Treatment of spasticity with botulinum toxin

Spasticity is a velocity-dependent pathologic increase in muscle resistance to stretch, and occurs in a variety of neurologic disorders. We report our controlled open study using botulinum toxin A for treatment of adductor spasticity in five patients with advanced multiple sclerosis. Clinical evaluation of spasticity and stiffness of joints is based on the Ashworth Scale and grade of passive abduction. Three patients showed no response; the two others experienced an excellent and longlasting effect. We also describe briefly the different spastic conditions where this treatment has been used successfully.     

Dilution and storage of botulinum toxin

BACKGROUND: There has been an ongoing controversy as to the best dilution for botulinum toxin for use in cosmetic applications. Recommended dilutions have ranged from 1 ml per vial to 10 ml per vial. There has also been much discussion on the diluent, i.e., preserved versus unpreserved saline, to be used and on storage time of the material after dilution. OBJECTIVES: The objective of this paper is to examine the literature and experience of practitioners in the field to try to resolve some of the questions concerning dilution and storage of botulinum toxin. CONCLUSIONS: Although there is great variation in the dilutions adopted by various physicians, much of this is a matter of personal preference. It does seem to appear that most clinicians use a dilution near 2.5 to 3.0 ml per vial and three-quarters of them limit the storage of the diluted product to 1 week or less.     

The adjunctive usage of botulinum toxin

BACKGROUND: Botulinum toxin is a safe, helpful adjunct to many other treatments for facial rejuvenation. Used together, the final result is more polished and refined. In addition, botulinum toxin can be used to maintain the surgical laser results by preventing dynamic facial muscular action re-establishing expressive wrinkles and folds. OBJECTIVES: We describe the facial areas best treated with botulinum toxin and our adjunctive techniques so that the cosmetic physician can easily incorporate these into their practice. RESULTS: The aesthetic results are improved with the combination of botulinum toxin and the surgical or laser procedure over either modality alone. CONCLUSIONS: We believe that there are many new treatment options for combined therapy with botulinum toxin, laser resurfacing, and surgical procedure in periocular and facial rejuvenation that the aesthetic physician can easily incorporate into their practice.     

Nerve injection injury with botulinum toxin

The therapeutic use of botulinum toxin (Botox) is increasing in popularity. Previous studies have shown that various drugs, especially when injected intrafascicularly, can cause major nerve damage. This study evaluates the potential for neurotoxicity of botulinum toxin in a rat sciatic nerve model. Lewis rats were randomly assigned to one of six groups (n = 10/group). Group 1, 2, and 3 rats received, respectively, an intrafascicular, extrafascicular, and extraneural injection of 50 microl of botulinum toxin (50 UI/ml). Group 4, 5, and 6 rats received 50 microl of 10% phenol as a positive control. Five animals received saline as a negative control. Animals were sacrificed at 2 and 7 weeks. Nerves were harvested and processed for histology and morphometry. Nerves in all botulinum toxin groups retained a normal architecture without cellular infiltration or demyelination. The number and diameter of fibers, the thickness of myelin, and the percentage of neural tissue were comparable with normal controls. Nerves injected intraneurally with phenol presented with severe damage, demyelination, and inflammation at 2 weeks and showed signs of early regeneration at 7 weeks. This study demonstrates that in a rat model, even direct intraneural injection of botulinum toxin caused no damage. This information should encourage the reconstructive surgeon to consider broader applications of this drug.     

Electromyographic guidance in injecting botulinum toxin

BACKGROUND: Many practitioners involved with the cosmetic applications of botulinum toxin believe that electromyography (EMG) is an invaluable tool in determining the precise locations to inject. Others feel that it is unnecessary and of no value whatsoever. OBJECTIVES: The objective of this paper is to (1) demonstrate the proper technique for usage of the EMG machine, and (2) determine if its use in connection with injection of facial muscles for cosmetic purposes is worthwhile. CONCLUSIONS: The anatomy of the muscles of the face is somewhat variable from person to person. Electromyography can be a valuable adjunct when injecting botulinum toxin for cosmetic purposes by ensuring that the injecting needle is precisely in the muscle, thereby ensuring that the botulinum toxin will have the greatest possible effect.     

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.     

Treatment of hemifacial spasm with botulinum toxin

We injected botulinum toxin to treat hemifacial spasm, and investigated the effects and the patient's impression of this treatment. Average duration of improvement lasted about 3.5 months in both the initial treatment group and the recurrent group. However the patients in the recurrent group received fewer units of botulinum toxin than those in the initial treatment group. Except for local paralysis that disappeared within a month, there were very few complications. Most patient were satisfied with this treatment. We conclude that the treatment of hemifacial spasm with botulinum toxin is both simple and useful.     

