Oromandiular dystonia and spasmodic dysphonia
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Oromandiular dystonia and spasmodic dysphonia Botulinum Toxin
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Oromandiular dystonia and spasmodic dysphonia
- 1. Teaching Courses BOTULINUM TOXIN WORKSHOP TC 13 CORDILLERA – 1 Date: SUNDAY, NOVEMBER 1, 2015 From: 14:00 To: 17:30 Co-Chair: Pedro Chana, Chile Co-Chair: Daniel Truong, USA 14:00 - 15:30 APPLICATION OF BOTULINUM TOXIN IN NONDYSTONIC DISORDERS Invited Speaker: Daniel Truong, USA 15:30 - 17:00 OROMANDIULAR DYSTONIA AND SPASMODIC DYSPHONIA Invited Speaker: Pedro Chana, Chile 17:00 - 17:30 DISCUSSION
- 2. OROMANDIBULAR DYSTONIA AND SPASMODIC DYSPHONIA P E D R O C H A N A M D C E N T R O D E T R A S T O R N O S D E L M O V I M I E N T O U N I V E R S I D A D D E S A N T I A G O C H I L E World Congress of Neurology , Santiago, Chile BOTULINUM TOXIN WORKSHOP TC 13 CORDILLERA – 1 Date: SUNDAY, NOVEMBER 1, 2015 From: 14:00 To: 17:30
- 3. Faculty Disclosure No, nothing to disclose
- 4. OROMANDIULAR DYSTONIA Definition Is focal dystonia involving the masticatory, lower facial, and tongue muscles and producing spasms and jaw deviation. The differential diagnosis of tonic spasms included tetanus, trauma, hysteria, brain stem lesions, and hypothermia. Convulsions, rigors, paralysis agitans, facial pain, and chorea were recognized as causes of clonic spasms.
- 5. OROMANDIULAR DYSTONIA Epidemiology Type of focal dystonia Total no. of cases F:M ratio CD 2634 1.5 SD 1411 2.0 BL 739 2.0 UL 296 0.6 oromandibular dystonia 37 3.1 Adapted Movement Disorders Special Issue: Advances in Dystonia Volume 28, Issue 7, pages 926–943, 15 June 2013
- 6. OROMANDIULAR DYSTONIA Etiology Number case % Primary 11 44 Neurodegenerative diseases (Parkinson disease, Huntington disease, other) 9 36 Secondary neuroleptic 3 12 Functional 2 8 January 2014 to Oct. 2015 CETRAM
- 7. Muscles possibly involved Masseter Temporalis Orbicularis oris Medial pterygoid Lateral pterygoid Digastric Geniohyoid Mylohyoid
- 8. Masseter muscle Function Close the jaw by elevating the mandible The sign denotes approximate injection site. Electromyographic guidance is optional
- 9. Masseter muscle The masseter is a thick quadrilateral muscle consisting of three parts, superficial, intermediate, and deep, which arise from the zygomatic arch and insert into the angle and the lateral surface of the ramus of the mandible The sign denotes approximate injection site.
- 10. Temporalis muscle The sign denotes approximate injection site. Function Close the jaw Posterior fibers retract the mandible Move jaw to the same side Electromyographic guidance is optional
- 11. Lateral pterygoid muscle Function Open the mouth Protrude the jaw Move the jaw to the opposite side
- 12. Lateral pterygoid muscle Function Open the mouth Protrude the jaw Move the jaw to the opposite side The sign denotes approximate injection site. Electromyographic guidance is necessary
- 13. Lateral pterygoid muscle percutaneous injection
- 14. Sub mental complex muscles Digastric ◦ Open the jaw ◦ Elevate the hyoid bone Mylohyoid ◦ Open the jaw ◦ Raise the floor of the mouth Geniohyoid ◦ Open the jaw ◦ Elevate and draw hyoid bone forward
- 15. Digastric muscle
- 16. Oromandibular Dystonia Dosing Ranges Muscle Botox (BTX-A) units Masseter 40 per side (25–100) Temporalis 40 per side (20–60) Anterior digastric, geniohyoid, mylohyoid 10 (10–200) Medial pterygoid 15 (15–50) very infrequently injected Lateral pterygoid 40 (20–100) Dilution 100 U/1–2 cc Dispensed in 1 cc siringes Needle 30 G, 0.5 in to 27 G, 37 mm MDVU. MD Virtual University. We Move. Adult Dosing Guidelines. Management of Dystonia with Botulinum Toxin Type A (Botox). Edition 2.0. Revised August 2005.
