Focal lingual dystonia, urinary incontinence, and sensory deficits secondary to low voltage electrocution: case report and literature review

Electrocution injuries are well reported in review articles and cases of high voltage electrocution injury are abundant. However, reports of low voltage electrocution injury are few. A case is presented of low voltage shock from a 120 volt AC source with presentation, acute and chronic course, and a five year follow up. The patient experienced several unusual complications of low voltage electrocution: a persistent right tongue deviation, which initially presents as an isolated hypoglossal nerve palsy, but subsequently manifests as a focal lingual dystonia; total body paresthesia with urinary incontinence; and persistent sensory deficits to the face and tongue.

Other noncosmetic uses of BOTOX

Botulinum toxin A has a wide variety of clinical applications, which are related by blockade of acetylcholine and often are related to abnormal muscle contractures. These applications include ocular disorders, disorders of the upper aerodigestive tract, dystonia and hemifacial spasm, cosmetic, gastrointestinal disorders, genitourinary disorders, management of pain, and use in autonomic nervous system disorders. Many of these diseases will be discussed with regard to their treatment with botulinum toxin compared to conventional treatments. Advantages and disadvantages of botulinum toxin use are delineated. General guidelines for adult and pediatric dosing will also be discussed.

[Dopa-responsive dystonia--a hereditary dystonia easy to treat]

BACKGROUND

Dopa-responsive dystonia is a genetically determined disorder with early onset. The dystonia usually manifests as a disturbance of gait with fatigue and may be confused with spasticity. The diagnosis is based on clinical recognition and response to l-dopa, which is usually complete and long lasting. The most common genetic defect involves the gene for GTP cyclohydroxylase I.

MATERIAL AND METHODS

We describe a Norwegian family in which three generations are affected.

RESULTS

All those affected had gait disturbance from childhood; the disturbance became worse during the day and after exercise. Clinical examination revealed reduced fine motor skills and brisk tendon reflexes. Dystonic posturing of one or both legs could be seen during walking. All patients were treated with l-dopa with excellent effect.

INTERPRETATION

Though uncommon, this disorder is an important differential diagnosis in children with gait disturbance, particularly in those suspected as having spastic paraparesis.

[Laryngeal dystonia--personal experience with botulin toxin treatment]

Laryngeal dystonia is a focal dystonia occurring more often than it is diagnosed. Adductor type dystonia was described in 5 patients. In 3 cases it manifested itself as blepharospasm, which later developed into Meige's syndrome. The patients were treated with botulinum toxin A injections under EMG control administering 10 i.m. into laryngeal muscles on both sides with good and very good results. There were no serious side effects.

X-linked dystonia ("Lubag") presenting predominantly with parkinsonism: a more benign phenotype?

"Lubag," or Filipino X-linked dystonia, typically presents with either pure dystonia (that inexorably becomes generalized) or combined dystonia-parkinsonism. We report on three cases of Lubag presenting with isolated parkinsonism without dystonia or late-onset dystonia and a slower course.

[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.

Atypical presentation of dopa-responsive dystonia: generalized hypotonia and proximal weakness

Dopa-responsive dystonia (DRD) is an autosomal dominant disorder typically presenting as dystonia with diurnal variability. Described is an 8-year-old boy who had had waddling gait, generalized hypotonia, and proximal weakness since early childhood. He responded well to low-dose L-dopa. He had a point mutation of the GTP cyclohydrolase I gene. The patient's father and sister had the same mutation but did not have proximal weakness. GTP cyclohydrolase I deficiency can present with hypotonia and weakness.

Treatment of dystonic clenched fist with botulinum toxin

Fourteen patients with "dystonic clenched fist" (three with Corticobasal Ganglionic Degeneration, seven with Parkinson's disease, and four with Dystonic-Complex Regional Pain Syndrome) were treated with botulinum toxin A (BTXA, Dysport). The muscles involved were identified by the hand posture and EMG activity recorded at rest and during active and passive flexion/extension movements of the finger and wrist. EMG was useful in distinguishing between muscle contraction and underlying contractures and to determine the dosage of BTX. All patients had some degree of flexion at the proximal metacarpophalangeal joints and required injections into the lumbricals. The response in patients depended on the severity of the deformity and the degree of contracture. All patients had significant benefit to pain, with accompanying muscle relaxation, and palmar infection, when present, was eradicated. Four patients with Parkinson's disease and one patient with Dystonia-Complex Regional Pain Syndrome obtained functional benefit.

