Application Of Botulinum Toxin Research Articles

Electromyography assited application of botulinum toxin in pterygoid musculature for the treatment of masticatory myofascial pain

espanolObjetivo: Evaluar la eficacia de la inyeccion de toxina botulinica A (TBA) en los musculos pterigoideos guiada por electromiografia (EMG) para el tratamiento del dolor miofascial masticatorio. Material y metodos: Realizamos un estudio retrospectivo de 31 pacientes diagnosticados de dolor miofascial de origen masticatorio a los que se le administro TBA en los musculos pterigoideos laterales y mediales guiada por EMG. Se evaluo la efectividad por disminucion de intensidad del dolor mediante escalas numericas (EN) y escalas categoricas (EC). Ademas, se determino el impacto de esta patologia en su calidad de vida, la duracion del tratamiento y la disminucion de la demanda de analgesicos. Resultados: La disminucion media del dolor en la EN tras tratamiento fue de 4,9 ± 2,9 puntos. Se observo una disminucion estadistica del dolor (p Conclusiones: La administracion de TBA guiada por EMG en los musculos pterigoideos es eficaz en el tratamiento del dolor miofascial masticatorio, mejor la calidad de vida y se consigue una disminucion del consumo de analgesicos postratamiento. EnglishAim: To evaluate the efficacy of botulinum toxin A injection (BTA) in the lateral pterygoid muscles assisted by electromyography (EMG) for the treatment of masticatory myofascial pain (MMP). Material and methods: We conducted a retrospective study of 31 patients diagnosed of MMP who were treated by infiltration of botulinum toxin A in 1, 2 or 3 times, in the lateral and medial pterygoid muscles by electromyographic control of the puncture site. We assessed the treatment effectiveness in pain intensity decrease by numerical scales (NS) and categorical scales (CS). The impact of pathology on its quality of life, the decrease of demand for analgesic drugs, and the duration of BTA effect and its side effects were also valued. Results: The mean decrease in pain after treatment was 4.9 ± 2.9 points in NS. A statistical decrease of the pain (p = 0.01) can be shown after treatment. There is no statistical relationship between greater improvement after the administration of a greater number of injections. However, there is a significant improvement in the decrease of the pain in CS (p = 0.028) after the administration of several injections. There is also a significant decrease (p = 0.012) of the use of analgesic medication post-treatment. Conclusions: EMG assisted pterygoid muscles infiltration of BTA is effective in the treatment of MMP; it improves quality of life and decreases the consumption of health resources.

Endometriosis-Like Syndrome: From the Concept of Painful Uterine Syndrome to the use of Myometrial Botulinum Toxin Injections under Hysteroscopy

Background: A new concept is being advanced to explain undiagnosed chronic pelvic pain, severe dysmenorrhoea, painful uterine contractions, and deep dyspareunia in women, which has been shown to be anatomically negative. Search strategy: In these "endometriosis-like" syndrome situations, there are many pathophysiological arguments supporting the existence of a visceral uterine sensitization syndrome. Data collection and analysis: These arguments are further developed and use central sensitization mechanisms, just like those for irritable bowel syndrome (IBS) or painful bladder syndrome (PBS). The name "painful uterine syndrome" (PUS) has been suggested, and a basis for a PUS diagnostic score has been established. Central sensitization and visceral sensitization mechanisms have been developed. Muscular hypertonia is common in condition of central sensitization and increased uterine contractility has been confirmed using cine magnetic resonance imaging in PUS situations. These findings led to the application of botulinum toxin (BTX) injections under hysteroscopy of the uterine myometrium in PUS. Main results: A significant amount of physio-pathological evidence supports the existence of visceral uterine sensitization syndrome. We call it Painful Uterine Syndrome (PUS). A pilot study reported the first use of BTX uterine injections under hysteroscopy in PUS and this pilot study, previously presented, has been analysed. It focuses on a simple and reproducible treatment procedure which shows improvement in dysmenorrhoea and dyspareunia as well as improved quality of life scores. Conclusions: PUS should be consider as one main mechanim for Chronic Pelvic Pain. Uterine BTX injection could be a very interesting therapeutic option. Only long-term randomised studies will be able to confirm that BTX injections are useful as a treatment for this condition. The randomised long-term study, Uteroxine, started in 2020 and will shortly release its results.

