Botulinum toxin type A induces apoptosis in nasal glands of guinea pigs

Comparing The Effects of Botulinum toxin-A and multiple surgical parasympathectomy on treatment of allergic rhinitis

OBJECTIVE

Allergic rhinitis (AR) is a common disease with a recent increasing in prevalence. Traditional treatment strategies of AR, sometimes, show limited effectiveness and side effects. Intranasal injection of Botulinum toxin type A (BTX-A) and multiple postganglionic parasympathectomy of pterygopalatine ganglion (PPG) are among the increasingly used alternative treatment options of AR. In this study, we compared the early efficacy of BTX-A and multiple surgical parasympathectomy (MSP) on treatment of uncontrolled AR.

METHODS

Sixty patients who were diagnosed with uncontrolled AR, were recruited to the study. Participants randomly underwent either intranasal injection of BTX-A (45 IU in each nostril) (Group A) or bilateral MSP (Group B). All patients were evaluated in terms of nasal hypersecretions, congestion and sneezing with visual analogue scale prior to treatment and at weeks 1, 2, 4, 8, 12 and 6 months during the follow-up period.

RESULTS

A significant difference in the degree of nasal hypersecretions and sneezing could be identified in both groups before and after the interventions. Although the significant efficacy on sneezing was documented in group A and B only in the first 4 and 8 weeks, respectively, such efficacy on nasal hypersecretions extended for 12 weeks in group A and throughout the follow-up period in group B. Nasal congestion did not differ significantly in both groups.

CONCLUSION

Both BTX-A and MSP, in patients with uncontrolled AR, may be a long-lasting therapeutic option for the treatment of nasal hypersecretions, but not as effective as for sneezing and nasal congestion.

[Research progress of botulinum toxin type A in the treatment of chronic rhinitis]

Botulinum toxin（BoNT）, a superfamily of neurotoxins produced by the bacterium Clostridium botulinum, disturbs the signal transmission at the neuromuscular and neuroglandular junctions by inhibiting the neurotransmitter release from the presynaptic nerve terminal. BoNT has been widely used in neuromuscular, hypersecretory, and autonomic nerve system disorders. In recent years, botulinum toxin type A（BoNT-A） has been used to treat chronic rhinitis. Studies have shown that intranasal administration of BoNT-A is safe and effective, and can reduce nasal symptoms in rhinitis patients with long-lasting effects. This article reviews the research progress of BoNT-A in the treatment of chronic rhinitis.

Comparison between botulinum toxin and steroid septal injection in the treatment of allergic rhinitis

OBJECTIVE

To compare the effects of botulinum toxin and steroid septal injections in treating allergic rhinitis (AR) by evaluating improvements in the rhinitis control assessment test (RCAT), visual analog scale (VAS), nasal obstruction symptom evaluation (NOSE) scores, and active anterior rhinomanometry (RMM) measurements.

METHODS

This prospective, single-blinded cohort study was conducted at the Department of Otolaryngology, Taipei City Hospital between January 2017 and December 2018. Ninety-five patients were randomized to receive botulinum toxin, dexamethasone, or normal saline (group A, group B, and placebo, respectively). The main outcome measures were pretreatment subjective nasal symptoms (RCAT, VAS, and NOSE) and active anterior RMM measurements. All measurements were repeated during posttreatment 1, 2, and 3 months.

RESULTS

No significant difference was observed in pretreatment questionnaire scores and RMM values between the study and placebo groups. The mean posttreatment RCAT, VAS, and NOSE scores after 1 and 2 months significantly improved in the treatment groups compared to placebo. The VAS and NOSE at posttreatment 2 months and RCAT, VAS, and NOSE at posttreatment 3 months were significantly different comparing group A to group B. All RMM parameters showed better values in group A than in group B at 1, 2, and 3 months posttreatment, with significant differences in four parameters in posttreatment 3 months.

CONCLUSIONS

Botulinum toxin septal injection is a safe treatment option for AR and improves subjective nasal symptoms for 3 months. Botulinum toxin A injection tended to be more effective than steroid septal injection in terms of duration and degree.Level of Evidence: 2b, individual cohort study.

The Effect of Turbinate Injection of Botulinum Toxin A on the Symptoms of Idiopathic Rhinitis

Introduction  Idiopathic rhinitis is a nonallergic and noninfectious rhinitis characterized mainly by nasal obstruction and rhinorrhea, resulting from an autonomic imbalance. Botulinum toxin type A (BTX-A) demonstrated its action in reducing rhinorrhea and nasal obstruction when injected into the nasal turbinates or septum.

Objective  To analyze the effects of intranasal BTX-A injection to control the symptoms of idiopathic rhinitis and its possible adverse effects.

