively reviewed the medical records of 36 patients who were admitted because of brainstem stroke. Information on the patients' clinical features, feeding status, and the results of clinical and videofluoroscopic swallowing examinations were obtained through chart review. Follow-up interviews were conducted via telephone to learn the general medical condition and feeding status of the patients 7-43 mo after hospital discharge. RESULTS: A total of 81% of the patients had dysphagia at the time of initial clinical swallowing evaluation, which was performed 10-75 days after the onset of stroke. A total of 79% of the dysphagic individuals depended on tube feeding at the initial evaluation; 22% of all individuals could not resume oral intake at discharge. Statistical analyses revealed a significant association between poor outcome and disease involving the medulla, the presence of a wet voice during the initial swallowing test, and a delay or absence of the swallowing reflex. The incidence of aspiration pneumonia was 11%. There was a correlation between the detection of aspiration by modified barium meal videofluoroscopy and the development of aspiration pneumonia. Follow-up interviews showed that 88% of the 27 patients who were contacted had resumed full oral intake 4 mo after the onset of stroke. CONCLUSIONS: The incidence of dysphagia was relatively high in our study population. The long-term outcome was favorable.     

不同稠度和容积吞咽任务对卒中后吞咽障碍患者吞咽生理成分表现及渗漏误吸的影响

目的 探讨不同稠度和容积吞咽任务对卒中后吞咽障碍患者吞咽生理成分表现及渗漏误吸的影响。 方法 选取在我院康复科治疗的59例脑卒中后吞咽障碍患者作为研究对象,参照中国改良容积粘度测试程序,按2、1、0、3号（分别对应中稠度、低稠度、硫酸钦原液及高稠度）顺序分别对每种稠度食物进行3、5、10 ml的吞咽造影检查。使用标准化吞钡造影功能障碍评价量表（MBSImP）和Rosenbek渗漏/误吸量表进行量化分析。记录患者在执行不同稠度及容积吞咽任务时其各个吞咽生理成分评分和渗漏误吸分级。 结果 入选患者舌控制、咽期吞咽启动及喉关闭均在吞咽0号食物时表现较差,口腔残留在执行大容积吞咽任务时表现较差,咽蠕动在执行较小容积吞咽任务时表现较差。入选患者在执行低稠度、大容积吞咽任务时发生渗漏误吸的风险较高;其渗漏误吸分级与咽期总分间具有明显正相关性（r=0.365,P<0.01）,并以喉关闭与渗漏误吸分级间的相关性尤为显著（r=0.772,P<0.01）。 结论 脑卒中吞咽障碍患者口咽期各吞咽生理成分的表现与进食食物稠度及容积密切相关,患者在执行较低稠度、较大容积吞咽任务时发生渗漏误吸的风险较高。     

脑损伤后吞咽功能障碍患者康复护理干预及效果评价

目的：评价综合康复治疗和康复护理干预对脑损伤后吞咽功能障碍患者的效果。方法：脑损伤致吞咽功能障碍患者60例,随机分为A、B 2组各30例,均接受药物治疗、吞咽功能训练、球囊扩张术及低频电刺激等综合康复治疗。A组同时实施摄食直接训练、摄食行为训练、食物调节与营养及心理康复等护理干预。治疗前后评定2组吞咽功能。结果：治疗1个月后,2组洼田饮水试验改善程度和X线透视（VFSS）评分均明显高于治疗前;A组高于B组（均P〈0.05,0.01）。临床疗效比较,A组总有效率明显高于B组（93.3%与73.3%,P〈0.05）。结论：综合康复治疗结合康复护理干预能更加有效促进脑损伤后吞咽功能障碍的恢复。     

16例鼻咽癌放射治疗后进食困难患者的康复护理

总结16例鼻咽癌放射治疗后进食困难患者的康复护理经验.本组行胃造瘘置管术后,均进行了有效的口腔护理和鼻咽腔护理.通过吞咽功能训练和进食管理,14例恢复经口进食功能,其中,8例拔除胃造瘘管,6例经口进食量不足,需继续经胃造瘘管注食.本组患者体重明显增加,吸入性肺炎得以控制.康复成功率达81.25％.     

重型闭合性颅脑损伤患者的康复临床研究

目的：研究重型闭合性颅脑损伤住院患者综合康复治疗的效果以及影响因素。方法：对住院的69例重型颅脑损伤患者进行综合康复治疗，采用Glasgow昏迷量表（GCS）、日常生活能力（ADL）、残疾分级量表（DRS）、简易精神状态检查表（MMSE）等评定疗效并进行统计学分析。结果：本组病例的年龄、病程、治疗时间、GCS、昏迷时间等均有较大差异，其中GCS评分明显受昏迷时间的影响（P＜0．001）；患者的日常生活能力、认知能力和残疾水平均有较大程度的改善（P＜0．001）；手术组认知功能的恢复较非手术组明显（P＜0．05）；日常生活能力的恢复主要受损伤严重程度（GCS评分）和治疗时间的影响（P＜0．05）；认知功能的恢复除受GCS影响外（P＜0．01），病程短恢复好（P＜0．05）。结论：临床综合康复治疗对于重型闭合性颅脑损伤患者各种功能的恢复具有肯定的效果，日常生活能力和认知能力的恢复受颅脑损伤程度的影响、脑损伤患者认知功能的康复体系有待加强。     