Improvement of Severe Gummy Smile by Botulinum Toxin Application and Gingivoplasty

Currently, the search for aesthetic excellence has become the main objective in the dental treatment. The gummy smile is one of the complaints from the patients, since this situation may influence their self-esteem and social relationship. The development of new techniques, such as the application of botulinum toxin, may be a therapeutic option more conservative, in the treatment of gummy smile. The purpose of this article is to present a case of a patient with dentogingival discrepancy and severe gummy smile, who was treated with gingivoplasty and application of botulinum toxin in order to optimise the harmony of the smile.

Six years of experience using an advanced algorithm for botulinum toxin application.

Botulinum toxin (BTX) products continue to be widely used for facial rejuvenation. Variables to consider prior to BTX treatment include the anatomical area to be treated, gender, muscle mass, ethnicity, skin thickness, and the effects of aging. To describe a treatment algorithm which has been developed for facial rejuvenation to help physicians to easily and systematically customize BTX treatment, and to describe its use in a large number of patients. Prior to treatment, digital images of patients were obtained while relaxed and while forming different facial expressions. This information was used to plan the depth, dose, and location of BTX injections (onabotulinumtoxinA; Botox® ; Allergan, Inc). Dilution was 100U of BTX to 1mL 0.9% preserved saline. Injections were performed with 30U insulin syringes and 30 gauge needles. The treatment algorithm described here has been used by the author for facial rejuvenation for more than 5years. It was originally based on published guidelines; however, by carefully noting treatment outcomes, the number and location of injection points and the dose of BTX used have been modified to create the current treatment system. Published guidelines for the use of BTX are an excellent starting point for clinicians with little experience; however, each practitioner is likely to develop their own algorithm for achieving good facial rejuvenation outcomes.

Application of botulinum toxin in Horner's muscle for the treatment of dry eye

Abstract Objective/methods The aim of this study is to describe the use of botulinum toxin to increase tear retention in patients with dry eye through the description of 2 cases. Results Patients with moderate to severe dry eye who received an injection of type A botulinum toxin in the Horner's muscle. The results at one month and 3 months are reported. An assessment was made of the subjective perception of the patient as regards any improvement, as well as taking into account, the Ocular Surface Disease Index, superficial punctate keratitis, tear break-up time and tear meniscus height. A significant improvement was observed in the subjective perception of the patient, the Ocular Surface Disease Index, superficial punctate keratitis, tear break-up time and tear meniscus height at one month after treatment, and the good results still being maintained at the third month. There were no adverse events. Discussion The use of type A botulinum toxin can be considered as an alternative to increase tear retention in moderate to severe dry eye, with a good response during the first month, with an acceptable response still being maintained at the third month. Given the temporary effect of the drug, re-treatments could be required.

Type A Botulinum Toxin as Complement to Gingivoplasty in the Treatment of Gummy Smile. Case Report

Background: The pursuit of esthetic excellence has become a major goal in the dental treatment. Gummy smile is one of the complaints of the patients, since such a situation can influence self-esteem and social relationships. The beauty of the smile is not only constituted by the shape, position and size of the teeth, but also based on the characteristics of the gingival tissue and conformation of the lips, which should be as harmonious as teeth. The development of new more conservative techniques may provide a better therapeutic option than surgical procedures, such as the application of botulinum toxin, in the treatment of gummy smile. Purpose: to present the case of a patient who presented dentogingival discrepancy caused by gingival overgrowth and gummy smile, treated by gingivoplasty and complemented by application of botulinum toxin. Description of the case: The gingivoplasty was performed followed by the application of botulinum toxin type A. Results: The gingivoplasty resulted of the improvement of gingival arches and the application of botulinum toxin promoted the dehiscence of upper lip, reducing the gingival exposure. Conclusions: The application of botulinum toxin, associated with gingivoplasty, is an important tool at the management of gummy smile, optimizing smile harmony and achieving improved self-esteem and quality of life.

