Botox Grand Rounds

Therapeutic Applications of
Botulinum Toxin
Michael D. Puricelli, MD
C.W. David Chang, MD
Overview
Background
Pharmacology of botulinum toxin
Indications
Salivary
Sialorrhea/ptyalism
Freys syndrome
Muscular
Cosmetic
Others
Migraine
Background
Clostridium botulinum
Gram positive
Anaerobic
Spore forming rod
Seven known serotypes based upon unique toxins
A-G
A most lethal
Secretes botulinum toxin, one of the potent neurotoxins
Blocks release of acetylcholine
Causes neuroparalytic botulism
LD 50 in monkeys: 39 U/kg (estimated 2500-3000 U in humans)
Bell MS, Vermeulen LC, Sperling KB. Pharmacotherapy with botulinum toxin: harnessing nature's most potent neurotoxin.
Pharmacotherapy. 2000 Sep;20(9):1079-91. Review. PubMed PMID: 10999501.
Shukla HD, Sharma SK. Clostridium botulinum: a bug with beauty and weapon. Crit Rev Microbiol. 2005;31(1):11-8. Review.
PubMed PMID: 15839401.
Botulinum Toxin
150 kDa protein
Post-translationally modified into a heavy chain and a
light chain
Heavy Chain
Binding domain and translocation domain
Light Chain
Catalytic domain
Cleaves SNARE (soluble N-ethylmaleimide-
sensitive factor attachment protein receptor)
proteins
Neuroparalytic Botulism
Types:
Infantile botulism due to inadequate gut flora and or immature gut
physiology leads to colonization with toxin secretion/exposure
Wound botulism deep wounds or lacerations allow anaerobic growth
conditions
Food-borne botulism colonization of GI tract with toxin production
Inhalational botulism Absorbed through lungs and has been used in the past
as a biological weapon
Symptoms: blurred vision, droop eyelids, slurred speech, difficulty
swallowing, dry mouth and muscle weakness.
Persist until new motor axon branches re-innervate muscles or protease
breakdown
One study has shown that, among three toxins, Toxin A causes the longest
interval of neuromuscular paralysis (four months), followed by B and E
Treatment: passive immunotherapy with immunoglubulins
Overview
Background
Indications
Salivary
Sialorrhea/ptyalism
Freys syndrome
Muscular
Cosmetic
Others
Migraine
Pharmacology of Botulinum Toxin
Onset:
Approximately 23 days after introduction into a muscle,
botulinum toxin causes muscle weakness.
Total paralysis typically occurs within 10 days
Duration:
Toxin A causes the longest interval of neuromuscular paralysis
(four months), followed by B and E.
Reversal:
The once-innervated muscle may atrophy but can redevelop
neurotransmitter sensitivity by producing extrajunctional
acetylcholine receptors.
Autonomic neurons sprout new terminals that eventually
reverse the paralysis.
Botulinum Toxin
Mechanism of Action:
Inhibition of synaptic transmission at cholinergic
nerve terminals by inhibiting pre-synaptic release
of acetylcholine
Botulinum Toxin Serotypes
Botox
Xeomen
Dysport
Myobloc
SNARE Matching
OnabotulinumtoxinA SNAP-25
(Botox, Botox Synaptobrevin
Cosmetic) Syntaxin
AbobotulinumtoxinA
(Dysport)
IncobotulinumtoxinA
(Xeomin)
RimabotulinumtoxinB
(Myobloc)
SNARE Matching
OnabotulinumtoxinA SNAP-25
(Botox, Botox Synaptobrevin
Cosmetic) Syntaxin
AbobotulinumtoxinA
(Dysport)
IncobotulinumtoxinA
(Xeomin)
RimabotulinumtoxinB
(Myobloc)
Botulinum Toxin Serotypes
Botox
Xeomen
Dysport
Myobloc
Shukla HD, Sharma SK. Clostridium botulinum: a bug with beauty and weapon. Crit Rev Microbiol. 2005;31(1):11-8. Review. PubMed PMID: 15839401.
