Botulinum toxin treatment of children with cerebral palsy - a short review of different injection techniques

The intramuscular application of botulinum toxin type A (BoNT/A) has emerged to be an established treatment option to reduce muscular hyperactivity due to spasticity in children with cerebral palsy. Accurate injection is a prerequisite for efficient and safe treatment with BoNT/A. So far, treatment procedures have not been standardized. This paper is a short review of different injection techniques, i.e., manual needle placement as well as guidance by electromyography, electrical stimulation, and ultrasound. Advantages and disadvantages of the different injection techniques are discussed with a focus on needle positioning within the targeted muscle, injection close to the neuromuscular junction and diffusion of BoNT/A within the target muscles and through fascia. The additional information gained by each injection technique is weighed in terms of the clinical impact for children with cerebral palsy.

Muscle fiber orientation in muscles commonly injected with botulinum toxin: an anatomical pilot study

The endplate zone is assumed to be at about the midpoint of a muscle fiber. This study was designed to locate the middle of the muscle fibers of commonly injected muscles, thus identifying the endplate zone of these muscles. The proximal and distal musculotendinous junctions in muscles of the upper and lower extremities were identified. Orientation of muscle fibers was determined. Measurements using common surface landmarks were used to determine the relationship of these muscles with the landmarks (e.g., biceps muscle bulk extends from the upper fourth to the lower fourth of the humerus). Figures were developed using these measurements so as to be able to extrapolate these measurements to other patients of varying sizes. Illustrations of muscle fiber orientation were done and the assumed location of motor endplate bands marked. Color illustrations will be shown. With the thought that the endplate zone is at the middle of the muscle fiber, this detailed study of muscle fibers helps identify assumed location of motor endplates of specific muscles, thereby improving technique and efficacy of botulinum toxin injections.

Botulinum toxin as a treatment for tardive dyskinesia

Two older female patients with a history of psychotic depression were treated with a combination of an antipsychotic and an antidepressant. Both developed persistent tardive dyskinesia with severe tongue protrusion. Botulinum toxin was injected into the genioglossal area and the embarrassing tongue protrusion practically disappeared. Both patients chose to continue taking botulinum toxin.

Symptomatic palatal myoclonus with ear click after tick-borne meningoencephalitis

We present a case of a 39-year-old patient, who was diagnosed and treated for a tick-borne meningoencephalitis. Three months after the treatment he started to complain of annoying, cracks-resembling, rhythmical sounds, coming from the inside of his head to both his ears. Physical examination revealed rhythmical oscillations of the soft palate with a frequency of 100-120 per minute and a clock ticking noise synchronic with the palate tremor. Electromyography revealed continuous motor unit activity at rest in the tensor veli palatini muscle. Palatal myoclonus (PM) as a result of tick-borne meningoencephalitis was diagnosed. Treatment with several medications was started with no effect, then botulinum toxin was administered under EMG guidance to both sides of the patient's soft palate with great improvement. A 5-year follow-up and continuation of botulinum toxin injections with only minor and reversible side effects proved the treatment efficacy and safety. In the article we present a case of symptomatic palatal myoclonus with ear click and shortly discuss its aetiology, types and treatment options. We also stress the efficacy and safety of PM treatment with repetitive injections of botulinum toxin.

Botulinum toxin treatment of oesophageal achalasia in the old old and oldest old: a 1-year follow-up study

BACKGROUND

Intrasphincteric injection of botulinum toxin (BTX) has become one of the most frequent therapeutic approaches for the treatment of oesophageal achalasia. This treatment seems particularly effective in elderly patients who are not candidates for more invasive procedures.

AIMS

There are few or no data on BTX treatment of achalasia in the old old and oldest old. Therefore, we evaluated BTX treatment in a group of patients with achalasia in the extreme age range who were too ill or frail to undergo surgery or pneumatic dilatation.

PATIENTS AND METHODS

Twelve elderly achalasic patients (age range 81-94 years, average age 86 years) with American Society of Anesthesiologists (ASA) class III-IV status were recruited for the study. After baseline clinical and instrumental evaluations, BTX 100U was injected at time 0 and 1 month later. Clinical follow-up was carried out after 3, 6 and 12 months.

