[Botulinum toxin in ENT medicine]

In otorhinolaryngology, botulinum toxin is a suitable therapeutic option in the muscular and the autonomic nervous system concerning dysfunctions. Respecting some special aspects, it is an effective treatment for disorders of different etiology with very few side-effects. The positive therapeutic effect is temporarily limited, so that the patients need further treatment. Beside the classical indications like the facial hyperkinesias (i.e. blepharospasms, hemifacial spasm) the treatment of complex dystonias (oromandibular dystonia, laryngeal dystonia, cervical dystonia), gustatory sweating, hypersalivation and crocodile tears is successful. Botulinum toxin is an alternative treatment of tension type headache and migraine. A new indication of botulinum toxin application may lay in the treatment of nasal hypersecretion through the effect on the nasal glands.

Tongue representation in the lateral cortical motor region of the human brain as assessed by transcranial magnetic stimulation

Motor evoked potentials (MEPs) of the lingual muscles elicited by focal cortical transcranial magnetic stimulation (TMS) with a figure 8-shaped coil were investigated in 17 healthy subjects with special regard to amplitude and onset latency as a function of the coil position on the head surface. Bilateral reproducible responses could be observed at coil positions mostly varying from approximately 6 to 13 cm lateral to the vertex. During moderate muscle activation, maximum responses were obtained at a mean stimulus position of about 11 cm lateral and 3 cm anterior to the vertex with similar onset latencies, but with significantly higher amplitudes on the contralateral side (3.5 +/- 1.9 mV, 9.5 +/- 1.1 ms contralateral; 2.6 +/- 1.5 mV, 9.7 +/-1.0 ms ipsilateral). Comparing our data on the orbicularis oculi muscle with the results obtained on lower lip muscles, we found a considerable overlap of those coil positions from which reproducible MEPs could be elicited in both groups of target muscles, but the lingual area was placed more laterally. Thus, a statistically significant separation of the cortical representation areas of lingual and lower lip mimetic muscles is possible by focal cortical TMS, reflecting somatotopic organization of the face-associated motor cortex.

Successful management of drooling with botulinum toxin A in neurologically disabled children

OBJECTIVES

The present study investigates the effect of topical injections of botulinum toxin A into the cephalic salivary glands of children with chronic hypersalivation due to neurodegenerative diseases.

METHODS

Five children with hypersalivation due to severe neurological diseases received, under ultrasound guidance, a total of 50-65 units of botulinum toxin A (Botox) into the parotid and submandibular glands on both sides. All injections were tolerated without local anaesthesia. Before and 1, 2, 4, 8 and 12 weeks after toxin injection, salivary flow rates and the concentrations of total protein, alpha-amylase, acid phosphatase, kallikrein, and immunoglobulin A were measured in the secretions; simultaneously, the patients were clinically examined with regard to severity of symptoms, and their salivary glands were subjected to ultrasound study.

RESULTS

A distinct improvement of symptoms within the first 2 weeks following toxin administration were reported by the parents. Sialometry revealed considerably reduced flow rates but sialochemistry showed an increase of amylase activity. Ultrasound examination did not reveal any changes of the salivary parenchyma, and side-effects were absent.

CONCLUSION

Treatment of drooling by topical injection of botulinum toxin A into the salivary glands is a reliable and also side-effect-free therapeutic option for children with neurological disorders. All children involved in our study experienced a distinct improvement of their quality of life.

Neuronal nitric oxide synthase-immunoreactivity. A neuromodulating system independent of peripheral nasal gland denervation in guinea pig nasal mucosal tissue after treatment with botulinum toxin type A

The influence of botulinum toxin type A (BTA) on cellular mechanisms has not been studied in much detail. Since nitric oxide (NO) is of increasing interest as a neuromodulator in the innervation of the nose, its localization was examined in the nasal mucosa of guinea pigs treated with BTA or saline. Neuronal nitric oxide synthase-immunoreactivity (nNOS-IR) was found around vessels and nasal glands. Immunoreactivity was seen in the respiratory epithelium, in the periost and the osteocytes of the turbinate bone. A distinct interindividual difference in the strength of nNOS-IR was obvious among the animals, but there was no difference in the strength of immunoreactivity between the animals treated with BTA or saline. NO might therefore contribute to the regulation of vascular tone, glandular function, respiratory epithelial cell function and bone metabolism. BTA does not seem to influence the processes regulated and modulated by NO. This may represent a benefit for the application of BTA.

