Botulinum toxin treatment for spasmodic dysphonia: percutaneous versus transoral approach

Spasmodic dysphonia (SD) is at present defined as focal dystonia. Botulinum toxin (BT) injection is the treatment of choice for SD. BT is usually injected by a percutaneous route, but a direct, visually guided transoral approach has also been successful. It is not known whether percutaneous injection is as effective as the transoral approach. This article reviews our experience with both techniques of injection on 29 patients with adductor type SD. Since 1992, we have carried out 48 treatment sessions with the transoral technique and 76 treatment sessions with the percutaneous technique. Two patients did not respond to the percutaneous technique despite several attempts, but they did respond to the transoral approach. Globally, transoral technique was superior to percutaneous technique in terms of effectiveness (48 of 48 responses with transoral technique versus 61 of 76 responses with percutaneous approach, p < 0.01). Dosage of BT, duration, and side effects were similar with both techniques. This article also describes a simple, inexpensive device, composed of materials on hand at every hospital, that facilitates the transoral approach.

Muscle fiber type compartmentalization and expression of an immature myosin isoform in the sternocleidomastoid muscle of rabbits and primates

The sternocleidomastoid muscle is located in the neck and is both a neck rotator and flexor. Cervical dystonia, a focal dystonia disorder, is characterized by forceful involuntary contraction of a group of neck muscles, usually including the sternocleidomastoid. Little is known about the fiber type composition, fiber type compartmentalization and innervation patterns in this muscle in rabbit and primates. Sternocleidomastoid muscles from rabbit and monkey were analyzed for muscle fiber type composition and number, muscle fiber cross-sectional area and patterns of innervation. The sternocleidomastoid muscle was composed of two distinct regions, or compartments, with different fiber type compositions: an outer or superficial region composed of mostly type 2 myofibers and an inner deep region composed of both type 2 and type 1 myofibers. Neonatal myosin heavy chain isoform was detected in approximately 25% of the myofibers in both regions of the muscle. Neuromuscular junctions were located in seven endplate bands approximately 1-3 cm apart throughout the length of the muscle. There is clear evidence of anatomical subdivisions within this muscle. Not only is there variation in fiber type composition between superficial and deep regions of the muscle, but unlike most other mature skeletal muscles, it continues to express neonatal myosin heavy chain isoform in the adult. The motor program for neck movements is extremely complex, and the histological complexity plays a role in allowing for a continuum of movements of the head and neck, from maintenance of posture to rapid head movements.

The effect of botulinum toxin on hand function after incomplete spinal cord injury at the level of C5/6: a case report

OBJECTIVE

To investigate the benefits of the focal use of botulinum toxin in spasticity in the forearm seen after incomplete spinal cord injury.

DESIGN

A single case study with standardized assessment before and at three-week intervals after injection.

INTERVENTION

EMG-guided selective injection of botulinum toxin.

SUBJECT

A 23-year-old man, 18 months post injury.

MEASURES

Rivermead Motor Assessment; grip strength; Jebsen hand tests; visual analogue scale; Ashworth spasticity scale.

RESULTS

Weakness was seen as expected with some functional losses, but the patient made gains in the areas of concern: shaking hands, typing, using the hand to drink. These gains were sustained at 12 weeks.

CONCLUSION

Selective use of botulinum toxin to weaken muscles can lead to functional benefit.

A Comparison of Methods of Botulinum Toxin Injection for Abductory Spasmodic Dysphonia

Treatment of abductory spasmodic dysphonia with botulinum toxin injection into the posterior cricoarytenoid muscles often results in only partial symptom relief. In contrast, excellent results can be achieved after thyroarytenoid injection for the adductory type of spasmodic dysphonia. One reason for disappointing results may be inaccurate placement of the botulinum toxin into the posterior cricoarytenoid muscles. We describe a new approach to posterior cricoarytenoid injection used in 18 patients for treatment of abductory spasmodic dysphonia. Of the 30 patients treated for abductory spasmodic dysphonia at Loyola University-Chicago, 6 underwent both a retrocricoid approach and the newer franscricoid method, thus allowing patient and clinician comparison of techniques. We and all six of our patients preferred the franscricoid approach because of less discomfort, equivalent or better voice results, and fewer side effects.