Effect of Cosmetic Procedures in the Periorbital Area on the Organ of Vision: Overview

Practitioners in ophthalmology in recent years often face the effects of cosmetic procedures on the paraorbital area, as well as directly on the eyelids. Such influences include botox injections in paraorbital area, blepharoplasty, eyelash extensions, injections of various fillers, etc. These manipulations are widely used and often lead to various complications of the vision organ. Eyelash extensions are a popular procedure, especially among urban, young women, but there are potential health risks from the procedure. Tattooing of eyelids leads is the cause of dysfunction of meibomian glands, which can lead to the dry eye syndrome, manifested as complaints about a feeling of chronic discomfort in the eyes. Due to the growing popularity of the age tattoo, it is necessary to pay close attention to the training of specialists who conduct this procedure. The procedure for permanent eyelid make-up should be performed after careful consideration of possible complications, and by special trained professionals. In recent years, various cosmetic procedures for rejuvenating the face plays great role, for example, injections of botulinum toxin, as well as various dermal fillers — the application of which is aimed at eliminating the aging signs. The qualification of the specialist his awareness of the occurrence of possible complications, as well as the awareness of patients who undergo this procedure is an important aspect in the application of botulinum toxin, both for therapeutic and cosmetic purposes. Of great interest are the complications associated with ischemia in the form of soft tissue necrosis and vascular occlusion caused by fillers introduction. It is reported that the frequency of vascular occlusion with dermal fillers is up to 3 per 1000 injections. The only proven elimination of soft tissue ischemia in case of a hyaluronic acid filler use is early high-dose hyaluronidase injections, since this drug helps deactivate the action of hyaluronic acid. Modern ophthalmologic practice is inextricably linked with the latest methods of modern cosmetology medicine, the results of it can effect on the functions of the whole organism as the organ of vision in particular. This fact and the specificity of possible complications arising from cosmetic procedures in the periorbital zone should be taken into account during the anamnesis collecting anamnesis, and examining patients, including preoperative preparation, and in choosing the treatment method.

Literature review of the adverse events associated with botulinum toxin injection for the masseter muscle hypertrophy.

Masseteric hypertrophy is a benign condition characterized by the enlargement of the masseter muscles. A square-shaped jawline due to masseter muscle prominence or hypertrophy is one of the general characteristics of the Asian face, making it a frequent target for esthetic treatment requests. While the application of botulinum toxin on the masseter muscle is an off-label use, it is very popular in Asian countries. However, comprehensive reviews of the complications associated with this procedure remain limited in scope. The goal of this study is to help physicians achieve a comprehensive understanding of the complications associated with neuromodulator injection over the masseter muscle via a thorough literature review. A literature search was performed on the PubMed/MEDLINE, Google Scholar, and Science Direct databases using the search terms botulinum toxin, masseter hypertrophy, masseteric hypertrophy, and/or masseter hyperplasia. Literature from January 1994 to February 2018 was deemed to be allegeable for inclusion and analysis. All available prospective and retrospective studies, case series, case reports, and expert reviews were included, with an emphasis on types of complications, incidence rate, onset time, recovery time, and product used. Articles that do not mention side effects, complications, or adverse events were excluded. Thirty-six articles were found, covering type, incidence rate, and clinical course of the complications. These studies were summarized into tabular form for easy reference and comparison. Botulinum toxin masseter injections are commonly performed procedures with good results and safety profiles. The majority of complications appeared within 2-4weeks of injection and disappeared within 12weeks. Despite the temporary nature of these complications, they often decrease patient satisfaction and confidence, so physicians should familiarize themselves with the regional anatomy and injection safety zones.