Adverse Effects
Few serious adverse effects
Tend to be localized to the area of injection
Overweakening of muscles by administering too
much toxin
Inadvertent diffusion into adjacent areas
Adverse Effects
Systemic effects Flulike syndromes, rash, dry eyes,
xerostomia, and urinary retention
No prospective long-term studies have been completed
to assess safety of repeated BTX-A injection. Thus,
long-term treatment can be neither justified nor
dismissed due to safety concerns alone.
Antibody formation versus toxin may result in
decreased efficacy with repeat therapy.
May benefit from alternative neurotoxin therapy
Antibodymediated resistance to serotype A does not
convey cross-resistance to BTX-B
Therapeutic uses of botulinum toxin
injection
Focal dystonias - Involuntary, sustained, or spasmodic patterned muscle activity
Cervical dystonia (spasmodic torticollis) Strabismus (disorder of conjugate eye movement)[31, 32] and nystagmus
Blepharospasm (eyelid closure) Chronic pain and disorders of localized muscle spasms
Laryngeal dystonia (spasmodic dysphonia) Chronic low back pain
Limb dystonia (writer's cramp) Myofascial pain syndrome
Oromandibular dystonia Tension headache
Orolingual dystonia Chronic migraine headache
Truncal dystonia Medication overuse headache
Spasticity - Velocity-dependent increase in muscle tone Lateral epicondylitis
Stroke Knee pain
Traumatic brain injury Shoulder pain
Cerebral palsy Neuropathic pain
Multiple Sclerosis Smooth muscle hyperactive disorders
Spinal cord injury Neurogenic bladder Detrusor hyperreflexia
Nondystonic disorders of involuntary muscle activity Detrusor-sphincter dyssynergia
Hemifacial spasm Benign prostatic hypertrophy
Tremor Achalasia cardia
Tics Hirschsprung disease
Myokymia and synkinesis Sphincter of Oddi dysfunctions
Tinnitus (due to myoclonus of stapedius muscle& tensor veli palatini muscle) Hemorrhoids
Hereditary muscle cramps Chronic anal fissures
Nocturnal bruxism Raynaud's Phenomenon
Trismus Cosmetic use
Anismus Hyperkinetic facial lines (glabellar frown lines, crow's feet)
Hypertrophic platysma muscle bands
Sweating, salivary, and allergy disorders
Axillary and palmar hyperhidrosis
Frey syndrome, also known as auriculotemporal syndrome (gustatory
sweating of the cheek after parotid surgery)
Drooling in cerebral palsy and other neurological disorders
Nasal allergy and allergic rhinitis
FDA Approved Indications
OnabotulinumtoxinA
(Botox/Botox Cosmetic)
Cervical dystonia
Glabellar lines (wrinkles between the eyebrows, known as frown lines)
Blepharospasm (eyelid spasm)
Moderate to severe lateral canthal lines, known as crows feet, in adults.
Chronic migraine
Severe underarm sweating
Strabismus (misalignment of the eyes when one or both eyes turn inward or
outward).
Neurogenic detrusor overactivity
Upper limb spasticity
Hemifacial spasm
Boxed warning that says the effects of the botulinum toxin may spread from the
area of injection to other areas of the body, causing symptoms similar to those of
botulism. There has not been a confirmed serious case of toxin spread when Botox
or Botox Cosmetic has been used at the recommended dose for the approved
indications..
http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm367662.htm
IncobotulinumtoxinA (Xeomin)
Cervical dystonia
Moderate to severe glabellar lines.
Blepharospasm
Lorenc ZP, Kenkel JM, Fagien S, Hirmand H, Nestor MS, Sclafani AP, Sykes JM, Waldorf HA.
IncobotulinumtoxinA (Xeomin): background, mechanism of action, and manufacturing. Aesthet
Surg J. 2013 Mar;33(1 Suppl):18S-22S. doi: 10.1177/1090820X12474633. Review. PubMed
PMID: 23515195.
http://emedicine.medscape.com/article/325451-overview#a1
AbobotulinumtoxinA (Dysport)
Cervical dystonia
Moderate to severe glabellar lines
RimabotulinumtoxinB (Myobloc)
Cervical dystonia
T/F:
FDA Indications for Botulinum Toxin
Spasmodic dysphonia
Cervical dystonia
T/F:
Spasmodic dysphonia
Cervical dystonia
T/F:
Strabismus (misalignment of the eyes when
one or both eyes turn inward or outward).