Method  Patients with idiopathic rhinitis were divided into two groups. Group A had 15 participants (8 female and 6 male), of ages from 47 to 84 years (mean 66.57 years), and these received 60 U of Dysport (Ipsen Ltd, Maidenhead, Berkshire, UK) in each inferior nasal turbinate; group B had 12 participants (1 male and 11 female), of ages from 50 to 76 years (mean 60 years), and they received 1 ml of 0.9% saline. The individuals were reevaluated in the 1 ^st , 2 ^nd , 4 ^th , 8 ^th , and 12 ^th weeks after injection by a questionnaire, accompanied by nasal inspiratory peak flow and acoustic rhinometry.

Results  Group A showed significant improvement, mainly regarding the symptoms of sneezing/itching and nasal obstruction, over time and when compared to group B. Acoustic rhinometry confirmed the improvement in nasal obstruction. There was no relationship between the nasal peak flow data and the nasal obstruction score. No major adverse effects have been reported.

Conclusion  The injection of botulinum toxin in the inferior nasal turbinates of patients with idiopathic rhinitis reduces the symptoms of sneezing, itching, nasal obstruction, and runny nose without significant adverse effects, suggesting that it is an option in the treatment of these patients.

Botulinum toxin for chronic rhinitis: A systematic review and meta-analysis

BACKGROUND

Botulinum toxin type A (BTX-A) is a potential treatment for chronic rhinitis. This study aimed to assess the effectiveness and safety of BTX-A in treating patients with chronic rhinitis.

METHODS

Systematic searches of MEDLINE, Scopus, and EMBASE databases were performed. Randomized controlled trials (RCTs) that assessed the efficacy of BTX-A in allergic rhinitis and/or nonallergic rhinitis patients, compared with either placebo or active treatment, were included. The outcomes were total nasal symptom (TNSS), disease-specific quality of life (QOL), and adverse events.

RESULTS

Nine RCTs (340 patients) met the eligibility criteria. Compared with placebo, the ≤ 12-week effects favored BTX-A injection on TNSS (standardized mean difference [SMD] -2.22, 95% confidence interval [CI] -3.27 to -1.17, p < 0.01, four RCTs). Beneficial effects > 12 weeks over placebo (MD -9.69, 95% CI -11.29 to -8.09, p < 0.01, one RCT) were demonstrated up to 24 weeks. However, the benefits were not shown on nasal congestion and individual nasal symptoms. Compared with active comparators (triamcinolone injection, ipratropium bromide, and cetirizine), there was no difference in the < 12-week effect between groups on TNSS. There was no difference between BTX-A and cetirizine on QOL (one RCT). The > 12-week effects on TNSS and individual nasal symptoms favored BTX-A over triamcinolone injection (one RCT). The risk ratio of adverse events favored BTX-A over cetirizine (one RCT).

CONCLUSIONS

BTX-A improved TNSS and QOL in patients with chronic rhinitis. These effects were demonstrated up to 24 weeks post treatment. BTX-A was safe, well tolerated, and may be considered in patients who are refractory to current standard-of-care therapies.

Noninvasive allergic sinus congestion and resolution assessments using microcomputed tomography imaging

Sinus congestion resultant of allergic rhinosinusitis is associated with development and worsening of asthma and can result in difficulty breathing, headaches, and missed days of school and work. Quantification of sinus congestion is important in the understanding of allergic rhinosinusitis and the development of new drugs for its treatment. Noninvasive microcomputed tomography (micro-CT) was investigated in a guinea pig model of allergic rhinosinusitis to determine its utility to determine accurately the degree of sinus congestion and resolution with anti-inflammatory drug administration. Three-dimensional sinus air-space volume, two-dimensional sinus width, sinus image air-space area, and sinus image sinus perimeter were measured in guinea pigs administered ragweed pollen (RWP), intranasally (i.n.), followed by administration of fluticasone, i.n. To determine their relative accuracy in assessing sinus congestion, the micro-CT image results were compared with the "gold-standard" method of sinus fluid fill-volume (SFFV) measurements. As measured by SFFV method, RWP increased sinus congestion in a RWP concentration-dependent fashion, approaching near-total sinus blockage with concentrations ≥22 µg of RWP. At this level of congestion, fluticasone (25-100 µg) progressively decreased sinus congestion in a concentration-dependent fashion. The noninvasive micro-CT methods were found to accurately determine the amount of sinus congestion and resolution, with patterns of increases and decreases of congestion that were nearly identical to the SFFV method. We conclude that noninvasive micro-CT measurements of allergic sinus congestion can be useful as an investigative tool in the assessment of congestion intensity and the development of new drug therapies for its treatment. NEW & NOTEWORTHY Allergic rhinosinusitis afflicts significant portions of the world population, resulting in loss of work productivity and decreased quality of life. Thus the development of methodological approaches, which incorporate accurate and reproducible noninvasive assessments of sinus congestion, are desirable. Microcomputed tomography of the guinea pig sinuses offers a noninvasive evaluation tool in an animal model of IgE-dependent allergy similar to that in humans, with potential relevance toward development of therapeutics for human sinus diseases.

