Botulinum toxin (BTX) treatment has previously been shown to improve voice quality, quality of life, and the physical component of vocal effort in adductor laryngeal dystonia (ADLD) patients. More recently, cognitive load has been identified as a contributor to vocal effort in ADLD patients. This study aims to identify the effects of BTX on speech-related cognitive load and the association of cognitive load with voice-related quality of life. A prospective study of ADLD patients undergoing BTX treatment was conducted. NASA Task Load Index (NASA-TLX), the Voice-Related Quality of Life (VRQOL) scale, and voice recordings were obtained on the day of, 1 week after, and 4-6 weeks after BTX injection. Auditory-perceptual evaluation of the voice samples was performed by four speech-language pathologists. Twenty-one patients completed all measures and voice recordings. Mental and physical demand subscales, derived from the NASA-TLX, decreased by 4-6 weeks (p = 0.001 and 0.019, respectively). Median VRQOL improved from 40 to 68 by 4-6 weeks post injection (p < 0.001). On multilevel multiple linear regression, mental demand and overall voice quality correlated with VRQOL (p = 0.003 and 0.001, respectively), but physical demand did not (p = 0.16). Laryngeal BTX injection reduces cognitive load associated with speaking in ADLD patients. Cognitive load may be more predictive of voice-related quality of life than the physical effort associated with speaking.

The FUTURE study (International Standard Randomised Controlled Trial Number ISRCTN63268739) has reignited debate on the utility of urodynamics, this time in women presenting with refractory overactive bladder (OAB) symptoms [1]. The study concluded that incorporating urodynamics into the diagnostic work-up does not enhance clinical outcomes. This conclusion has sparked significant criticism and controversy within the urological community, underscoring the need for critical evaluation of the pathophysiology and management of OAB in women, clinical utility of urodynamics, and the generalisability of the FUTURE study's findings [2, 3]. Over the past three decades, OAB treatment options have expanded dramatically, culminating in a strict stepwise management algorithm. However, this approach has not proved to be patient centred. Many patients find the process protracted and demotivating. Moreover, the prevailing philosophy of transitioning from least invasive to most invasive treatments may be flawed. Concerns about the long-term cognitive effects of anticholinergics raise questions about their safety compared to more invasive options, such as intradetrusor injections of botulinum toxin A or sacral neuromodulation, and the alternative pharmacotherapy, beta-3 agonists, has notably poor adherence rates. Recent updates to the AUA/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) guidelines (https://www.auanet.org/guidelines-and-quality/guidelines/idiopathic-overactive-bladder) recommend moving away from step therapy in favour of shared decision-making and personalised treatment. Implicit in this shift toward patient-centred care in OAB management is the expectation that both clinicians and patients are equipped with adequate information to choose a treatment that maximises the likelihood of success while minimising the risk of complications. Urodynamics has long been recognised as the ‘gold standard’ for objectively diagnosing lower urinary tract (LUT) dysfunction. Furthermore, women with similar OAB symptoms can exhibit vastly different underlying dysfunctions, highlighting the necessity of urodynamics for guiding treatment decisions. One study identified BOO in 19% of women with OAB [4], for whom empirical treatments like anticholinergics or botulinum toxin would have adverse effects. Detrusor overactivity (DO) is commonly presumed to be the cause of OAB symptoms, and some argue that its presence is predictable. However, standard urodynamics demonstrates DO in only about 40–60% of patients with OAB [5]. This may be because the DO is latent (in which case ambulatory urodynamics is indicated) or DO is not the primary cause of the OAB symptoms. Again, this insight is key in determining the likely benefit of treatment options. Urodynamic parameters have not only been demonstrated to predict outcomes but also to guide choice of second-line interventions by matching their primary mechanism of action to the specific LUT dysfunction demonstrated. An under-recognised but invaluable role of urodynamic testing is its ability to support shared decision-making. By increasing diagnostic certainty and revealing underlying LUT physiology, urodynamics empowers clinicians to explain clearly why specific treatments may or may not be effective and to estimate the likelihood of benefit or adverse effects. Integrating this physiological evidence with patient preferences, symptom burden, and risk tolerance enables more informed, transparent, pragmatic and personalised treatment decisions. The FUTURE study [1] has prompted essential discussions about the role of urodynamics in the management of female OAB. The value of urodynamics in characterising LUT function to allow tailored management is undeniable. As the provision of urodynamics is often limited, the motivation to prioritise which patients would benefit the most from the test is understandable. However, limited access or funding should not be reasons to downplay its overt clinical utility, which translates into five meaningful benefits for healthcare practice and the lives of our patients (Fig. 1). As the field of urology continues to evolve, it is crucial to challenge the perception that randomised controlled trials, which assess the value of a diagnostic test with the outcomes of an intervention at a population level, represent the apex of evidence, particularly in the context of heterogeneous syndromes like OAB. A nuanced understanding of each patient's unique presentation will ultimately lead to more effective and personalised treatment strategies and fully informed shared decision-making. No conflicts exist.