Glabellar lines (wrinkles between the
eyebrows, known as frown lines)
Facial synkinesis
Moderate to severe lateral canthal lines,
known as crows feet, in adults.
T/F:
Strabismus (misalignment of the eyes when
one or both eyes turn inward or outward).
Glabellar lines (wrinkles between the
eyebrows, known as frown lines)
Facial synkinesis
Moderate to severe lateral canthal lines,
known as crows feet, in adults.
T/F:
Chronic migraine
Freys syndrome
Hemifacial spasm
T/F:
Chronic migraine
Freys syndrome
Hemifacial spasm
Contraindications
Pregnancy
Lactation
History of reaction to toxin or albumin
Preexisting motor neuron disease (eg,
myasthenia gravis, Eaton-Lambert syndrome,
neuropathies)
Age younger than 12 years
Infection at the injection site
Coincident administration of aminoglycosides can
potentiate paralysis (relative contraindication)
Potency
FDA required product labeling for all approved
botulinum neurotoxin products, specifically
stating that potency units for each product
are product specific.
Formulations
Formulations
Overview
Background
Indications
Salivary
Sialorrhea/ptyalism
Freys syndrome
Muscular
Cosmetic
Others
Migraine
Salivary Physiology
1-1.5 L of saliva is produced per day
Salivary flow is regulated by the autonomic nervous system
Parasympathetic cholinergic stimulation and via acetylcholine
activates phospholipase C which increases calcium to stimulate fluid
formation and transport
Sympathetic beta-adrenergic stimulation by norepinepherine using a
G-protein activated second messenger cAMP
Parotid gland
Glossopharyngeal nerve parasympathetic innervation
Superior cervical ganglion supplies sympathetic innervation
Primary source of stimulated saliva production
Submandibular/sublingual glands
Facial nerve via chorda tympani provides secretomotor innervation
Submandibular gland highest basal flow rate and predominant
producer of unstimulated saliva
Lee, KJ. Essential Otolaryngology. 10th ed.

Salivary Anatomy
Hornibrook J, Cochrane N. Contemporary surgical management of severe sialorrhea in children. ISRN Pediatr. 2012;2012:364875. doi: 10.5402/2012/364875.
Epub 2012 Mar 28. PubMed PMID: 22548185; PubMed Central PMCID: PMC3324931.
Sialorrhea/Ptyalism(drooling)
Reduced neuromuscular control of the tongue, oral
tissues, and swallowing mechanism occurs in
neurologic disorders such as cerebral palsy, Parkinsons
disease, and ALS.
Risk of complications such as aspiration
Perioral irritation and chapping
Oral infections
Dehydration
Foul odor and reduced hygiene
Interference with speech
Social isolation
Drooling is abnormal after the age of 4 years
Persaud R, Garas G, Silva S, Stamatoglou C, Chatrath P, Patel K. An evidence-based review of botulinum toxin (Botox)
applications in non-cosmetic head and neck conditions. JRSM Short Rep. 2013 Feb;4(2):10. doi:
10.1177/2042533312472115. Epub 2013 Feb 12. PubMed PMID: 23476731; PubMed Central PMCID: PMC3591685.
Salivary Physiology
Therapeutic Options
Pharmacotherapy
Radiation therapy
Botulinum toxin
Surgery
Vashishta R, Nguyen SA, White DR, Gillespie MB. Botulinum toxin for the treatment of sialorrhea: a meta-analysis.
Otolaryngol Head Neck Surg. 2013 Feb;148(2):191-6. doi: 10.1177/0194599812465059. Epub 2012 Oct 30. Review. PubMed
PMID: 23112272.
Pharmacologic Agents
Benzotropine
Glycopyrolate
Lakraj AA, Moghimi N, Jabbari B. Sialorrhea: anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins
(Basel). 2013 May 21;5(5):1010-31. doi: 10.3390/toxins5051010. Review. PubMed PMID: 23698357; PubMed Central PMCID: PMC3709276.
