• Jian-Min Chen, Yang-Jia Chen, Jun Ni, and Zhi-Yong Wang.
• Department of Rehabilitation Medicine, The First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, China.
• Medicine (Baltimore). 2021 Mar 19; 100 (11): e24909e24909.

IntroductionBotulinum toxin (BTX) injection is a widely used treatment option for dysphagia associated with cricopharyngeal (CP) muscle achalasia, but uniform standards and protocols for administration techniques and injection sites are still lacking. This case study suggests that a unique administration technique involving a combination of ultrasound, electromyography, and balloon guidance for injecting the CP muscle can reduce inadvertent migration of BTX to non-injected tissues and increase the effectiveness and safety of BTX treatment.Patient ConcernsWe describe the case of a 74-year-old man who could not swallow food or saliva for 8 months.DiagnosisThe patient showed signs of true bulbar paralysis, including dizziness, hoarseness, and dysphagia. The fiberoptic endoscopic evaluation of swallowing showed massive mucilage secretion and residual materials in the postcricoid region and aspiration when swallowing 1 ml of yogurt. The video fluoroscopic swallowing study showed profoundly limited epiglottic folding and CP muscle non-relaxation, despite several unsuccessful swallow attempts.InterventionsTo manage insufficient relaxation opening of the CP muscle, BTX injection was performed using ultrasound, electromyography, and balloon catheter guidance. The narrow CP muscle situated above the balloon was identified as the target of injection by ultrasound.OutcomesThe patient was able to eat a soft diet. The follow-up fibrotic endoscopic swallowing study demonstrated a reduction in the amount of pharyngeal residue. The video fluoroscopic swallowing study showed that CP muscle relaxation was significantly enhanced and no penetration was shown.ConclusionThe unique administration technique with triple guidance holds several advantages, suggesting that it may be a promising treatment for CP muscle achalasia.Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.

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