Botulinum toxin in the management of head and neck disorders

Temporomandibular Disorder Patients Benefit From Intramuscular Botulinum Toxin Type a Injections

PURPOSE

The aim of this study was to analyze the clinical outcome of the use of botulinum toxin type A (BTX) intramuscular injections to the head and neck, particularly the masticatory muscles of patients with temporomandibular disorder (TMD).

METHODS

The medical records of all patients who had received intramuscular BTX injections between 2005 and 2018 at Päijät-Häme Central Hospital, Lahti, Finland were analyzed retrospectively. Gender, age, previous medical history, number of injections, injection areas, and therapeutic results were collected and analyzed. The outcome was divided into three categories based on the patients' subjective reports: not beneficial, beneficial, and highly beneficial.

RESULTS

A total of 68 patients had received intramuscular BTX injections in our unit for TMD symptoms. Clinical effectiveness could be analyzed from 63 patients. Overall, 87% of them reported favorable outcomes. 8 (13%) reported BTX injections as not beneficial, 15 (24%) as beneficial, and 40 patients (63%) as highly beneficial.Most patients had already received conventional treatment with an occlusal splint (93%) combined with pain medication (60%) in the primary care units before they were referred to our hospital.There were 59 (83%) female patients, and they responded better to BTX therapy than the male patients: 91% versus 57% (P value = 0.04). Average age at the first BTX injection visit was 44.6 years (range 17.8-77.2). Most commonly (65%), BTX was divided bilaterally to the masseter and temporalis muscles.

CONCLUSIONS

BTX injections had good therapeutic outcomes for our TMD patients. However, most patients require multiple injection visits.

Is Botulinum Toxin Useful in Systemic Sclerosis Related Peripheral Vasculopathy? A Literature Review

INTRODUCTION

In systemic sclerosis (SSc), peripheral vasculopathy presents typically as Raynaud Phenomenon (RP) and Digital Ulceration (DU). Over the last decade, botulinum toxin (BT) has been reported effective in this scenario. Our goal was to review existing literature evaluating the efficacy of BT on RP/DU in SSc.

MATERIALS AND METHODS

We performed a search in Pubmed with the MeSH terms "systemic sclerosis" and "botulinum toxin". Original studies evaluating BT in the treatment of SSc-associated RP/DU were considered for inclusion. Results were screened by title, abstract and full-text.

RESULTS

We identified 30 results, of which 5 original papers were included: 2 randomized controlled trials (RCT), 2 case series and 1 case control study, from a total of 133 patients. Only one RCT showed negative results, with worse blood flow in treated arm, but with lower dose of BT. Despite this, all 5 included studies reported improvement of at least 1 RP/hand function outcome measure. Concerning DU healing, resolution of baseline DU at the end of follow-up was reported in 75-100% of the patients, with 1 RCT showing superiority over placebo. The only reported adverse effect was transient hand weakness, affecting only 0-16.7% of patients. BT injection protocols were highly heterogeneous.

CONCLUSION

Despite conflicting results in 1 RCT, evidence points BT as an option in the treatment of SSc-related peripheral vasculopathy. However, future larger prospective trials are necessary to corroborate this hypothesis.

Novel Interventional Nonopioid Therapies in Headache Management

PURPOSE OF REVIEW

Headaches encompass a broad-based category of a symptom of pain in the region of the head or neck. For those patients who unfortunately do not obtain relief from conservative treatment, interventional techniques have been developed and are continuing to be refined in an attempt to treat this subset of patients with the goal of return of daily activities. This investigation reviews various categories of headaches, their pathophysiology, and types of interventional treatments currently available.

RECENT FINDINGS

Injection of botulinum toxin has been shown to increase the number of headache free days for patients suffering from chronic tension-type headaches. Suboccipital steroid injection has been demonstrated as a successful treatment option for patients suffering from cluster headache. Occipital nerve stimulation (ONS) has been described as a treatment for all types of trigeminal autonomic cephalgias. Percutaneous ONS is a minimally invasive and reversible approach to manage occipital neuralgia performed utilizing subcutaneous electrodes placed superficial to the cervical muscular fascia in the suboccipital area. Radiofrequency lesioning is another commonly used treatment in the management of chronic pain syndromes of the head and neck. If a diagnostic sphenopalatine ganglion block successfully resolves the patient's symptoms, neurolysis can be employed as a more permanent solution. Although many patients who suffer from headaches can be treated with conservative, less-invasive treatments, there still remains at present an ever-increasing need for those patients who are refractory to conservative measures and thus require interventional treatments. These procedures are continually evolving to become safer, more precise, and more readily available for clinicians to provide to their patients.

Ultrasound Guidance for Botulinum Neurotoxin Chemodenervation Procedures

Injections of botulinum neurotoxins (BoNTs) are prescribed by clinicians for a variety of disorders that cause over-activity of muscles; glands; pain and other structures. Accurately targeting the structure for injection is one of the principle goals when performing BoNTs procedures. Traditionally; injections have been guided by anatomic landmarks; palpation; range of motion; electromyography or electrical stimulation. Ultrasound (US) based imaging based guidance overcomes some of the limitations of traditional techniques. US and/or US combined with traditional guidance techniques is utilized and or recommended by many expert clinicians; authors and in practice guidelines by professional academies. This article reviews the advantages and disadvantages of available guidance techniques including US as well as technical aspects of US guidance and a focused literature review related to US guidance for chemodenervation procedures including BoNTs injection.