Pharmacologic Agents
Glycopyrolate
Radiation Therapy
Significant adverse effects
May consider in the elderly and those who are
not surgical candidates
Botulinum Toxin
Schroeder et al evaluated 39 patients with cerebral
palsy and showed that use of botulinum toxin A and B
led to improvement, though greater with botulinum
toxin B
Need for care reduced by 79%
Social interaction improved by 84%
Antibody development occurred, especially with Toxin B
Guidubaldi et al showed that botulinum toxin A and B
have similar duration of action of approximately 3
months
Guidubaldi A, Fasano A, Ialongo T, Piano C, Pompili M, Mascian R, Siciliani L, Sabatelli M, Bentivoglio AR. Botulinum toxin A versus B in sialorrhea: a prospective, randomized,
double-blind, crossover pilot study in patients with amyotrophic lateral sclerosis or Parkinson's disease. Mov Disord. 2011 Feb 1;26(2):313-9. doi: 10.1002/mds.23473. Epub
2011 Jan 21. PubMed PMID: 21259343.
Majid OW. Clinical use of botulinum toxins in oral and maxillofacial surgery. Int J Oral Maxillofac Surg. 2010 Mar;39(3):197-207. doi: 10.1016/j.ijom.2009.10.022. Epub 2009
Dec 2. Review. PubMed PMID: 19959337.
Botulinum Toxin
Vashiishta et al performed a meta analysis of studies
showing the effect of botulinum toxin administration
Eight studies involving 181 patients (83 placebo; 98 active) were
included
Botulinum toxin was found to significantly decrease the
severity of drooling
standardized mean difference [SMD], -1.54; 95% confidence
interval [CI], -2.05 to -1.04
Botulinum toxin A and B produced similar effects
Botulinum toxin doses greater than 50 U (SMD, -3.81; 95%
CI, -6.19 to -1.43) produced much stronger effects
compared with doses less than or equal to 50 U (SMD, -
1.32; 95% CI, -2.28 to -0.36).
PMID: 23112272.
Botulinum Toxin
PMID: 23112272.
Botulinum Toxin
Botulinum Toxin Administration
Variable techniques are
described
BoNT injections are given in
the parotid and
submandibular glands, as
they are the greatest
contributors to salivary
production
Facial nerve is very close in
the parotid gland; caution
must be taken when injecting
to avoid this nerve
No descriptions of how
avoided
Most authors use emla cream
and not local anesthetic but
practice patterns vary widely
PMID: 23112272.
Botox Injection Techniques
Surgical Therapy for Sialorrhea
Reed et al performed a meta analysis of surgical therapy for sialorrhea
Systematically reviewed articles reporting on the use of surgical
procedures to treat sialorrhea published from 1963 to 2008
Inclusion criteria:
Data on the success of surgical treatment of sialorrhea, English language, sample size
greater than 5, and presentation of extractable data regarding the subjective success of
surgical management of sialorrhea.
50 articles were sampled
Success was reported in more than 50% of patients in 49 of 50 studies
Random-effects modeling estimated the overall subjective success rate for all
procedures to be 81.6% (95% confidence interval, 77.5%-85.7%; P < .001)
Bilateral submandibular gland excision and parotid duct rerouting appeared to
have the highest subjective success rates at 87.8% (k = 8 studies; 95%
confidence interval, 80.5%-95.1%; P <.001)
4-duct ligation was the lowest at 64.1% (4 studies; 27.6%-100%; P = .001)
Reed J, Mans CK, Brietzke SE. Surgical management of drooling: a meta-analysis. Arch Otolaryngol Head Neck Surg. 2009 Sep;135(9):924-31. doi: 10.1001/archoto.2009.110.
Review. PubMed PMID: 19770427.
Surgical Therapy for Sialorrhea
Freys syndrome
Occurs after salivary gland surgery (usually
parotid) and is caused by aberrant
regeneration of postganglionic
parasympathetic fibers innervating
sympathetic cholinergic sweat glands.
Results in sweating, flushing and piloerection
while eating (gustatory sweating).