RESULTS

A significant improvement in symptom score was documented at each follow-up step. On the basis of improvements in scores, approximately 70% of patients were considered responders at the end of follow-up.

CONCLUSIONS

BTX treatment is an effective treatment in a substantial proportion of achalasic patients >80 years of age, in whom benefits are still detectable after 12 months. BTX is a therapeutic option in patients unsuitable for surgery or pneumatic dilatation.

Blepharospasm and hemifacial spasm: a protocol for titration of botulinum toxin dose to the individual patient and for the management of refractory cases

PURPOSE

To evaluate a protocol for the treatment of facial dystonias.

METHOD

A retrospective noncomparative interventional case series of all patients who attended a specialised tertiary referral clinic between January 2000 and January 2003. At the start of treatment, patients were seen and treated at weekly intervals until their symptoms were controlled or they developed complications. The sum of the weekly doses was taken as the individual patient dose and then given at 3-4 monthly intervals as required for the individual patient. Refractory cases of spasm underwent orbicularis muscle reduction. Pretarsal spasm was treated with pretarsal botulinum toxin. If the spasm was relieved but the patient could not open their eyelids, a trial of ptosis props was undertaken and the toxin injections continued, before considering a brow suspension. If patients could not see because of a spastic Bell's phenomenon, they were given centrally acting systemic medication.

RESULTS

Of 182 new patients, 63 (35%) required two or more sets of injections to titrate their optimum dose of toxin. Symptoms improved in 169 patients (93%). Of a total 332 new patients and follow-up patients, 47 (14%) underwent surgery during their management, 36 protractor myectomy, and 13 brow suspension. Protractor myectomy improved symptoms in 23 (64%). Brow suspension improved symptoms in 12 patients (92%).

CONCLUSIONS

The dose of botulinum toxin can be titrated to the individual patient, and the refractory cases managed satisfactorily if a logical protocol is followed.

Tetrabenazine as antichorea therapy in Huntington disease: A randomized controlled trial

BACKGROUND

Tetrabenazine (TBZ) selectively depletes central monoamines by reversibly binding to the type 2 vesicular monoamine transporter. Open-label reports indicate TBZ is effective in treating chorea.

OBJECTIVE

To examine the safety, efficacy, and dose tolerability of TBZ for treating chorea in Huntington disease (HD).

METHODS

The authors randomized 84 ambulatory patients with HD to receive TBZ (n = 54) or placebo (n = 30) for 12 weeks. TBZ was increased over 7 weeks up to a maximum of 100 mg/day or until the desired antichoreic effect occurred or intolerable adverse effects supervened. The primary outcome was the change from baseline in the chorea score of the Unified Huntington's Disease Rating Scale (UHDRS) RESULTS: TBZ treatment resulted in a reduction of 5.0 units in chorea severity compared with a reduction of 1.5 units on placebo treatment (adjusted mean effect size = -3.5 +/- 0.8 UHDRS units [mean +/- SE]; 95% CI: -5.2, -1.9; p < 0.0001). There was also a significant benefit on ratings of clinical global improvement. There were five study withdrawals in the TBZ group and five serious adverse events (SAEs) in four subjects (drowning suicide, complicated fall, restlessness/suicidal ideation, and breast cancer) compared with one withdrawal and no SAEs in the placebo group.

CONCLUSION

Tetrabenazine (TBZ), at adjusted dosages of up to 100 mg/day, effectively lessens chorea in ambulatory patients with Huntington disease. TBZ should be dosed individually based on ongoing assessment of possible adverse side effects.

[Experiences with botulinum toxin injections against spasticity in children]

BACKGROUND

Botulinum toxin injection is one of the newer options in the treatment of spasticity. Treatment with botulinum toxin is always combined with physiotherapy and often with casting. We show the extent to which botulinum toxin treatment has been taken into use in our department and discuss advantages and disadvantages of giving botulinum toxin injections at local hospitals.

MATERIAL AND METHODS

88 children with cerebral palsy aged 14 months to 16 years were treated with botulinum toxin between March 2000 and Dec. 2004. Injections were given in an outpatient setting, usually with the patient sedated with midazolam. Clinical examination after injection included assessment of spasticity and range of movement of joints. Motor function was videotaped. Side effects were continuously supervised.

