Localised autonomic failure due to botulinum toxin injection

Prise en charge non chirurgicale des plaies de la glande parotide et du canal de Stenon: intérêt de la toxine botulinique

Salivary fistulas and sialoceles are rare complications of post-traumatic or postoperative parotid gland and duct injuries. Local injections of type A botulinum toxin represent a new and effective treatment for complications of these injuries, which is less invasive, stressful and lengthy than conventional methods. The authors report five cases in which three salivary fistulas and two sialoceles were successfully treated by botulinum toxin injections. The therapeutic protocol is described; it allows simple management of these complications and use of smaller doses than those described in the literature for treatment of sialoceles. The authors recommend use of botulinum toxin injections in first intention for management of salivary fistulas and sialoceles.

Post-surgical role of botulinum toxin-A injection in patients with head and neck cancer: personal experience

Personal experience is discussed in the use of botulinum neurotoxin injections into both parotids, performed in order to transiently reduce salivation in patients undergoing major ablative and ablative-reconstructive oncologic surgery for head and neck tumours. Overall, 8 adult patients (2 female, 6 male) have been treated. Six cases were affected by pharyngocutaneous fistulas, one by severe sialorrhoea and one recurrent sialocele. After the injection, patients were regularly observed at follow-up and asked to give their subjective assessment of salivary flow. Investigations concerning possible complaints, including side-effects, as well as complete examination of the head and neck area were performed. Follow-up periods ranged from 12 to 24 weeks (mean 20 weeks). Following botulinum neurotoxin injection, the fistula was dry after a mean period of 4.5 days (min 3 days, max 8 days) and was closed 6.6 days (min 5 days, max 8 days) later. The patient affected by severe hypersalivation reported subjective improvement in sialorrhoea 4 days post-treatment. The patient affected by recurrent sialocele, required only one aspiration of fluid two days after the treatment, after which there were no further problems. Post-operative saliva-related complications significantly increase patient morbidity and hospital stay after major tumour surgery. The easy, safe and effective treatment with botulinum neurotoxin injection, observed in our experience, suggest its significant role as a useful option in the post-operative saliva-related complications.

Dental implications of some common movement disorders: a concise review

Movement disorders - or dyskinesias - are characterized by involuntary movements. Despite the major role for medical specialists in the diagnosis and treatment of dyskinesias, dentists are confronted with such disorders as well. Unfortunately, the literature regarding the dental implications of movement disorders is still scarce. This concise review describes the dental implications of some common dyskinesias, viz., Gilles de la Tourette's syndrome, Huntington's disease, idiopathic torsion dystonia, oral dyskinesias, and Parkinson's disease. It was concluded that these dyskinesias may have profound dental implications. Not only do generalized dyskinesias have focal manifestations in the orofacial region, but there are also dyskinesias that exclusively affect the orofacial area. The oral manifestations of dyskinesias are in part directly related to the disorder, and in part medicine-related. Dentists should be able to recognize the oral manifestations and, when properly trained, to manage them adequately. In most instances, a multidisciplinary approach upon referral is necessary, including the medical specialists involved. Unfortunately, the level of evidence of the selected papers was generally low. In our rapidly ageing population, it is a challenge for all of us to improve the quality of this emerging field, for the sake of this sometimes heavily infirmed category of patients.

[Treatment of sialorrhea with botulinum toxin: an overview]

Hypersalivation (sialorrhea) is a common complaint of patients with neurodegenerative disorders such as Parkinson's disease or amyotrophic lateral sclerosis and a frequently disabling side effect of atypical antipsychotic drugs. Conventional treatment including oral anticholinergic or antihistamine medication is often limited by adverse effects and lack of efficacy. Over the past few years, several studies reported decreased drooling after injections of botulinum toxin into the salivary glands. This review describes the current state of treatment of sialorrhea with botulinum toxin.

Botulinum toxin A for the treatment of cervical dystonia

Idiopathic cervical dystonia (ICD) is the most common adult-onset focal dystonia. It is characterised by relatively sustained, involuntary contractions of neck muscles. Injections of botulinum toxin (BTX)-A are safe and effective for the treatment of ICD, and have substantially improved its treatment. BTX-A is manufactured by Allergan Pharmaceuticals in the US and Ireland, and is distributed as Botox. In Europe, BTX-A is manufactured and distributed by Ipsen Pharmaceuticals as Dysport. Success rates for BTX-A injections for ICD ranges 64-90%, with 76-93% of injected patients experiencing pain reduction. Side effects are generally mild and include dysphagia and neck weakness.

Intraparotid Injection of Botulinum Toxin A as a Treatment to Control Sialorrhea in Children with Cerebral Palsy

OBJECTIVE

To determine the efficacy of botulinum toxin A in the management of drooling (sialorrhea) in children and young adults with cerebral palsy.

DESIGN

Twenty-one children were enrolled in an open-label, nonblinded prospective study. Subjective and objective measures were used to determine the effect of botulinum toxin A on drooling and saliva production. Subjective measures included visual scales to document the child's severity and frequency of drooling. Objective measures included the number of bibs used per day and salivary secretion. At the initial visit, subjective and objective measures established the child's baseline drooling and saliva production. Fifteen units of botulinum toxin A was injected into each parotid glans. At each fellow-up visit of telephone survey, subjective and objective measures were recorded to monitor the child's drooling and saliva production. A postinjection questionnaire evaluated overall effect and caregiver satisfaction.