Neuronal nitric oxide synthase immunoreactivity in the nasal mucosa of patients with idiopathic and allergic rhinitis

The localization of neuronal nitric oxide synthase (nNOS) in the mucosa of the inferior and middle turbinates of 30 patients with and without allergic rhinitis was examined by immunohistochemical methods. Staining of paraffin sections from allergic and nonallergic patients revealed nNOS immunoreactivity (nNOS-IR) in the muscular layer of vessels, in the basal portion of submucosal glands and in the periost and the osteocytes of the turbinate bones. In contrast to earlier investigations, nNOS-IR was also seen in the nasal respiratory epithelium of allergic and nonallergic patients. The immunostaining of sections of submucosal glands from allergic patients was stronger than that of sections from patients with idiopathic rhinitis or patients with no nasal obstruction. The present result - nNOS-IR around glands is elevated in patients with allergic rhinitis - could indicate that this enzyme is involved in the pathogenesis and symptomatology of allergic rhinitis.

Genetic analysis of the human oncoprotein MDM2 in benign and malignant tumors of the salivary gland

INTRODUCTION

Genetic alterations of oncogene MDM2 promote malignant transformation of several human tumors. In tumors of the salivary gland, however, the genetic status of MDM2 has not been evaluated so far.

METHODS AND RESULTS

Benign and malignant tumors of the salivary gland (6 pleomorphic adenomas, 3 Warthin's tumors, 1 adenocarcinoma, 1 basal cell adenocarcinoma, 1 mucoepidermoid carcinoma, 3 acinic cell carcinomas, 2 adenoid cystic carcinoma, 1 squamous cell carcinoma) were analyzed by fluorescence-based PCR techniques and immunochemistry for MDM2 gene amplification, MDM2 gene expression, MDM2 gene mutation, MDM2 RNA splicing and MDM2 accumulation. Data show that all samples contained nonamplified MDM2 genes with nonmutant zinc finger regions. However, in two benign and two malignant samples, novel MDM2 mRNA splicing variant types 1 and 2 were detected. Furthermore, three malignant tumors revealed significant nuclear MDM2 accumulation. Correlation between levels of MDM2 mRNA and MDM2 protein could not be detected in the specimens.

CONCLUSION

The present study suggests that MDM2 gene mutation and gene amplification do not contribute to MDM2 accumulation detected in malignant tumors of the salivary gland. However, the role of novel MDM2 splicing variants in MDM2 expression and malignant transformation must be elucidated further.

Surgical and nonsurgical treatment options in patients with movement disorders of the platysma

PURPOSE

Movement disorders of the platysma may constitute both an aesthetic and a functional problem for the affected patients, who almost always have hyperkinesis. This article describes the different treatment options for movement disorders of the platysma.

PATIENTS AND METHODS

The therapeutic options that we used involved surgical and nonsurgical strategies (33 patients), including neurectomy of the cervical branch of the facial nerve, myectomy of the platysma, and the injection of botulinum toxin A. After therapy, patients were evaluated through self-assessment of the clinical outcome, clinical examination, and electromyography.

RESULTS

All patients showed improvement or complete alleviation of their symptoms. The data also showed that resection of the cervical branch of the facial nerve after its anterograde neurolysis may be performed during facial nerve reconstruction.

CONCLUSIONS

The various nonsurgical and surgical strategies are suitable for the treatment of different forms of platysmal movement disorders.

Botulinum toxin to reduce saliva flow: selected indications for ultrasound-guided toxin application into salivary glands

OBJECTIVES/HYPOTHESIS

The study investigates the effect of local injections of botulinum toxin type A (Botox) into the major salivary glands of the head in various states of hypersalivation. In particular, we studied pathological states with permanent as well as passing hypersalivation disorders and present new indications for local application of botulinum toxin to the salivary glands.

STUDY DESIGN

Retrospective clinical investigation.

METHODS

A total of 55 to 65 units of Botox were injected under sonographic control into the left and right parotid and submandibular glands of four patients with hypersalivation resulting from head and neck carcinoma, tracheostomy, and "idiopathic" hypersalivation disorder. At defined time intervals following injection, flow rate, total protein and immunoglobulin A content, and the enzymatic activities of amylase, acid phosphatase, and kallikrein were determined in the saliva. The patients were clinically examined to assess the severity of their symptoms, including sonographic control of the major salivary glands.