Evaluation of the protective effect of Botulinum toxin type A injection on otitis media with effusion. Acta Otolaryngol 2017;137:917-922. [PMID: 28434389 DOI: 10.1080/00016489.2017.1314008]

OBJECTIVE

This study makes an analysis of the effect of Botulinum toxin type A on otitis media with effusion in rats.

METHOD

As part of the study, 24 male Wistar Albino rats were divided into three groups: Group 1: Botulinum toxin Type A and Histamıne (intratympanic 0.2 ml = 20 unit BTA); Group 2: Saline and Histamine (intratympanic 0.2 ml 0.9%); Group 3: Histamine (intratympanic 0.2 ml). Histamine (intratympanic 0.2 ml) was administered into the right ear for all groups. DPOAE and ABR tests were carried out on days 5, 10, 15 and 20 from the beginning of the study.

RESULTS

There was no significant difference between DPOAE and ABR scores of the groups. In each group, the DPOAE scores for the right ear significantly decreased on day 5 when compared to the basal scores. In each group, there was no significant difference between days 5, 10 and 15 for the right ear.

CONCLUSIONS

Botulinum toxin type A blocked the secretion of glands in the middle ear and showed no effect to prevent the formation of serous otitis. In addition, it was found out that Botulinum toxin did not lead to any morphological change in the cochlea.

Botulinum Toxin for Rhinitis

PURPOSE OF REVIEW

Rhinitis is a common clinical entity. Besides nasal obstruction, itching, and sneezing, one of the most important symptoms of rhinitis is nasal hypersecretion produced by nasal glands and exudate from the nasal vascular bed. Allergic rhinitis is an IgE-mediated inflammatory reaction of nasal mucosa after exposure to environmental allergens. Idiopathic rhinitis describes rhinitis symptoms that occur after non-allergic, noninfectious irritants. Specific allergen avoidance, topical nasal decongestants, nasal corticosteroids, immunotherapy, and sinonasal surgery are the main treatment options. Because the current treatment modalities are not enough for reducing rhinorrhea in some patients, novel treatment options are required to solve this problem.

RECENT FINDINGS

Botulinum toxin is an exotoxin generated by Clostridium botulinum. It disturbs the signal transmission at the neuromuscular and neuroglandular junction by inhibiting the acetylcholine release from the presynaptic nerve terminal. It has been widely used in neuromuscular, hypersecretory, and autonomic nerve system disorders. There have been a lot of published articles concerning the effect of this toxin on rhinitis symptoms. Based on the results of these reports, intranasal botulinum toxin A administration appears to be a safe and effective treatment method for decreasing rhinitis symptoms in rhinitis patients with a long-lasting effect. Botulinum toxin type A will be a good treatment option for the chronic rhinitis patients who are resistant to other treatment methods.

Botolinum toxin in rhinitis: Literature review and posterior nasal injection in allergic rhinitis

BACKGROUND

Current pharmacological management of allergic rhinitis (AR) varies in onset, duration, symptom control, and requires frequent administration. Single-dose botulinum toxin (BTX) has been documented in various trials as a treatment option in rhinitis.

OBJECTIVE

We review the current literature on the use of BTX in rhinitis and investigate the efficacy and safety profile of a novel intranasal injection site for AR control.

STUDY DESIGN

Single-arm pilot study.

METHODS

Ten adult patients having moderate to severe AR with proven house dust-mite allergy were recruited. Each patient received 12.5 units of Botox injected to the posterior lateral wall of each side of the nose under endoscopic guidance. Immediate postprocedural discomfort and Total Nasal Symptom Score (TNSS) at 2 and 4 weeks were used as primary outcome measures. Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) was used as secondary outcome measure.

RESULTS

Overall TNSS (minimum = 0; maximum = 20) showed an improvement from a mean of 15.1 (preinjection) to 7.6 (2 weeks) and 7.7 (4 weeks). Greatest effect was seen in subscales of rhinorrhea (4.0-1.7) followed by sneeze, nasal congestion, and itch. Mean discomfort of the procedure was scored 5.7 over 10. RQLQ scores similarly showed an improvement in all domains of quality of life. Two subjects complained of mild headache not requiring any medical intervention.

CONCLUSION

Based on our review of current literature, BTX shows clear efficacy on symptoms of both intrinsic and allergic rhinitis, with a good safety profile. Single-dose posterior nasal injection demonstrates good efficacy and duration of action, with moderate discomfort.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2447-2454, 2017.