Efficacy has been demonstrated in multiple
series
Freys syndrome
Refer to Dr. Hopewells grand rounds from
3/5/14 for further details
Overview
Background
Indications
Salivary
Sialorrhea/ptyalism
Freys syndrome
Muscular
Cosmetic
Others
Migraine
Neuromuscular Junction Physiology
Cosmetic Uses of Botulinum Toxin
Facial lines are caused by patterns of facial muscle
contractions
Injection with botulinum toxin causes a temporary paralysis
of the affected facial muscles, which leads to a flattening of
facial skin and an improved facial appearance
Botulinum toxin injection for facial rejuvenation is the most
common cosmetic procedure in the United States
Doses given are for onabotulinumtoxinA or

incobotulinumtoxinA; approximate dosages for
abobotulinumtoxinA can be determined using a 2:1 or
2.5:1.
Lorenc ZP, Kenkel JM, Fagien S, Hirmand H, Nestor MS, Sclafani AP, Sykes JM, Waldorf HA. IncobotulinumtoxinA (Xeomin): background, mechanism of action,
and manufacturing. Aesthet Surg J. 2013 Mar;33(1 Suppl):18S-22S. doi: 10.1177/1090820X12474633. Review. PubMed PMID: 23515195.
Carruthers A, Kane MA, Flynn TC, Huang P, Kim SD, Solish N, Kaeuper G. The convergence of medicine and neurotoxins: a focus on botulinum toxin type A and
its application in aesthetic medicine--a global, evidence-based botulinum toxin consensus education initiative: part I: botulinum toxin in clinical and cosmetic
Cosmetic Uses of Botulinum Toxin
FDA Approved Indications:
Glabellar lines
Lateral canthal lines crows feet
Off Label Uses:
Forehead lines
Platysmal bands
Many others
Glabellar Lines
Product labeling recommends
20 U of onabotulinumtoxinA
or incobotulinumtoxinA,
generally divided into 5 equal
injection points
Inject more superficially at the
tail of the corrugator or at the
subdermal insertion points and
deeper (intramuscularly) at the
more medial body of the
corrugator muscles
Lower doses are advocated by
some initially (10-15 U) and
higher doses for large muscle
mass (30-40 U)
Lorenc ZP, Kenkel JM, Fagien S, Hirmand H, Nestor MS, Sclafani AP, Sykes JM, Waldorf HA. Consensus panel's assessment and recommendations
on the use of 3 botulinum toxin type A products in facial aesthetics. Aesthet Surg J. 2013 Mar;33(1 Suppl):35S-40S. doi:
10.1177/1090820X13480479. PubMed PMID: 23515197.
Carruthers J, Fournier N, Kerscher M, Ruiz-Avila J, Trindade de Almeida AR, Kaeuper G. The convergence of medicine and neurotoxins: a focus on
botulinum toxin type A and its application in aesthetic medicine--a global, evidence-based botulinum toxin consensus education initiative: part II:
incorporating botulinum toxin into aesthetic clinical practice. Dermatol Surg. 2013 Mar;39(3 Pt 2):510-25. doi: 10.1111/dsu.12148. Review.
Physician Assessment
Carruthers et al
performed a RCT of
botulinum toxin versus
placebo for glabellar
lines
Carruthers JD, Lowe NJ, Menter MA, Gibson J, Eadie N; Botox Glabellar Lines II
Study Group. Double-blind, placebo-controlled study of the safety and efficacy of
botulinum toxin type A for patients with glabellar lines. Plast Reconstr Surg. 2003
Sep 15;112(4):1089-98. PubMed PMID: 12973229.
Patient Assessment
Carruthers JD, Lowe NJ, Menter MA, Gibson J, Eadie N; Botox Glabellar Lines II
Study Group. Double-blind, placebo-controlled study of the safety and efficacy of
botulinum toxin type A for patients with glabellar lines. Plast Reconstr Surg. 2003
Sep 15;112(4):1089-98. PubMed PMID: 12973229.
Botox and Depression
Wollmer et al performed a randomized double-blind placebo-controlled
trial evaluating botulinum toxin injection to the glabellar region as an
adjunctive treatment of major depression.
