MEDICAL ACUPUNCTURE

Volume 19, Number 3, 2007

© Mary Ann Liebert, Inc.
DOI: 10.1089/acu.2007.0554

Acupuncture for Progressive Oropharyngeal Dysphagia and

Esophageal Motility Disorder: Case Report

Tapan K. Chaudhuri, MD

ABSTRACT

Background: The treatment of progressive oropharyngeal dysphagias of neurological origin as well as

esophageal motility disorders is extremely difficult and may involve artificial means of maintaining nutrition
and hydration, such as the use of percutaneous gastrostomy and other surgeries. Acupuncture has been found
to be beneficial in poststroke oropharyngeal dysphagia.
Objective: To describe acupuncture treatment of a patient with progressive oropharyngeal dysphagia and
esophageal motility disorder of undetermined etiology.
Design, Setting, and Patient: Case report of a 68-year-old woman at a solo private practice in Kansas City,
Missouri, treated beginning in 2004 and followed up through early 2007.
Intervention: Acupuncture treatment including electroacupuncture for 11 sessions. Points used were SP 6 and
SP 9 (connected with 2.5-Hz stimulation), LU 7, LI 4, and ST 36, bilaterally. From the second treatment on-
ward, CV 22 was added. Each treatment lasted 25 minutes.
Main Outcome Measure: Symptom response following acupuncture.
Results: The patient reported complete resolution of symptoms after 11 sessions, and she has remained symp-
tom-free for 2 years without needing further acupuncture treatment or any other therapy.
Conclusion: Acupuncture should be considered as one of the therapeutic tools for treating oropharyngeal dys-
phagia and esophageal motility disorder.

Key Words: Dysphagia, Acupuncture, Esophageal Motility Disorder

INTRODUCTION centuries. The US National Institutes of Health reviewed the

T HE TREATMENT OF PROGRESSIVE oropharyngeal dysphagia
and esophageal motility disorder is extremely difficult
with conventional modern medicine and may involve naso-
gastric feeding as well as surgical procedures including per-
cutaneous gastrostomy tube placement for maintenance of hy-
dration and nutrition. These treatments are not corrective; they
often involve a multidisciplinary approach, are very labor-in-
tensive, and have many potential complications.1
Acupuncture has been practiced successfully for a vari-
ety of medical problems in China for more than 2500 years
and in European countries and other parts of the world for
effectiveness of acupuncture as a scientific therapeutic
modality in 1997.2 Consideration of the above, in addition
to the fact that acupuncture is a relatively safe modality,3
has facilitated the use of acupuncture in patients with prob-
lems that do not respond to conventional medicine. A re-
view of the literature reveals studies4–8 that conclude that
acupuncture may be effective in the treatment of poststroke
dysphagia.
The following is a case report of a patient with progres-
sive dysphagia of unknown etiology whose condition did
not respond to treatment with modern allopathic medical
treatment, and underwent acupuncture therapy.

Kansas Research Hospital and Medical Center, Kansas City, MO.