Treatment of allergic rhinitis with intranasal infusion of botulinum toxin type A in mice

AIMS

To determine whether intranasal infusion of botulinum toxin type A (BTX-A) relieves symptoms of ovalbumin (OVA)-induced allergic rhinitis (AR) and reduces nasal inflammation in mice.

MAIN METHODS

AR was induced via intraperitoneal injection of OVA followed by daily intranasal challenge with OVA. Five weeks after the initiation of OVA sensitization, nasal cavities were exposed to a single intranasal infusion of BTX-A. The behavior of mice was observed before and 1, 3, 5, 7, 14, 21, and 28days after infusion. Mice were sacrificed after 28days and late histological findings were examined. PBS was administered to control mice.

RESULTS

On Day 3, the frequency of typical AR symptoms, including sneezing and nose scratching, significantly decreased in the BTX-A-treated group (n=6) compared to the control group (n=6). Although the AR-inhibiting effects of BTX-A persisted until Day 21, AR symptoms re-appeared in response to daily OVA stimulation. Histological findings of the nasal mucosa also improved following BTX-A administration. Although capillary dilatation and eosinophil infiltration decreased by Day 3, these effects disappeared by Day 28. In contrast, the number and size of the secretary glands in the nasal mucosa did not change following BTX-A administration. PBS had no effect on nasal symptoms or histology.

CONCLUSIONS

Topical treatment with BTX-A efficiently and temporarily ameliorates AR symptoms. Intranasal infusion does not cause pain or bleeding, and the effects of a single infusion of BTX-A last for at least three weeks. This treatment might be a promising therapeutic strategy for the treatment of AR.

Botulinum toxin A inhibits salivary secretion of rabbit submandibular gland

Botulinum toxin A (BTXA) has been used in several clinical trials to treat excessive glandular secretion; however, the precise mechanism of its action on the secretory function of salivary gland has not been fully elucidated. In this study, we aimed to investigate the effect of BTXA on secretion of submandibular gland in rabbits and to identify its mechanism of action on the secretory function of salivary gland. At 12 weeks after injection with 5 units of BTXA, we found a significant decrease in the saliva flow from submandibular glands, while the salivary amylase concentration increased. Morphological analysis revealed reduction in the size of acinar cells with intracellular accumulation of secretory granules that coalesced to form a large ovoid structure. Expression of M3-muscarinic acetylcholine receptor (M3 receptor) and aquaporin-5 (AQP5) mRNA decreased after BTXA treatment, and distribution of AQP5 in the apical membrane was reduced at 1, 2 and 4 weeks after BTXA injection. Furthermore, BTXA injection was found to induce apoptosis of acini. These results indicate that BTXA decreases the fluid secretion of submandibular glands and increases the concentration of amylase in saliva. Decreased expression of M3 receptor and AQP5, inhibition of AQP5 translocation, and cell apoptosis might involve in BTXA-reduced fluid secretion of submandibular glands.

A novel botulinum neurotoxin topical gel: Treatment of allergic rhinitis in rats and comparative safety profile

BACKGROUND

Rhinitis affects a significant proportion of adults and children with typically seasonal or chronic symptoms. Botulinum neurotoxin type A (BoNTA) is a well-known cholinergic antagonist widely used in a number of approved neurological and esthetic indications. This study was designed to assess the therapeutic effect of RT001, a novel topical gel formulation of BoNTA, in the treatment of allergic rhinitis using a rat model and to compare its safety profile with that of an aqueous formulation of BoNTA complex.

METHODS

A rat model of allergic rhinitis was used involving induction of classic rhinitis signs (sneezing and nasal itch) in addition to nasal inflammatory pathology to assess the degree of therapeutic effect of RT001. Comparative safety of RT001 and BoNTA complex was assessed in guinea pigs based on lethality and body weight gain.

RESULTS

Clinical signs of rhinitis were significantly (p < 0.01) relieved after a single intranasal administration of RT001 and resolved to normal baseline levels within 5 days after treatment. Mucosal inflammation characterized by edema, congestion, and vascular dilatation along with increased expression of vasoactive intestinal peptide was noted in control animals after allergy induction, whereas RT001 treatment resolved inflammation to essentially normal baseline levels. Safety studies in guinea pigs via intranasal dosing revealed ∼31-fold greater safety factor for RT001 when compared with BoNTA complex.

CONCLUSION

These results suggest that topical intranasal application of RT001 is effective in relief of clinical signs and inflammatory pathology associated with allergic rhinitis in a rodent model and may provide a safe treatment for rhinitis.

Comparing the effects of Botulinum Toxin-A and cetirizine on the treatment of allergic rhinitis

BACKGROUND

There are few reports on the effects of intranasal Botulinum Toxin-A (BTX-A) as a treatment of allergic rhinitis (AR). In this study, we compared the efficacy of intranasal BTX-A to cetirizine in the treatment of AR.