Muscle Insertion and Strength of the Muscle Contraction as Guidelines to Enhance Duration of the Botulinum Toxin Effect in the Upper Face.

In this series of patients the cutaneous insertion and strength of voluntary contraction of the muscles in the upper third of the face were used as guidelines for botulinum toxin application named "BTA Codes." Anatomical dissection of fresh cadavers identified the shape and cutaneous insertions of the muscles in the upper third of the face. Patient voluntary contraction of the muscles in the upper third of the face created different patterns of skin lines classified by the 4-grade Facial Wrinkle Scale. For botulinum toxin application injections points followed the muscle cutaneous insertion and dose the 4-grade Facial Wrinkle Scale. Injection points ranged from 3 to 23 points per patient, average of 9.4 points. Dose per point varied from 2.5 to 7.5U, ranging from 12.5 to 72.5U per patient, average of 33.82U. Skin lines resulting from the voluntary contraction of the muscle prior to toxin application were stated as baseline 1. The absence of skin lines and muscle activity on day fifteen after toxin application defined baseline 2. Skin lines resulting from the recovered voluntary contraction of the muscle after toxin application like those of baseline 1 established baseline 3. The botulinum toxin effect was the time elapsed between baselines 2 and 3, ranging from 171 to 204days, average of 183.72days, greater than the 3 or 4 months reported in the literature. "BTA Codes" is a set of rules to apply botulinum toxin supported by muscle anatomy and degree of voluntary contraction to enhance the duration of its effect. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Treatment of spasticity in spinal cord injury with botulinum toxin

Context: Spasticity is one of the most frequent complications in spinal cord injury (SCI), and is routinely managed with oral pharmacologic therapy. Botulinum toxin (BT) is not accepted as a treatment for spasticity in SCI in Spain but may be used in certain cases of focal distribution.Objective: To report the results with BT for treatment of spasticity in SCI.Design and Setting: Descriptive retrospective study conducted at a specialist SCI rehabilitation center in Spain, covering patients first treated from 2012 through 2014, and successfully followed up for a minimum of 1 year. Data were collected on the following variables: demographic and SCI characteristics (level and grade); nature of spasticity, e.g. tone, distribution, spasms, articular involvement and pain; function; application of BT; tolerance and adverse reactions.Results: The study covered 90 patients, predominantly male with incomplete injuries. Improvement in tone as measured by the modified Ashworth scale was a mean of 1.17 points. Goniometric improvement was achieved in 65.6% and improvement in pain in 38.9% of cases. There were no adverse side-effects.Patients with focal spasticity showed a significantly greater improvement in tone (P < 0.0001). The earlier the BT injection, the greater the improvement in goniometric performance (P < 0.006) and pain (P < 0.033), with the best results being obtained within the first 6 months of clinical course. ASIA D injuries showed a greater improvement in tone (P < 0.0001).Conclusions: BT can be both an effective treatment for focal spasticity in SCI and a good coadjuvant for oral treatments in generalized spasticity.

Bruxism- is botulinum toxin an effective treatment?

