1. The Otolaryngologic Uses of Botox
Malcolm Baxter FRACS

2. Botox Clostridium botulinum toxin 7 Serotypes -ABCDEFG
Type A used Botox (Allergan)
Dysport
Neurotoxin-paralyses neuromuscular transmission by binding ACh
Mouse units

3. Botox cont. Now widely used for muscle spasms and spasticity:
Laryngeal Conditions
Blepharospasm
Hemifacial Spasm
Spasmodic Torticollis
Palatal Myoclonus
Frey’s Syndrome
Failed TOP Speech Post Laryngectomy
Drooling (intraparotid )
Achalasia
Cerebral Palsy Patient Limbs
Cosmetic

4. Laryngologic Uses of Botox
Spasmodic Dysphonia-Adductor &Abductor Types
Laryngeal Tremor
Muscle Tension Dysphonia –unresponsive to SP and local physio techniques
Refractory Laryngeal Granulomata
Cricopharyngeal Spasm –intact larynx and post-laryngectomy
CA Joint Dislocation/Relocation
Vocal Cord Dysfunction (PVFM)

5. Botox cont. Side Effects Effects of overweakening-depends on location
Abs produced-Anaphylaxis theoretically possible but not in practice
? No Deaths

6. Laryngeal Botox for SD in Melbourne
RVEEH Baxter,Hughes & Oates
Continues as private clinics
MMC Monash Neurolaryngology Clinic Baxter & Raghav

7. SPASMODIC DYSPHONIA
Action induced laryngeal motion disorder resulting in a dysphonia characterised by spasms in phonation

8. Spasmodic Dysphonia
Classified as Focal Dystonia (class of movement disorder)
These are task specific movement disorders involving a few muscles (laryngeal in this case)
Other examples are: Spasmodic Torticollis, Writers Cramp, Hemifacial Spasm, Blepharospasm,
Meige’s syndrome-orofacial dystonia

9. Aetiology of SD Unknown Genetic Probable in some cases ??Stress
??Infective
PM Studies-unhelpful with varying findings, eg basal ganglia

10. ABDuctor SD <10% -breathy interruptions to fluency (PCA)
SD-2 Types
ADDuctor SD >90% -strained and strangled voice due to spasmodic interruptions to fluency (Thyroarytenoid-vocalis)
ABDuctor SD <10% -breathy interruptions to fluency (PCA)

11. Spasmodic Dysphonia F>M about 2:1 Onset any age (Satalhoff ave 62)
Many patients relate to some traumatic or stressful event

15. Diagnosis of SD Typical Phonation
Demonstrated Spasms on Video during connected speech
Lack of response to other treatment (espec. ST)
EMG ??
Must exclude other neurological disease

16. Differential Diagnosis
Laryngeal Tremor
Severe Hyperfunctional or Muscle Tension Dysphonia
Psychogenic Dysphonia

17. Treatment of SD
Psychiatric
Drugs
Speech Therapy
Surgery
BOTOX

18. Botox in SD Transoral Concious pt / GA Transcutaneous with EMG Control
Monopolar Teflon coated EMG neeedle connected to EMG machine
GA -occasionally

19. Botox in SD cont
Adductor - via CT membrane intoThyroarytenoid/ vocalis
-2.5 Mu per vocal cord starting dose (titrate response)
Abductor - Into PCA
-More difficult
-Lateral or translaryngeal approach
Mu starting (titrated)
-Unilateral Injection
-May assess weakness by scope
Rating??

24. Method Prospective study
Botox injections for adductor and abductor spasmodic dysphonia between 1992 and 2003
Assessment and diagnosis by otolaryngologist, neurologist and speech pathologist in voice clinic

25. Method
Pre and post-injection self evaluation of voice function on equal appearing interval scale 1 to 10
1= severe disabling voice problem, 10= no perceived voice problem
Complications (mild/ moderate/ severe)
Breathiness
Dysphagia
Pain
bruising

26. Method
Pre and post-injection self evaluation of voice function on equal appearing interval scale 1 to 10
1= severe disabling voice problem, 10= no perceived voice problem
Complications (mild/ moderate/ severe)
Breathiness
Dysphagia
Pain
bruising

27. Injection Method
Transcutaneous submucosal injection through cricothyroid membrane with EMG control
few injections required transoral and translaryngeal technique
Adductor patients- injection into thyroarytenoid muscle
Abductor patients- injection into posterior cricoarytenoid muscle

28. Results
Consecutive series of 81 patients, complete information available in 79
511 injections of Botox
59 female, 20 male

29. Adductor Group 72 patients, 481 injections
Bilateral injections in 96% (464 injections), unilateral 4% (17 injections)
Median dose 2.5 mouse units (range 0.5-5)

30. Adductor Group 95% of injections (459) improvement in symptoms
Median improvement 4 points (range 1-8)
Mean duration of response 15.3 weeks (range )

31. Adductor group 72% complications (346 injections)
Breathiness (317), 68% mild, median duration 2 wks
Dysphagia- (110) 86% mild, median duration 2 wks
Pain (12)
Bruising (4)

32. Abductor group 7 patients, 30 injections
2 bilateral injection, 28 unilateral
median dose 4.5 (range 2.5 to 6.25)

33. Abductor group 60% injections (18) symptom improvement
Median improvement 3 points ( range 1-5)
Mean duration response 11.4 weeks (range 4-20)

34. Conclusions
Laryngeal botox injections results in significant, sustained voice improvements in adductor spasmodic dysphonia
Side effects are frequent but majority are mild in severity
Results in abductor spasmodic dysphonia less favourable

35. Can we extrapolate to VCD?

36. Vocal Cord Dysfunction (VCD)
Various names-Paradoxical Vocal Cord Movement (PVFM ) probably best
Adduction of VCs during inspiration
Various types
Dystonia
Asthma associated (? >10% ED ‘asthma” presentations (?? All have asthma)
Exercise induced
Psychological
LPR—Acute laryngeal spasms-? different

38. Diagnosis of VCD History Flexible Scope 360 Slice CT
Stridor Not responding to asthma meds
Exercise induced
Psych ??
Flexible Scope
360 Slice CT

39. Treatment of VCD Breathing Exercises (SP) Effective ~80%
Medication – Asthma meds,Diazepam etc
PPIs often effective for the Laryngospasm
Botox –Anecdotal evidence , Awaiting RCT