Thirty patients were randomly assigned to onabotulinumtoxinA, (n = 15)
or placebo (saline, n = 15)
Throughout the sixteen-week follow-up period there was a significant
improvement in depressive symptoms in the botox group compared to the
placebo group as measured by the Hamilton Depression Rating Scale
Treatment-dependent clinical improvement was also reflected in the Beck
Depression Inventory, and in the Clinical Global Impressions Scale
This study shows that a single treatment of the glabellar region with
botulinum toxin may shortly accomplish a strong and sustained alleviation
of depression in patients, who did not improve sufficiently on previous
medication
It supports the concept, that the facial musculature not only expresses,
but also regulates mood states
Wollmer MA, de Boer C, Kalak N, Beck J, Gtz T, Schmidt T, Hodzic M, Bayer U, Kollmann T, Kollewe K, Snmez D, Duntsch K, Haug MD, Schedlowski M, Hatzinger M, Dressler
D, Brand S, Holsboer-Trachsler E, Kruger TH. Facing depression with botulinum toxin: a randomized controlled trial. J Psychiatr Res. 2012 May;46(5):574-81. doi:
Complications Glabella
Blepharoptosis calculated to occur in 6.5%
based on the pooled data from forehead
rhytid treatment
Injections of the orbicularis oculii,
corrugator supercilii, and procerus muscles
have the highest likelihood of producing lid
ptosis
Direct digital pressure can be used to

isolate the injection site
Place corrugator injections at least 1 cm
above the level of the supraorbital ridge
Lid ptosis responds well to several alpha-

adrenergic agonist ophthalmic eye drops:
Apraclonidine 0.5%, Naphazoline,
phenylephrine stimulate muellers muscles
Vartanian AJ, Dayan SH. Complications of botulinum toxin A use in facial rejuvenation. Facial Plast Surg Clin North Am. 2005 Feb;13(1):1-10. Review. PubMed PMID:
15519923.
Crows Feet
Consensus
recommendation
8-16 U on each side of
the face divided into
multiple injection points,
usually four on each side
Crows Feet RCT
Lowe NJ, Ascher B, Heckmann M, Kumar C, Fraczek S, Eadie N; Botox Facial Aesthetics Study Team. Double-blind, randomized, placebo-controlled, dose-response
study of the safety and efficacy of botulinum toxin type A in subjects with crow's feet. Dermatol Surg. 2005 Mar;31(3):257-62. PubMed PMID: 15841623.
Complications Crows Feet
Ectropion
Keep injections >1 cm lateral to lateral canthus
can reduce this complication
Managed with local care to prevent ocular injury
Strabismus
Lateral rectus weakness from crows feet area
injection
Patient may require temporary patching
15519923.
Horizontal Forehead Lines
If the frontalis is to be treated, the
glabella must also be treated, thus
treating both the elevators and the
depressors
The number of injection sites can
vary significantly, although most
injectors use 4 to 6 sites. It is
important that all injections remain 1
to 2 cm above the orbital rim to
decrease the risk for brow ptosis.
Total starting dosages generally are
10 to 20 U for women and may be
doubled for men depending on the
muscle mass observed
Some injectors have used as few as 2 to
4 U, particularly for women
10.1177/1090820X13480479. PubMed PMID: 23515197.
Complications
Brow malposition
Exaggerate previously
present asymmetry
Brow ptosis
Avoided by conservative
treatment of medial
forehead and
undertreating the lateral
forehead
Sinister or Joker Face
Arises from treatment of
the glabella and middle
1/3 of forehead
selectively
15519923.
Platysmal Bands
Use for this indication is
felt to be high risk
complications such as
swallowing change or
indiscernible results
10.1177/1090820X13480479. PubMed PMID: 23515197.
Complications
Voice changes
Dysphagia
15519923.
Other Sites for Cosmetic Botox
Injection
Lips
Lower eyelid
Depressor anguli oris
Mentalis
Review
What are the two FDA approved indications
for administration of botulinum toxin for
cosmetic conditions?
Review
What are the two FDA approved indications
for administration of botulinum toxin for
cosmetic conditions?
Crows feet
Glabella treatment
Facial nerve paresis
Botox may be used to induce therapeutic ptosis,
thereby protecting the cornea during the acute
phase of facial nerve paresis
Transcutaneous injection into Muellers muscle and
the levator palpebrae superioris.
In addition, Botox can reduce synkinesis after
aberrant facial nerve regeneration following facial
nerve paresis.
Botox was injected to several synkinetic muscles of
patients with facial nerve paresis and all 30 patients
experienced improvement
Weakening the functional side
Lindsay RW, Edwards C, Smitson C, Cheney ML, Hadlock TA. A systematic algorithm for the management of lower lip asymmetry. Am J Otolaryngol. 2011 Jan-Feb;32(1):1-7.
doi: 10.1016/j.amjoto.2009.08.011. Epub 2009 Oct 9. PubMed PMID: 20015805.
Overview
Background
Indications
Salivary
Sialorrhea/ptyalism
Freys syndrome
Muscular
Cosmetic
Others
Migraine
Migraine
28 million Americans have classic migraine
Common prophylactic medications include
beta blockers, calcium channel blockers, SSRIs,
tricyclic antidepressants
FDA approved use of botulinum toxin A for
migraine prophylaxis at a dose of 155 units
divided among 31 injection sites for chronic
migraine >14 days per month
Headaches/migraines
Numerous multicenter double-blind placebo
controlled trials support the use of Botox as a
prophylactic therapy for chronic migraine
A recent meta-analysis confirmed these beneficial
effects of Botox but only in the treatment of
chronic daily headaches and chronic migraines
(>15 episodes per month).
There is no statistical difference in the results between
Botox administration and topirimate, valproate and
amitriptyline for chronic migraine
Botox is superior to methylprednisolone for chronic
migraine
Jackson JL, Kuriyama A, Hayashino Y. Botulinum toxin A for prophylactic treatment of migraine and tension headaches in adults: a meta-analysis. JAMA. 2012 Apr
25;307(16):1736-45. doi: 10.1001/jama.2012.505. PubMed PMID: 22535858.
Jackson JL, Kuriyama A, Hayashino Y. Botulinum toxin A for prophylactic treatment of migraine and tension headaches in adults: a meta-analysis. JAMA. 2012 Apr
25;307(16):1736-45. doi: 10.1001/jama.2012.505. PubMed PMID: 22535858.
31 Injection Sites
http://www.botoxchronicmigraine.com/botox-treatment-expectations/
Question
Which of the following is not an indication for
botulinum toxin treatment?
Blepharospasm
Glabellar lines
Strabismus
Chronic neck pain
Question
Which of the following is not an indication for
botulinum toxin treatment?
Blepharospasm
Glabellar lines
Strabismus
Chronic neck pain
References
Bell MS, Vermeulen LC, Sperling KB. Pharmacotherapy with botulinum toxin: harnessing nature's most potent neurotoxin. Pharmacotherapy. 2000
Sep;20(9):1079-91. Review. PubMed PMID: 10999501
Blumenfeld AM, Binder W, Silberstein SD, Blitzer A. Procedures for administering botulinum toxin type A for migraine and tension-type headache.
Headache. 2003 Sep;43(8):884-91. Review. PubMed PMID: 12940810.
Carruthers A, Kane MA, Flynn TC, Huang P, Kim SD, Solish N, Kaeuper G. The convergence of medicine and neurotoxins: a focus on botulinum toxin
type A and its application in aesthetic medicine--a global, evidence-based botulinum toxin consensus education initiative: part I: botulinum toxin in
clinical and cosmetic practice. Dermatol Surg. 2013 Mar;39(3 Pt 2):493-509. doi: 10.1111/dsu.12147. Review. PubMed PMID: 23458294
Guidubaldi A, Fasano A, Ialongo T, Piano C, Pompili M, Mascian R, Siciliani L, Sabatelli M, Bentivoglio AR. Botulinum toxin A versus B in sialorrhea: a
prospective, randomized, double-blind, crossover pilot study in patients with amyotrophic lateral sclerosis or Parkinson's disease. Mov Disord. 2011
Feb 1;26(2):313-9. doi: 10.1002/mds.23473. Epub 2011 Jan 21. PubMed PMID: 21259343.
Hornibrook J, Cochrane N. Contemporary surgical management of severe sialorrhea in children. ISRN Pediatr. 2012;2012:364875. doi:
10.5402/2012/364875. Epub 2012 Mar 28. PubMed PMID: 22548185; PubMed Central PMCID: PMC3324931.
http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm367662.htm
Jackson JL, Kuriyama A, Hayashino Y. Botulinum toxin A for prophylactic treatment of migraine and tension headaches in adults: a meta-analysis.