- 17. Subtypes of oromandibular dystonia Jaw-closing oromandibular dystonia Jaw-opening oromandibular dystonia Jaw-deviating oromandibular dystonia Lingual oromandibular dystonia Pharyngeal oromandibular dystonia
- 18. Jaw-closing oromandibular dystonia Muscle involved OnabotulinumtoxinA (Botox) AbobotulinumtoxinA (Dysport) Temporalis 25 – 50 UI 100- 400 UI Masseter 25 – 50 UI 100 -200 UI Medial pterygoid 25 – 100 UI 100 -400 UI
- 19. Jaw-opening oromandibular dystonia Muscle involved OnabotulinumtoxinA (Botox) AbobotulinumtoxinA (Dysport) Sub mental complex 5 – 20 UI 20- 80 UI Lateral pterygoid 25 – 100 UI 100 -100 UI
- 20. Jaw-deviating oromandibular dystonia Muscle involved OnabotulinumtoxinA (Botox) AbobotulinumtoxinA (Dysport) Contralateral lateral pterygoid 25 – 100 UI 100 -400 UI Contralateral medial pterygoid 25 – 100 UI 100 -400 UI
- 21. Lingual oromandibular dystonia Tongue protrusion or deviation dystonia The main danger with injecting the genioglossus and overweakening it is pharyngeal airway obstruction especially during sleep. Muscle involved OnabotulinumtoxinA (Botox) AbobotulinumtoxinA (Dysport) Genioglossus 10 – 50 UI 40 -200 UI
- 22. Lingual oromandibular dystonia submandibular approach to inject BTX-A in the left genioglossus muscle using EMG guidance. Parkinsonism and Related Disorders 16 (2010) 438e441
- 23. Lingual oromandibular dystonia Submandibular approach Case: diagnosis Maximum genioglossus BTX-A®dose (units-each) BTX-A®response BTX-A®side effects Average duration response (wks) Total # of genioglossus injections Average # weeks between injections 1: Primary cranial 7.5 Excellent None (4) 17.25 4 9.25 2: Primary cranial 15 Excellent Severe dysphagia (1), none (2) 18.5 3 10 3: Primary cranial 10 Mild (3), moderate (8), excellent (45) Mild dysarthria (1), mild dysphagia (1), none (54) 10.9 56 12 6: Primary generalized 5 None Mild-to-moderate dysphagia (1) N/A 1 14 8: Tardive 5 Excellent None (6), facial bruise (1) 15 7 15.5 9: Tardive 25 Mild (1), moderate (2), none (4) Mild dry mouth (2), none (5) 4.3 7 9 10: Tardive 10 None None (2) N/A 2 N/A 15: Heredodegenerative 12.5 Excellent Mild dysphagia (3), moderate dysphagia (1) N/A 4 N/A 16: Multifactorial 30 Mild None (5) 1.5 5 6.25 Parkinsonism and Related Disorders 16 (2010) 438e441
- 24. Oromandibular dystonia Botulinum Toxin Treatment 32 Oromandibular Dystonia: Treatment of 96 Patients with Botulinum Toxin Type A Mitchell F. Brin, Andrew Blitzer, Susan Herman, and Celia Stewart Columbia University College of Physicians and Surgeons, New York, New York Therapy with Botulinum Toxin edited by Joseph Jankovic and Mark Hallett
- 25. Oromandibular dystonia Botulinum toxin: complications NEUROLOGY 1999;53:2102±2107
- 26. Oromandibular dystonia Adverse Effects 32 Oromandibular Dystonia: Treatment of 96 Patients with Botulinum Toxin Type A Mitchell F. Brin, Andrew Blitzer, Susan Herman, and Celia Stewart Columbia University College of Physicians and Surgeons, New York, New York Therapy with Botulinum Toxin edited by Joseph Jankovic and Mark Hallett
- 27. SPASMODIC DYSPHONIA Definition oSpasmodic dysphonia is a focal dystonia characterized by task-specific, action-induced spasm of the vocal cords. It adversely affects the patient’s ability to communicate. It can occur independently, as part of cranial dystonia (Meige’s syndrome), or in other disorders such as in tardive dyskinesia. ois a rare disorder, with an estimated incidence of 1 case per 100,000 (10). The true incidence of the disorder may be greater, because the diagnosis is often missed. Because of its Spasmodic Dysphonia heterogeneous presentation and paucity of expert laryngeal clinicians, epidemiological data, such as age of onset, race and ethnic prevalence, regional variation, and risk factors, have been difficult to assess.