151
152
CASE REPORT
History
A 68-year-old woman presented with a 1-month history
of a dull aching pain in the retrosternal area and a sensation
of food “sticking” in her esophagus. She reported that food
would eventually pass through but felt that the transit was
not smooth. She denied any significant odynophagia, heart-
burn, nausea, vomiting, abdominal pain, alteration of bowel
habits, or weight loss.
The patient had well-controlled hypertension as her only
other medical issue. Her daily medications included lisino-
pril, trimethoprim-hydrochlorothiazide, and a baby aspirin.
Past surgical history included a hysterectomy with bilateral
salpingo-oophorectomy and a cholecystectomy. Her family
history was strongly positive for cancer; both her father and
sister had lung cancer, and her brother had esophageal can-
cer. She stopped smoking 18 years earlier and rarely drank
alcohol.
Clinical Findings
Physical examination revealed a well-built, well-nour-
ished woman who was not in any distress. Her blood pres-
sure was 110/70 mm Hg, heart rate 68/min, and weight,
184.5 lb. There was no anemia or icterus. Her pharyngo-
tonsillar area was normal and the neck was devoid of any
lymphadenopathy, thyromegaly, tenderness, or mass. Car-
diopulmonary examination results were normal. The ab-
domen did not reveal any organomegaly, tenderness, or
mass. Rectal examination findings were normal and the stool
was hemoccult-negative. There were no objective findings
to suggest systemic sclerosis.
Laboratory Workup and Tests
The patient’s laboratory workup revealed a normal com-
plete metabolic panel, negative Helicobacter serology,
slightly decreased hemoglobin of 11.8 g/dL, normal white
blood cell count, and normal differential. Her erythrocyte
sedimentation rate was modestly elevated at 36 mm/h (nor-
mal range, 0-30 mm/h). Thyroid function studies, serology
for antinuclear antibody, and rheumatoid factor were all neg-
ative.
Chest x-ray, electrocardiogram, and stress test results
were normal. The esophagogram revealed the patient’s dif-
ficulty with the barium bolus. She had the liquid barium ex-
tending into her hypopharynx into the valleculae and pyri-
form sinuses. The patient did not aspirate during the
examination. The bolus, when she was asked to swallow,
had very poor motility. There was delayed emptying of the
esophagus. The study was terminated due to the patient’s
dysmotility of the esophagus and difficulty with the swal-
lowing mechanism.
CHAUDHURI
Consultations
A gastroenterologist was consulted and an esophagogas-
troscopy revealed a normal-appearing esophagus, stomach,
and duodenum with a small hiatal hernia. Esophageal
manometry revealed a nonspecific motility disorder with
peak contractions and low pressure contractions in the
esophagus, as well as uncoordinated contractions. The lower
esophageal sphincter pressure was in the range of 20 mm
Hg (normal, 10-30 mm Hg) with normal relaxation.
An otolaryngologist did not find any overt pathology.
Magnetic resonance imaging of the brain revealed minimal
dots of subcortical atherosclerotic changes in the hemi-
spheres, without any significant changes in the brainstem.
A neurology consultation was obtained. No dysarthria or any
cranial nerve deficit was found. A complete neurological ex-
amination was normal except absent ankle reflexes bilater-
ally and an absent right knee reflex. Considered were the
differential diagnoses of a brainstem lacunar infarct with a
possible pseudobulbar state, myasthenia gravis, oculopha-
ryngeal dystrophy, scleroderma, and Sjögren syndrome.
None of these diagnoses could be clinically established.
She was treated by the gastroenterologist with
hyoscyamine sulfate, antireflux therapy including proton
pump inhibitors, and metochlorpromide, with no relief.
Amantidine, prescribed by the neurologist, was also of no
benefit.
Eight months after the onset of symptoms, it was appar-
ent that the patient’s condition was progressively deterio-
rating. She was unable to swallow solids, especially pieces
of meat; her food had to be blended. She had lost 16.5 lbs
since the onset of her symptoms. She also reported a slight
change in the strength of her voice. Despite numerous con-
sultations and conventional therapies, the patient derived no
significant benefit. Therefore, a trial of acupuncture treat-
ment was proposed and the patient gave informed consent
for such treatment.