A comparison of methods of botulinum toxin injection for abductory spasmodic dysphonia

Treatment of abductory spasmodic dysphonia with botulinum toxin injection into the posterior cricoarytenoid muscles often results in only partial symptom relief. In contrast, excellent results can be achieved after thyroarytenoid injection for the adductory type of spasmodic dysphonia. One reason for disappointing results may be inaccurate placement of the botulinum toxin into the posterior cricoarytenoid muscles. We describe a new approach to posterior cricoarytenoid injection used in 18 patients for treatment of abductory spasmodic dysphonia. Of the 30 patients treated for abductory spasmodic dysphonia at Loyola University-Chicago, 6 underwent both a retrocricoid approach and the newer transcricoid method, thus allowing patient and clinician comparison of techniques. We and all six of our patients preferred the transcricoid approach because of less discomfort, equivalent or better voice results, and fewer side effects.

[A case of post-hemiplegic painful dystonia following thalamic infarction with good response to botulinus toxin]

We report a 67-year-old hypertensive right-handed woman who developed severe pain and dystonia in her left upper and lower extremity after a thalamic infarction. She was well until 9 months prior to the present admission to our hospital, when she had an acute onset of left hemiparesis which turned out to have been caused by a thalamic infarct. Her hemiparesis showed nearly complete recovery during the next four months. She noted an onset of severe spontaneous pain and difficulty in using her left hand four months prior to the present admission. Neurologic examination on admission revealed an alert and well oriented Japanese woman. Cranial nerves were intact. Although she did not have weakness, her left hand showed thalamic posture, and upon standing, she showed a dystonic posture in which her left forearm took pronation and flexion at the elbow joint and her left lower extremity took extension in the knee joint and planter flexion in the ankle joint. Her dystonic posture increased during walking and disappeared in the supine position. She complained of severe spontaneous pain and tingling sensation in her left extremities. Position sense was diminished in her left leg. However other sensations were intact. She had slight ataxia on the left side. Deep tendon reflexes were symmetric, but the planter response was extensor on the left side. MRI revealed a small lacunar infarct involving the right posterolateral thalamic region. EMG with surface electrodes revealed non-reciprocal tonic discharges in the left biceps brachii and forearm flexor and extensor muscles. She responded poorly to various medications. Only trihexyphenidyl showed partial alleviation of her pain and dystonic posture. We thought her pain might be caused by dystonic contraction of the skeletal muscles, at least in part. We injected 25 IU of botulinus toxin as a total dose into her biceps brachii, triceps brachii, and wrist flexor muscles. A few days after the injection, her dystonic posture began to show marked improvement; as her dystonia improved, her pain also showed marked improvement. This patient appeared to represent a case of post-hemiplegic dystonia. Her pain was initially thought to be the thalamic pain. However, as her pain disappeared with improvement of her dystonia, her pain is most likely to have been caused by the dystonic muscle contraction. Botulinus toxin treatment appears to be useful for post-hemiplegic painful dystonia.

Botulinum toxin type B: a double-blind, placebo-controlled, safety and efficacy study in cervical dystonia

We enrolled and treated 122 patients with idiopathic cervical dystonia in a double-blind, placebo-controlled safety and efficacy study of botulinum toxin type B (BotB). Both A-responsive and A-resistant patients were enrolled. Patients received intramuscular injections of either BotB (2,500 U, 5,000 U, or 10,000 U) or placebo. The primary outcome measure of efficacy was the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS)-Total score at 4 weeks following study drug administration. Secondary measures of efficacy were TWSTRS-Severity, -Disability, and -Pain subscale scores, and Analog Pain Assessment, Investigator Global Assessment, Patient Global Assessment, and Sickness Impact Profile scores. Duration of effect was estimated with an intent-to-treat analysis of responders. Safety measures included clinical parameters, laboratory tests, and adverse events. The primary and most of the secondary analyses indicated a statistically significant treatment effect and a dose response. BotB is safe, well tolerated, and efficacious in the treatment of cervical dystonia at the doses tested.