- 28. SPASMODIC DYSPHONIA Subtypes oAdductor spasmodic dysphonia is characterized by a strained-strangled voice quality and intermittent voice stoppage or breaks due to overadduction of the vocal folds, resulting in a staccato-like voice. oAbductor spasmodic dysphonia is characterized by intermittent breathy breaks, associated with prolonged abduction folds during voiceless consonants in speech. oMixed type.
- 29. SPASMODIC DYSPHONIA Adductor spasmodic dysphonia o Botulinum toxin odouble-blind study o97% improvement in voice Muscles injected with botulinum toxin is thyroarytenoid muscles mostly injection
- 30. SPASMODIC DYSPHONIA Adductor spasmodic dysphonia oInjection techniques oPercutaneous (Miller et al.,1987) oTransoral (Ford et al., 1990) oTransnasal (Rhew et al., 1994) oTouch injections (Green et al., 1992).
- 31. Adductor spasmodic dysphonia Thyroarytenoid muscles Percutaneous approach Sulica L, Blitzer A. Botulinum toxin treatment of spasmodic dysphonia. Op Tech Otolaryngol Head Neck Surg 2004;15:76–80.
- 32. Abductor spasmodic dysphonia Posterior cricoarytenoid muscle Percutaneous approach Laryngeal rotation technique for botulinum toxin injection to the posterior cricoarytenoid muscle for abductor spasmodic dysphonia. Sulica L, Blitzer A. Botulinum toxin treatment of spasmodic dysphonia. Op Tech Otolaryngol Head Neck Surg 2004;15:76–80.
- 33. SPASMODIC DYSPHONIA Botulinum Toxin Treatment The Laryngoscope Volume 108, Issue 10, pages 1435–1441, October 1998
- 34. SPASMODIC DYSPHONIA Adverse Effects Breathiness Choking mild swallowing difficulty (Truong et al., 1991; Brin et al., 1998).
- 35. Gracias….
Editor's Notes
- OROMANDIULAR DYSTONIA Definition Is focal dystonia involving the masticatory, lower facial, and tongue muscles and producing spasms and jaw deviation. The differential diagnosis of tonic spasms included tetanus, trauma, hysteria, brain stem lesions, and hypothermia. Convulsions, rigors, paralysis agitans, facial pain, and chorea were recognized as causes of clonic spasms.
- The etiology of OMD is most often idiopathic or primary. Tardive dystonia represents the most common cause of secondary OMD, with haloperidol, thioridazine, and metoclopramide accounting for the majority of the drug-induced cases. The calcium channel blockers flunarizine and cinnarizine can also cause OMD, and are commonly prescribed as anti-vertiginous durgs. Other secondary causes of OMD may include a variety of brainstem lesions, cerebrovascular disease, traumatic brain injury, and neurodegenerative disorders including MSA, PSP, Huntington’s disease, and neuroacanthocytosis [38,39]. Of the neurodegenerative disorders, neuroacanthocytosis should always be in the differential in OMD cases with coexisting chorea, seizures, amyotrophy, or subcortical dementia. Edentulous dyskinesia refers to oromandibular movements triggered by ill- fitting
- Muscles possibly involved are: Masseter Temporalis Orbicularis oris Medial pterygoid Lateral pterygoid Digastric Geniohyoid Mylohyoid in next slide we will review one by one involved muscles
- Masseter muscle its function is “Close the jaw by elevating the mandible” Injection is individualized for each patient and electromyographic (EMG) guidance is optional to identify deep muscles which are not available to manual palpation since there is suggestion that comparable results could be obtained without EMG. It can be injected with 2 or 3 points
- The masseter is a thick quadrilateral muscle consisting of three parts, superficial, intermediate, and deep, which arise from the zygomatic arch and insert into the angle and the lateral surface of the ramus of the mandible.
- Temporalis muscle function is Close the jaw Posterior fibers retract the mandible Move jaw to the same side
- Lateral pterygoid muscle function is Open the mouth Protrude the jaw Move the jaw to the opposite side
- Access to the muscle is complex and can be performed from inside the oral cavity or percutaneously this way is that we use. And electromyographic guidance is necessary
- The position of patient is sitting or supine. For the location of the injection point must be open mouth , first with fingers touch the condyle and the zygomatic arch , at the midpoint is the site of injection, found deep to the mandibular notch 60 mm in deep aproximaly Warn the patient not to close the mouth while the needle is in situ. Avoid skull base structures, particularly the carotid artery. EMG is essential. we can see in the video the injection technique
- From a practical point of view is the group of muscles you can be treated as a group to inject The Sub mental complex muscles: Digastric, Mylohyoid, Geniohyoid all open jaw also have another function associated
- The Position of patient is supine with the neck extended. Paired submental muscles passing posteriorly from 1-2cm lateral to point of chin. Ask the patient to open the mouth for activate muscle. Insert the needle in the anterior third of the muscle. Avoid deep injections into the tongue complex.
