Botox cidofovir mitomycin c in ent

1. BOTOX
MITOMYCIN C
CIDOFOVIR
Dr. Ankit Choudhary

2. BOTOX
 German physician Justinus kerner was the first
to conceive the therapeutic uses of botulinum
toxin.
 Produces eight immunologically distinct toxins
that are potent neuroparalytic agents: A, B, C1,
C2, D, E, F, and G.
 Botulinum toxin type A is most commonly
used, and type B is also available for clinical
application.
 BOTOX by Allegan Neuronox by Ranbaxy.
 Temporary Measure (Need to repeated 4-6
months)

4. Uses in ENT
 Spasmodic dysphonia
 Oculopalatolaryngopharyngeal myoclonus
 Stuttering
 Essential Vocal Tremor
 Cricopharyngeal dysphagia
 Sialorrhea
 Facial hyperkinesia
 Migrane
 Frey's syndrome
 Postparotidectomy fistula
 Voice rehabilitation - after Laryngectomy

5. Spasmodic Dysphonia
 Focal dystonia involving uncontrollable spasms in the
muscles for voicing
 Onset is gradual with average age of onset is between
30 and 50.
 More common in females than in males
 Some cases are hereditary (gene on chromosome 9)
 Aggrevating Factors
 Respiratory tract infections
 Laryngeal damage due to injury
 Vocal overuse
 Stressful conditions
 Talking on the phone

6. Types
Mainly
 Adductor
 Abductor
Others are-
 Mixed
 Tremor
 Respiratory
Injected by Tuberculin syringe with a 27-gauge
monopolar poly teflon coated hollow EMG recording
needle.
Improvement in voice within 24 hours followed by a
breathy, hypophonic period lasting 1 to 2 weeks with
occasionally causing hyperventilation and dizziness
when trying to speak.

7. Adductor spasmodic dysphonia
Laryngeal injections are given percutaneously through the
cricothyroid membrane into the thyroarytenoid-vocalis muscle
complex

8. Adductor spasmodic dysphonia
Botox Inj. are administered in the posterior cricoarytenoid
(PCA) rotating the larynx behind the posterior edge of the
thyroid lamina

9. Other Uses
 Oculopalatolaryngopharyngeal myoclonus
 Uncommon disorder consisting of rhythmic
contractions of the soft palate, pharynx, and
larynx at a rate of one or two contractions per
sec.
 Caused by a lesion in the central tegmental tract.
 The palate and vocal folds may be treated with
injections of botulinum
 Stuttering
 Small doses of botulinum toxin (1 unit or less,
given bilaterally)
 Causes chemodenervation of thyroarytenoid
muscles

10.  Essential vocal tremor
 Given into most tremulous muscles
 Most tremulous muscles are sternohyoid and
sternothyroid
 5 units are injected on each side.
 If the vocal folds are tremulous, they are injected at a
second sitting
 PROSTHETIC VOICE
 Hypertonicity of the PE segment is the most important
reason for failure to acquire fluent prosthetic speech
 After proper identification of the hypertonic PE segment
with videofluoroscopy, marking the segment on the skin,
100 MU of Botox is injected in the constrictor
pharyngeus muscle area
 Effect is long lasting
 Migrane
 Gustatory Sweating
 Sialorhea

11. Adverse effects
 Mild pain, local Oedema, erythema at the injection site
 Transient numbness
 Headache, malaise, mild nausea, Influenza-like illness
 Temporary unwanted weakness, neck weaknes & paralysis
of nearby musculature
 Fatigue
 Dysphagia
 Brachial plexopathy-A condition affecting the nerves either
side of the neck and chest
 Dry mouths
 Hypersensitivity (Hives, rashes, wheezing)

12. MITOMYCIN C
 Methylazirinopyrroloindoledione
 Antineoplastic antibiotic isolated from the bacterium
Streptomyces caespitosus
 Bioreduced mitomycin C generates oxygen radicals
Alkylates DNA Produces interstrand DNA cross-links
Inhibits DNA synthesis
 Preferentially toxic to hypoxic cells
 Also inhibits RNA and protein synthesis at high
concentrations
 Mitomycin powder is stable for at least 4 years at room
temperature
 Used in treatment regime, Palliative regime of various
CA and also as Intravesical injection in Bladder CA

13. IN ENT
 Antiproliferative agent- Inhibit fibroblastic
proliferation and decrease Scar formation
 Because of these properties used as topical
solution in various ENT surgeries viz.,
 FESS
 Endoscopic DCR
 Subglottic Stenosis
 Ventilation tube in OME
 Choanal atresia
 Oesophageal stenosis
 Hypopharyngeal stenosis
 Tracheal stenosis

14. CIDOFOVIR
 Cytosine nucleoside analogue
 Incorporated in growing viral and mammalian
DNA chains
 Inhibits viral DNA polymerization
 Antiviral effect lasts for days-weeks
 FDA approved only for CMV retinitis in AIDS
pts
 Use for RRP is “off label”
 Nephrotoxic and Neutropenic
 Vistide

15. Recurrent Respiratory
Papillomatosis
 Most common benign neoplasm of the larynx among
children
 Exophytic airway lesions & may involve entire aerodigestive
tract
 Etiology- HPV (Type 6 and 11 most common)
 HPV infection can remain clinically and histologically
normal. Reactivation can occur at any time
 Transmission linked to mothers with genital HPV infection –
Pts most likely to be first born, vaginally delivered to
primigravid mothers
 Hallmark triad
 Progressive hoarseness
 Stridor

16.  Surgery is treatment of choice for RRP
(By CO2 laser, Microdebrider, Nd yag laser, MLS, etc)
 Cidofovir is most commonly used Adjuvant therapy for RRP
(As per ASPO and BSPO)
 Cidofovir for RRP is given as intralesional injections to
avoid nephrotoxicity.
 Pransky et al. reported positive results with cidofovir in
children with severe RRP and have the longest follow-up
period of any series to date (51.6 months).They used a
treatment protocol of four initial injections (in conjunction
with surgical debulking) at a concentration of 5 mg/ml in 2-
4 week intervals, followed by subsequent injections as
dictated by recurrent disease. Prior to initiation of cidofovir
injections, patients required operations every 2 to 6 weeks.
After completing treatment with cidofovir, 5 of 11 patients
were free of disease and 5 patients had mild disease. One
patient had recalcitrant disease and continued to require

17.  Akst et al. reported a similar decrease in disease
burden following monthly injections and debulking,
although the response was not as dramatic, with 5
of 11 patients requiring an additional four
injections at a stepped-up dose of 10 mg/ml with
mixed results
 Optimal concentration still remains unclear
however most author recommends 5mg/ml(FDA
approved IV dose for CMV retinitis in HIV) as
standard dose with 7.5-10 mg/ml reserved for
refractory disease
 Half life of Cidofovir is 17-65 hours. Intralesional
injections beyond 4 wks have unfavourable
therapeutic response