Intra-articular therapies for synovial joint dysfunction: a comprehensive integrative review.

Evaluation of the ultrasonography-guidance for botulinum toxin type a injection into lateral pterygoid muscle in patients with TMJ anterior disc displacement with reduction.

Enhancing Hand Vascular Assessment: The Role of Hyperspectral Imaging in Perfusion Monitoring.

Hyperhidrosis, or sweating beyond the physiological amount, can be either focal or generalized and sometimes runs in families. The prevalence of primary idiopathic hyperhidrosis is 2-5%. Secondary hyperhidrosis is associated with specific illnesses and medications. In this article, we discuss the diagnostic evaluation of hyperhidrosis and treatments for it, along with their efficacy and side effects. This narrative review is based on publications retrieved from the Medline and Cochrane databases with the search term "hyperhidrosis" and other specific terms relating to treatment. Expert recommendations and guidelines were considered as well. The diagnostic evaluation consists of a clinical history, a Minor (starch-iodine) test, gravimetry, and dynamic sudometry. There have been no more than a few high-quality published studies on specific interventions. Depending on the severity and symptom burden, aluminum chloride and anticholinergic drugs are used first, followed by botulinum toxin injections and subcutaneous curettage for axillary hyperhidrosis. These treatments reportedly bring about marked improvement in 60-70 % of patients; their side effects, depending on the particular treatment used, include local reactions such as itch, pain, and cutaneous irritation and anticholinergic effects such as dry mouth, mydriasis, urinary retention, and headache. Further therapeutic options are tap water iontophoresis; radiofrequency, focused ultrasound, and microwave treatment; systemically administered anticholinergic drugs; and thoracic or lumbar sympathectomy for palmar or plantar hyperhidrosis, respectively. A variety of methods can be used to relieve hyperhidrosis and improve these patients' quality of life. There have been no more than a few high-quality studies on their efficacy and long-term results.

A single injection of botulinum toxin injected in masticatory muscles induces alveolar bone loss associated with muscle enthesis hypertrophic bone proliferation. The tissular and cellular mechanisms involved in this phenomenon are unknown. Because new bone formation due to inflammation at enthesis is observed in articular disorder like spondyloarthritis, we hypothesize that an inflammatory process could explain the development of hypertrophic bone proliferation in the BTX model. The aims of the study were to test this hypothesis and to determine whether IL-17A was involved. Mature Sprague-Dawley male rats (n=36) were randomized into 4 groups. Three groups received BTX injections in right masseter and temporalis muscle. One BTX group was treated with an anti-IL17A antibody for 31 days (BTX31+antiIL17A). The two other groups were respectively sacrificed at 21 (BTX21) and 31 (BTX31) days post BTX injection. The remaining non-BTX group received anti-IL17A treatment for 31 days (control+anti-IL-17A). Alveolar bone loss and hypertrophic bone proliferation at enthesis were studied using microcomputed tomography. The presence of inflammatory process and the implication of IL17A was assessed by histology and immunohistochemistry on decalcified right side hemimandibles. Quantitative measurement of the hypertrophic bone (bone volume and thickness) showed no significant differences between the 3 BTX groups. Histology revealed the presence of chondrocytes in large hypertrophic area but no inflammatory infiltrated cells. Immunochemistry confirmed the absence of inflammatory process but positive reaction for Ki67 which is in favor of actively growing and proliferative chondrocytes. BTX-related muscle atrophy of masticatory muscle induced chondrocyte proliferation at enthesis without inflammation process.

