The Otolaryngologic Uses of Botox

Malcolm Baxter FRACS

BotoxClostridium botulinum toxin

7 Serotypes -ABCDEFG

Type A used Botox (Allergan)

Dysport

Neurotoxin-paralyses neuromuscular transmission by binding ACh

Mouse units

Botox cont.

Now widely used for muscle spasms and spasticity:

Laryngeal Conditions

Blepharospasm

Hemifacial Spasm

Spasmodic Torticollis

Palatal Myoclonus

Frey’s Syndrome

Failed TOP Speech Post Laryngectomy

Drooling (intraparotid )

Achalasia

Cerebral Palsy Patient Limbs

Cosmetic

Laryngologic Uses of Botox• Spasmodic Dysphonia-Adductor &Abductor

Types• Laryngeal Tremor• Muscle Tension Dysphonia –unresponsive to SP

and local physio techniques• Refractory Laryngeal Granulomata• Cricopharyngeal Spasm –intact larynx and post-

laryngectomy• CA Joint Dislocation/Relocation• Vocal Cord Dysfunction (PVFM)

Botox cont.

Side Effects

Effects of overweakening-depends on location

Abs produced-Anaphylaxis theoretically possible but not in

practice

? No Deaths

Laryngeal Botox for SD in Melbourne

• RVEEH 1992-2008 Baxter,Hughes & Oates

Continues as private clinics

• MMC Monash Neurolaryngology Clinic 2010- Baxter & Raghav

SPASMODIC DYSPHONIA

Action induced laryngeal motion disorder resulting in a dysphonia

characterised by spasms in phonation

Spasmodic Dysphonia

Classified as Focal Dystonia (class of movement disorder)

These are task specific movement disorders involving a few muscles

(laryngeal in this case)

Other examples are: Spasmodic Torticollis, Writers Cramp,

Hemifacial Spasm, Blepharospasm,

Meige’s syndrome-orofacial dystonia

Aetiology of SD

Unknown

Genetic Probable in some cases

??Stress

??Infective

PM Studies-unhelpful with varying findings, eg basal ganglia

SD-2 TypesADDuctor SD >90% -strained and

strangled voice due to spasmodic interruptions to fluency

(Thyroarytenoid-vocalis)

ABDuctor SD <10% -breathy interruptions to fluency (PCA)

Spasmodic DysphoniaF>M about 2:1

Onset any age (Satalhoff ave 62)

Many patients relate to some traumatic or stressful event

Diagnosis of SD

Typical Phonation

Demonstrated Spasms on Video during connected speech

Lack of response to other treatment (espec. ST)

EMG ??

Must exclude other neurological disease

Differential Diagnosis

Laryngeal Tremor

Severe Hyperfunctional or Muscle Tension Dysphonia

Psychogenic Dysphonia

Treatment of SD• Psychiatric

• Drugs

• Speech Therapy

• Surgery

• BOTOX

Botox in SD

Transoral Concious pt / GA

Transcutaneous with EMG Control

Monopolar Teflon coated EMG neeedle connected to EMG machine

GA -occasionally

Botox in SD cont

Adductor - via CT membrane intoThyroarytenoid/ vocalis

-2.5 Mu per vocal cord starting dose (titrate response)

Abductor - Into PCA

-More difficult

-Lateral or translaryngeal approach

- 3.75 Mu starting (titrated)

-Unilateral Injection

-May assess weakness by scope

Rating??

Method

• Prospective study

• Botox injections for adductor and abductor spasmodic dysphonia between 1992 and 2003

• Assessment and diagnosis by otolaryngologist, neurologist and speech pathologist in voice clinic

Method

• Pre and post-injection self evaluation of voice function on equal appearing interval scale 1 to 10 1= severe disabling voice problem, 10= no perceived

voice problem

• Complications (mild/ moderate/ severe)

– Breathiness

– Dysphagia

– Pain

– bruising

Method

• Pre and post-injection self evaluation of voice function on equal appearing interval scale 1 to 10 1= severe disabling voice problem, 10= no perceived

voice problem

• Complications (mild/ moderate/ severe)

– Breathiness

– Dysphagia

– Pain

– bruising

Injection Method

• Transcutaneous submucosal injection through cricothyroid membrane with EMG control– few injections required transoral and translaryngeal technique

• Adductor patients- injection into thyroarytenoid muscle

• Abductor patients- injection into posterior cricoarytenoid muscle

Results

• Consecutive series of 81 patients, complete information available in 79

• 511 injections of Botox

• 59 female, 20 male

Adductor Group

• 72 patients, 481 injections

• Bilateral injections in 96% (464 injections), unilateral 4% (17 injections)

• Median dose 2.5 mouse units (range 0.5-5)

Adductor Group

• 95% of injections (459) improvement in symptoms

• Median improvement 4 points (range 1-8)

• Mean duration of response 15.3 weeks (range 0.5-72)

Adductor group

• 72% complications (346 injections)– Breathiness (317), 68% mild, median duration

2 wks– Dysphagia- (110) 86% mild, median duration 2

wks– Pain (12)– Bruising (4)

Abductor group

• 7 patients, 30 injections

• 2 bilateral injection, 28 unilateral

• median dose 4.5 (range 2.5 to 6.25)

Abductor group

• 60% injections (18) symptom improvement

• Median improvement 3 points ( range 1-5)

• Mean duration response 11.4 weeks (range 4-20)

Conclusions

• Laryngeal botox injections results in significant, sustained voice improvements in adductor spasmodic dysphonia

• Side effects are frequent but majority are mild in severity

• Results in abductor spasmodic dysphonia less favourable

Can we extrapolate to VCD?

Vocal Cord Dysfunction (VCD)• Various names-Paradoxical Vocal Cord

Movement (PVFM ) probably best

• Adduction of VCs during inspiration

• Various types – Dystonia– Asthma associated (? >10% ED ‘asthma”

presentations (?? All have asthma)– Exercise induced – Psychological– LPR—Acute laryngeal spasms-? different

Diagnosis of VCD

• History– Stridor Not responding to asthma meds– Exercise induced– Psych ??

• Flexible Scope

• 360 Slice CT

Treatment of VCD

• Breathing Exercises (SP) Effective ~80%

• Medication – Asthma meds,Diazepam etc

• PPIs often effective for the Laryngospasm

• Botox –Anecdotal evidence , Awaiting RCT