METHODS

Fifty AR patients at the age of 26.2 ± 9.1 years (64% females), were recruited to the trial according to the Allergic Rhinitis and its Impact on Asthma (ARIA) criteria. Participants randomly received either intranasal injection of BTX-A (75IU Dysport®) or cetirizine (10mg/day). Symptoms (based on the ARIA) and side effects were assessed every two weeks for two months. Quality of life was evaluated before and after the study using the Rhinasthma questionnaire.

RESULTS

Total symptom severity score of patients significantly decreased (P < 0.001) and quality of life significantly improved (P < 0.001) at the same level in both groups. Side effects included nasal dryness (4%) and epistaxis (4%) in the BTX-A group. In the cetirizine group 44% sleepiness and 4% blurred vision was reported.

CONCLUSIONS

Nasal injection of BTX-A shows the same therapeutic effects as cetirizine in the management of AR. Since BTX is expensive, we do not suggest it in the first line of treatment for AR. However, BTX-A is a potential treatment for patients who are resistant or not compliant to the routine medications of AR. Further studies are required to investigate implications and limitations of BTX-A in the treatment of AR.

Effects of botulinum toxin type a on collagen deposition in hypertrophic scars

A recent study reported that Botulinum toxin type A (BTXA) could inhibit the growth of hypertrophic scars and improve their appearance. However, the mechanism of BTXA's action on hypertrophic scars is still unknown. Some in vitro studies had shown BTXA could alleviate hypertrophic scars by acting on the biological behavior of fibroblasts, but there are few in vivo experiments, especially animal model experiments, supporting these findings. The aim of the study reported herein was to investigate the effect of BTXA on collagen deposition on hypertrophic scars in a rabbit ear model and partially clarify the mechanism of BTXA on the hypertrophy of scars. The rabbit hypertrophic scar model was used and eight rabbits were employed. BTXA was injected into the hypertrophic scar tissue of one ear; and the other ear in the same rabbit was the control without BTXA injection. The scar thickness and deposition of collagen was examined through immune histochemistry including haematoxylin and eosin (H&E) and Masson trichrome staining. The thicknesses of hypertrophic scars in the BTXA treatment group were obviously lower than in the control groups (P < 0.01). H&E and Masson staining showed that collagen fibers were stained blue. Compared with the treatment group, the collagen fibers were thicker and the arrangement of collagen fibers were disordered in the control group. This study used the rabbit ear model of hypertrophic scars to assess the effects of BTXA on scar hypertrophy. The application of BTXA may be useful for inhibiting hypertrophic scars.

Minimally invasive application of botulinum toxin A in patients with idiopathic rhinitis

Background

Nasal hypersecretion due to idiopathic rhinitis can often not be treated sufficiently by conventional medication. Botulinum toxin A (BTA) has been injected into the nasal mucosa in patients with nasal hypersecretion with a reduction of rhinorrhea lasting for about 4 to 8 weeks. Since the nasal mucosa is well supplied with glands and vessels, the aim of this study was to find out if the distribution of BTA in the nasal mucosa and a reduction of nasal hypersecretion can also be reached by a minimally invasive application by sponges without an injection.

Methods

Patients were randomly divided into two groups. The effect of BTA (group A, C, D) or saline as placebo (group B) was investigated in 20 patients with idiopathic rhinitis by applying it with a sponge soaked with BTA (40 units each nostril) or saline. Subgroups C and D contained these patients of group A and B who did not improve in symptoms one week after the original treatment (either BTA or saline) who then received the alternative medication. Changes of symptoms (rhinorrhea, nasal obstruction) were scored by the patients in a four point scale and counted (consumption of tissues, sneezing) in a diary. The patients were followed up weeks 1, 2, 4, 8 and 12.

Results

There was a clear reduction of the amount of secretion in group A compared to group B, C and D. This did not correlate with the tissue consumption, which was comparably reduced in group A and B, but reduced less in group C and D. Sneezing was clearly reduced in group A but comparably unchanged in group B and C and increased in group D. Nasal congestion remained unchanged.

Conclusion

In some patients with therapy-resistant idiopathic rhinitis BTA applied with a sponge is a long-lasting and minimal invasive therapy to reduce nasal hypersecretion.

A comparison of the effects of botulinum toxin A and steroid injection on nasal allergy

Objectives

To compare the effects of botulinum toxin A (BTX-A) with intranasal steroid injections on nasal symptoms in patients with allergic rhinitis (AR).

Study Design

A randomized, placebo-controlled, single-blinded clinical trial (patients were blinded).

Material and Methods

Thirty-nine patients were included in the study. AR was diagnosed by means of history, clinical examination, and skin prick test. Patients were randomly divided into three subgroups as follows: in group A, 25 units of BTX-A were injected into each inferior turbinate (total 50 units); in group B, 1 cc (20 mg/mL) of triamcinolone was injected into each inferior turbinate; and in group C, 1 cc of isotonic saline was injected as placebo. The symptoms of AR were scored by the patient on a six-point scale.