JAMA. 2012 Apr 25;307(16):1736-45. doi: 10.1001/jama.2012.505. PubMed PMID: 22535858.
Lakraj AA, Moghimi N, Jabbari B. Sialorrhea: anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins (Basel).
2013 May 21;5(5):1010-31. doi: 10.3390/toxins5051010. Review. PubMed PMID: 23698357; PubMed Central PMCID: PMC3709276.
Lee, KJ. Essential Otolaryngology. 10th ed.
Lindsay RW, Edwards C, Smitson C, Cheney ML, Hadlock TA. A systematic algorithm for the management of lower lip asymmetry. Am J Otolaryngol.
2011 Jan-Feb;32(1):1-7. doi: 10.1016/j.amjoto.2009.08.011. Epub 2009 Oct 9. PubMed PMID: 20015805.
Lorenc ZP, Kenkel JM, Fagien S, Hirmand H, Nestor MS, Sclafani AP, Sykes JM, Waldorf HA. IncobotulinumtoxinA (Xeomin): background, mechanism of
action, and manufacturing. Aesthet Surg J. 2013 Mar;33(1 Suppl):18S-22S. doi: 10.1177/1090820X12474633. Review. PubMed PMID: 23515195.
Lowe NJ, Ascher B, Heckmann M, Kumar C, Fraczek S, Eadie N; Botox Facial Aesthetics Study Team. Double-blind, randomized, placebo-controlled,
dose-response study of the safety and efficacy of botulinum toxin type A in subjects with crow's feet. Dermatol Surg. 2005 Mar;31(3):257-62.
Majid OW. Clinical use of botulinum toxins in oral and maxillofacial surgery. Int J Oral Maxillofac Surg. 2010 Mar;39(3):197-207. doi:
10.1016/j.ijom.2009.10.022. Epub 2009 Dec 2. Review. PubMed PMID: 19959337.
Persaud R, Garas G, Silva S, Stamatoglou C, Chatrath P, Patel K. An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic
head and neck conditions. JRSM Short Rep. 2013 Feb;4(2):10. doi: 10.1177/2042533312472115. Epub 2013 Feb 12. PubMed PMID: 23476731;
PubMed Central PMCID: PMC3591685.
Reed J, Mans CK, Brietzke SE. Surgical management of drooling: a meta-analysis. Arch Otolaryngol Head Neck Surg. 2009 Sep;135(9):924-31. doi:
10.1001/archoto.2009.110. Review. PubMed PMID: 19770427.
Shukla HD, Sharma SK. Clostridium botulinum: a bug with beauty and weapon. Crit Rev Microbiol. 2005;31(1):11-8. Review. PubMed PMID:
15839401.
Vartanian AJ, Dayan SH. Complications of botulinum toxin A use in facial rejuvenation. Facial Plast Surg Clin North Am. 2005 Feb;13(1):1-10. Review.
Vashishta R, Nguyen SA, White DR, Gillespie MB. Botulinum toxin for the treatment of sialorrhea: a meta-analysis. Otolaryngol Head Neck Surg. 2013
Feb;148(2):191-6. doi: 10.1177/0194599812465059. Epub 2012 Oct 30. Review. PubMed PMID: 23112272
Wollmer MA, de Boer C, Kalak N, Beck J, Gtz T, Schmidt T, Hodzic M, Bayer U, Kollmann T, Kollewe K, Snmez D, Duntsch K, Haug MD, Schedlowski
M, Hatzinger M, Dressler D, Brand S, Holsboer-Trachsler E, Kruger TH. Facing depression with botulinum toxin: a randomized controlled trial. J
Psychiatr Res. 2012 May;46(5):574-81. doi: 10.1016/j.jpsychires.2012.01.027. Epub 2012 Feb 24. PubMed PMID: 22364892.

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Botox Grand Rounds

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Therapeutic Applications of

Lee, KJ. Essential Otolaryngology. 10th ed.

Doses given are for onabotulinumtoxinA or

Direct digital pressure can be used to

Lid ptosis responds well to several alpha-

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