Frontalis suspension in the treatment of essential blepharospasm unresponsive to botulinum-toxin therapy: long-term results

Thirty-one patients with essential blepharospasm or lid opening disorder of the levator-inhibiting type, unresponsive to treatment with botulinum toxin, underwent frontalis suspension. Twenty-eight patients received bilateral surgery (three patients with bilateral complaints of different severity were operated on the more affected side; these patients were not included in the statistical analysis). The mean age was 62.4 years +/- 8.52 (range 42-80 years). The individual improvement of complaints was assessed by the patients using a percentage scale (0% = no improvement; 100% = no complaints). Objective and subjective improvement was achieved in 26 of 28 patients. The mean subjective improvement was 57.7% +/- 31.4. In 23 cases an additional treatment with botulinum toxin was administered. During follow-up period (mean 22.1 months +/- 11.6; range 5-40 months) the effect of surgery remained stable. There were no serious complications, in a 5 of 56 operated eyes suture granuloma had developed. Unlike other surgeries for treatment of blepharospasm (excision of the orbicularis muscle, resection of facial nerve branches) frontalis suspension can be considered as a minimally invasive, but very effective and (if desired) reversible procedure. Moreover, additional treatment with botulinum toxin can bring about further improvement.

[Intrasphincteric injection of botulinum toxin in patients with esophageal achalasia]

BACKGROUND

Intrasphincteric injection of botulinum toxin (BoTx) has demonstrated to be effective in the short-term treatment of achalasia.

AIM

To assess the efficacy, safety and long-term outcome of BoTx injection into the lower esophageal sphincter (LES) of patients with achalasia.

PATIENTS AND METHODS

Eight patients received 80 units of BoTx. Assessment of response was based on changes in the symptom scores (0-9) and esophageal manometric studies.

RESULTS

Six out of 8 patients (75%) had sustained clinical improvement after therapy. This effect was maintained for a mean time of 17.8 months. The symptom score decreased from a mean of 6.7 to 0.5 (p < 0.01) and after treatment, LES pressure decreased from 63 to 25.5 mm Hg (p = 0.07). There were no serious adverse effects. Five of the six responders have relapsed. Two of these patients received a second BoTx injection with satisfactory results, two went to surgery and one refused other type of therapy and died of pneumonia.

CONCLUSIONS

Intrasphincteric BoTx injection is a simple, safe and effective method of treatment in patients with achalasia, with a duration of response averaging 1.5 years. Its use may be suggested in some patients with high surgical risk and those who refuse a more invasive therapy. It is also useful in malnourished patients to attain an adequate nutritional status before surgery.

Lower-eyelid blepharoplasty

In summary, the concept of one operation for all patients who present for lower-eyelid blepharoplasty should be abandoned. Surgical procedures should be tailored for each individual, depending on the sources of concern and the anatomical defects present. The vast majority of patients are served best by combining transconjunctival blepharoplasty with adjunctive procedures. Transcutaneous lower-lid blepharoplasty has few indications. By combining and choosing the proper techniques, the aesthetics surgeon can achieve lower-eyelid rejuvenation while preserving function and minimizing complications.

Treatment of ventricular dysphonia with botulinum toxin

Ventricular dysphonia, traditionally known as dysphonia plica ventricularis, is a voicing disorder in which the false vocal folds are used as a vibratory source in addition to or instead of the true vocal folds. Traditional treatment of ventricular dysphonia has been voice therapy, which may be slow to produce results if the false fold activity masks an underlying problem of the true folds, is long standing, or has produced hypertrophy of the supraglottic structures. We present seven cases of ventricular dysphonia treated with botulinum toxin injection into the false vocal folds followed by speech therapy. The addition of botulinum toxin to the treatment regimen speeds recovery of normal voicing and allows immediate evaluation of dynamic true vocal fold function by the treating professional.

Achalasia: outcome of patients treated with intrasphincteric injection of botulinum toxin

BACKGROUND

To evaluate the safety and clinical efficacy of botulinum toxin (BT) in patients with achalasia followed up for six months.

METHODS

Fifty five symptomatic patients with manometrically proven achalasia were included in a multicentre prospective trial. Before and two weeks and two months after intrasphincteric injection of BT, symptoms of dysphagia, regurgitation, and chest pain were scored on a 0-3 scale, and lower oesophageal sphincter pressure (LOSP) was assessed. The symptom score was determined again at six months, clinical improvement being defined by < or = 3, relapse by > 3, and failure as a relapse after two injections or loss to follow up.

