**7. Conclusion**

types might be considered "neurogenic," the authors of some studies suggest that the postural signs were sufficiently selective and specific to warrant a separate classification [7]. Therefore, Riski et al. [7] considered the presence of pharyngeal asymmetry with large boluses to be a sign of "postural dysphagia." Of 43 patients, 16 showed only neurologic signs; three showed only postural signs; and three showed combined postural and neurologic signs. The findings of Riski et al. suggest that swallowing abnormalities in CD are primarily neurogenic but may be solely postural or combined neurogenic and postural in nature. In agreement with this conclusion that CD involves neurogenic dysphagia, similar clinical and electrophysiological findings were reported in patients with OMD and laryngeal dystonia but not CD and in others with CD. Therefore, dysphagia can occur without abnormal head or neck movements [6]. Electrophysiological abnormalities in dystonic muscles are frequent and are all compatible

Two-thirds of those who complained of dysphagia showed evidence of swallowing abnor‐ malities, and at least one swallowing abnormality was detected radiographically in half of those who did not complain. This lack of close agreement between subjective reports and videofluoroscopic results may reflect several factors. Firstly, videofluoroscopic examination of swallowing can show dysfunctions; however, as the protocol is standardized, it does not simulate all factors present during meals in the patient's home, e.g., the full range of textures and bolus sizes, the speed of bolus presentation and the presence of external distractions. Secondly, some patients' concerns with the discomfort or cosmetic disability associated with their CD may overshadow the relatively subtle abnormalities in oropharyngeal function. Thirdly, CD patients may have adapted to changes in swallowing function and therefore be

Dysphagia and dysarthria (which account for 10.2 % to 37 % and 0.9 % of complaints, respec‐ tively) are the two most common adverse effects of BoNT treatment for OMD [37,42]. Clinical and videofluoroscopic evaluations have also indicated a high incidence of swallowing disorders in CD patients before any treatment such as BoNT injection or rhizotomy [7-9]. In a study by Comella et al., although new radiologic changes occurred in 50 % of CD patients following BoNT treatment, clinically only 33 % of these patients reported new dysphagia symptoms. The severity of new dysphagia symptoms correlated highly with the severity of new radiologic pharyngeal abnormalities. This suggests that rather than being routinely indicated, videofluoroscopic swallowing evaluations should be reserved mainly for patients with the severest clinical symptoms as an objective measure to assess the possibility of

**6. Avoiding dysphagia as an adverse effect of treatment for dystonia**

condition did not worsen following treatment [8].

Radiologic findings show that in patients with dysphagia prior to treatment with BoNT-A, the

Careful choice of the correct muscle groups with the aid of electromyography before applica‐ tion of BoNT and the use of low dosages may prevent adverse effects [29]. In a study by

with neurogenic dysphagia [6].

196 Seminars in Dysphagia

asymptomatic [7].

aspiration [8].

Dystonia is an important cause of dysphagia. The main aspects to observe in dystonic patients are:

