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Botulinum A toxin treatment of hemifacial spasm and blepharospasm
Abstract
We studied the effects of botulinum A toxin in 101 patients with hemifacial spasm and 11 patients with blepharospasm in an open trial and double blind manner. All patients in the open trial and 6 patients in the double blind trial improved after the first injection of botulinum toxin. There was no improvement with placebo. The peak effect ranged from one to 6 days after injection and mean peak effect was 3.6 days in blepharospasm, and 4 days in hemifacial spasm. Of 144 treatments, 98.6% had excellent results, (below grade I). The duration of beneficial effect ranged 11 to 40 weeks (mean 16.5 weeks) in hemifacial spasm and 9 to 30 weeks (mean 14.2 weeks) in blepharospasm. Complications were encountered in 63.4% in hemifacial spasm and 72.7% in blepharospasm. The common side effects were dry eyes, mouth droop, ptosis and lid edema in order of frequency. These side effects were mild and resolved spontaneously in 1 to 3 weeks. Botulinum A toxin therapy is effective and convenient, and the treatment of choice for patients with hemifacial spasm and blepharospasm.
... Reports indicate that BoNT injections have improved the quality of life for those suffering from HFS. According to large-scale studies, the efficacy of BoNT ranges from 78% to 98.4%, with the mean duration of the effect being around 15 weeks [15][16][17][18]. The results from various large-scale studies involving over 100 patients are summarized in Table 2. BoNT treatment schedules are typically set at 12-week intervals, based on the expected duration of the drug's effect. ...
... Patients are asked to rate their spasms on a scale from 1 (mild) to 10 (severe). This scale is easy to use and understand, but it may not capture the full complexity of the condition [15]. ...
Hemifacial spasm is typically caused by contact between the facial nerve and blood vessels. Microvascular decompression, a treatment that directly addresses this pathogenesis, is often considered the most effective treatment method. However, surgery is not immediately performed for patients at risk from the surgical treatment, or for those with an unclear diagnosis. In these instances, Botulinum toxin injection can help manage the patient’s symptoms. Numerous studies corroborate the effectiveness and safety of Botulinum toxin treatment, with large-scale studies indicating symptom control lasts, on average, around 15 weeks.
... 5,6 First-line nonoperative management of HFS is various preparations of botulinum toxin, and standard surgical treatment is microvascular decompression (MVD). 7,8 Developmental venous anomaly (DVA) is a rare cause of HFS. DVAs are the most common vascular malformation, with one study reporting an incidence of 2.6% in 4069 brain autopsies. ...
BACKGROUND
Developmental venous anomaly (DVA) is a rare cause of hemifacial spasm (HFS). The treatment of HFS caused by a DVA varies in the literature and includes medication management, botulinum toxin injections, and microvascular decompression (MVD).
OBSERVATIONS
A 64-year-old woman presented with right-sided HFS. Preoperative magnetic resonance imaging showed a DVA in the right inferior pons, with an enlarged segment compressing the facial nerve at its root detachment point prior to drainage into the superior petrosal sinus. MVD was performed, and the facial nerve was decompressed without sacrifice of the vein. Immediately following the procedure, the patient had significantly reduced spasms. The patient became spasm-free 3 months after MVD and maintained spasm freedom for 3 months. Six months after MVD, the patient had a partial return of spasms. At 8 months, the patient continued to have reduced and intermittent spasms in the right orbicularis oculi muscle.
LESSONS
MVD for HFS caused by a DVA is a safe procedure and can be effective at reducing spasm frequency and severity.
... The estimated cost is 2,000-3,000 Thai Baht (approximately 60-90 USD) per injection. Even though there have been many studies about health-related quality of life (HRQOL) in BEB patients [14][15][16][17], the use of BTX-A for BEB is not covered by Thai universal health care coverage because there has been no previous study investigating the cost and benefits of BTX-A injection for BEB in Thai population. We evaluated HRQOL in Thai patients who had daily-life-affected BEB before and after BTX-A treatment, including efficacy and safety of the treatment. ...
Purpose:
To compare Thais' health-related quality of life (HRQOL) and severity grading, efficacy and safety in daily-life-affected benign essential blepharospasm (BEB) patients at baseline and after Botulinum toxin type A (BTX-A) treatment.