RESULTS

Except for transient chest or epigastric pain (22%), no side effects were observed. There was a significant decrease in LOSP after treatment. Symptom scores were significantly improved at two weeks (2.0 (SD 1.6)), two months (1.7 (1.8)), and six months (1.9 (2.0)) compared with pretreatment values (5.1 (1.8), p < 0.001). At six months, 33 patients had clinical improvement (27 after one injection), 17 were considered failures, and five had just relapsed. Although there was a trend for age (older patients being more responsive), age, sex, prior duration of symptoms, initial symptom score, weight loss, LOSP, magnitude of oesophageal contractions, vigorous or non-vigorous achalasia, previous dilatations, and radiological features were not predictive of results.

CONCLUSIONS

This multicentre series confirms that intrasphincteric injection of BT is a safe procedure, resulting in clinical improvement in 60% of patients with achalasia at six months. The therapeutic role of BT in achalasia needs further evaluation with regard to other alternatives.

Automatic EMG-guided botulinum toxin treatment of spasticity

Conventional electromyographic (EMG) guidance in botulinum toxin therapy can localize a muscle, but the amount of electrical activity is assessed only subjectively. We wanted to introduce a quantitative EMG criterion, according to which the decision for/against toxin application could be made. Turn/amplitude analysis (TAA) was applied to nine patients with severe paraspasticity (n = 5), right upper or lower limb spasticity (n = 3), or tetraspasticity (n = 1) before and after toxin administration. Muscles were selected for toxin application if both mean turns/second and mean amplitude/turn exceeded the level of 150. A mean Dysport dose of 116 mouse units (mu) (range 40-240 mu) was administered to each of the 26 muscles that met the EMG criterion. Thirty days after the injection, activities of daily living, pain, and TAA count improved in 89%, tone in 78%, and range of motion in 56% of the patients by at least 1 point on corresponding 5-point rating scales. TAA provides a useful EMG criterion for/against botulinum toxin application. Muscle selection according to this criterion leads to a significant subjective and objective toxin effect. TAA is a valuable tool to determine the benefit of single and subsequent botulinum toxin injections in the treatment of spasticity.

[Cerebral palsy therapy]

Unfortunately, in spite of the advances in foetal and perinatal medicine in the last twenty years, the incidence of cerebral palsy has remained unchanged (1.5-2.5 per 1000 live births). It has even possibly risen slightly in premature babies of low birth weight, in parallel with the increased survival of these babies. In spite of modern techniques of rehabilitation, 25% of these patients cannot walk and 35% are mentally retarded. This costs society 5,000 million dollars annually, not counting the loss of opportunity and the emotional and economic burden imposed on these families. The development of new preventive measures such as the use of antagonists of the cortical excitatory amino acids (which when in excess may cause irreversible cerebral damage in cases of hypoxic-ischaemic encephalopathy of the new born). Intramuscular botulinum toxin and continuous intrathecal baclofen seem to promise a reduction in the incidence and functional incapacity of cerebral palsy.

Blepharospasm and hemifacial spasm. Randomized trial to determine the most appropriate location for botulinum toxin injections

PURPOSE

The purpose of the study is to analyze the effectiveness and side effects of botulinum toxin using four different treatment site applications to determine the most successful treatment regime with the least side effects.

METHODS

In a prospective trial, 92 patients (50 blepharospasm and 42 hemifacial spasm) were assigned randomly to 1 of 4 different treatment groups (standard [S], brow [B], inner orbital [IO], or outer orbital [OO]). Each treatment group had a different pattern of injection sites in the orbicularis. A total of 285 treatments were given, and the mean follow-up time was 16.4 months.

RESULTS

In the blepharospasm group, patients assigned to the standard group had a significantly longer duration of effect than for those in the brow, inner orbital, and outer orbital groups (8.1 weeks compared with 4.5, 4.2, and 3.1 weeks, respectively; P < 0.001). In the hemifacial spasm group, patients in the outer orbital group had significantly shorter duration of effect than those in standard, brow, or inner orbital group (7.2 weeks compared with 12.6, 12.8 and 10.4 weeks, respectively; P < 0.001). The four major complications of botulinum toxin treatment were epiphora, ocular irritation, ptosis, and diplopia. The inner orbital treatment produced significantly more episodes of ptosis (13% of treatments). However, the standard treatment produced the most epiphora and ocular irritation (18% of treatments).

