Considerations for Initial Dosing of Botulinum Toxin in Treatment of Adductor Spasmodic Dysphonia

Article · March 2013with10 Reads
DOI: 10.1177/0194599813484685 · Source: PubMed
Abstract
Objectives To assess the effect on voice improvement and duration of breathiness based on initial dose of onabotulinum toxin A (BTX-A) in the management of adductor spasmodic dysphonia (SD) and to compare voice outcomes for initial bilaterally injected doses of 1.25 units (group A) vs 2.5 units (group B) of BTX-A.Study DesignCase series with chart review of patients with adductor SD treated at a tertiary care facility from 1990 to 2011.SettingAcademic subspecialty laryngology practice.Methods Demographic data (age and sex), voice rating, duration of voice improvement, and breathiness were evaluated and compared between groups A and B using the Student t test and χ(2) analysis.ResultsOf 478 patients identified, 305 (223 in group A, 82 in group B) patients met inclusion criteria. The average age was 56.2 years in group A and 57.4 years in group B (P = .5). The female to male ratio was 2.91 for group A vs 3.56 for group B (P = .61). Good voice outcomes (grade 3 or 4) were reported by 91% of group A patients vs 94% of group B (P = .75). The average duration of voice improvement was 99.7 days for group A and 108.3 days for group B (P = .54). The average duration of breathiness was 10.88 days for group A vs 15.42 days for group B (P = .02).Conclusion Patients injected with 1.25 units bilaterally had a statistically significant shorter duration of breathiness without a statistically significant difference in clinical effectiveness or voice outcome. It is therefore recommended that a relatively low initial BTX-A dose be used with subsequent titration to achieve improved voice outcomes.
    • This may be due to inaccurate placement into PCA.Meleca et al. (1997)described a transcricoid technique and compared it with the standard retrocricoid approach in six patients. Both practitioners and patients preferred the transcricoid method because of less discomfort, equivalent or better voice results, and fewer side effects[57,60]. For treating abductor SD, the cricothyroid muscle can also be injected[4]. Unilateral or bilateral protocols have been proposed for treating both SD types[4,61].
    [Show abstract] [Hide abstract] ABSTRACT: There is irrefutable evidence for the effectiveness of botulinum toxin (BoNT) in the treatment of various disorders associated with excessive muscle contraction or autonomic dysfunction. One of the earliest indications as well as the most common BoNT treated movement disorder is dystonia, predominantly its focal forms, including blepharospasm, oromandibular, spasmodic, cervical and limb dystonia. Spastic disorders comprise another area where BoNT treatment has proved beneficial. Optimal therapeutic results, however, depend on several factors, including the BoNT serotype, dose, concentration, injected volume, frequency of application, as well as precise localization of the muscles producing the abnormal movement. The accuracy in targeting muscle localization is considered to be a key factor for determining the outcome of BoNT injections, even more important than dilution volume and dose. Various techniques to find the best injection site for the delivery of BoNT have been described in the literature. An attempt was made to summarize in one place the available evidence, and when possible to compare and point out the advantages and disadvantages of different techniques for localization of BoNT injections. The widely applied clinical indications for dystonia and spasticity have been specifically chosen as our focus in this present work.
    Full-text · Chapter · Dec 2016 · The Journal of Laryngology & Otology
    • No other drug is used in a broader range dose. doses of Botox Ò 1.25 MU (Rosow et al. 2013) have been used for spasmodic dysphonia. The upper end of the therapeutic dose range, however, still needs to be explored.
    [Show abstract] [Hide abstract] ABSTRACT: Botulinum toxin (BT) used for dystonia and spasticity is dosed according to the number of target muscles and the severity of their muscle hyperactivities. With this no other drug is used in a broader dose range than BT. The upper end of this range, however, still needs to be explored. We wanted to do this by a prospective non-interventional study comparing a randomly selected group of dystonia and spasticity patients receiving incobotulinumtoxinA (Xeomin(®)) high-dose therapy (HD group, n = 100, single dose ≥400 MU) to a control group receiving incobotulinumtoxinA regular-dose therapy (RD group, n = 30, single dose ≤200 MU). At the measurement point all patients were evaluated for systemic BT toxicity, i.e. systemic motor impairment or systemic autonomic dysfunction. HD group patients (56.1 ± 13.8 years, 46 dystonia, 54 spasticity) were treated with Xeomin(®) 570.1 ± 158.9 (min 400, max 1,200) MU during 10.2 ± 7.0 (min 4, max 37) injection series. In dystonia patients the number of target muscles was 46 and the dose per target muscle 56.4 ± 19.1 MU, in spasticity patients 35 and 114.9 ± 67.1 MU. HD and RD group patients reported 58 occurrences of items on the systemic toxicity questionnaire. Generalised weakness, being bedridden, feeling of residual urine and constipation were caused by the underlying tetra- or paraparesis, blurred vision by presbyopia. Dysphagia and dryness of eye were local BT adverse effects. Neurologic examination, serum chemistry and full blood count did not indicate any systemic adverse effects. Elevated serum levels for creatine kinase/MB, creatine kinase and lactate dehydrogenase were most likely iatrogenic artefacts. None of the patients developed antibody-induced therapy failure. Xeomin(®) can be used safely in doses ≥400 MU and up to 1,200 MU without detectable systemic toxicity. This allows expanding the use of BT therapy to patients with more widespread and more severe muscle hyperactivity conditions. Further studies-carefully designed and rigorously monitored-are necessary to explore the threshold dose for clinically detectable systemic toxicity.