RESULTS

The visual analog scales and number of bibs used per day demonstrated statistically significant reduction in severity and frequency of drooling at 2 wks, 1 mo and 2 mos. Salivary production was significantly reduced at 1-mo fellow-up. Eighty-nine percent of the caregivers reported and improvement of their child's drooling after botulinum toxin A injection. Severity-nine percent of caregivers were satisfied with the treatment and would perform the treatment again.

CONCLUSION

Intraparotid injections of botulinum toxin A are efficacious in decreasing severity and frequency of drooling, the number of bibs used per day, and the production of saliva in children with cerebral palsy. The injections are relatively safe and adverse effects were observed in this study.

Botulinum toxin to reduce saliva flow: selected indications for ultrasound-guided toxin application into salivary glands

OBJECTIVES/HYPOTHESIS

The study investigates the effect of local injections of botulinum toxin type A (Botox) into the major salivary glands of the head in various states of hypersalivation. In particular, we studied pathological states with permanent as well as passing hypersalivation disorders and present new indications for local application of botulinum toxin to the salivary glands.

STUDY DESIGN

Retrospective clinical investigation.

METHODS

A total of 55 to 65 units of Botox were injected under sonographic control into the left and right parotid and submandibular glands of four patients with hypersalivation resulting from head and neck carcinoma, tracheostomy, and "idiopathic" hypersalivation disorder. At defined time intervals following injection, flow rate, total protein and immunoglobulin A content, and the enzymatic activities of amylase, acid phosphatase, and kallikrein were determined in the saliva. The patients were clinically examined to assess the severity of their symptoms, including sonographic control of the major salivary glands.

RESULTS

All four patients reported distinct improvement of their symptoms within 1 week after injection. Salivary flow rate had considerably dropped, whereas the concentrations of the salivary components were much increased. Sonography did not reveal any changes of the salivary gland parenchyma. Therapeutic side effects were absent.

CONCLUSIONS

Treatment of hypersalivation by local injections of Botox into the salivary glands of the head is a reliable and efficient therapy without side effects for certain otolaryngological diseases, especially if injections are performed under sonographic control. Extension of this therapeutic concept to other indications is suggested.

The effect of local injection of botulinum toxin A on the parotid gland of the rat: an immunohistochemical and morphometric study

PURPOSE

In this investigation, the effect of a local injection of botulinum toxin A on the concentration of acetylcholinesterase in the parotid gland of the rat was examined.

MATERIALS AND METHODS

After local injection into the parotid glands of female Wistar rats, the treated glands were excised, and immunohistochemical staining for acetylcholinesterase was performed. To discover possible changes in cell morphology after local application of botulinum toxin A, morphometric measurements also were performed on the excised parotid glands.

RESULTS

In contrast to the untreated, physiologic saline-injected, glands, there was a decrease in the concentration of acetylcholinesterase in the glands treated with botulinum toxin. No persistent changes in the number of acinar cells could be observed.

CONCLUSIONS

Because the cholinergic pathway of the autonomic nervous system has great importance in the secretion of fluid from the salivary glands, blocking this pathway and local application of botulinum toxin offers a possible therapeutic option for the treatment of hypersalivation in various otolaryngologic and neurologic diseases.

Does botulinum toxin alter laryngeal secretions and mucociliary transport?

Localized botulinum toxin injection disrupts cholinergic transmission and has potential to cause focal dysautonomia. Mucociliary transport and laryngeal secretions are thought to be mediated in part by autonomic, cholinergic transmission. We questioned whether patients who receive Botox injection for adductor spasmodic dysphonia (ADSD) report postinjection symptoms possibly related to altered mucociliary clearance or laryngeal secretions. Medical histories, audiotaped interviews, and symptom ratings were retrospectively examined for 29 patients with ADSD who were followed after one or more Botox injections. Patients had received bilateral, percutaneous Botox injections of 2.5 units using an EMG-guided approach. One or more weeks after injection, four patients reported either burning, tickling, or irritation of the larynx/throat, excessive thick secretions, or dryness. Symptoms recurred with subsequent injections in two patients and were not associated with swallowing difficulty. These symptoms are consistent with, but not diagnostic of, the known effects of botulinum toxin on cholinergic, autonomic transmission.

Idiosyncratic adverse reactions to intramuscular botulinum toxin type A injection

Three cases of adverse reactions to repeated intramuscular botulinum toxin A (BTA) injections are described: a persistent rash on the face at the site of injection, a localized anaphylactic reaction following BTA injection into one leg, and bilateral ptosis repeatedly following BTA injection into neck muscles. The mechanisms for these idiosyncratic adverse responses are not known.

Sialorrhea in amyotrophic lateral sclerosis: a hypothesis of a new treatment--botulinum toxin A injections of the parotid glands

The inhibitory action of botulinum toxin is not confined to the neuromuscular junction. The toxin has long been known to block all the autonomic cholinergic fibers, including the major secretomotor parasympathetic fibers to salivary glands. The parotids are the largest of the salivary glands and their selective chemodenervation with botulinum toxin A is likely to result in substantial reduction of saliva production. Injection of the parotid glands with botulinum toxin is proposed as an new treatment for sialorrhea in patients with amyotrophic lateral sclerosis and other neurological diseases.

Botulinum toxin in the therapy of gustatory sweating

Three patients suffering from gustatory sweating following trauma to the preauricular region from a bullet wound or parotid gland surgery were treated by intracutaneous injection of botulinum toxin A. Within 2 weeks, gustatory sweating in the area injected completely ceased in all patients with no side-effects. The efficacy of treatment was confirmed by repeated Minor's iodine starch tests. So far, sweating has not recurred during a follow-up period of up to 8 months. Botulinum toxin appears to be a promising new drug for the treatment of this autonomic disorder.