Botulinum neurotoxin injection after total laryngectomy

BACKGROUND

One of several causes of tracheoesophageal puncture (TEP) speech failure after total laryngectomy is disturbance in relaxation of the pharyngoesophageal (PE) segment. We introduce the use of chemical denervation of the PE segment through botulinum neurotoxin (Botox) injection to improve TEP speech.

METHODS

An analysis was performed on eight patients who received Botox injections for TEP speech problems after total laryngectomy at the University of Iowa between June 4, 1991 and August 8, 1994. Retrospective chart review identified the evolution of pretreatment evaluation and injection technique which became standardized in April 1992. Prospective evaluation of results was recorded by a single speech pathologist who subjectively identified the response to Botox in all patients and recorded pressure readings at the tracheostoma site during speech in 6 patients.

RESULTS

Seven of the eight patients were noted to have improved TEP speech following injection. Five of these seven patients experienced substantially improved speech, three of whom had no ability to produce speech prior to the Botox injection.

CONCLUSION

Botox injection is a safe and effective method of improving TEP speech in selected patients with disturbed relaxation of pharyngoesophageal segment.

Hyperkinesias in a prepubertal boy with autistic disorder treated with haloperidol and valproic acid

A 7-yr.-old Bangladeshi boy with autistic disorder, unspecified mental retardation, asthma, pica, and generalized tonic seizures, presented for hyperactivity, aggression, and disruptive behaviors. He had a history of an elevated blood lead level. He was being treated with haloperidol and valproic acid. He was assessed in an unstimulated state for the occurrence of adventitious movements. He exhibited hand flapping, jumping, running, and spinning as well as other motor and phonic stereotypes typical of autistic disorder. Although the presence of subjective distress and a sensation of inner restlessness could not be ascertained given his cognitive impairments, the objective picture of constant leg movement and inability to sit still was consistent with akathisia. The hyperkinesias may be due to autistic disorder, multiple comorbid conditions, and medications. Further studies with large populations of medicated and unmedicated children with autistic disorder are needed to characterize further the associated movement disorders which may result from neurological disorders and pharmacological treatments.

Clinical trials of botulinum toxin in the treatment of spasticity

Botulinum toxin has been tested as a treatment for spasticity resulting from cerebral palsy, multiple sclerosis, traumatic brain injury, spinal cord injury, and stroke. The results of 18 studies are reviewed in this article. In both open label and double-blind, placebo-controlled trials, botulinum toxin has proven to be an effective measure for reduction of focal spasticity. Improvements have been documented in tone reduction, range of motion, hygiene, autonomic dysreflexia, gait pattern, positioning, and other criteria, though not all criteria tested showed improvement in all studies. In none of the studies were there significant adverse effects. Future trials may be improved by refinement of several design parameters, including patient selection, treatment timing, and selection of dose and injection site.

Biperiden and haloperidol plasma levels and extrapyramidal side effects in schizophrenic patients

Anticholinergic drugs such as biperiden are used for the treatment of extrapyramidal side effects (EPS) induced by neuroleptics such as haloperidol. The effects of biperiden and haloperidol plasma levels on EPS were studied in 29 chronically ill schizophrenics. The results show relationships between biperiden dose and biperiden plasma levels (BPL), and between BPL and haloperidol plasma levels (HPL). Neither BPL nor HPL seem to influence EPS.

Symptomatic improvement in achalasia after botulinum toxin injection of the lower esophageal sphincter

OBJECTIVES

The aim of this study was to assess the long term clinical outcome of patients with achalasia after treatment with botulinum toxin.

METHODS

Sixty five patients with achalasia (60 idiopathic, five secondary) were treated with injection of botulinum toxin at the gastroesophageal junction. Dysphagia, chest pain, and regurgitation were scored (0 = no symptoms, 1 = mild, 2 = moderate, 3 = severe, 4 = very severe), with the sum representing the total symptom score, at 0, 7, 30, 120, 240, and 365 days posttreatment. Responders were defined as patients with a 50% decrease in total symptom score at 1 month posttreatment.

RESULTS

The 60 patients with idiopathic achalasia had significant improvement in symptoms of dysphagia, chest pain, and regurgitation at 1 and 4 wk posttreatment. At 1 month posttreatment, 42 of 60 patients (70%) were classified as responders. Of 33 patients with at least 1 yr follow-up, 36% continued to have a good or excellent response, whereas 39% underwent a subsequent treatment with botulinum toxin, pneumatic dilation, or myotomy. When symptoms recurred after an initial response, patients responded to a second injection of botulinum toxin in six of seven cases. In four of five patients with secondary achalasia, there was no response to botulinum toxin.

CONCLUSIONS

Botulinum toxin injection at the gastroesophageal junction significantly improved symptoms in 70% of patients with idiopathic achalasia at 1 month. Recurrent symptoms responded to repeat botulinum toxin treatment in initially responsive patients. In contrast, most patients with secondary achalasia did not improve after botulinum toxin injection.