Data sourcesPubMed, Scopus, Web of Science, Embase, Cochrane, Scielo and Lilacs databases were searched from 1980 to March 2016. Literature reviews were explored in order to retrieve any other relevant papers.Study selectionRandomised controlled studies (RCTs), prospective and before and after studies that applied botulinum toxin (BoNT-A) to the masseter and/or temporalis muscles assessing objective and subjective parameters of bruxism published in English were included.Data extraction and synthesisThree reviewers independently assessed for eligibility. Disagreement was solved by discussion and when reaching consensus between at least two. Standard data items were extracted. Quality assessment was assessed using the Cochrane Collaboration's risk of bias tool and the Critical Appraisal Skills Program (CASP) tool. Before-After Study Checklist was used for the nonrandomised studies. Results were presented as a narrative review.ResultsFive studies were included in the review, of those three were RCTs and two before and after. A total of 188 subjects were included. Regimen was unique in each study and the follow-up ranged from two to 24 weeks. The risk of bias of the RCTs was assessed as low to unclear, while the before and after studies were assessed as of moderate risk of bias.ConclusionsThe authors concluded that botulinum toxin represents a possible option for the management of sleep bruxism (SB), minimising symptoms and reducing the intensity of contractions rather than for SB itself.

Botulinum toxin application in the treatment of anterior disc displacement in TMJ – review of literature

Introduction. The displacement of the articular disc with reduction in the temporomandibular joints (TMJ) is a disorder with complex and multifactorial aetiology requiring adequate treatment. According to the authors of many studies, increased tension and a direct attachment of muscle fibers of the upper part of the lateral pterygoid muscle to the articular disc increase the likelihood of the disorder. The treatment of choice is conservative, including increasingly frequent intramuscular injections of botulinum toxin. By blocking the secretion of acetylcholine in the neuromuscular plate Botox causes a reverse tension reduction or complete paralysis of the upper part of the lateral pterygoid muscle. In consequence, it may lead to the return of the disk to the right place in the TMJ with the simultaneous decrease of clinical symptoms in patients. Aim. To perform a systematic review of treatments for the anterior articular disc displacement using botulinum toxin. Material and Methods: For the preparation work, the available databases: PubMed, Google Scholar, OVID and Embase were used. Original papers published in the last twenty years, in Polish and English, using the key words: botulinum toxin, the displacement of the articular disc, were searched. Results and conclusions. The current state of knowledge and results of studies in the literature suggest that botulinum toxin is suitable for the treatment of anterior articular disc displacement.

Occipitalis muscle: using for repetitive facial nerve stimulation in myasthenia gravis

Repetitive nerve stimulation (RNS) is a highly sensitive electrophysiological test used for diagnosing myasthenia gravis (MG). Here, we evaluated electrodiagnostic value of RNS using facial nerve and occipitalis muscle. Patients with generalized MG were included. Clinical findings were assessed. RNS test was performed on occipitalis, nasalis, trapezius, abductor policis brevis (APB) and abductor digiti minimi (ADM) muscles. Twenty-five (78%) patients had relevant decrement during RNS test of at least one muscle. Nasalis muscle had the highest diagnostic potential (68.8%), followed by trapezius (53.3%), occipitalis (50%), APB (30%) and ADM (16.7%) muscles. There was not a significant relationship between clinical symptoms and facial RNS recorded on occipitalis muscle. In conclusion, we suggest that facial RNS recording over occipitalis muscle can be added in electrodiagnosis of MG because of cranial nerve innervation and proximal location. Facial RNS recording over occipitalis muscle provides a good choice under the conditions such as atrophy, cosmetic surgery, or botulinum toxin application in which nasalis muscle is unavailable for use.

Clinical Application of Botulinum Toxin A for Calf Hypertrophy Followed by 3-Dimensional Computed Tomography.

Clinical Application of Botulinum Toxin A for Calf Hypertrophy Followed by 3-Dimensional Computed Tomography.

Correction of Malocclusion by Botulinum Neurotoxin Injection into Masticatory Muscles.

Botulinum toxin (BTX) is a neurotoxin, and its injection in masticatory muscles induces muscle weakness and paralysis. This paralytic effect of BTX induces growth retardation of the maxillofacial bones, changes in dental eruption and occlusion state, and facial asymmetry. Using masticatory muscle paralysis and its effect via BTX, BTX can be used for the correction of malocclusion after orthognathic surgery and mandible fracture. The paralysis of specific masticatory muscles by BTX injection reduces the tensional force to the mandible and prevents relapse and changes in dental occlusion. BTX injection in the anterior belly of digastric and mylohyoid muscle prevents the open-bite and deep bite of dental occlusion and contributes to mandible stability after orthognathic surgery. The effect of BTX injection in masticatory muscles for maxillofacial bone growth and dental occlusion is reviewed in this article. The clinical application of BTX is also discussed for the correction of dental malocclusion and suppression of post-operative relapse after mandibular surgery.