RESULTS

All four patients reported distinct improvement of their symptoms within 1 week after injection. Salivary flow rate had considerably dropped, whereas the concentrations of the salivary components were much increased. Sonography did not reveal any changes of the salivary gland parenchyma. Therapeutic side effects were absent.

CONCLUSIONS

Treatment of hypersalivation by local injections of Botox into the salivary glands of the head is a reliable and efficient therapy without side effects for certain otolaryngological diseases, especially if injections are performed under sonographic control. Extension of this therapeutic concept to other indications is suggested.

[Oromandibular dystonia. Clinical forms, diagnosis and examples of therapy with botulinum toxin]

BACKGROUND

The present study reports on our experience with clinical aspects and therapy of oromandibular dystonia (OMD) with botulinum toxin A. OMD is a very rare form of focal dystonias. The clinical symptoms can vary considerably, depending on the musculature affected.

PATIENTS

The various clinical forms are described. The description of the diagnostic analysis and the therapy with botulinum toxin A is explained with reference to the patients. In these cases, injections are made into the musculature of the base of the mouth, the muscles involved in chewing, the extrinsic muscles of the tongue and the caudal facial musculature.

RESULTS

Most of the patients showed an improvement of their symptoms. The average dose of Botox(R) used was 35.4+/-23.6 units. The duration of the effect was 14+/-9.2 weeks on average.

CONCLUSION

The therapy for OMD using botulinum toxin A has proved to be successful, the amount of improvement in this form of dystonia is, however, lower in comparison to other forms of mobility disorders in the head and neck region.

Minimally invasive application of botulinum toxin type A in nasal hypersecretion

We report on the effect of the local application of botulinum toxin A on nasal hypersecretion in a female patient with intrinsic rhinitis. 20 units of botulinum toxin A (Botox) was inserted into each nostril using a small sponge in close contact with the lower and middle turbinates. The effect was scored by the patient and by rhinomanometry. Nasal hypersecretion diminished clearly 5 days after the treatment. The rhinomanometric flow increased 2 weeks after the application. No side effects occurred. We conclude that this minimal invasive method of local botulinum toxin application might be a very effective and safe option for the treatment of nasal hypersecretion of different etiologies.

Cortical representation of the orbicularis oculi muscle as assessed by transcranial magnetic stimulation (TMS)

OBJECTIVES

To analyze characteristic features and details on motor-evoked potentials (MEPs) of the orbicularis oculi muscle resulting from cortical transcranial magnetic stimulation (TMS) in normal subjects as a basis for further investigations on motorcortical representation in patients presenting with facial nerve diseases.

STUDY DESIGN

MEPs of the orbicularis oculi muscle resulting from focal cortical TMS with a figure-8-shaped coil were investigated in 17 healthy subjects with special regard to amplitude and onset latency as a function of the coil position on the head surface along the interaural line and in the anterior-posterior direction. The results were then compared with our data on lower-lip mimetic muscles and on the frontalis muscle obtained in previous studies.

RESULTS

Bilateral reproducible responses could be observed at coil positions varying from 1 to 13 cm lateral to the vertex. During moderate muscle activation, maximum responses (mean amplitude 0.75 +/- 0.44 mV contralateral, 0.74 +/- 0.36 mV ipsilateral) were obtained at a mean stimulus position of 8.6 +/- 1.6 cm lateral and 2.0 +/- 2.2 cm anterior to the vertex for contralateral responses, and of 8.6 +/- 2.0 cm lateral and 2.8 +/- 2.4 cm anterior to the vertex for ipsilateral responses, respectively. Voluntary muscle activation by forced eye-closure was associated with a further increase in mean amplitudes. At rest, bilateral responses could be elicited in 15 subjects (88.2%). During moderate muscle activation, the shortest mean onset latencies were obtained at the optimum stimulus position on the interaural line, both for contralateral (10.2 +/- 1.3 ms) and ipsilateral (10.6 +/- 1.5 ms) MEPs. Comparing our data on the orbicularis oculi muscle with those obtained on lower-lip muscles and on the frontalis muscle, there was a considerable overlap of coil positions from which reproducible MEPs could be elicited in all three groups of mimetic muscles, but with the orbicularis oculi area being placed between forehead and lower-lip motorcortical areas.