Results

At all time points, group A was significantly better than group C. In the nasal obstruction and rhinorrhea scores, group A was significantly better than group B after 8 weeks.

Conclusion

BTX-A may provide better AR symptom relief in terms of duration and degree than a steroid injection. © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

Early indicators of exposure to biological threat agents using host gene profiles in peripheral blood mononuclear cells

Background

Effective prophylaxis and treatment for infections caused by biological threat agents (BTA) rely upon early diagnosis and rapid initiation of therapy. Most methods for identifying pathogens in body fluids and tissues require that the pathogen proliferate to detectable and dangerous levels, thereby delaying diagnosis and treatment, especially during the prelatent stages when symptoms for most BTA are indistinguishable flu-like signs.

Methods

To detect exposures to the various pathogens more rapidly, especially during these early stages, we evaluated a suite of host responses to biological threat agents using global gene expression profiling on complementary DNA arrays.

Results

We found that certain gene expression patterns were unique to each pathogen and that other gene changes occurred in response to multiple agents, perhaps relating to the eventual course of illness. Nonhuman primates were exposed to some pathogens and the in vitro and in vivo findings were compared. We found major gene expression changes at the earliest times tested post exposure to aerosolized B. anthracis spores and 30 min post exposure to a bacterial toxin.

Conclusion

Host gene expression patterns have the potential to serve as diagnostic markers or predict the course of impending illness and may lead to new stage-appropriate therapeutic strategies to ameliorate the devastating effects of exposure to biothreat agents.

Botulinum toxin for treatment of glandular hypersecretory disorders

SUMMARY

The use of botulinum toxin to treat disorders of the salivary glands is increasing in popularity in recent years. Recent reports of the use of botulinum toxin in glandular hypersecretion suggest overall favourable results with minimal side-effects. However, few randomised clinical trials means that data are limited with respect to candidate suitability, treatment dosages, frequency and duration of treatment. We report a selection of such cases from our own department managed with botulinum toxin and review the current data on use of the toxin to treat salivary gland disorders such as Frey's syndrome, excessive salivation (sialorrhoea), focal and general hyperhidrosis, excessive lacrimation and chronic rhinitis.

The use of botulinum toxin in head and face medicine: an interdisciplinary field

Background

In this review article different interdisciplinary relevant applications of botulinum toxin type A (BTA) in the head and face region are demonstrated.

Patients with head and face disorders of different etiology often suffer from disorders concerning their musculature (example: synkinesis in mimic muscles) or gland-secretion.

This leads to many problems and reduces their quality of life. The application of BTA can improve movement disorders like blepharospasm, hemifacial spasm, synkinesis following defective healing of the facial nerve, palatal tremor, severe bruxism, oromandibular dystonias hypertrophy of the masseter muscle and disorders of the autonomous nerve system like hypersalivation, hyperlacrimation, pathological sweating and intrinsic rhinitis.

Conclusion

The application of botulinum toxin type A is a helpful and minimally invasive treatment option to improve the quality of life in patients with head and face disorders of different quality and etiology. Side effects are rare.

The effects of one botulinum toxin type A (BTX-A) injection after UPPP

Botulinum toxin type A (BTX-A) can be used in various medical fields for more than simply cosmetic purposes, especially in pain control. Unlabelled uses of BTX-A for reducing pain include migraines, chronic anal fissures, chronic non-specific muscular pain syndrome, and temporomandibular joint arthritis. However, there are no reports of using BTX-A in postoperative situation. Therefore, we evaluated the effects of BTX-A after surgical procedures, especially in terms of pain reduction. We randomly selected 74 people who visited us not excluded by the criteria and were provided with uvulopharyngopalatoplasty for primary snoring from February 2005 to January 2007. Group A is the BTX-A-injected group and group B is the control group (normal saline injected group or N/S). Group A had 35 patients and group B had 39 patients. Among these patients, we chose 58 patients who can be under tracing observation. The mean age was 26 years (range 18-41). There were 49 males and 9 females. We compared the level of snoring, postoperative pain, use of drugs, and postoperative foreign body sensation with survey paper. Snoring scores were dramatically decreased in both the groups. Postoperative pain scores and foreign body sensation scores were much more decreased in group A than in group B (P < 0.001) and the total amount of NSAIDs used were lower in group A (P < 0.001). BTX-A could be used to reduce postoperative pain after snoring surgery by reducing a specific complication.