Electromyography in a Patient with Idiopathic Bruxism Treated with Occlusal Splint and Application of Botulinum Toxin- Case Report

Electromyography in a Patient with Idiopathic Bruxism Treated with Occlusal Splint and Application of Botulinum Toxin- Case Report

Anesthetic blocks in the elderly in the treatment of headache

Introduction: Headache in elderly patients is a frequent complaint, with atypical clinical features in this group. In addition, treatment options are limited, considering the presence of other comorbidities and daily medications in use. The possibility of anesthetic blocks would be an interesting option for this group of patients. Objectives: This study aimed to describe and analyze, in a single center, elderly patients who were treated with anesthetic blocks for headache. The main types of headache, indications of peripheral blocks, blocked points and, adverse effects response to treatment were also assessed. Methods: The study was conducted from the review of medical records in a Neurological Clinic. Patients with headache diagnosis, with 50 years old and older, who received anesthetic blocks were included. Diagnosis of headache, characteristics, intensity and frequency, associated comorbidities, instituted treatments, including anesthetic blocks and botulinum toxin application, as well as therapeutic response and presence of adverse effects were described. Results: Medical records from 2013 to 2017 were reviewed (n= 4,106). Of these, 785 patients were treated for chronic pain with anesthetic blocks and 82 patients were elderly with headache, treated with anesthetic blocks. The mean age of the patients was 57.7 years (SD 7.89) and 65 (79.3%) were women. The main diagnosis of headache was migraine (41, 50%), cervicogenic headache (33, 40.2%), temporomandibular dysfunction (11, 13.4%), trigeminal-autonomic headache (4, 4.8%) and tension-type headache (2, 2.4%). The frequency of pain was 24.3 days/month (SD 9.2) and mean pain intensity was 9.3 (0-10). The abusive use of analgesic medications was described in 17 (20.7%) patients. The main anesthetic blocks were major and minor occipital nerves (62, 75.6%) and muscular trigger points (19, 23.2%). Botulinum toxin application was performed in 6 patients (7.3%). The average number of blocks was 2.74 (SD 2.38) per patient. There was a total improvement of the symptoms in 52 (63.4%) and partial improvement in 22 (26.83%). The mean frequency of pain after treatment was 4.3 days/month (SD 6.09). There were no adverse events related to the procedures. Conclusion: The use of anesthetic blocks in the elderly in the treatment of headache was considered safe and effective as a therapeutic option.

Persistent idiopathic facial pain, a diagnosis and treatment of challenge. Case report

ABSTRACT BACKGROUND AND OBJECTIVES: Persistent idiopathic facial pain is a chronic disease with neuropathic origin, whose etiology is usually unknown; it is a medical condition that does not respond satisfactorily to drug therapy. It is also a disease with a major impact on patient quality of life and difficult to diagnose. This study aimed to report the diagnosis of a complex, persistent idiopathic facial pain, the pharmacological intervention taken and the adoption of integrative and complementary practices for the management of persistent idiopathic facial, as well as the clinical course and the impact of these actions on the patient’s quality of life. CASE REPORT: A female patient, 52, diagnosed 06 years ago as a carrier of persistente idiopathic facial pain associated with bruxism and temporomandibular disorders. The patient presented with a complaint of orofacial pain which did not meet the diagnostic criteria for temporomandibular disorders. The patient also presented myofascial and trigeminal neuralgia pain in the left buccal region which emerged after performing a root canal procedure. The therapeutic plan adopted was based on pharmacological therapy with pregabalin (450mg) in combination with venlafaxine hydrochloride (150mg), continuously. As additional measures, weekly acupuncture sessions, therapy sessions with psychologists, including hypnosis and meditation, as well as peripheral nerve and a venous block during crises and botulinum toxin application were applied. CONCLUSION: The therapeutic plan adopted led to a considerable improvement in the patient’s quality of life, evidenced by the reduction in pain intensity and a decrease in the frequency of painful crises. The need for interdisciplinary monitoring, as it is a multifactorial disease, as well as for the ongoing training of various categories of health professionals involved in the treatment of persistent idiopathic facial, given that it is a complication which is rare and difficult to diagnose, is observed.