CONCLUSIONS

A statistically significant separation of the cortical representation areas of forehead, orbicularis oris, and lower-lip mimetic muscles is possible by focal cortical TMS reflecting a kind of somatotopic organization of the face-associated motorcortex. Compared with the results on lower-lip and forehead muscles, orbicularis oculi muscle responses show characteristics of both.

Botulinum toxin type A induces apoptosis in nasal glands of guinea pigs

Nasal hypersecretion is predominantly caused by overaction of nasal glands, which are mainly under cholinergic control. In this work, we investigated the influence of botulinum toxin A (BTA) on the nasal mucosal tissue of the maxillary sinus turbinates of guinea pigs (n = 10) that were painlessly sacrificed 10 days (short-term group) or 3 months (long-term group) after local treatment with 20 units of BTA (Botox) or 0.2 mL of 0.9% sodium chloride (control). Histologic investigation of the nasal mucosal tissue of the BTA-treated animals (short-term group) showed degeneration of glands and ducts and apoptotic nuclei on TUNEL staining of these structures. The control animals revealed normal glandular tissue and no apoptosis. The animals of the long-term group showed almost normal glandular tissue and only a few apoptotic nuclei. In conclusion, BTA induces temporary apoptosis in the nasal glandular compartment of guinea pigs.

[Blocking secretion of exocrine glands in the head-neck area by administration of botulinum toxin A. Therapy of a rare disease picture]

BACKGROUND

Hypersecretion disorders of the exocrine glands of the head and neck area are a therapeutic problem in the field of otorhinolaryngology. In the present study, we demonstrate the effectiveness of local injections of botulinum toxin A to block secretions of exocrine glands of the head and neck area.

PATIENTS AND METHODS

Four patients suffering from hypersecretion disorders received local injections of botulinum toxin A. Two patients suffered from disorders of the salivary glands: one presented an idiopathic hypersialorrhea and another a salivary fistula after parotidectomy. A third patient suffered from epiphora and a further patient presented severe hyperhidrosis on the pilose head region. In a retrospective clinical study, the outcome of therapy was evaluated by clinical examination and chemical parameters.

RESULTS

Clear blocking of secretion in the treated glands could be demonstrated in all four cases. Possible side effects of the treatment could not be observed.

CONCLUSIONS

The present study was able to demonstrate a clear blocking of secretion of the exocrine glands of the head and neck region through botulinum toxin A, offering an improvement in therapy especially for the innovative indication of blocking the salivary glands of the head.

Treatment of gustatory sweating with botulinum toxin: special aspects

Botulinum toxin treatment is an efficient, well-tolerated technique for patients suffering from gustatory sweating, first described by our group. With the experience gained in recent years we were able to improve on some of our skills in the diagnosis and treatment of gustatory sweating and here we wish to focus on some interesting aspects: (1) the necessity for an exact anamnesis before treatment with botulinum toxin to ensure correct treatment; (2) the advantages of Minor's test in special situations, for example, when sweating occurs in regions of hairy skin, retroauricular, at the back of the auricle and in areas distant from the site of salivary gland surgery; (3) the reduction of pain during treatment using an anesthetic ointment containing lidocaine and prilocaine as active substances; (4) intracutaneous injections in areas anterior to the fascia-protected skin of the lateral face-covering mimetic muscles, and (5) the occasional necessity for short-time reinjection in small areas of persistent sweating.

Cortical transcranial magnetic stimulation of the frontalis muscle: characteristic features and details on motor-evoked potentials of the forehead

The effect of coil position on the head surface along the interaural line on motor-evoked potentials (MEPs) of the frontalis muscle due to cortical transcranial magnetic stimulation was investigated in 16 healthy subjects. Bilateral reproducible responses could be observed in all subjects investigated at coil positions varying from 2 to 12 cm lateral to the vertex. MEP amplitudes of the frontalis muscle offered no significant side differences neither in amplitude nor in onset latency. Despite a considerable overlap, a statistically significant separation (p < 0.0001) of the two areas from which reproducible MEPs of upper and lower mimetic muscles could be elicited was evident for the calculated mediolateral center with the frontalis muscle area being placed more medially. Our findings are in accordance with anatomical studies indicating a predominance of corticonuclear descending fibers to lower but not to upper facial motoneurons.

The effect of local injection of botulinum toxin A on the parotid gland of the rat: an immunohistochemical and morphometric study

PURPOSE

In this investigation, the effect of a local injection of botulinum toxin A on the concentration of acetylcholinesterase in the parotid gland of the rat was examined.