CONCLUSIONS

The position of the injection sites around the orbicularis influences the effectiveness and side effects of botulinum toxin treatment for patients with blepharospasm and hemifacial spasm. The further the treatment is away from the eyelid margin, the lower the risk of ocular side effects. The standard treatment produces the longest duration of effect in the blepharospasm group but with the most transient ocular irritation and epiphora. In the hemifacial spasm group, the brow treatment has an equally long duration of effect as that of the standard treatment with fewer side effects.

Tongue protrusion dystonia: treatment with botulinum toxin

We report the treatment experience in a series of patients with involuntary tongue protrusion resulting from oromandibular dystonia (OMD) or Meige's syndrome. A retrospective analysis of clinical findings and results of treatment was conducted on patients treated at Vanderbilt University Medical Center between 1989 and 1995. After unsuccessful treatment with conventional oral medications, nine patients having involuntary tongue protrusion resulting from OMD or Meige's syndrome were treated with botulinum toxin type A (BTX-A) injected into the genioglossus muscle at four sites via a submandibular approach. A marked reduction in tongue protrusion was achieved in six patients (67%). Of 35 consecutive injections, 83% were successful at reducing tongue protrusion. Mild dysphagia complicated 14% of the injections. The average dose injected was 34 (+/- 3) units producing a 15 (+/- 2) week average duration of effect. Injection of the genioglossus with BTX-A may prove to be a valid treatment option for involuntary tongue protrusion related to OMD or Meige's syndrome. A double-blind, placebo-controlled trial is needed to better define efficacy and adverse events.

The management of hyperfunctional facial lines with botulinum toxin. A collaborative study of 210 injection sites in 162 patients

OBJECTIVE

To determine the optimum dose and efficacy of botulinum toxin injections in the management of hyperfunctional facial lines.

DESIGN

This study included 210 hyperfunctional facial sites in 162 different patients. The patients had preinjection and postinjection photographic documentation and ratings on a 4-point qualitative evaluation scale of lines at rest and with action. The patients then had botulinum toxin type A injections via a monopolar hollow bore, Teflon-coated electromyographic needle into the facial muscles associated with the hyperfunctional lines. The total dose for each region of 1.25 to 25 U was divided into 1.25- to 5-U aliquots representing 0.1 to 0.2 mL per injection site, depending on the site and the prior experience with that patient on using toxin. The patients had their reevaluation at 2 to 3 weeks after injection. Patients returned for further follow-up when the therapeutic effect diminished.

PATIENTS

One hundred sixty-two patients had 210 hyperfunctional sites evaluated and injected. The group consisted of 25 male patients and 137 female patients ranging in age from 21 to 78 years with a mean (+/-SD) of 46.1 (+/-1.98) years. All patients had cosmetically troubling hyperfunctional lines involving the forehead, glabella, crow's feet (lateral canthal lines), nasolabial area, platysma, and mentalis region.

RESULTS

All patients had an effect of toxin within the first 24 to 72 hours. Ninety-five percent of the patients treated had cosmetic improvement of unsightly facial lines or contractions. The best results were achieved in management of the forehead lines, followed by glabella, crow's feet, and nasolabial. The dose for forehead lines was 5 to 25 U (mean +/- SD, 17.3 +/- 6.2 U); glabellar lines, 5 to 20 U (mean +/- SD, 11.1 +/- 3.1 U); crow's feet, 5 to 15 U (mean +/- SD, 6.2 +/- 1.6 U); nasolabial, 2.5 to 5 U (mean +/- SD, 3.12 +/- 1.2 U); and platysma, 10 to 20 (mean +/- SD, 15 +/- 4.0 U). Evaluation by age and site suggested a trend of increased toxin dose with increased age. Effects of the toxin are usually seen 24 to 72 hours after injection, and last from 3 to 6 months, whereon the increased muscular activity returns, as do the hyperfunctional lines. The only morbidity was related to temporary mild weakness of other adjacent facial muscles. There were no systemic side effects noted.

CONCLUSION

Botulinum toxin is a safe and important adjunctive technique for the management of patients with symptomatic hyperfunctional facial lines.