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Introduction Botulinum toxin (BT) injections may play a role in preventing Hirschsprung associated enterocolitis (HAEC) episodes related to internal anal sphincter (IAS dysfunction). Our aim was to determine the association of outpatient BT injections for early obstructive symptoms on the development of HAEC. Methods A retrospective review of children who underwent definitive surgery for Hirschsprung disease (HSCR) from July 2010 – July 2020 was performed. The timing from pull-through to first HAEC episode and to first BT injection was recorded. Primary analysis focused on the rate of HAEC episodes and timing between episodes in patients who did and did not receive BT injections. Results Eighty patients were included. Sixty patients (75%) were male, 15 (19%) were diagnosed with trisomy 21, and 58 (72.5%) had short-segment disease. The median time to pull-through was 150 days (IQR 16, 132). Eight patients (10%) had neither an episode of HAEC or BT injections and were not included in further analysis. Forty-six patients (64%) experienced at least one episode of HAEC, while 64 patients (89%) had at least one outpatient BT injection. Compared to patients who never received BT injections (n = 9) and those who developed HAEC prior to BT injections (n = 35), significantly fewer patients who received BT injections first (n = 28) developed enterocolitis (P Conclusion Outpatient BT is associated with decreased episodes of HAEC and increased interval between HAEC episodes requiring inpatient treatment. Scheduling outpatient BT injections to manage obstructive symptoms may be beneficial after pull-through for HSCR.

The aim of this study was to assess the impact of botulinum toxin injection in women with myofascial pelvic pain (MFPP) syndrome of the pelvic floor who had failed conservative treatment. This was a retrospective descriptive observational study of 48 consecutive patients receiving botulinum toxin to the pelvic floor for MFPP syndrome in a tertiary teaching hospital over an 8-year period. Trigger points were identified, and botulinum toxin was injected into the pelvic floor at the trigger points in doses ranging from 50 to 200 units. The patient-reported global impression of improvement scale was used to evaluate the success at follow-up, and adverse effects were recorded. Forty-six women attended for follow-up at 3–6 months. Of these, 34 (74%) reported an improvement in their symptoms (slightly better, much better, very much better), 12 (26%) had no change, and no patients reported worsening of symptoms. One patient (2%) reported transient postoperative faecal incontinence, which resolved after 2 weeks. There appeared to be no difference in outcome between the doses. Botulinum toxin injection into the pelvic floor of women with MFPP appears to be beneficial in those who have failed conservative treatment. Prospective studies, including dose-finding studies, are now required.

Botulinum toxin (BoNT) is a valuable therapeutic tool with several medical indications and the most popular of all cosmetic procedures worldwide. This is the reason for the growing number of unregistered products that may be the reason for adverse reactions. We present a case of a 51-year-old woman, who developed a pyoderma gangrenosum-like reaction at injection sites after the administration of an unregistered BoNT product by a beautician. The clinical course, the morphology of the lesions, the result of histopathological biopsy, and the response to the treatment meets the criteria for diagnosis of pyoderma gangrenosum. The case presented by us is the first adverse reaction of this type after BoNT administration.

Stiff-person syndrome (SPS) is an uncommon neurological disorder characterized by significant rigidity and muscle spasms primarily affecting the truncal and proximal musculature. Furthermore, a wide-based gait with functional impairment is generally seen. High-dose benzodiazepines or baclofen are widely considered the optimal initial therapy; however, major adverse effects often preclude adequate dosing. Refractory cases may be treated with intravenous immunoglobulins (IVIG), plasma exchange, or B-cell depletion with rituximab, although these are also associated with major, sometimes fatal, adverse reactions. Several reports have validated the safety and utility of botulinum injections in this setting, yet botulinum remains markedly underutilized in this cohort. Below, a case report and review of the literature show botulinum can decrease pain and stiffness, improve gait and balance, and decrease dependence on powerful systemic treatments in this group.