RESULTS

We performed 278 treatments; during the last year (2004) 7 treatments a month on average. 59 children were injected in lower limbs only, 14 were injected in upper limbs only, and 15 were injected in both upper and lower limbs. No serious side effects were recorded, neither from the botulinum toxin itself nor related to the injection procedure.

INTERPRETATION

Assessment of indications for the use of botulinum toxin is now part of the medical follow up for children with spastic cerebral palsy. Treatment can safely be given at the paediatrics department in a local hospital. Injection in superficial muscles of the lower limbs is an easy task, while injection in small muscles and deep-seated muscles requires more special skills.

Nonsurgical treatment of chronic anal fissure: nitroglycerin and dilatation versus nifedipine and botulinum toxin

BACKGROUND

Surgical sphincterotomy for chronic anal fissure can cause fecal incontinence. This has led to the investigation of nonsurgical treatment options that avoid permanent damage to the internal anal sphincter.

METHODS

We conducted a retrospective, ongoing chart review with telephone follow-up of 88 patients treated for chronic anal fissure between November 1996 and December 2002. During the first half of the study period, patients were treated with topical nitroglycerin and pneumatic dilatation. With the availability of new therapies in June 1999, subsequent patients received topical nifedipine and botulinum toxin injections (30-100 units). Lateral anal sphincterotomy was reserved for patients who failed medical treatment.

RESULTS

In 98% of patients the fissure healed with conservative nonsurgical treatment. The combination of nifedipine and botulinum toxin was superior to nitroglycerin and pneumatic dilatation with respect to both healing (94% v. 71%, p < 0.05) and recurrence rate (2% v. 27%, p < 0.01). There was no statistical difference between the number of dilatations and botulinum toxin injections needed to achieve healing. Three patients who received botulinum toxin reported mild transient flatus incontinence. At an average telephone follow-up of 27 months, 92% of patients reported having no pain or only mild occasional pain with bowel movements.

CONCLUSIONS

Chronic anal fissures can be simply and effectively treated medically without the risk of incontinence associated with sphincterotomy. Topical nifedipine and botulinum toxin injections are an excellent combination, associated with a low recurrence rate and minimal side effects.

[A case of fibromyalgia treated with medical and autogenic training]

Fibromyalgia, which is relatively rare, may include symptoms of dizziness, vertigo and tinnitus. Subject was 38 years old woman reporting vertigo and whole body pain. Cochleovestibular function was normal. Pain was gradually intensified during her outpatient clinic and she was admitted. Treatments including intramusclular injection of botulinus toxin and intravenous injection of steroid were applied. Psychological counseling and autogenic training were effective in relieving her pain and vertigo. During her admission, several spells of vertigo occurred but no nystagmus was found. The abnormality in proprioception and neural disintegration may be related to vertigo. Treatment should start as early as possible together with psychological therapy.

Botulinum toxin improves sialorrhea and quality of living in bulbar amyotrophic lateral sclerosis

Sialorrhea is frequently a socially disabling symptom in patients with bulbar amyotrophic lateral sclerosis (ALS). In this open-label prospective study, we report the effect of botulinum toxin A (Botox) injection into the parotid glands in 10 patients with bulbar ALS and socially disabling sialorrhea. We applied three different outcome measures to determine the effect of Botox therapy on sialorrhea. Botox significantly improved the degree of sialorrhea and a drooling impact score and, by inference, the quality of living, in over half of the patients with bulbar ALS and severe sialorrhea. The beneficial effect of Botox lasted for at least 2 months in those who responded. No major adverse effects were noted. Local injection of a small dose of Botox into the parotid glands can control sialorrhea and potentially improve living quality in some patients with bulbar ALS.

Improvement of wound healing after hemorrhoidectomy: a double-blind, randomized study of botulinum toxin injection

PURPOSE

Hemorrhoidectomy is usually associated with significant pain during the postoperative period. The spasm of the internal sphincter seems to play an important role in the origin of pain. This study was designed to evaluate the effectiveness of intrasphincter injection of botulinum toxin after hemorrhoidectomy in reducing the maximum resting pressure of the anal canal, accelerating wound healing, and decreasing postoperative pain when resting and during defecation.