Health related quality of life is improved by botulinum neurotoxin type A in long term treated patients with focal dystonia

OBJECTIVES

The advent of botulinum neurotoxin type A (BoNT/A) gave rise to substantial progress in the treatment of focal dystonias. In the light of the high costs of the toxin and the necessity to establish valid outcome indices for this treatment apart from sheer reduction of dystonic muscle tone and posture, the impact of focal dystonia and its treatment with BoNT/A on patients' health related quality of life (HRQL) was determined.

METHODS

Fifty patients with cranial and cervical dystonia treated long term with BoNT/A were enrolled in a prospective, open labelled cohort study. The HRQL was assessed using the EuroQol (EQ-5D) and the short form 36 health survey questionnaire (SF-36) at baseline before BoNT/A injections and at two follow up visits after 6 and 12 weeks covering one BoNT/A treatment period with maximum effect size at the first follow up.

RESULTS

Compared with a general population sample, a considerable negative impact of focal dystonia on HRQL was found in patients under investigation. In both disease types, BoNT/A treatment led to a significant improvement in several HRQL dimensions, in particular providing moderate to marked effect sizes in the fields of mental health and pain. The impairment of HRQL due to pain as well as the BoNT/A induced improvement within this SF-36 subscore were significantly higher in patients with cervical dystonia. Under BoNT/A therapy, no correlation was found between changes of clinical outcome scores and HRQL measures.

CONCLUSIONS

The data confirm that BoNT/A is able to induce a significant, but temporary amelioration of several aspects of HRQL in both types of focal dystonia. This may substantially contribute to the patients' subjective benefit from the therapy. Moreover, the data provide further arguments to accept high costs of the BoNT/A treatment in these severely handicapped patients, as a consequence of its considerable benefit on quality of life.

Focal dystonia: the role of botulinum toxin

Botulinum toxin (BTX) has been found to be effective in a wide range of focal dystonias. Debate surrounds the selection of injection sites. In general, localization is satisfactory by clinical examination, but poor response, requiring localization of deep muscles, may necessitate use of electromyography for localization. Delineation of optimal doses of BTX is a work in progress; as studies have tended to show efficacy at lower doses than used in the past, the trend is to use lower doses. This is important, because development of antibodies to BTX, the main reason for secondary resistance to this treatment, is more frequent with larger doses and shorter inter-injection intervals. Although the mechanism of denervation of the neuromuscular injunction by BTX is relatively well understood, secondary changes at the level of the basal ganglia, thalamus, and cortex, and their role in response to BTX, need further exploration.

Response to levodopa treatment in dopa-responsive dystonia

BACKGROUND

Dopa-responsive dystonia (DRD) is similar to Parkinson disease in that both disorders have impaired dopamine synthesis and respond to levodopa treatment. Dopa-responsive dystonia differs in that dopamine storage is intact in contrast to Parkinson disease in which it is markedly reduced.

OBJECTIVE

To examine the short- and long-duration responses to levodopa dosing in subjects with DRD.

METHODS

The response to brief infusions of levodopa was examined in 4 subjects with DRD and the effects of withdrawal of levodopa for 3 to 7 days studied in the 3 subjects receiving long-term levodopa therapy. Motor function was measured with tapping speed, Unified Parkinson's Disease Rating Scale motor score, and global dystonia score.

RESULTS

The short-duration response to levodopa dosing seems to develop more slowly and persists longer in subjects with DRD than in subjects with Parkinson disease. Withdrawal of levodopa leads to a gradual decline in tapping speed and reemergence of dystonia over several days, similar to the rate of decay of motor function in Parkinson disease. The short- and long-duration responses were not clearly differentiated in DRD.

CONCLUSIONS

This pilot study suggests that retained dopamine storage in DRD may prolong the short-duration response and blur the distinction of the short- and long-duration responses. The decline in motor function in DRD on withdrawal of long-term levodopa therapy resembles that in Parkinson disease, suggesting that a long-duration response, if it exists in DRD, is unrelated to dopamine storage.

