Botulinum toxin type A (Botox) and botulinum toxin type B are commonly used neuroparalytic agents to treat various ENT conditions like spasmodic dysphonia, oculopalatolaryngopharyngeal myoclonus, stuttering, and vocal tremors. Botox injections are administered to specific muscles to temporarily paralyze them. Potential adverse effects include pain, weakness, and dry mouth. Mitomycin C is an antiproliferative antibiotic used as a topical solution in ENT surgeries to decrease scar formation. Cidofovir is an antiviral medication approved to treat CMV retinitis but also used off-label for recurrent respiratory papillomat

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