METHODS

Thirty patients with hemorrhoids of third and fourth degree were included in the study and randomized in two groups. Anorectal manometry was performed preoperatively and 5 and 30 days afterward in all patients undergoing Milligan-Morgan hemorrhoidectomy. One group received an injection of 0.4 ml of saline into the internal anal sphincter, the other group were injected with 0.4 ml of solution containing 20 units of botulinum toxin.

RESULTS

After five days from hemorrhoidectomy, maximum resting pressure decreased in the group injected with botulinum toxin and increased in the placebo group. The time of healing and postoperative pain when resting and during defecation significantly decreased in the group treated with an injection of botulinum toxin.

CONCLUSIONS

Botulinum toxin injection into internal anal sphincter after hemorrhoidectomy is effective in reducing maximum resting pressure, time of healing, and postoperative pain both on resting and during defecation in absence of complications or side effects.

The use of botulinum toxic injection to treat excessive drooling in children with neurological conditions

Drooling is a frequent complaint in children with chronic neurological conditions. This is due to poor neuromuscular coordination of the oropharyngeal musculature. Treatment options such as anticholinergic medications and surgical treatment have generally been unsuccessful or associated with side effects and complications. A new treatment for these children is botulinum toxin injection into the parotid glands to decrease saliva production. This article reports on two cases in which this modality was effectively utilized to treat this neurological condition.

Madarosis and facial alopecia presumed secondary to botulinum a toxin injections

PURPOSE

: Botulinum neurotoxins are considered relatively safe therapy for treatment of inappropriate muscle spasms. As seen in this report, undesirable consequences may result.

METHODS

: The author conducted a clinical interview and examination of the patient.

RESULTS

: Unilateral left-sided madarosis and facial alopecia were observed in a patient undergoing botulinum A toxin injections for the treatment of left oromandibular dystonia. The patient had started treatment 18 months previously. He received injections every 3 months in the left masseter and left temporalis muscles. He first noted loss of his left sideburn 8 months into treatment. After 10 months of treatment, he noted that he no longer needed to shave on the left side of his face. Eighteen months after receiving his first botulinum toxin injection, madarosis of the temporal aspect of the left lower lid was observed.

CONCLUSIONS

: This is the first case report documenting an idiosyncratic unilateral madarosis and facial alopecia as adverse side effects presumed secondary to botulinum A toxin injections.

Safety of Simultaneous Bilateral Botulinum Toxin Injections for Abductor Spasmodic Dysphonia

OBJECTIVE

To review the safety of simultaneous bilateral posterior cricoarytenoid muscle botulinum toxin injections.

DESIGN

Retrospective case series review.

SETTING

Tertiary care academic clinic.

PATIENTS

Twenty-one patients with abductor spasmodic dysphonia.

INTERVENTIONS

Patients received 100 simultaneous bilateral posterior cricoarytenoid muscle botulinum toxin injections for isolated abductor spasmodic dysphonia over a 6-year period.

MAIN OUTCOME MEASURES

Major and minor complications, injection dosing, and demographics.

RESULTS

The total bilateral botulinum toxin injection dose per session ranged from 2.50 to 7.50 U, and the average total bilateral dose per patient was 4.70 U. There were no major complications, and minor complications were self-limited. There was a 5% incidence of significant dyspnea and a 2% incidence of dysphagia, and all patients were treated conservatively. The average doses at which dyspnea and dysphagia occurred were 4.97 and 5.56 U, respectively.

CONCLUSIONS

This case series demonstrates that simultaneous bilateral posterior cricoarytenoid muscle botulinum toxin injection is safe up to the highest doses reported. Complications with this approach are consistent with those previously reported using other methods. Prospective studies on vocal outcome measures are needed for simultaneous bilateral posterior cricoarytenoid muscle botulinum toxin injections to evaluate the efficacy of this technique.