[Camptocormia--segmental dystonia. Proposal of a new definition for an old disease]

Camptocormia is defined as a forced posture with a forward-bent trunk which appears during standing and sitting. It was first described in 1818 by Brodie. In the last 100 years, numerous cases were observed. A psychogenic origin was presumed in most cases. We describe four patients with typical symptoms of camptocormia who present with the clinical and electromyographical criteria of a segmental dystonia. A new classification of camptocormia is proposed including (1) the primary form, a segmental dystonia of the abdominal wall muscles and (2) secondary forms. Among other conditions (psychogenic disorder, neurosis, myopathy, myositis, Parkinson's disease, multiple-system atrophy, thoracolumbar kyphosis, paraneoplastic syndrome), camptocormia is to be considered in essential tremor. A combination of dystonia of the abdominal wall muscles and essential tremor seems possible.

[Botulinum toxin A for the treatment of headache disorders and pericranial pain syndromes]

For 20 years botulinum toxin A has been used for the treatment of a variety of disorders characterised by pathologically increased muscle contraction. Recently, treatment of tension headache, migraine, cluster headache, and myofascial pain syndromes of neck, shoulder girdle, and back with botulinum toxin A has become a rapidly expanding new field of research. Several modes of action are discussed for these indications. The blockade of cholinergic innervation reduces muscular hyperactivity for 3 to 6 months. Degenerative changes in the musculoskeletal system of the head and neck are prevented. Nociceptive afferences and blood vessels of the pericranial muscles are decompressed and muscular trigger points and tender points are resolved. The normalisation of muscle spindle activity leads to a normalisation of muscle tone and central control mechanisms of muscle activity. Oromandibular dysfunction is eliminated and muscular stress removed. However, the effect of botulinum toxin A cannot be explained by muscular actions only. Its retrograde uptake into the central nervous system modulates the expression of substance P and enkephalins in the spinal cord and nucleus raphe. Recent findings suggest an inhibition of sterile inflammation which may lead to a blockade of the neurogenic inflammation believed to be the pathophysiological substrate of primary headache disorders. The efficacy of botulinum toxin A in the treatment of pain disorders is being investigated in several studies at the moment. The results and experiences obtained so far present new alternatives in the treatment of chronic pain disorders. The practical use of botulinum toxin A is demonstrated.

[Reduction of pain and muscle spasms by botulinum toxin A]

Botulinum toxin A (BoNT-A) develops its muscle-relaxing effect by the inhibition of acetylcholine (ACh) release. This toxin is also known to relieve muscular pain in different disorders. Conspicuously, pain in some patients responds earlier and sometimes even better than muscle tension, indicating that the effect of BoNT-A on pain is not only due to inhibition of ACh release. A questionnaire was distributed to 88 patients suffering from cervical dystonia (CD). Thirty-five completed questionnaires could be used for data analysis. After intramuscular injections of BoNT-A, patients with CD experience significant reductions in pain which sometimes occur significantly earlier than the improvements in head posture. In the iris sphincter muscle of the rabbit and in dorsal root ganglion cells (DRG) of the rat, inhibition of the release of substance P by BoNT-A has been shown experimentally, and BoNT-C has been proven to develop endopeptidase activity toward substance P (SP) in vitro. Findings in the current literature and our observations allow the conclusion that alleviation of muscle pain by BoNT-A may also be due to an effect on the release of nociceptive neuropeptides, among which SP seems to have a key function.

Remote F-wave changes after local botulinum toxin application

OBJECTIVE

Although the therapeutic effects of botulinum toxin A can be explained by its action at the neuromuscular junction, central or more proximal effects have also been discussed.

METHODS

Eleven patients with torticollis spasmodicus and 3 patients with writer's cramp were studied before and 1 and 5 weeks after the first treatment with botulinum toxin. We measured compound muscle action potentials (CMAPs), motor conduction velocities (MCVs), the shortest (SFL) and the mean F-wave latencies (MFL) and F-wave persistence (30 trials) of untreated muscles for each side (ulnar nerve-abductor digiti minimi muscle, peroneal nerve-tibialis anterior muscle).

RESULTS

CMAPs and MCVs showed no significant changes. For both nerves, however, SFL and MFL were prolonged slightly 1 week after treatment and returned to about baseline after 5 weeks (t test). The F-wave persistence was reduced 1 week after treatment for the right ulnar and both peroneal nerves (t test).

CONCLUSIONS

These results are not likely due to an impairment of neuromuscular transmission. Instead, we propose a decreased excitability of alpha-motoneurons supplying non-treated muscles. A reduction of muscle spindle activity or changes of the recurrent inhibition are discussed as possible causes.