Design:
Prospective-observational study.
Participants:
BEB patients with Jankovic rating scale (JRS) at least 3 in both severity and frequency graded from 14 institutes nationwide were included from August 2020 to June 2021.
Methods:
Demographic data, HRQOL evaluated by the Thai version of EQ-5D-5L and NEI-VFQ-25 questionnaires, and severity grading score evaluated by Jankovic rating scale (JRS) at baseline, 1, and 3 months after the treatment were collected. The impact of the BTX-A injections and their complications were recorded.
Results:
184 daily-life-affected BEB patients were enrolled; 159 patients (86.4%) had complete data with a mean age of 61.40±10.09 years. About 88.05% were female, and 10.1% were newly diagnosed. Most of the patients had bilateral involvement (96.9%) and 12.6% had history of BEB-related accident. After BTX-A treatment, HRQOL improved significantly in 4 dimensions of EQ-5D-5L, except self-care. The EQ_VAS (mean±SD) was 64.54±19.27, 75.13±15.37, 73.8±15.85 (p<0.001) and EQ-5D-5L utility score was 0.748±0.23, 0.824±0.19 and 0.807±0.19 at baseline, 1, 3 months after treatment, respectively. From NEI-VFQ-25, HRQOL also improved in all dimensions, except eye pain. The JRS improved in all patients. Self-reported minor adverse events were 22.6%, which mostly resolved within the first month.
Conclusion:
Daily-life-affected BEB impacted HRQOL in most dimensions from both generic and visual-specific questionnaires. BTX-A treatment not only decreased disease severity, but also improved quality of life.
... The complications are usually mild and resolved within 1-2 weeks. 25 lIMItAtIon This is an unblinded study. There was erratic attendance of a group of patients in the follow-up session. ...
Background:
Hemifacial spasm (HFS) is a distressing, involuntary, irregular tonic-clonic contraction of the facial muscles innervated by the seventh cranial nerve. It affects the quality of life. Botulinum toxin is a preferred symptomatic treatment option for the condition. However, there is a lack of study in the Indian scenario. Therefore, we observed the demographic profile, clinical spectrum, therapeutic response, and adverse effects of botulinum toxin and assessed the quality of life in the pre and postinjection phases in our subjects with HFS.
Materials and methods:
The study design is a prospective open-label observational study. Consecutive cases of HFS were selected from the general neurology outpatient department (OPD) and movement disorder clinic of a medical college hospital in Eastern India. Clinical and relevant neuroimaging studies excluded mimickers and secondary causes of HFS. Institutional Ethics Committee's permission was obtained. Informed consent was taken from patients before botulinum toxin injection. The pre and postinjection assessment tools were spasm rate for a specific period of time, quantification of facial asymmetry, widening palpebral fissure by visual analog scale, Jankovic disability rating scale, HFS-7 scale, and videography.
Results:
A total of 250 cases of HFS (F:M = 138:112) were studied. The mean age of presentation was 47 years. The mean dose of botulinum toxin injection was 24.2 units per patient. The mean duration of improvement was 4 months. The spasm frequency was decreased by 90%, and the facial asymmetry was improved by 86%. The improvement in quality of life was 86%. Local adverse effects are seen in 10.4% of cases, and all were reversible.
Conclusion:
This is one of the largest studies on the effects of botulinum toxin in subjects with HFS in the Indian population. Periodic injection of botulinum toxin is a safe and effective therapy for subjects with HFS. There is a significant improvement in the quality of life following botulinum toxin therapy in subjects with HFS. Adverse effects were local, mild, well-tolerated, and reversible.
Botulinum toxins, after injection into the muscle, block the release of acetylcholine from the neuromuscular junction. Acetylcholine is a chemical neurotransmitter that, upon release from nerve endings, activates the muscles. In disease conditions characterized by presence of overactive muscles with involuntary movements (dystonias, tremors, tics), injection of the botulinum toxin into the affected muscles decreases the involuntary movements substantially and improves the patients’ quality of life.
Background
Botulinum toxin is an effective treatment for hemifacial spasm in elderly patients. However, some patients do not tolerate the side effects and frequency of botulinum toxin treatments.