Use of botulinum toxin type F injections to treat torticollis in patients with immunity to botulinum toxin type A

Fifteen patients with torticollis who had been treated with repeated injections of botulinum toxin type A (botox A) developed antibodies to the toxin. This resulted in loss of benefit in the 13 patients who had improved with botox A injections and failure to develop muscle atrophy after injection in all 15 patients. Patients were then injected with botulinum toxin type F (botox F) in the same muscles that had been injected with botox A. Ten of the 15 improved after botox F injections, including 9 of the 12 patients who had improved with type A toxin. Six of 9 patients with pain had improvement in pain after botox F injections. Patients reported similar improvement with type F and type A toxins, but duration of benefit was approximately 3 months with type A and approximately 1 month with type F. Botox F is an effective treatment for torticollis in patients who are immune to botox A. The usefulness of type F toxin, however, is limited by short duration of benefit.     

Treatment of Frey's syndrome with botulinum A toxin

A 74-year-old woman suffered from severe gustatory sweating and flushing of the preauricular skin following parotidectomy (Frey's syndrome). She was treated with intracutaneous botulinum A toxin injections in the affected skin area. Minor's test was used to determine the extent of the affected area. Within one week, the symptoms disappeared. After three weeks, Minor's test was repeated and showed minimal residual hyperhidrosis. These small areas were treated again. No side effects were noted. At follow-up one year later, the patient was free of symptoms.     

Therapeutic use of botulinum A toxin in neurology

The highly potent neurotoxins produced by Clostridium botulinum lead to botulism when ingested in appreciable amounts. However, botulinum toxin injections delivered intramuscularly in very small quantities can produce a therapeutically intended focal paresis while producing only negligible local or systemic side effects. Over the past several years, various neurological disorders, especially those involving increased muscle tone and/or abnormal movements, have been successfully treated with local botulinum A toxin injections. The success of this method has led to a general change in the management of blepharospasm, torticollis spasmodicus, hemifacial spasm, and other disorders. Treatment is usually effective for 4 to 12 weeks; if symptoms recur, the injections can be repeated over a period of several years, usually with the same success. Side effects depend on the site of the injections, and are rare at the optimal dosage and always reversible. For optimum therapeutic results, this treatment must be restricted to specialized centers.     

The long-term use of botulinum toxin for adult strabismus

PURPOSE: To characterize patients choosing repeated botulinum toxin injection as a treatment for their strabismus, and assess their demand for it over time (up to 8 years). METHOD: Patients who had undergone at least eight injections were identified and their clinical records analyzed for diagnosis, demographic details, and demand for toxin injections with time. To establish any predictive variables, the details for these cases were compared with those of matched controls who had undergone fewer injections. Lastly, a questionnaire was mailed to research patients' views as to the indications and preferences for regular toxin injection as a method of treatment. RESULTS: Ninety-five patients were identified (34 men, 61 women; median age 37 years), of whom 35 had consecutive exotropia and 16 had secondary exotropia. Other diagnoses represented were residual and primary deviations, restrictive exotropias, and oscillopsias. A trend of fewer injections over the attendance period was seen, and the only complication observed was upper lid ptosis in 1% of injections. Cases exhibited similar demographic composition to matched controls, but were more likely to have consecutive exotropia or secondary esotropia as a diagnosis. Univariate analysis showed evidence (p < 0.001) of an association between the number of previous operations and the odds of being a case. No evidence was found that cases and controls lived at differing distances from our hospital. The questionnaire found that 71% of patients stated appearance as the prime reason for seeking treatment, and 37% stated simplicity of toxin therapy as their reason for reattendance. Twenty-six percent of the patients were disillusioned with the results of previous surgery and preferred toxin therapy as a means of controlling their symptoms. CONCLUSION: Botulinum toxin injection is an appropriate long-term treatment for some strabismus patients who choose not to undergo further surgery. A trend toward fewer injections with time was observed, and no adverse effects were associated with long-term treatment.     

The treatment of hemifacial spasm using botulinum toxin]

Hemifacial spasm is a disagreeable disturbance with involuntary unilateral twitching of the facial muscles. Its most common form is supposedly due to an irritation of the facial nerve at its proximal intracranial segment by vascular structures. Various forms of treatment including surgical procedures are employed, very often without satisfactory results but frequently involving the risk for severe complications. For a few years a new method has been using injection of botulinum toxin into the affected muscles, which in the majority of patients relieves the abnormal movements for about half a year; therefore, this very effective and secure procedure is recommended as first-line treatment of hemifacial spasm.