MATERIALS AND METHODS

After local injection into the parotid glands of female Wistar rats, the treated glands were excised, and immunohistochemical staining for acetylcholinesterase was performed. To discover possible changes in cell morphology after local application of botulinum toxin A, morphometric measurements also were performed on the excised parotid glands.

RESULTS

In contrast to the untreated, physiologic saline-injected, glands, there was a decrease in the concentration of acetylcholinesterase in the glands treated with botulinum toxin. No persistent changes in the number of acinar cells could be observed.

CONCLUSIONS

Because the cholinergic pathway of the autonomic nervous system has great importance in the secretion of fluid from the salivary glands, blocking this pathway and local application of botulinum toxin offers a possible therapeutic option for the treatment of hypersalivation in various otolaryngologic and neurologic diseases.

Transient changes in cortical distribution of S100 proteins during reorganization of somatotopy in the primary motor cortex induced by facial nerve transection in adult rats

In adult rats, the primary motor cortex (MI) comprises a somatotopic map of muscle representations. This somatotopy is modified after transection of the facial nerve (N7x). Mapping with cortical stimulation revealed that the underlying cortical reorganization is biphasic. Primary changes cause a transient disinhibition of long cortico-cortical connections in both hemispheres. While the first reaction vanishes within a few hours, short intra-areal connections are disinhibited within MI contralateral to N7x. The resulting co-operation between adjacent parts of MI persists as long as peripheral reinnervation is prevented. Cellular mechanisms underlying this cortical reorganization are largely unknown. Here, we utilized changes in immunoreactivity of S100 proteins (S100-IR) known as a sensitive indicator of astroglial reactions during plastic reactions in the central nervous system. Within 1 h of N7x, zones with enhanced S100-IR appeared in both hemispheres. Between 3. 5 and 18 h, reaction patterns with changing topography were transiently prominent in many cortical areas including parts of MI which surrounded the facial muscle representation fields. After 24 h, the facial muscle representation contralateral to N7x became labelled while S100-IR enhancement disappeared in most of the cortex. S100-IR-enhancement vanished completely during the next day of survival. Data presented suggest that (i) enhancement of S100-IR labels cortical tissue during the functional reorganization that is induced by N7x, (ii) large parts of the cerebral cortex participate in the reorganization, before it is finally focused on the representation field of MI that corresponds with contralateral N7x, and (iii) temporo-spatial patterns of astrocytic reactions apparently play a role in the underlying plasticity reaction.

Relationship between GAGE-1/-2 expression, EBV infection and interferon-gamma expression in undifferentiated carcinoma of nasopharyngeal type

GAGE-1/-2 proteins are novel tumour markers, functionally related to tumour rejection. The objective of the present study was to identify the existence of a relationship between GAGE-1/-2 expression, Epstein Barr Virus (EBV) infection and viral infection-induced cytokine expression in cultivated tumour cells and archival specimens of undifferentiated carcinoma of nasopharyngeal type (UCNT). PCR and in situ hybridization techniques were employed. In cultivated UCNT cells, interferon-gamma (IFN-gamma) induced synthesis of GAGE-1/-2 mRNA. In archival tumour specimens (n = 10) however, GAGE-1/-2 gene expression was detected in only 3/8 cases with coincident EBV infection and IFN-gamma expression. In conclusion, EBV infection appears to induce IFN-gamma gene expression in most tumors, but GAGE-1/-2 expression in only some tumours. The role of IFN-gamma and other factors in triggering GAGE-1/-2 gene activation must be elucidated further. The relevance of GAGE-1/-2 gene expression and its detection by PCR for future immunotherapy is discussed.

Motor potentials of lower-lip mimetic muscles and distal arm muscles to cortical transcranial magnetic stimulation: the possibility of one-dimensional separation of two cortical representation areas

The cortical representation of the abductor pollicis brevis muscle (APB) was investigated by transcranial magnetic stimulation (TMS) along the interaural line on the head surface in 17 healthy subjects. Comparing amplitudes of motor evoked potentials (MEPs) with those obtained by cortical TMS of lower-lip muscles, we found a considerable overlap between the areas from which reproducible MEPs of APB and lower-lip muscles could be elicited. However, there was a statistically significant separation of the two areas, the APB area being placed more medially. With regard to short examination procedures it can be concluded that a separation between distal arm and facial muscles is possible not only by two-dimensional cortical mapping procedures, but also by one-dimensional cortical TMS.