Raynaud's phenomenon (RP) is a functional vascular disorder involving extremities. In his practice, the dermatologist may frequently encounter RP which affects mainly women and is categorized into a primary benign form and a secondary form associated with different diseases (infections, drugs, autoimmune and vascular conditions, haematologic, rheumatologic and endocrinologic disorders). Still today, the differential diagnosis is a clinical challenge. Therefore, a careful history and a physical examination, together with laboratory tests and nailfold capillaroscopy, is mandatory. RP is generally benign, but a scheduled follow-up for primary RP patients should be established, due to risk of evolution to secondary RP. A combination of conservative measures and medications can help in the management of RP. The importance of avoiding all potential physical, chemical and emotional triggers, as well as quitting smoking, should be strongly suggested to the patient. As first-line treatment, dihydropyridine calcium channel blockers should be used. If this approach is not sufficient, prostacyclin derivatives, phosphodiesterases inhibitors and endothelin receptor antagonists can be considered as second-line treatment. In cases of acute ischaemia, nifedipine and intravenous prostanoids are helpful. In refractory cases, botulinum injections have shown a significant benefit. The approach to the RP patients requires therefore a coordinated care of specialists together with the primary care physician.

To compare bilateral medial rectus muscle injection of botulinum toxin with surgery as primary treatment for infantile esotropia.A single-center, prospective, nonrandomized comparative study was undertaken of botulinum toxin versus surgery in children who presented by age 36 months with esotropia onset before 12 months. Successful outcome was defined as ocular alignment within 10Delta of orthotropia after one surgery or 1 to 3 bilateral botulinum injections.Of 442 subjects, 322 received botulinum toxin (1 injection, 49%; 2, 41%; 3, 10%); 120 had surgery. Motor success was achieved in 66% of surgery patients, compared with 45% of botulinum patients (p0.001). Among subjects with deviation30Delta, surgery achieved 69% success versus 36% with botulinum toxin (relative risk, 1.95; 95% CI, 1.53-2.49). At deviationsor = 30Delta, there was no difference (surgery, 60%; botulinum toxin, 59%; relative risk, 1.03; 95% CI, 0.78-1.35). There were no statistically significant differences in mean pretreatment deviation (botulinum toxin, 38.8Delta; surgery, 38.2Delta) or mean follow-up (botulinum toxin, 22.6 months; surgery, 20.7). Surgery occurred later than botulinum injection (mean age at treatment, 27.0 vs. 16.7 months; p0.001) with greater duration of misalignment (21.0 vs 12.5 months, respectively; p0.001), but neither variable influenced outcome in multivariate regression.In this large, nonrandomized prospective cohort, surgery was more successful than botulinum toxin in the treatment of large-angle esotropia. Botulinum toxin appeared most effective for esotropia30Delta to 35Delta, with a success rate comparable with surgery. Botulinum toxin may be an alternative to surgery in children with small- to moderate-angle infantile esotropia.

Objective: Botulinum toxin injections are used routinely to treat patients with adductor spasmodic dysphonia. After an initial “breathy phase,” most patients experience improvement for a few weeks to months and then a gradual decline until their next injection. In this study, voice-related quality of life (VRQOL) data were collected at 4 week intervals through one to three injection cycles in an attempt to quantify the proportion of each cycle during which patients experience meaningful benefit. Study Design: Prospective, nonrandomized case series. Methods: Patients receiving stable-dose botulinum injections for adductor spasmodic dysphonia were invited to participate. Voice recordings and clinical outcomes data were collected by telephone every 4 weeks throughout each injection cycle. Quality of life data were normalized for cycle length and interpolated to generate composite curves. Results: Twenty-two patients completed data collection for at least one full injection cycle. The average cycle was 25.9 weeks; the mean age was 59.8 years. On a 100-point scale, the total VRQOL scores peaked at 77.4, at 30% of the cycle, then gradually declined. The social-emotional (SE) subscale scores were significantly better than the physical subscale scores (P < .05). The total VRQOL score exceeded 75 during only 14% of the cycle (52.6% for SE subscores, 0% for physical subscores). If the threshold is lowered to 70, the total VRQOL exceeded this level during 54.6% of the cycle (69.6% for SE subscores, 44.1% for physical subscores). For the 11 patients completing three full injection cycles, there were no significant differences between the three cycles, and the mean VRQOL scores were similar to the values given above. At the beginning and end of each cycle, the total VRQOL scores averaged 52.8 (56.0 for SE subscale, 50.7 for physical subscale). Conclusion: Although botulinum toxin injections provide significant improvement for these patients, the initial breathy phase and the late declining phase add up to a significant proportion of each cycle spent with a reduced quality of life. At best, the total VRQOL averaged below 80%. This longitudinal study provides a unique look at the effect of this condition and its treatment on these patients' lives. A suitable long-term treatment for this condition is needed to eliminate the cyclical voice results experienced with the botulinum toxin injection approach.