Quantification of muscle morphology and stiffness in spastic hemiplegic cerebral palsy versus typically developing controls using magnetic resonance elastography.

Botulinum toxin and fillers are among the most effective antiaging treatments in aesthetic medicine and modern plastic surgery. They serve to contour, model, and rejuvenate the face. The relatively long duration of action of these treatments, as well as the long-term positive impact of these materials, allows us to characterize them as helpful tools for aesthetic facial optimization. These substances complement each other and can be combined. The focus of such attractiveness-enhancing treatment concepts is the optimization of age-related changes while taking into account the three-dimensional proportions of the aging structures as well as the dynamics of the facial muscles and also respecting individual beauty.

Achalasia is a rare, progressive oesophageal motility disorder defined by impaired lower oesophageal sphincter relaxation and absent peristalsis, leading to dysphagia, regurgitation, chest pain, weight loss, and increased long-term risks of aspiration and malignancy. Management has evolved from open surgical myotomy to minimally invasive laparoscopic and robotic techniques and, more recently, peroral endoscopic myotomy (POEM). This review summarises contemporary diagnostic strategies, including high-resolution manometry, timed barium oesophagram, endoscopy, and emerging applications of impedance planimetry, and critically appraises current endoscopic and surgical therapies. The review compares outcomes of pneumatic dilation, botulinum toxin injection, minimally invasive Heller myotomy with fundoplication, POEM, POEM with fundoplication, and newer approaches for advanced disease such as per-oral oesophageal plication and oesophagectomy, integrating data from randomised trials and long-term cohort studies. Key issues including post-treatment gastroesophageal reflux, cancer surveillance, and management of recurrent or refractory symptoms are addressed. Treatment selection is emphasised as individualised, incorporating manometric subtype, oesophageal morphology, patient comorbidity, institutional expertise, procedural durability, complication profiles, and evolving guideline recommendations across international expert consensus groups. Contemporary multimodal therapy enables durable symptom control and meaningful quality-of-life improvement for most patients, while ongoing innovation and longer-term follow-up will continue to refine treatment algorithms and standards of care.

Background: Spasticity following central nervous system lesions impairs health-related quality of life (HR-QoL) through reduced mobility, pain, sleep disturbances and loss of independence, while increasing care-giver burden. Botulinum neurotoxin type A (BoNT-A) effectively reduces muscle tone, but its real-world impact on patient HR-QoL and caregiver burden remains incompletely characterized, particularly over long-term follow-up. Objective: To evaluate the clinical impact of BoNT-A on spasticity, patient HR-QoL, caregiver burden, pain and sleep in a real-world neurological cohort. Methods: Retrospective observational study of 108 consecutive patients attending a spasticity clinic (Villa delle Ginestre, ASP Palermo, 2023–2025). Primary outcomes were patient HR-QoL (EQ-5D index and 5 dimensions: mobility, self-care, usual activities, pain/discomfort, anxiety/depression) and caregiver burden (Zarit Burden Interview, ZBI). Secondary outcomes included muscle tone (Modified Ash-worth Scale, MAS), pain (Numeric Rating Scale, NRS), insomnia (Insomnia Severity Index, ISI) and spasms (Penn Spasm Frequency/Severity Scale). Assessments were performed at baseline and long-term follow-up (median 16 months from first injection, IQR 8–24), with data prospectively collected in a clinical database. Inclusion criteria: confirmed central spasticity, ≥1 complete BoNT-A cycle. Statistical analysis: Wilcoxon signed-rank tests for pre-post changes, Spearman correlations for delta scores (Jamovi software). Results: Patients (67 M/ 41F, mean age 46.2 years, range 4–85) had mixed etiologies (stroke 28%, myelopathy 17%, cerebral palsy 14%, multiple sclerosis 9%, other 32%) and were referred at median 18 months post-event (IQR 6–48). BoNT-A (mean 4 cycles/year) yielded significant improvements (all p&lt;0.001): MAS 3.0→2.0 (Δmed -1.0), NRS 6→3 (Δmed -3), ISI 8→5 (Δmed -3), EQ-5D index 0.10→0.30 (Δmed +0.20), ZBI 25→18 (Δmed -7, ~25% reduction). EQ5D gains were driven by pain/discomfort and anxiety/depression (both Δ -1 level), while mobility remained stable. Cerebral palsy caregivers showed the largest ZBI reduction (Δmed -10, p&lt;0.001 vs overall). Spearman correlations revealed ΔEQ-5D associated with ΔNRS (ρ=0.52, p&lt;0.001), ΔISI (ρ=0.22, p=0.02) and spasms (ρ=0.22, p=0.02), but not ΔMAS (ρ=0.16, p=0.09). ΔZBI correlated with patient self-care, EQ-5D and ISI improvements (ρ=0.18-0.24, all p≤0.04). Conclusions: In real-world practice, long-term BoNT-A treatment significantly improves patient HR-QoL and reduces caregiver burden, primarily through non-motor benefits (pain, sleep). These effects are most pronounced in cerebral palsy families. Real-world data complement RCT limitations, supporting comprehensive spasticity management targeting motor and non-motor domains.