METHODS
Tai Yin and Yang Ming (Spleen-Lung-Stomach-Large In-
testine) Meridians were activated. These coupled Meridians
were chosen for their known influence on the gastrointesti-
nal system.9 The points used were: SP 6 (Sanyinjiao) and
SP 9 (Yinlingquan), LU 7 (Lieque), LI 4 (Hegu), and ST 36
((Zusanli), bilaterally. SP 6 (negative) and SP 9 (positive)
were connected to 2.5-Hz stimulation with the purpose of
tonification, because the overall condition of the patient was
Yin.
Each needle was introduced with a clockwise turn and no
effort was made to evoke Qi with each introduction. From
the second treatment onward, CV 22 (Tiantu) was added in
dispersion (counterclockwise). The duration of each treat-
ment was 25 minutes and treatments were tolerated with no
OROPHARYNGEAL DYSPHAGIA, ESOPHAGEAL MOTILITY DISORDER
problems. Acupuncture needles used were Seirin L 30 x 20
mm metal needles (Shimizu City, Japan); electrical stimu-
lation was delivered using ITO Electro Acupuncture IC-
1107 (ITO Ltd, Tokyo, Japan).
RESULTS
The patient showed no response after the first treatment.
However, after the second treatment, improvement was
noted. She received 5 more treatments on a weekly basis.
Progressive improvements after each treatment were ob-
served and the patient reported complete resolution of her
symptoms at the end of 7 sessions. She was able to eat solid
foods, including meat. She was given 1 more treatment and
then therapy was stopped. One month later, dysphagia re-
curred. The patient received 4 more similar acupuncture
treatments on a weekly basis (ending November 2004), with
complete resolution of dysphagia. She has remained asymp-
tomatic to date without any further treatment and regained
her lost weight.
DISCUSSION
The patient appeared to have an oropharyngeal dyspha-
gia as well as an esophageal motility disorder. The etiology
of her syndrome is unclear. A pseudobulbar state is defined
as “A syndrome characterized by dysarthria, dysphagia, dys-
phonia, impairment of voluntary movements of tongue and
facial muscles, and emotional lability. This condition is
caused by diseases that affect the motor fibers that travel
from the cerebral cortex to the lower brain stem (i.e., corti-
cobulbar tracts); including multiple sclerosis, motor neuron
disease, and cerebrovascular disorder.”10
This patient had dysphagia and may have had mild dys-
phonia, but she did not have any of the other characteristics
of a pseudobulbar state. She did not have or later develop
any of the neurological disorders that may contribute to a
pseudobulbar state. The patient had a progressive oropha-
ryngeal dysphagia of obscure etiology, though the studies
pointed to neurological problems related to deglutination, as
well as esophageal dysmotility.
The prognosis for this disorder is poor. Patients with se-
vere oropharyngeal dysphagia are predisposed to medical
complications such as aspiration pneumonia11 and inanition.
Failing conservative therapy, including medications, speech
therapy, and physical therapy, these patients would need ar-
tificial means such as nasogastric tube feeds or percutaneous
gastrostomy tube placement for nutrition and hydration.
However, the procedure is palliative and associated with
complications. The patient’s quality of life is dramatically
altered; furthermore, it does not eliminate the potential for
aspiration pneumonia.12
153
Efficacy of Acupuncture
Recently, several articles suggest that acupuncture may be
beneficial in dysphagia following stroke and in pseudobulbar
state. Yang et al4 reported a striking beneficial effect of
acupuncture in 325 patients afflicted with pseudobulbar state.
Seki et al5 demonstrated that acupuncture restored the swal-
lowing reflex. Zhang et al6 conducted electromyography of the
muscles of deglutination and came to the same conclusion.
Nowicki and Averill8 demonstrated significant improvement
in videofluoroscopic swallowing studies in patients with post-
stroke dysphagia. It has been suggested that cholinergic, hist-
aminergic, and dopaminergic neural networks are involved in
the regulation of the swallowing reflex.13 Voluntary swallow-
ing may be associated with functional activation in several
brainstem regions as well.14 Acupuncture modulates the lim-
bic system and subcortical gray structures of the human brain15
and as such, may exert a beneficial effect leading to restora-