Purpose of review The treatment options for the management of dystonias continue to evolve and improve. Clinical outcomes, however, are not predictably consistent using a single treatment regimen in all patients. Recent findings Botulinum toxin is still considered the best treatment option for the treatment of focal dystonias: blepharospasm, hemifacial spasm, and apraxia of eyelid opening. New findings indicate that physicians may be a little more aggressive with the dosage when the disease progresses. A new formulation of botulinum toxin has been produced that includes no proteins and may address the immunoresistance that can occur with prolonged use. Additional systemic medications may be helpful as adjuncts only in selected cases. Improved surgical techniques are now more successful and cause fewer complications. Therefore, many refractory cases are now offered a surgical approach alone or in combination with botulinum toxin. Summary There have been recent therapeutic developments in the treatment of ocular dystonias.

Forty patients (mean age 5 years) with a spastic disorder treated by botulinum injections (53 sessions) were evaluated for functional outcome in terms of achievement of their individual predetermined goals of treatment, rated on a modified Goal Attainment Scale from 1 (worsening function) to 4 (improved gross motor function). At the 2-week follow-up, 40% had a score of 1, 33% a score of 2, and 13% a score of 3; 12% showed no functional change. Botulinum treatments failed to significantly improve the gross motor function in this patient group. Treatment goals and expectations should clearly be established beforehand.

Background The aim of this study was to determine the prevalence of neutralizing antibodies in a large cohort of long-term treated patients with cervical dystonia (CD) still responding to repetitive injections with botulinum toxin (BoNT). Methods Consecutively recruited CD patients (n = 221) under long-term BoNT treatment (≥2-21 years) underwent a clinical examination at the same time blood samples were taken for neutralizing antibody determination. Collected data included demographics, mean dose of the last 10 botulinum injections, treatment duration, Tsui score for CD severity, and patients' subjective impression of treatment effect. Blood samples were screened for antibody presence by ELISA; positive samples were further analyzed by mouse hemidiaphragm test. The two laboratories performing antibody testing were blinded to the coded samples. Results Antibody status could be determined for 212 patients; 39 (18.4%) were ELISA positive and 31 (14.6%) additionally positive in the mouse hemidiaphragm test. Patients with positive neutralizing antibody titers had significantly higher Tsui scores and were treated for a significantly longer time with significantly higher doses. There were no differences between male and female patients and between onabotulinumtoxinA- and abobotulinumtoxinA-treated patients. When BoNT preparations had been switched during the last 10 injections, a significantly higher proportion of neutralizing antibody-positive patients was detected. Conclusions Neutralizing antibody prevalence in long-term treated, still responding CD patients is substantially higher than suggested by follow-up studies with a shorter time frame. It should therefore be emphasized that antigenicity of BoTN preparations is still a relevant problem and should be taken into account in long-term treatment decisions.

Background. Hyperhidrosis is a troublesome problem that can be embarrassing in both social and professional situations. Botulinum toxin injections have proven efficacious in the treatment of hyperhidrosis. However, when treating palmar hyperhidrosis, pain at the injection site limits this therapy. We describe a method of cryoanalgesia using dichlorotetrafluoroethane to lessen the pain of botulinum toxin injections during the treatment of palmar hyperhidrosis. Objective. To show the successful use of dichlorotetrafluoroethane or Frigiderm in the treatment of palmar hyperhidrosis. Methods. This is a case report of a patient with a 20-year history of palmar hyperhidrosis who had previously tried several unsuccessful techniques to control pain during botulinum toxin injections to his palms. The left hand of the patient was pretreated with a spray of Frigiderm for 5 seconds before each of the botulinum injections. Two to 3 seconds of dichlorotetrafluoroethane at a distance of 2 to 4 inches were sprayed before each palmar injection. There was 1 to 2 seconds of frosting on the skin before the botulinum toxin was administered. After the botulinum toxin injection was administered, the patient was subjectively asked about pain during injection. Results. The patient subjectively reported a 75% decrease in the intensity of pain with the Frigiderm application, which he said made the injections much more tolerable. No epidermal changes were noted at the time of treatment or at the telephone follow-up visit. The patient presented for follow-up 3 months later. He stated that the sweating had minimally returned but that he had not yet returned to baseline. Conclusion. The use of botulinum toxin for the treatment of palmar hyperhidrosis is often limited because of the pain of multiple injections. In this case report, we describe the successful use of cryoanalgesia with dichlorotetrafluoroethane or Frigiderm to lessen the pain of botulinum toxin injections during the treatment of palmar hyperhidrosis.