Swallowing disorders in patients with prolonged orotracheal intubation or tracheostomy tubes

Eleven patients were tested for swallowing dysfunction after prolonged orotracheal intubation. Ten had a tracheostomy tube. Mean duration of orotracheal intubation was 19.9 days, mean age 65 yr, and no patient had a concomitant neurologic deficit. All patients had a modified barium swallow with videofluoroscopy. All patients had at least one defect of 11 defects characterized. There was a mean of six defects/patient. The most common defects were delayed triggering of the swallow response (present in all patients) and pharyngeal pooling of contrast material (n = 9). Follow-up videofluoroscopy was performed in five patients (all had improved) with mean defects decreasing from 6.1 to 2.8/patient. With one exception, no patient had any defect that was worse than mild in severity. We concluded that prolonged orotracheal intubation with or without tracheostomy may cause prolonged and severe swallowing dysfunction. The deficits improve with time. The presence of a gag reflex does not confer protection against aspiration of pharyngeal contrast.     

Early tracheostomy in closed head injuries: experience at a tertiary center in a developing country – a prospective study

Background

An important factor contributing to the high mortality in patients with severe head trauma is cerebral hypoxia. The mechanical ventilation helps both by reduction in the intracranial pressure and hypoxia. Ventilatory support is also required in these patients because of patient's inability to protect the airway, persistence of excessive secretions, and inadequacy of spontaneous ventilation. Prolonged endotracheal intubation is however associated with trauma to the larynx, trachea, and patient discomfort in addition to requirement of sedatives. Tracheostomy has been found to play an integral role in the airway management of such patients, but its timing remains subject to considerable practice variation. In a developing country like India where the intensive care facilities are scarce and rarely available, these critical patients have to be managed in high dependency cubicles in the ward, often with inadequately trained nursing staff and equipment to monitor them. An early tracheostomy in the selected group of patients based on Glasgow Coma Score(GCS) may prove to be life saving.Against this background a prospective study was contemplated to assess the role of early tracheostomy in patients with isolated closed head injury.

Methods

The series consisted of a cohort of 50 patients admitted to the surgical emergency with isolated closed head injury, that were not considered for surgery by the neuro-surgeon or shifted to ICU, but had GCS score of less than 8 and SAPS II score of more than 50. First 50 case records from January 2001 that fulfilled the criteria constituted the control group. The patients were managed as per ATLS protocol and intubated if required at any time before decision to perform tracheostomy was taken. These patients were serially assessed for GCS (worst score of the day as calculated by senior surgical resident) and SAPS scores till day 15 to chart any changes in their status of head injuries and predictive mortality. Those patients who continued to have a GCS score of <8 and SAPS score of >50 for more than 24 hours (to rule out concussion or recovery) underwent tracheostomy. All these patients were finally assessed for mortality rate and hospital stay, the statistical analysis was carried out using SPSS10 version. The final outcome (in terms of mortality) was analyzed utilizing chi-square test and p value <0.05 was considered significant.

Results

At admission both tracheostomy and non-tracheostomy groups were matched with respect to GCS score and SAPS score. The average day of tracheostomy was 2.18 ± 1.0038 days. The GCS scores on days 1, 2, 3, 4, 5, 10 between tracheostomy and non-tracheostomized group were comparable. However the difference in the GCS scores was statistically significant on day 15 being higher in the tracheostomy group.Thus early tracheostomy was observed to improve the mortality rate significantly in patients with isolated closed head injury

Conclusion

It may be concluded that early tracheostomy is beneficial in patients with isolated closed head injury which is severe enough to affect systemic physiological parameters, in terms of decreased mortality and intubation associated complications in centers where ICU care is not readily available. Also, in a selected group of patients, early tracheostomy may do away with the need for prolonged mechanical ventilation.     

Severe Dysphagia after botulinum toxin B injection to the lower limbs and lumbar paraspinal muscles

We report a case of severe dysphagia in a 29-yr-old woman with cerebral palsy after she was injected with botulinum toxin B to her lower limbs and lumbar paraspinal muscles. Four days after the treatment, she developed difficulty swallowing, more severe for solid foods than for liquids, accompanied by dry mouth, blurred vision, and voice hoarseness. Fifteen days after the injection, with worsening of her dysphagia, she was hospitalized. A laryngoscopic evaluation revealed bilateral vocal cord paresis, and a modified barium swallow test demonstrated delayed oral initiation, upper airway penetration, and no reflexive cough. In the following days, she improved spontaneously and was discharged 12 days later when she re-acquired the ability to swallow solid foods. Her symptoms resolved completely only 75 days after the injection. Although dysphagia is a common side effect of botulinum injection in the neck, to our knowledge, this is the first reported case of severe dysphagia after injection in a distant anatomic site.