tion of the swallowing reflex.
Kaada16 demonstrated a beneficial effect of transcutaneous
electrical nerve stimulation in patients with achalasia and sys-
temic sclerosis, and attributed this to a 30% increase in the
plasma level of vasoactive intestinal polypeptides in the circu-
lation. The mobilization of these polypeptides has been specu-
lated to be a part of the mechanism of action for acupuncture.17
CONCLUSIONS
A patient with progressive dysphagia of obscure etiology
responded to acupuncture treatment after her condition did not
respond to conventional therapy. She appeared to have a neu-
rological component with oropharyngeal dysphagia as well as
some esophageal motility disorder. A postulated mechanism
of action of acupuncture includes correcting the swallowing
reflex as well as the beneficial effect of vasoactive intestinal
polypeptides. This patient needed only 12 sessions of acupunc-
ture for a long-term resolution of an exceptionally difficult
problem. She could be considered cured as she has not had
any recurrence during a 2-year-plus follow-up. Compared with
conventional therapies including percutaneous gastrostomy
tube placement, the lack of side effects and complications,
preservation of the patient’s quality of life, and diminished
need for labor-intensive care make acupuncture treatment an
attractive therapeutic option. Acupuncture should be consid-
ered in patients with progressive oropharyngeal dysphagia and
esophageal motility disorder of uncertain etiology.
ACKNOWLEDGEMENTS
I thank Gregory E. Merritt, MD, for providing the gas-
troenterological consultation of this patient and reading the
manuscript, and Pakhi Chaudhuri, MD, for work on the man-
uscript.
154
REFERENCES
1. Groher ME. Dysphagia: Diagnosis and Management. 3rd ed.
Newton, MA: Butterworth-Heineman; 1997:Chap9-15.
2. NIH Consensus Conference: acupuncture. JAMA. 1998;
280(17):1518-1524.
3. Melchart D, Weidenhammer W, Streng A, et al. Prospective
investigation of adverse effects of acupuncture in 97 733 pa-
tients. Arch Intern Med. 2004;164(1):104-105.
4. Yang ZG, et al. Acupuncture treatment of pseudobulbar palsy:
a clinical observation in 325 patients. Int J Clin Acupuncture.
1999;10(3):299-302.
5. Seki T, Kurusu M, Tanji H, Arai H, Sasaki H. Acupuncture
and swallowing reflex in poststroke patients. J Am Geriatr Soc.
2003;51(5):726-727.
6. Zhang W, Liu Z, Sun S, Huang M, Liu Y. Study of the mech-
anisms of acupuncture treatment of moderate to severe dys-
phagia at the chronic stage of apoplexy. Int J Clin Acupunc-
ture. 2005;14(3):177-181.
7. Wang C, Du S, Li H, Ding Z. 120 Cases of pseudobulbar paral-
ysis treated by needling lianquan and chize. J Tradit Chin Med.
1998;18(2):96-98.
8. Nowicki NC, Averill A. Acupuncture for dysphagia following
stroke. Medical Acupuncture. 2001;14(3):17-19.
9. Helms JM. Acupuncture Energetics: A Clinical Approach for
Physicians. Berkeley, CA: Medical Acupuncture Publishers;
1995:351-390.
10. Adams RD, Victor M, Ropper AH. Principles of Neurology.
6th ed. New York, NY: McGraw Hill; 1998:489.
CHAUDHURI
11. Eisenhuber E, Schima W, Schober E, et al. Videofluoroscopic
assessment of patients with dysphagia: pharyngeal retention is
a predictive factor for aspiration. AJR Am J Roentgenol.
2002;178(2):393-398.
12. Griggs BA. Nursing management of swallowing disorder. In:
Groher ME, ed. Dysphagia: Diagnosis and Management. 3rd
ed. Newton, MA: Butterworth-Heineman; 1997:339.
13. Jia YX, Li JQ, Matsui T, et al. Neurochemical regulation of
swallowing reflex in guinea pigs. Geriatr Gerontol Int.
2001;1(1-2):56-61.
14. Zald DH, Pardo JV. The functional neuroanatomy of volun-
tary swallowing. Ann Neurol. 1999;46(3):281-286.
15. Hui KK, Liu J, Makris N, et al. Acupuncture modulates the
limbic system and subcortical gray structures of the human
brain: evidence from fMRI studies in normal subjects. Hum
Brain Mapp. 2000;9(1):13-25.
16. Kaada B. Successful treatment of esophageal dysmotility and
Raynaud’s phenomenon in systemic sclerosis and achalasia by
transcutaneous nerve stimulation: increase in plasma VIP con-
centration. Scand J Gastroenterol. 1987;22(9):1137-1146.
17. Pert CB. Biochemical and cellular substrates of acupuncture
transmission [video]. Berkeley, CA: Medical Acupuncture
Publishers; 1991.
Address correspondence to:
Tapan K. Chaudhuri, MD, FACP, FRCP(C), FAAMA
6225 Raytown Trafficway
Raytown, MO 64133
E-mail: sudtap1@aol.com