The effect of physical therapy in the treatment of patients with cervical dystonia with or without concomitant use of botulinum toxin

Background/Aim. Botulinum toxin is a basic, recommended method of treatment in controlling cervical dystonia (CD). Physical therapy has limited effect due to the nature of the disease that is a result of a disorder in structures and relationships of the basal ganglia. The aim of this study was to analyze the effect of physical therapy applied as monotherapy, or with parallel application of botulinum toxin in patients with CD. Methods. Randomized controlled clinical pilot study included 14 patients diagnosed with idiopathic CD. All patients were initially assessed by using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) and Torticollis Rating Scale (Tsui scale). In the control group, composed of 5 patients, the treatment included only physical therapy. The experimental group (9 patients) was first given botulinum toxin, and physical therapy was applied after five days. Physical therapy was conducted five times a week in the period of two weeks at the Clinic. Patients of both groups were instructed to continue with the physical therapy at home. The effects of treatment were analyzed after 1, 3 and 6 months using TWSTRS and Tsui scale. Results. At the beginning of the investigation, the differences in TWSTRS and Tsui scale between the groups were not significant. In the control group, after 1 month, significant improvement was achieved in all three parts of the TWSTRS. After 3 and 6 months, the effects of physical therapy were reduced to control levels. In the experimental group, highly significant increase of all parameters of TWSTRS was noted after 1, 3 and 6 months. In the control group, highly significant decrease of changes in Tsui scale was noticed only after one month while in the experimental group, it was maintained after 3 and 6 months. Conclusion. Application of physical therapy provides a significant improvement in disease severity, but the effect is better and of longer duration when combined with the botulinum toxin.

Standardization of sternocleidomastoid for botulinum toxin applications

Objectives: Botulinum toxin is frequently applied to the sternocleidomastoid muscle (SCM) for torticollis treatment. During this application, bulb of the jugular vein located under SCM makes the interventions unsafe. Also, injecting the botulinum toxin into the infrahyoid muscles which lie under SCM may cause hoarseness and swallowing disorders. The aim of this study was to describe the most reliable and appropriate botulinum toxin injection sites to the SCM to avoid injury to neighboring neurovascular structures and adjacent muscles. Methods: In ten male cadavers, SCM was evaluated in three equal segments (upper, middle and lower). Muscle width and thickness at the center of each segment were measured. In one male cadaver, colored latex was injected according to the results of the measurements. Results: The respective mean width of upper, medial and lower segments were 33.15 (23–41) mm, 36.45 (28–45) mm and, 39.35 (15–50) mm, respectively. The mean thickness of upper, medial and lower segments were 5.29 (3.87–7.68) mm, 5.89 (3.56–8.32) mm and 3.60 (0.69–7.75) mm, respectively. There was no significant difference between the right and left sides. The thickest part of the muscle was the middle part, and the lower part was the thinnest. When the colored latex injected cadaver was dissected, the center of the muscle was observed as colored, while the neighboring structures were avoided. The thickest and safest part of SCM for the botulinum toxin injections was the middle part. Conclusion: Knowing the thickness of SCM will make the botulinum toxin applications to this muscle safer and easier.