Excessive sweating in the head area may cause skin irritation, increased energy consumption, and functional impairment of hearing aids and semi-implantable hearing systems. This study investigated the frequency of sweat-related complaints and evaluated the effectiveness of intracutaneous Botulinumtoxin A (BoNT-A) injections for treating local hyperhidrosis in hearing aid and implant users. In this single-center observational study, 51 users of cochlear implants, active middle ear implants, bone conduction devices, or conventional hearing aids completed a 12-item questionnaire addressing sweat production and device-related problems. Patients with severe hyperhidrosis received intracutaneous BoNT-A treatment (n = 6). Frequent sweating in the head area was reported by 22/51 patients (43%), while 17/51 (33%) reported occasional sweating. Local skin problems occurred in 35/51 patients (69%). Increased energy consumption and impaired wearing comfort or device function were each reported by 16/51 patients (31%). All patients treated with BoNT-A reported marked symptom improvement, with no further functional impairment. The collected data reveals a significant number of patients with sweat-related problems and suggests that increased sweat production is associated with clinically relevant impairments in some of the respondents and may lead to skin irritation and technical malfunctions of the hearing aids. Intracutaneous BoNT-A injections are an effective, safe, and practical treatment option for reducing hyperhidrosis-related complaints in this area.

Ptosis, the drooping of the upper eyelid caused by levator palpebrae superioris muscle dysfunction, is a common condition that can impair vision and quality of life. It can arise independently or as a secondary condition to diseases such as myasthenia gravis. Traditional treatments for ptosis include surgical interventions, but botulinum toxin injections have gained interest due to their non-invasive nature and promising results in improving eyelid function. To evaluate the efficacy and safety of orbicularis oculi muscle toxin injections in comparison to traditional levator palpebrae superioris muscle shortening surgery for the treatment of ptosis. A cohort study was conducted with 36 patients diagnosed with levator palpebrae superioris muscle weakness. Patients were divided into two groups: an experimental group receiving botulinum toxin injections and a control group undergoing traditional surgery. Primary outcomes included changes in palpebral fissure height, visual scores, and patient satisfaction. Secondary outcomes involved adverse reactions and recovery time. The experimental group showed a significant improvement in palpebral fissure height (3.5 mm) and visual function compared to the control group (1.7 mm). Patient satisfaction was higher in the experimental group, particularly due to the non-invasive nature and shorter recovery period. The incidence of adverse reactions was lower in the experimental group, with fewer complications like scarring. Botulinum toxin injection may represent a minimally invasive alternative in carefully selected patients, particularly those with mild dysfunction or those wishing to avoid surgery. It provides significant improvements in palpebral fissure height and visual function, with fewer side effects and a faster recovery, making it a viable option for early-stage patients or those wishing to avoid surgery. Further studies should explore its long-term effectiveness.