Clinical application of botulinum toxin in otolaryngology, head and neck practice (brief review)

Botulinum toxin (Botox) is useful in controlling the symptoms of patients with movement disorders. Application of Botox serves to (1) inhibit hypertonicity, (2) enhance the action of the antagonistic muscles, and (3) avoid an impingement in order to reestablish "the balance of forces". In accordance with the principles mentioned above, Botox can be used to treat dystonias of the larynx (adductor laryngeal spasmodic dysphonia, abductor laryngeal spasmodic dysphonia), laryngeal granulomas, laryngeal joint dislocation, cricopharyngeal spasm, and posterior glottic synechiae. In addition, extra-laryngeal disorders such as blepharospasm, hemifacial spasm, oromandibular dystonia, and spasmodic torticollis respond well to Botox. The effects of Botox are reversible and have specific localized activity. Hence, Botox has served as a powerful diagnostic method in exploring the underlying mechanism of various types of dystonias and provides some therapeutic benefits before pursuing surgical options. Here we review the literature and describe our experiences with Botox, including such topics as preparing and storing Botox, identifying the target muscles under EMG-guidance, choosing an appropriate dose, and outlining the applications of Botox in Otolaryngology, Head and Neck Surgery practice.

[Treatment of focal dystonia with botulinum toxin A]

Local injections with Botulinum toxin A (BtxA) are safe and effective in the treatment of focal dystonia. In cervical dystonia and blepharospasm, BtxA injections have become the treatment of choice. However, good results have also been reported with oromandibular dystonia, spasmodic dysphonia and writer's cramp. In cervical dystonia, muscles for injection are selected by clinical presentation or in complex forms with EMG guidance. Several studies have shown that 500 units Dysport are safe and effective in the treatment of cervical dystonia. In blepharospasm, injections are performed in the periorbital part of the orbicularis oculi muscle with good results for 12-14 weeks. The most frequently employed starting dose is 120 units Dysport per eye, divided in three periorbital injection sites. In case of levator inhibition, the pretarsal part of the orbicularis oculi muscle should be injected in a lower dose. EMG guidance is not necessary. By contrast, BtxA treatment of spasmodic dysphonia and writer's cramp require EMG-guided injections in order to avoid side-effects. Dose recommendations for the various types of dystonia are given in the text. In up to 5% of patients with dystonia, the development of neutralising antibodies is reported following repetitive injections with BtxA. Patients with antibodies had a shorter interval between injections, more "boosters", a higher dose per 3-month interval, and a higher total dose injected. In case of neutralizing antibodies against the A toxin, the treatment with Botulinum toxin B (Neurobloc) is a possible alternative.

Thalamic hand dystonia: an MRI anatomoclinical study

Focal dystonia has been attributed to lesions involving the basal ganglia and/or thalamus. Hand dystonia was studied in a patient with a unilateral thalamic infarction documented by MRI. A 18-year-old girl presented with severe isolated dystonia of the right hand as a sequel of perinatal infarction. MRI scan revealed infarction affecting part of the dorsomedian, lateral posterior, ventral lateral, ventral posterior lateral nuclei, and centromedian-parafascicular nucleus of the contralateral thalamus. The unique MRI anatomoclinical presentation of this case, taken together with the literature data, could provide evidence that a lesion affecting one or several thalamic nuclei, including the centromedian nucleus, can induce hand dystonia.

[Botulinum toxin treatment of patients with oromandibular dystonia]

INTRODUCTION

Oromandibular dystonia (OMD) is a frequently disabling focal dystonia, which may be treated with injections of botulinum toxin in the affected muscles. The aim of the present study was to evaluate the population, effect and side-effects of patients treated in Denmark during a nine year period.

METHODS

We evaluated all 45 consecutive patients treated with quantitative EMG guided injections of botulinum toxin for OMD.

RESULTS

The OMD symptoms varied but were most often mixed symptoms (n = 13), jaw closing (n = 11) and jaw opening (n = 7). Thirty-two patients (71%) had other focal or generalised dystonia, and in 24 the additional dystonia were also treated with botulinum toxin. The 45 patients had a total of 277 treatments (mean 6.2 treatments pr. patient), each including one to six muscles. Marked effect was observed or experienced after 193 (70%) treatments, and 33 patients (73%) experienced at least one effective treatment. Side-effects occurred after 35 treatments (13%) experienced by a total of 16 patients (35.6%), most frequently as transient mild dysphagia.

DISCUSSION

The study shows that botulinum toxin treatment of OMD, guided by quantitative EMG, is safe and effective.