- The muscles responsible for jaw-closing are the masseters, medial pterygoids, and the temporalis muscle. The masseter is a thick quadrilateral muscle with 3 parts (superficial, intermediate and deep) that arise from the zygomatic arch and insert into the angle and lateral surface of the mandibular ramus. The muscle is usually approached by inserting the injection needle 1cm anterior to the posterior border of the ramus, and is easily palpable by making the patient clench his/her teeth. The EMG muscle discharges will ensure that the needle is in the muscle, and not in the parotid gland. The medial pterygoid occupies the inner aspect of the mandibular ramus opposite to the masseter. It arises from the lateral pterygoid plate and the pyramidal process of the palatine bone, and inserts into the lower and hind part of the medial surface of the ramus and angle of the mandible. The medial pterygoid can be approached either intraorally or from the angle of the mandible externally. When approached externally, the needle is inserted about 0.5-1cm anterior to the angle of the mandible along the interior aspect of the mandible and angled perpendicularly to the mandible until it can be verified by EMG with the patient clenching the teeth. One should avoid the facial artery which lies anteriorly. The temporalis muscle is a broad radiating muscle arising from the temporal fossa. It tendon inserts into the medial surface, apex, and anterior border of the coronoid process, and the anterior border of the mandibular ramus. The temporalis closes the jaw, though its posterior fibers retract the mandible. The muscle is approaced perpendicular to its plane and as high possible in the temporal fossa. Because of tis wide radiating pattern, it is best to give 3-4 injections into the muscle. FIGURE ©
- The muscles involved in jaw opening are the lateral pterygoids, and the submentalis complex (which includes the digastrics, mylohyoid, and geniohyoid). The primary jaw-opening muscle is the lateral pterygoid, though it receives some assistance from the submental complex in the beginning of jaw-opening. The platysma may also play a minor role in jaw opening. The anterior digastrics are easy to localize and are usually the initial muscles injected. If insufficient, or if the jaw-opening is quite severe, injections are further given into the lateral pterygoids. The lateral pterygoid is short conical muscle arising from 2 heads, a superior head from the greater wing of the sphenoid, and an inferior head from the lateral surface of the lateral pterygoid plate of the sphenoid (Figure 6). The lateral pterygoid can be approached intraorally or externally. From the outside, the entry point is about 3.5 cm from the external auditory canal and 1 cm from the inferior margin of the zygomatic arch. Under EMG guidance, the needle is angled upward about 15 degrees to reach the inferior head of the lateral pterygoid. Care should be taken to avoid the pterygoid branch fo the maxillary artery which is more rostral. The digastric muscle, a part of the submental complex, arises from the mastoid notch of the temporal bone, and is attached to the digastric fossa of the mandible. It is divided into an anterior and posterior belly by the middle tendon attached to the hyoid bone. Apart from elevating the hyoid bone, the digastric pulls the chin backward and downward during jaw-opening in conjunction with the lateral pterygoid. In contrast to the posterior belly which is surrounded by numerous nerves, sympathetic truck, arteries and veins, the anterior belly is more amenable to injections. ©
- The contralateral lateral pterygoid works in conjunctiion with the ipsilateral medial pterygoid to deviate the tonge to the opposite side. The temporalis muscle pulls the jaw to the ipsilateral side. Lingual
- The main danger with injecting the genioglossus and overweakening it is pharyngeal airway obstruction especially during sleep. Thus, many clinicians prefer to do a tracheostomy first prior to lingual injections of Botulinum toxin, though tracheostomy can be averted if low doses are utilized.
- The efficacy of botulinum toxin in the treatment of spasmodic dysphonia has been proven in a double-blind study. On average, patients treated for ADSD with botulinum toxin experience a 97% improvement in voice. Side effects included breathiness, choking, and mild swallowing difficulty (Truong et al., 1991; Brin et al., 1998). The duration of benefit averages about 3–4 months depending on the dose used.
- Botulinum toxin is injected intramuscularly. Different techniques of injection have been proposed, including the percutaneous approach (Miller et al., 1987), the transoral approach (Ford et al., 1990), the transnasal approach (Rhew et al., 1994), and point touch injections (Green et al., 1992).