Background Converting the transient spasticity-reducing effect of botulinum toxin A (BTX-A) into durable neuroplastic adaptations through mirror therapy (MT) represents a promising yet understudied approach. Although MT facilitates motor recovery, evidence on its long-term synergistic use with BTX-A in chronic stroke remains limited. Aim To investigate the synergistic effects of MT combined with BTX-A on upper limb spasticity and motor recovery in chronic ischemic stroke. Design Randomized, single-blind, sham-controlled clinical trial. Methods and Population Thirty patients with unilateral chronic ischemic stroke and upper limb spasticity were randomized into two groups following BTX-A injection. The experimental group received MT plus standard rehabilitation, while the control group underwent sham therapy using a transparent panel. Interventions began 2 weeks postinjection and were applied three times weekly for approximately 60 sessions over six months. Outcomes were assessed using Brunnstrom recovery stages, modified Ashworth scale (MAS), and Fugl–Meyer assessment for upper extremity (FMA-UE). Results Both groups showed significant within-group improvements in motor and spasticity scores ( p &lt; 0.001). Greater improvements were observed in the MT group for Brunnstrom hand ( p = 0.021), Brunnstrom upper extremity ( p = 0.029), MAS upper extremity ( p = 0.012), and FMA-UE ( p = 0.002). Muscle strength differences were not significant. Conclusion MT combined with BTX-A improves motor recovery and reduces spasticity more than BTX-A alone in chronic stroke, supporting cortical reorganization and neuromuscular relaxation as a cost-effective rehabilitation strategy.

Background: Spasmodic dysphonia (SD) is a focal dystonia and adductor SD is the commonest form. The standard treatment for adductor SD is EMG-guided, transcutaneous injections of botulinum toxin into the thyroarytenoid muscle. Methods: This is a prospective study on patients with adductor spasmodic dysphonia done in Bangladesh Medical University, Dhaka from January 2020 to January 2023. All of the patients were studied with a complete head and neck and neurologic examination, fiberoptic laryngostroboscopy, and a speech evaluation including the Universal spasmodic dysphonia rating scale and VHI. Proper counselling regarding the results &amp; possible complication was done. All patients received botulinum toxin injections into the thyroarytenoid muscles under fiberoptic laryngostroboscopy guidance, post injections following results were recorded. Results: The median duration of symptoms prior to diagnosis was 12 months: all were adductor in type. The average age at onset was 44 years. The time for botulinum toxin to take effect averaged 3 days (peak effect, 7 days). The patients received substantialrelief from their SD symptoms, an average functional improvement of 40%. Patients’ best voice was achieved within one week and persisted for an average of 14 weeks. Side effects from the injections included mild breathiness (68%) and mild choking onfluid (56%). After injection, decreased potential for volume was a common complaint. Almost all of the patients returned for repeat injections when the benefit diminished (After 12-16 weeks). Conclusion: Botulinum toxin therapy has become the standard care for the treatment of SD. An acceptable and flexible treatment plan to produce a balance between decreased spasms and loss of function must be developed for each patient. Bangladesh J Otorhinolaryngol 2025; 31(2): 52-61

Botulinum neurotoxin A (BoNT-A) is widely used clinically, yet its temporary effects require repeated injections that increase cost and inconvenience. Claims that repeated BoNT-A use alters efficacy lack rigorous evaluation. Unlike peripheral nerve transection, which causes irreversible denervation after 12-24 months, the long-term physiological effects of BoNT-A chemodenervation remain unclear. Using electromyography (EMG), we investigated whether prolonged short-interval BoNT-A administration induces irreversible paralysis of glabellar muscles. Twenty-one Caucasian female participants aged 35-60 years with at least moderate glabellar lines were recruited and randomized to receive BoNT-A injections either every 6 weeks (Group I), every 9 weeks (Group II), or every 12 weeks (Group III). Each session consisted of five injections totaling 20 U of onabotulinum toxin A to the glabellar muscles. The 3-year study included a 108-week treatment phase and then a 48-week follow-up, with serial corrugator electromyographic recordings undertaken over the course of the 156-week period. The EMG data was analyzed using linear regression models. Analysis demonstrated a consistent, statistically divergent reduction in corrugator EMG activity across all post-treatment time points, with maximal suppression at 108 weeks, indicating a durable neuromodulatory effect. Predictive-margins analysis showed sustained suppression from baseline through 156 weeks in all groups, with only a late increase remaining well below pretreatment levels. Relative to the 9-week group, the 12-week group exhibited higher EMG activity, while no meaningful difference was observed for the 6-week group. In this 3-year study, including 2 years of short-interval BoNT-A injections and 3 years of EMG assessment, prolonged intermittent BoNT-A administration produced a sustained chemodenervation effect that persisted beyond treatment cessation and exceeded the duration typically observed with standard clinical dosing intervals. Larger studies with longer follow-up are required to confirm these findings.