Intratympanic application of botulinum toxin: experiments in guinea pigs for excluding ototoxic effects

The aim of the study was to exclude ototoxic side effects of intratympanally applied botulinum toxin. The background is that a transection of the tensor tympani tendon (tenotomy) may relieve symptoms of tinnitus due to myoclonic tensor contractions. Moreover, there are certain indications that in some cases tenotomy may influence the course of Menière's disease positively. In such cases, a temporary (probatory) inactivation of the muscle with botulinum toxin might be better than a definitive surgical solution. Although in theory botulinum toxin should not have ototoxic side effects, a study on animals (guinea pigs) should prove this assumption. On eight guinea pigs (16 ears), the middle ear spaces (bullae) were opened and botulinum toxin was introduced. Hearing thresholds were measured via ABR recordings, prior to 1 and 3 weeks, respectively, after botulinum toxin application. Histological examinations of the middle ear mucosa were performed on each animal. In our series, the hearing thresholds remained essentially unchanged. Furthermore, no middle ear pathologies could be found in histology. No negative effects of botulinum toxin on hearing could be observed in our series. This is a precondition for the further development of the concept of intratympanical applications of the drug, to inactivate the tensor tympani muscle or for other options.

Histopathological and radiological investigations of the influence of botulinum toxin on the submandibular gland of the rat

The aim of the study was to correlate the sonographic features of Botox A injection in rat submandibular gland with the histopathological changes. Fifteen Wistar albino rats were randomly assigned to 2 groups. Group 1 (control group) consisted of 5 animals not given any substance. Group 2 was divided as "a" and "b" each consisting of 5 animals. A median cervical incision has been performed to the rats in group 2 and 2.5 U Botulinum toxin A reconstituted 0.1 ml physiologic saline was injected into the right gland. Sonograms were obtained before the application, at the first day of the Botox A application, in addition to group 2a on the 14th day, and on 28th day to group 2b. Gland size was lower in group 2a and 2b comparing to control group. The gland size of group 2b was lower than group 2a. There was no change in vascularization. There was no other histopathological change except lymphocytic infiltration in group 2. It was observed that Botox A injection does not have a direct effect on the cells in submandibular gland but it causes a homogenic shrinking in gland size without atrophy.

The application of botulinum toxin in the prostate

PURPOSE

Botulinum neurotoxin is the most potent naturally occurring toxin known to inhibit various neurotransmitters. Injection of botulinum neurotoxin into the bladder and urethral sphincter has been used to treat bladder hyperactivity and sphincter dyssynergia. Recently botulinum neurotoxin application was extended to prostate disorders. Why would a urologist want to target the prostate?

MATERIALS AND METHODS

We reviewed the literature on the mechanisms of action and clinical efficacy of botulinum neurotoxin treatment of the prostate. In addition to our personal clinical experience and basic research, information was gathered from MEDLINE and published abstracts from international meetings. We also present basic research and discuss the potential mechanism of action of botulinum neurotoxin on the prostate.

RESULTS

There are 8 current peer reviewed publications on the injection of botulinum neurotoxin in the prostate. Cystoscopic transurethral or transperineal/transrectal ultrasound guided techniques have been used. Outcome improvement reported includes decreases in prostate size, prostate specific antigen and residual urine volume, and improvement in the flow rate and symptom score lasting 6 months or longer.

CONCLUSIONS

Botulinum toxin has demonstrated exciting and promising preliminary results for male lower urinary tract symptoms. Translational research suggests novel mechanism of action of botulinum toxin in the prostate for benign prostatic hyperplasia and chronic nonbacterial prostatitis. It may even be considered as adjuvant treatment for prostate cancer. The use of botulinum neurotoxin in the prostate is currently Food and Drug Administration off label and in support of evidence based medicine practices caution should be applied until larger, randomized clinical studies are completed. More basic research is needed to identify the mechanisms by which botulinum toxin affects the prostate.

The effect of intranasal injection of botulinum toxin A on the symptoms of vasomotor rhinitis

PURPOSE

Vasomotor rhinitis (VMR) is a common disease that is unrelated to allergy, infection, structural abnormalities, and systemic diseases. Patients with VMR usually complain of nasal obstruction accompanied by profuse watery nasal discharge. The exact pathophysiologic mechanisms of VMR are not known. Some studies suggested that it results from an autonomic nervous system dysfunction. No effective long-term treatment modalities exist for the VMR.

MATERIALS AND METHODS

Thirty patients with VMR were randomly and equally divided into 2 groups. The mean age was 38.46 years (range, 18-59 years; 1 men, 14 women) for group 1 and 41.60 (range, 29-62 years; 4 men, 11 women) for group 2. Five patients with VMR were accepted as a control group. Fifteen patients were injected 10 U of botulinum toxin A (BTX-A) (group 1) and patients in group 2 were injected 20 U to inferior and middle turbinates. Control patients were injected with saline solution into the inferior and middle turbinates.

