Oropharyngeal dysphagia in a case of wound botulism Megan Urban, MA, CCCSLP Samantha Cabla, MS, CCCS

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Oropharyngeal dysphagia in a case of wound
botulism Megan Urban, MA, CCC-SLP Samantha
Cabla, MS, CCC-SLPHarrison Jones, PhD


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Wound Botulism

• Acquired from the introduction of Clostridium
  botulinum spores into the body
• Results in descending, symmetrical bulbar
  paralysis of CNs V, VII, VIII, IX, X, XI, XII
• Progresses to the upper extremities, the
  respiratory muscles, and eventually the lower
  extremities
• Intact sensation

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Dysphagia in Botulism

• Dysphagia has long been recognized to be a sign
  of botulism
• Limited data describing specific swallowing signs
• Mangilli Furguim de Andrade (2007) described
  the signs of dysphagia in a male with food
  botulism and tracheostomy
• Reduced hyolaryngeal movement, absence of active
  swallow of saliva, and oromotor weakness
• Biggs Quick (2003) mystery dysphagia

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Patient Description34 year old male fell playing
soccer

• Day 1 surgical repair of fractured arm
• Day 10 ED for diplopia and ptosis with
  instructions to contact ophthalmology
• Day 11 admitted to OSH with difficulty
  swallowing and changes in speech
• Day 16 admitted to our facility
• EMG - evidence of a presynaptic disorder of the
  neuromuscular junction
• Wound Botulism diagnosed
• Day 17 CDC notified and antitoxin administered
• Day 27 discharged home

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Clinical Swallow Examination

• Day 15 (at OSH)
• Labored oral manipulation of an ice chip, limited
  hyolaryngeal excursion, and immediate cough
  following swallow
• Poor secretion management, inability to clear wet
  vocal quality, and oral suctioning
• Day 16, 18, 19, and 23 No change
• Required ICU airway observation

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Clinical Swallow Reassessment

• Day 25
• Managing secretions
• No overt clinical signs of aspiration
• Repeated swallows per bolus (5-6)
• VFSE recommended

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Videofluoroscopic Swallow Exam

• Thin liquid, pureed, and solid food trials
• Oral stage WNL
• Pharyngeal stage
• Decreased hyolaryngeal movement
• Moderate post-swallow residue
• Multiple swallows cleared residue
• Trace penetration with thin liquids (completely
  cleared w/ swallow)
• Trace penetration 1X with thin liquids (cleared
  with reflexive throat clear)

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Swallow Recommendations

• Mechanical soft diet with thin liquids
• Alternate solids and liquids
• Multiple swallows per bolus
• Dysphagia therapy
• Effortful swallow, Mendelson maneuver, and Masako
  maneuver
• Five sets of ten repetitions of these exercises
  daily

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Follow-up

• Patient consumed 100 of breakfast the following
  day
• Patient denied symptoms of aspiration, though
  multiple swallows per bolus remained necessary

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Outcome at one monthPhone interview

• Patient reported
• Perception of normal swallow function
• Return to a regular diet
• Swallowing one time per bolus
• Noncompliance with dysphagia therapy program

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Conclusion

• Dysphagia can be expected in cases of wound
  botulism
• Botulism does not result in sensory deficit
• This patient demonstrated poor secretion
  management, evidence of intact sensation, limited
  hyolaryngeal movement, and multiple swallows per
  bolus
• Eight days after the antitoxin was administered,
  improvement in swallow function was confirmed
  VFSE
• Findings correlated with clinical impressions

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Questions?

• Megan.Urban_at_duke.edu

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Thank you!