Background: Excessive gingival display, or “gummy smile,” occurs in up to 14% of adults and is associated with lip hyperactivity, dentoalveolar extrusion, or vertical maxillary excess. Botulinum toxin A (BTA) has emerged as a minimally invasive therapeutic option, but protocols vary widely and long-term data are limited. Objectives: To critically evaluate the current literature on BTA in gummy smile management, focusing on classification systems, injection techniques, efficacy, safety, and comparative outcomes against conventional surgical and orthodontic treatments. Methods: A narrative review was performed using PubMed, MEDLINE, and Scopus (2000-2023) with the terms “gummy smile,” “excessive gingival display,” and “botulinum toxin.” Clinical studies, case series, and reviews addressing BTA use were included. Data were synthesized into thematic categories. Results: BTA consistently reduced gingival exposure by 3 to 5 mm, with effects lasting 4 to 6 months. Three main injection strategies were identified: single-point (Yonsei), multi-point, and orbicularis oris (“lip flip”). Reported complications were rare and transient (mild asymmetry, lip weakness). Standardized protocols were lacking, with heterogeneity in dosing (2-5 units per site) and injection depth. Comparative studies suggested BTA is less durable than surgical approaches but offers superior patient acceptability and safety for mild to moderate cases. Conclusion: BTA provides reproducible, temporary improvement in gummy smiles with high safety and satisfaction rates. However, absence of consensus on optimal technique and limited long-term evidence highlight the need for standardized protocols and prospective multicenter studies.

This article presents four clinical observations of patients who underwent 14-day personalized rehabilitation activities. All patients complained of upper extremity weakness and pain on shoulder movement. The first patient received various physical rehabilitation treatments which allowed to improve a range of motion: shoulder flexion angle increased from 100° to 110°, abduction angle from 90° to 100°, and scores for the Fugl-Meyer assessment of the upper extremity (FMA-UE) increased from 11 to 14 and for FMA-LE from 15 to 19 points. In the second patient, who received physical rehabilitation combined with kinesio taping and muscle relaxant therapy, pain intensity in the right shoulder joint on VAS reduced from 7 to 5 points; flexion angle increased from 100° to 110°, abduction angle from 80° to 90°; and scores for FMA-UE increased from 7 to 8 and for FMA-LE from 2 to 27. In the third patient, physical rehabilitation care combined with botulinum toxin therapy resulted in a reduction of left shoulder joint pain on the VAS from 8–9 to 4 points, an increase in flexion angle from 60° to 90°, abduction angle from 30° to 45°, and an increase in the FMA-LE scores from 8 to 9 points. In the fourth patient, the combination of physical rehabilitation, botulinum toxin injections, and kinesiology taping allowed to achieve a reduction of left shoulder joint pain on the VAS from 8–9 to 4 points, an increase in flexion angle from 60° to 90°, abduction angle from 30° to 45°, and an increase in the FMA-LE scores from 8 to 9 points. All patients accomplished their treatment goals at the end of the rehabilitation course.

Challenges remain in measuring functional upper limb (UL) outcomes following Botulinum Toxin A (BTX-A) injections for muscle spasticity. Few measures exist to evaluate personally meaningful UL performance. The Upper Limb Performance Assessment (ULPA) is an observer-rated measure using patient-centred and selected tasks in real-world conditions. This multicentre, pre/post observational study examined the ULPA's ability to measure motor function of adults with UL spasticity following acquired brain injury on self-selected goals. The ULPA detected change in UL functional use for self-selected goals, with improved Task Performance Mastery and reduced Excessive and Missing task-specific movements. This corresponded with an increased number of Expected movements for the task. ULPA sub-measures correlated with goal attainment as measured by Goal Attainment Scaling. The ULPA, a skilled clinical observation measure, can detect change in functional UL performance following BTX-A injection in adults with acquired brain injury.

Botulinum toxin from foodborne hazard to aesthetic and biomedical tool: mechanisms, applications, detection strategies, and future perspectives.