Summary Background This study was performed to determine if pretreatment application of a topical anesthetic skin refrigerant reduced discomfort during botulinum toxin injection. Methods Twenty patients were assigned to four groups determined by side of the face pretreated with skin refrigerant and side receiving the first injection. On a Visual Analog Scale of 0–10 patients rated discomfort levels after injections in the glabellar complex with and without pretreatment. Results Mean discomfort rating for the pretreated side was 3.1, while the mean discomfort rating for the non-pretreated side was 4.5. Discomfort was not affected by the side sprayed ( p =0.33) nor by administering the injection to the sprayed side first ( p =0.37). The paired t-test revealed a significant difference between discomfort levels on the pretreated and non-pretreated sides ( p =0.038) yielding a 95% confidence interval of (−2.71, −0.09). Conclusions Topical anesthetic skin refrigerant significantly reduces discomfort in a cost-effective manner for reported by patients undergoing botulinum injections.

Objective To review vocal outcome measures, using the Voice Related Quality of Life (VRQOL) index, after simultaneous bilateral posterior cricoarytenoid muscle botulinum toxin injections. Study Design Case series. Setting Tertiary care academic clinic. Subjects and Methods Fourteen subjects with abductor spasmodic dysphonia received 37 simultaneous bilateral posterior cricoarytenoid muscle botulinum toxin injections for isolated abductor spasmodic dysphonia (ABSD) over a 16-month period. Main Outcome Measures VRQOL index. Results Of the 37 injections, 33 of 37 (89%) resulted in improvement. Three injections resulted in no improvement, and one injection resulted in a worse VRQOL. The overall VRQOL mean improvement was 19.8 (range 5-53), with an average pre/postinjection VRQOL interval of 36 days (range 21-45 days). Conclusions Simultaneous bilateral posterior cricoarytenoid muscle botulinum injections result in a statistically significant improvement in VRQOL index scores for a high percentage of ABSD patients, thus improving patient quality of life.

Purpose To report two patients who experienced improved drinking ability as well as facial appearance with contralateral injection of botulinum toxin. Design Retrospective case reports. Methods Two patients were treated with botulinum toxin contralateral to the VIIth nerve palsy to improve drinking ability as well as facial asymmetry. Results Botulinum toxin injections improved facial asymmetry as well as drinking ability in two patients with facial nerve palsies. Conclusions Contralateral botulinum toxin injections improved drinking ability in two patients with facial nerve palsy.

Purpose: Botulinum toxin is injected into extraocular muscles using electromyographic (EMG) guidance to confirm needle location prior to injection. The purpose of this study was to develop and test an automated, objective method of storing and grading EMG signal quality obtained during botulinum injection. A reliable, nonsubjective estimate of signal quality will enhance future studies of the complications or effectiveness of botulinum toxin injections into extraocular muscle. Methods: Injections were administered using a standard procedure. The EMG was digitized, recorded, and analyzed using discrete Fourier transform and power spectrum analysis. Audible signal quality was also graded subjectively by the surgeon. Patients were followed to determine the clinical response to the injection. Results: Eighteen patients 24 injections) were studied. Each sample was collected and analyzed in less than one second. The EMG contained signals over a range of frequencies from 50 to 500 Hz, with an average peak near 90 Hz. Substantial variability of the signal was observed between patients. Contracting muscle had a higher total power and peak frequency in most, but not all, cases. Total signal power correlated moderately with subjective estimates of signal quality. Neither subjective nor computer-derived signal quality estimates correlated with the response to injection or complications. Conclusions: Computerized signal analysis can automatically characterize EMG signal power and frequency distribution. Although this technique has the potential to identify needle location at the time of botulinum injection accurately, signal variability limited the clinical and research utility of the present protocol.

Botulinum toxin has recently been used as a nonsurgical treatment for blepharospasm and other facial dyskinesias. This report describes four patients between the ages of 32 and 37 years who failed to respond to botulinum injections for severe blepharospasm. Other than age, no other features could be identified in these patients that would differentiate this group. Particularly early age of onset for essential blepharospasm might be an indicator of failure to respond to the injections.