[Botulinum toxin: clinical uses and anesthetic implications]

Botulinum toxin, a neurotoxin responsible for botulism, is at present used to treat anomalous muscle contractions. Administration to children and relatively uncooperative patients requires general anesthesia, which should be selected taking into consideration the special characteristics of the surgical procedure and the possible interactions of anesthetic drugs and the toxin.

Dose-response curve of human extensor digitorum brevis muscle function to intramuscularly injected botulinum toxin type A

To develop a human model for measuring the effect of intramuscularly injected botulinum toxin, we injected both extensor digitorum brevis (EDB) muscles in 13 healthy volunteers with seven varying doses of botulinum toxin type A. We measured, pre- and postinjection, EDB M-wave amplitude, area, and mean rectified voltage (MRV) (obtained during maximal voluntary muscle activation). There was a logarithmic-appearing dose-response relationship between increasing doses of botulinum toxin and decline in EDB M-wave amplitude, area, and MRV. The decline was incrementally less at higher doses of toxin and appeared to level off at a maximal effect of 85 to 90% decrement from baseline (85 to 90% "paralysis") at 15 to 20 units. The peak toxin effect was present on day 6 postinjection. Measurement of EDB M-wave amplitude, area, and MRV is a simple objective method for quantifying the onset and degree of human muscle "paralysis" following botulinum-toxin injection.

Botulinum-A toxin as a treatment of detrusor-sphincter dyssynergia: a prospective study in 24 spinal cord injury patients

PURPOSE

The paralytic effect of botulinum-A toxin injections on the external urethral sphincter was investigated prospectively in patients with neurogenic voiding disorders.

MATERIALS AND METHODS

Transurethral versus transperineal botulinum-A toxin injections were performed in 24 spinal cord injury male patients with detrusor-sphincter dyssynergia and the respective efficacy was compared.

RESULTS

In 21 of 24 patients detrusor-sphincter dyssynergia was significantly improved with a concomitant decrease in post-void residual volumes in most cases. Botulinum-A toxin effects lasted 3 to 9 months, making reinjections necessary.

CONCLUSIONS

Although costly, botulinum-A toxin injections, which aim at suppressing detrusor-sphincter dyssynergia but not bladder neck dyssynergia, appear to be a valid alternative for patients who do not desire surgery or are unable to perform self-catheterization.

Long-term changes in duration of relief with botulinum toxin treatment of essential blepharospasm and hemifacial spasm

PURPOSE

To determine long-term changes in duration of relief with serial treatments of botulinum A toxin (BAT) used to treat benign essential blepharospasm and hemifacial spasm, in view of conflicting reports as to whether BAT has an increasing, decreasing, or an unchanging duration of effect over a long period of treatment.

METHODS

Thirty-two patients with facial dyskinesia (20 with essential blepharospasm, 12 with hemifacial spasm) were followed between 5 and 9 years through a mean of 18 (range, 12-32) BAT treatments with prospective documentation of intervals of relief from symptoms. Repeated measures and linear regression analyses were used to determine trends in each group.

RESULTS

Marked inter- and intrapatient variability was found in the length of effect of BAT. Statistical analysis showed no significant changes in mean duration of relief within each group (P = 0.65 for essential blepharospasm, 0.36 for hemifacial spasm). There was a trend to slow decline in the interval of relief, especially in patients with an initial duration of effect greater than 150 days. No relation was found between duration of relief and age or sex of patient or grade and duration of disease before initial treatment.

CONCLUSION

In the long term, the mean duration of relief from symptoms with BAT changes little over a period of serial treatments. Short-term fluctuations in the length of therapeutic effect did not indicate the development of a resistance to treatment.

[Torticollis spasmodicus as a manifestation of tardive dystonia]

Tardive dystonia is a subtype of tardive dyskinesia which is rarely recognised and diagnosed. Tardive dystonia occurs clearly less frequently than oro-bucco-lingual dyskinesia (approx. 1 vs. 20%). We present a case report and give a survey on the characteristics of tardive dystonia, its differential diagnosis and treatment as described in literature.

Antipsychotic drug-induced dysphoria

BACKGROUND

Dysphoric reactions to antipsychotic medication are well recognised in association with akathisia, but can also occur independently.

METHOD

Fifty-one healthy volunteers were given haloperidol 5 mg in two consecutive pharmacokinetic studies.

RESULTS

Dysphoria occurred in about 40% of the subjects on both occasions, but akathisia was only detected in 8% (first study) and 16% (second study). All adverse effects were transient and were abolished in nine of the ten subjects given procyclidine.

CONCLUSIONS

While dysphoria is a well-recognized reaction in healthy volunteers, it is probably insufficiently recognised in patients, particularly if it occurs in the absence of akathisia. Better detection could improve compliance in patients.