RESULTS

Total symptom scores generally decreased after the first week and increased after the eighth week. The symptoms of patients (nasal obstruction, sneezing, nasal discharge, and nasal itching) were scored from 1 to 5, with 1 as less severe and 5 as most severe. The statistical significance of the results was analyzed using Kruskal-Wallis and Mann-Whitney U test. When total symptom scores of group 1 (10 U BTX-A) were compared with the control group, there was a statistically significant difference regarding symptoms scores at all control weeks. There was also a statistically significant difference for total symptom scores between group 2 and control group, except for the first control week.

CONCLUSION

Intranasal injection of BTX-A is a highly effective, safe, and simple symptomatic treatment modality with a long-lasting effect for patients with VMR. Botulinum toxin A may be a good alternative especially for the treatment of resistant VMR cases.

Novel action of botulinum toxin on the stromal and epithelial components of the prostate gland

PURPOSE

Intraprostatic injection of BTX-A has demonstrated clinical improvement in men with bladder outlet obstruction. We investigated the mechanisms of action of BTX-A on the prostate.

MATERIALS AND METHODS

Adult male Sprague-Dawley rats were injected with varying doses of BTX-A into the prostate and the prostates were harvested after 1 or 2 weeks. The effects of BTX-A on prostate histology, and the proliferative and apoptotic indexes were determined using hematoxylin and eosin staining, proliferative cell nuclear antigen staining and TUNEL staining, respectively. Changes in alpha(1A) adrenergic receptor and androgen receptor were evaluated by Western blotting.

RESULTS

One week after BTX-A injection generalized prostate atrophy was observed. There was a significant increase in apoptotic cells (12, 16 and 22-fold), and decrease in proliferative cells (38%, 77% and 80%) and alpha(1A) adrenergic receptor (13%, 80% and 81%) for 5, 10 and 20 U, respectively. There was no significant change in androgen receptors. The effects were decreased 2 weeks after BTX-A treatment.

CONCLUSIONS

BTX-A injection into the prostate alters cellular dynamics by inducing apoptosis, inhibiting proliferation and down-regulating alpha(1A) adrenergic receptors. BTX-A may potentially be the drug that has dual actions on the static and dynamic components of benign prostatic hyperplasia.

[Botulinum toxin in otorhinolaryngology]

BACKGROUND AND OBJECTIVES

Through its anticholinergic effect, botulinum toxin is a suitable therapeutic option for dysfunctions of the muscular and the autonomic nervous system.

PATIENTS/METHODS

Beside the classical indications like facial hyperkinesis (i.e. blepharospasm, hemifacial spasm), the treatment of complex dystonias (oromandibular dystonia, spasmodic dystonia, cervical dystonia), gustatory sweating, hypersalivation and crocodile tears is successful. Botulinum toxin is an alternative treatment of tension type headache and migraine. A new indication of botulinum toxin application may involve the treatment of nasal hypersecretion through the effect on the nasal glands.

RESULTS

The positive therapeutic effect starts a few days after treatment and lasts longer in disorders of the autonomic nervous system. Because of its temporally limited therapeutic effect, the patients need further treatment. Side-effects are rare.

CONCLUSIONS

Botulinum toxin is an effective treatment for a variety disorders with different etiologies and has very few side effects.

Noncosmetic uses of botulinum toxin

In conclusion, botulinum toxin usage over the past 2 to 3 decades has expanded exponentially. Almost every discipline in medicine has found some therapeutic use for this toxin. Botulinum toxin has been shown to be safe, effective, and relatively easy to administer with proper training.

Noncosmetic uses of botulinum toxin

Since the introduction of botulinum toxin (BTX) as a therapeutic tool in the 1970s, the number of uses for this substance has increased exponentially. BTX's mechanism of action involves degrading the SNARE proteins blockading the release of acetylcholine into the neuromuscular junction. In many body systems, decrease of contractility, strength, and tension of certain muscle groups result in improved clinical outcomes. Applications now include cosmetic, gastroenterologic, otolaryngologic, genitourinary, neurologic, and dermatologic uses. In fact, BTX can be considered as a potential treatment in any situation involving inappropriate or exaggerated muscle contraction. Currently, the FDA has approved BTX-A (Botox) for treating glabellar lines, blepharospasm, strabismus, hemifacial spasm, cervical dystonia, and spasticity. With the addition of cosmetic applications to the FDA's approval list, the use of BTX has increased dramatically.

The current uses of botulinum toxin

Botulinum toxin is an extremely powerful neurotoxin that is a product of the anaerobic bacterium Clostridium botulinum and is responsible for the condition botulism. Public awareness of the toxin has recently been raised by its development as a weapon for biological warfare and its facial cosmetic effects. However, the acute paralytic illness after some forms of food poisoning had been recognized for many years and an association with a neurotoxin was demonstrated over a century ago.