    Full-text · Article · Jul 2014
    • No other drug is used in a broader range dose. In registered indications recommended single doses start from 20 MU of onabotulinumtoxinA (Botox Ò , Vistabel Ò , Botox doses of Botox Ò 1.25 MU (Rosow et al. 2013) have been used for spasmodic dysphonia. The upper end of the therapeutic dose range, however, still needs to be explored.
    [Show abstract] [Hide abstract] ABSTRACT: Botulinum toxin (BT) used for dystonia and spasticity is dosed according to the number of target muscles and the severity of their muscle hyperactivities. With this no other drug is used in a broader dose range than BT. The upper end of this range, however, still needs to be explored. We wanted to do this by a prospective non-interventional study comparing a randomly selected group of dystonia and spasticity patients receiving incobotulinumtoxinA (Xeomin(A (R))) high-dose therapy (HD group, n = 100, single dose a parts per thousand yen400 MU) to a control group receiving incobotulinumtoxinA regular-dose therapy (RD group, n = 30, single dose a parts per thousand currency sign200 MU). At the measurement point all patients were evaluated for systemic BT toxicity, i.e. systemic motor impairment or systemic autonomic dysfunction. HD group patients (56.1 +/- A 13.8 years, 46 dystonia, 54 spasticity) were treated with Xeomin(A (R)) 570.1 +/- A 158.9 (min 400, max 1,200) MU during 10.2 +/- A 7.0 (min 4, max 37) injection series. In dystonia patients the number of target muscles was 46 and the dose per target muscle 56.4 +/- A 19.1 MU, in spasticity patients 35 and 114.9 +/- A 67.1 MU. HD and RD group patients reported 58 occurrences of items on the systemic toxicity questionnaire. Generalised weakness, being bedridden, feeling of residual urine and constipation were caused by the underlying tetra- or paraparesis, blurred vision by presbyopia. Dysphagia and dryness of eye were local BT adverse effects. Neurologic examination, serum chemistry and full blood count did not indicate any systemic adverse effects. Elevated serum levels for creatine kinase/MB, creatine kinase and lactate dehydrogenase were most likely iatrogenic artefacts. None of the patients developed antibody-induced therapy failure. Xeomin(A (R)) can be used safely in doses a parts per thousand yen400 MU and up to 1,200 MU without detectable systemic toxicity. This allows expanding the use of BT therapy to patients with more widespread and more severe muscle hyperactivity conditions. Further studies-carefully designed and rigorously monitored-are necessary to explore the threshold dose for clinically detectable systemic toxicity.
    Full-text · Article · Jan 2014
  • [Show abstract] [Hide abstract] ABSTRACT: In otorhinolaryngology, botulinum toxin is a suitable therapeutic option in the muscular and the autonomic nervous system concerning dysfunctions. Respecting some special aspects, it is an effective treatment for disorders of different etiology with very few side-effects. The positive therapeutic effect is temporarily limited, so that the patients need further treatment. Beside the classical indications like the facial hyperkinesias (i.e. blepharospasms, hemifacial spasm) the treatment of complex dystonias (oromandibular dystonia, laryngeal 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 lay in the treatment of nasal hypersecretion through the effect on the nasal glands.
    Article · Apr 2003
  • Article · Apr 2014
  • [Show abstract] [Hide abstract] ABSTRACT: Objectives: This study aimed to evaluate the demographics of spasmodic dysphonia in the Indian population and to analyse the optimum dose titration of botulinum toxin type A in this group. A comparative analysis with international studies was also performed. Method: The study involved a retrospective analysis and audit of botulinum toxin type A dose titration in spasmodic dysphonia patients who visited our voice clinic between January 2005 and January 2012. Results: The average total therapeutic dose required for patients with adductor spasmodic dysphonia was 4.2 U per patient per vocal fold (total 8.4 U per patient), and for patients with abductor spasmodic dysphonia, it was 4.6 U per patient. Conclusion: Our audit revealed that 80 per cent of the spasmodic dysphonia patients were male, which contrasts dramatically with international studies, wherein around 80 per cent of spasmodic dysphonia patients were female. Our study also revealed a higher dose titration of botulinum toxin for the Indian spasmodic dysphonia population in both adductor and abductor spasmodic dysphonia cases.
    Article · Jul 2014
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