Objectives
The purpose of this study was to evaluate the characteristics and outcomes of a cohort of elderly patients referred by neurologists for surgical decompression of the facial nerve following botulinum toxin treatment.
Methods
In a prospective cohort study, logistic regression was used to detect potential predictors of spasm‐freedom after surgical decompression of the facial nerve in elderly patients that received ≤8 and >8 botulinum toxin treatments for hemifacial spasm before surgery. Age, sex, side, preoperative symptom duration, and preoperative botulinum toxin treatment were assessed as potential predictors of spasm‐freedom at last follow‐up.
Results
Of 76 elderly patients with hemifacial spasm treated with botulinum toxin and microvascular decompression, with at least 2‐years of follow‐up (median, 44.5 months), 84.2% were spasm‐free at last follow‐up. Age ( P = 0.38), sex ( P = 0.59), side ( P = 0.15), preoperative symptom duration ( P = 0.7), and number of preoperative botulinum toxin treatments ( P = 0.3) were not predictors of long‐term spasm‐freedom. Permanent ipsilateral hearing loss was the most frequent complication (3.9%).
Conclusion
This study provides evidence that elderly patients can undergo botulinum toxin treatment for hemifacial spasm without compromising their likelihood of achieving spasm‐freedom with future surgical decompression. Therefore, surgical decompression of the facial nerve is an effective therapy for elderly patients with hemifacial spasm refractory to botulinum toxin.
Botulinum neurotoxins are a group of biological toxins produced by the gram-negative bacteria Clostridium botulinum. After intramuscular injection, they produce dose-related muscle relaxation, which has proven useful in the treatment of a large number of motor and movement disorders. In this chapter, we discuss the utility of botulinum toxin treatment in three major and common medical conditions related to the dysfunction of the motor system, namely dystonia, tremor, and spasticity. A summary of the existing literature is provided along with different techniques of injection including those recommended by the authors.
The aim of this study was to investigate the frequency of hemorrhagic side effects of botulinum neurotoxin A injections (BoNT/A) for the treatment of benign essential blepharospasm (BEB) and hemifacial spasm (HFS) in patients taking antithrombotic drugs (ATD). A total of 140 patients were included (female: 65%; BEB: 75%; mean age: 70 ± 12 years). According to their current antithrombotic medication, participants were either assigned to the ATD group (41%), or to the control group (59%). The ATD group was further divided into subgroups depending on the medication administered: acetylsalicylic acid, ADP receptor antagonists, direct oral anticoagulants, vitamin-K antagonists, or dual antiplatelet therapy. The frequency of hemorrhagic side effects was recorded by retrospective analysis of past treatments as documented in the patient’s file set in relation to the number of past treatments (hematoma frequency of past treatments, HFretro) as well as by a prospective survey capturing the side effects of one single treatment (hematoma frequency of actual treatment, HFactual). There was no significant difference in hematoma frequency between the ATD group and the control group, neither for past (HFretro: ATD: 2%; 45/2554; control: 4%; 109/2744) nor for the current BoNT/A treatments (HFactual: ATD: 30%; 16/53; control: 31%; 22/72). Even between ATD subgroups, hematoma frequency did not differ significantly. Overall, hemorrhagic side effects of the BoNT/A treatment for BEB and HFS were mild and non-disabling.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
Fully updated throughout, the second edition of the Manual of Botulinum Toxin Therapy provides practical guidance on the use of Botox in a wide variety of disorders. New chapters have been added on the use of botulinum toxin in wound healing, in focal hand dystonia and in thoracic outlet syndrome, as well as others. There are new chapters on the use of botulinum toxins in conjunction with ultrasound guidance. Using clear line-drawings the Manual describes the relevant injection sites for each condition and gives comparative dosage tables for the various formulations of toxins used in different muscle groups. Throughout the emphasis is on technique and the book can be used as both a teaching aid and in bedside guidance. The manual will be of use to neurologists, otolaryngologists, urologists, ophthalmologists, dermatologists, internists, pain management specialists, rehabilitation specialists and plastic surgeons, and any other clinicians discovering the potential of botulinum toxin.
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