The use of haloperidol and associated complications in the agitated, acutely ill pediatric burn patient

The use of haloperidol to induce sedation and control agitation in the acutely ill adult patient has been well documented. There are few reports, however, of the use of this neuroleptic agent to control the severe delirium and agitation that may occur in critically ill pediatric patients or acute pediatric patients suffering from burn wounds. We assessed the effectiveness and safety of the use of haloperidol by completing a retrospective chart review of 855 acutely ill children treated consecutively during the period from April 1999 to May 2002, during which time 26 children received haloperidol. The safe use of haloperidol was assessed by documenting any adverse effects or reactions observed after the administration of the drug. Of patients given haloperidol, 23% had adverse effects. This result suggests that the use of haloperidol to treat the acutely agitated and delirious pediatric burn patients is fraught with a number of difficulties and is not completely safe and effective.

Clinical application of botulinum toxin type B in movement disorders and autonomic symptoms

OBJECTIVE

[corrected] To evaluate efficacy and safety of botulinum toxin type B (BTX-B) in treatment of movement disorders including blepharospasm, oromandibular dystonia, hemifacial spasm, tremor, tics, and hypersecretory disorders such as sialorrhea and hyperhidrosis.

METHODS

A retrospective study of BTX-B injections in treatment of 58 patients with various neurological disorders was performed. The mean follow-up time was 0.9 +/- 0.8 years. Results of the first and last treatment of patients with at least 3 injection sessions were compared.

RESULTS

The response of 58 patients to a total of 157 BTX-B treatment sessions was analyzed. Of the 157 treatment sessions, 120 sessions (76.4%) resulted in moderate or marked improvement while 17 sessions (10.8%) had no response. The clinical benefits after BTX-B treatment lasted an average of 14 weeks. Of the 41 patients with at least 3 injection sessions (mean 10 +/- 8.6), most patients needed increased dosage upon the last session compared to the first session. Nineteen patients (32.8%) with 27 sessions (17.2%) reported adverse effects with BTX-B treatment.

CONCLUSIONS

Though most patients require increased dosage to maintain effective response after repeated injections, BTX-B is an effective and safe treatment drug for a variety of movement disorders, as well as drooling and hyperhidrosis.

Contemporary management of spasmodic dysphonia

PURPOSE OF REVIEW

To review current concept in spasmodic dysphonia management.

RECENT FINDINGS

The standard of care for spasmodic dysphonia in 2004 remains botulinum toxin chemodenervation for symptomatic management. This is supported by a large body of literature attesting to its efficacy in many different hands, particularly for the adductor form of the disorder. New surgical approaches await the crucial test of time, in view of historical difficulties in achieving long-term benefit via recurrent nerve section, and currently, surgery is best reserved for the rare patient who does not benefit or cannot tolerate botulinum toxin injections. Despite efforts to refine both surgical and botulinum toxin treatment, symptom relief in abductor spasmodic dysphonia and dystonia with tremor remains suboptimal.

SUMMARY

Spasmodic dysphonia is a disorder of the central nervous system rather than the larynx, and as in other forms of dystonia, interventions at the end organ have not offered a definitive cure. The pathophysiology underlying dystonia is becoming better understood as a result of discoveries in genetically based forms of the disorder, and this approach is the most promising avenue to a long-term solution.

Bilateral vocal fold paralysis: an unusual treatment with botulinum toxin

We presented a patient with bilateral vocal fold paralysis treated with intralaryngeal Botox injection to improve the glottal airway. The use of Botox in this manner has not been previously reported and highlights the value and role of intralaryngeal Botox in changing the configuration of the glottis. The concept and various approaches for using Botox to alter pathologic vocal fold position is reviewed and discussed.

Injectable neuromodulatory agents: botulinum toxin therapy

Botulinum toxin therapy is a diverse treatment option for various dysfunctions of the lower urinary tract. The limited but growing clinical experience reveals that temporary chemodenervation with reduction or loss of neuronal activity at the target organ may be achieved with minimal risk. This highly favorable risk-benefit ratio in urology is derived from the clinical ability to treat an end-organ condition effectively with controllable site-specific delivery (eg, subcutaneous, intramuscular, or instillation) combined with high affinity for toxin uptake by the peripheral cholinergic nerves. Although many questions remain regarding the optimal use of this minimally invasive option for urologic applications, the opportunity for expanding indications will provide urologists with more options for addressing difficult challenges in voiding dysfunction.