Is chemodenervation with incobotulinumtoxinA an alternative to invasive chronic anal fissure treatments?

BACKGROUND: Botulinum toxin type A is currently strongly recommended for the treatment of anal fissures (AFs). However, there is still no consensus on dosage or injection technique. This study provides further efficacy and safety evidence in a 2-year follow-up. METHOD: Prospective, open-label, single-arm, single-center study carried out in adult patients with AFs non-responsive to previous treatments. Patients were treated with incobotulinumtoxinA (incoBoNT/A) injected in both laterals and posterior intersphincteric groove. Healing rate at 2 years was the primary endpoint. Secondary endpoints included internal anal sphincter pressures, incontinence, and safety. RESULTS: A total of 49 patients were treated with a mean incoBoNT/A dose of 40.5 U (spread across three locations). Healing rate at 2 years was 83.9% with a 24.5% of recurrence throughout the study. Only 7 patients (14.3%) reported adverse events (AEs) that were mild and temporary. Mean reduction in anal resting pressure was -9.1 mmHg at 3 months (p = 0.001). Mean reduction in voluntary squeeze pressure was -27.5 mmHg at 3 months (p < 0.001). Mean pain perception measured with a visual analog scale decreased by -6.5 points at 2 years (p < 0.001). There was an incontinence increase at 1 month of 1.3 points (p = 0.006), but baseline values were restored at 6 months. CONCLUSION: We present results that support the use of incoBoNT/A as a second line for AFs that do not respond to ointment therapy. IncoBoNT/A injection is a less invasive treatment that should be considered before surgery due to its efficacy and its safety which includes no permanent impairment. TRIAL REGISTRATION: ISRCTN90354265; Registered on 16th February 2024. Retrospectively registered.

Neglecting Bone Health: A Critical Gap in Management of Muscle Spasticity with Botulinum Toxin in Spinal Cord Injury.

Neuromuscular inhibitors have been quickly advanced from being used only for aesthetic purposes to being used as a treatment for musculoskeletal pain and muscle spasticity. This phenomenon stems from the diminished force exerted by muscles, which are essential for bone remodeling. In this context, it is hypothesized that botulinum toxin (BTX) might exert a direct influence on bone resorption. Although such treatments have the potential to provide patients with significant relief, bone loss occurring due to elective muscle paralysis has yet to be examined in clinical trials. The disuse model resulting from spinal cord injury, characterized by the absence of ground reaction and muscle forces, provides an ideal context for exploring the skeletal ramifications of intramuscular BTX injection. This approach enables an investigation into the intricate interplay between muscle and bone, encompassing the impact of spasticity on bone preservation, the potential positive and negative outcomes of BTX on bone metabolism, and the involvement of the autonomic nervous system in bone remodeling regulation. This paper presents a narrative review of research findings on the disturbance of the typical balance between muscles and bones caused by acute muscle paralysis from BTX, resulting in osteopenia and bone resorption.

Predictive Factors for the Successful Outcome of Urethral Sphincter Injections of Botulinum Toxin A for Non-Neurogenic Dysfunctional Voiding in Women.

PURPOSE: Dysfunctional voiding (DV) is not uncommon in women with non-neurogenic voiding dysfunction. Because of its unknown pathophysiology, effective and durable treatment is lacking. This study aimed to analyze the results of treatment and predictive factors for a successful outcome of botulinum toxin A (BoNT-A) treatment in female patients with DV. METHODS: In total, 66 women with DV confirmed by a videourodynamic study (VUDS) were treated with a BoNT-A injection into the urethral sphincter once (n = 33) or several times (n = 33). VUDS was performed before (baseline) and after the BoNT-A treatment. Patients with a global response assessment of the voiding condition of 2 or 3 and a voiding efficiency (VE) of >20% than baseline were considered to have a successful outcome. The baseline demographics, VUDS parameters, and VUDS DV subtypes were compared between the successful and failed groups. Predictive factors for a successful outcome were investigated by logistic regression analyses. RESULTS: Successful and failed outcomes were achieved in 27 (40.9%) and 39 (59.1%) women, respectively. After BoNT-A injections, the maximum flow rate (Qmax), voided volume, and VE all significantly increased, and the postvoid residual (PVR) was slightly improved. No significant difference in the number of injections and medical comorbidity was found between the groups. However, the successful group had a higher incidence of previous pelvic surgery. No significant difference in the treatment outcome was found among patients with different urethral obstruction sites. Significant improvements in Qmax, voided volume, PVR, VE, and the bladder outlet obstruction (BOO) index were noted in the successful group. A lower VE at baseline and a history of surgery were identified as predictive factors for a successful outcome of BoNT-A injections for treating DV. CONCLUSION: BoNT-A injections into the urethral sphincter can effectively improve VE in 40.9% of women with DV. Women with higher BOO grades and previous pelvic surgery are predicted to have a successful treatment outcome.

Intravesical Botulin Toxin-A Injections for Neurogenic Bladder Dysfunction in Children: Summary Update on Last 10 Years of Research.

Neurogenic bladder dysfunction (NB) represents a challenge in pediatric urology. Intravesical botulin toxin-A (BTX-A) bladder injection is part of the armamentarium for the treatment of this condition, usually after failed first-line medical strategies and before the escalation to more invasive options such as neuromodulation or augmented cystoplasty in severe cases. However, there is still a lack of consensus about the appropriate treatment modality for the pediatric population. A review of the last 10 years' research was performed on the PubMed database by two authors. Articles doubly selected and meeting the inclusion criteria were collected and analyzed for their study type, demographics, neurological disease(s) at diagnosis, BTX-A treatment modality and duration, previous treatment, clinical and urodynamic parameters, adverse events, outcomes, and follow-ups. A total of 285 studies were initially selected, 16 of which matched the inclusion criteria. A cohort of 630 patients was treated with BTX-A at a median age of 9.7 years, 40% of which had a diagnosis of myelomeningocele. The results of the selected publications show the overall efficacy and safety of BTX-A injections in children and confirmed BTX-A as a valuable strategy for NB treatment in pediatric population. Nevertheless, up to now, the literature on this topic offers scarce uniformity among the published series and poor protocol standardization.

Efficacy of Urethral Sphincter Botulinum Toxin A Injection in Patients with Spinal Cord Injury with Dysuria: A Retrospective Cohort Study.

Spinal cord injury (SCI) often leads to neurogenic lower urinary tract dysfunction, causing dysuria and affecting patients' well-being. This study aimed to evaluate the efficacy of a urethral sphincter botulinum toxin A (BoNT-A) injection in patients with SCI and dysuria. This was a retrospective study including 118 patients with SCI who underwent a urethral BoNT-A injection following a standardized protocol for refractory voiding dysfunction. The protocol involved injecting BoNT-A into the urethral sphincter under cystoscopic guidance. Patient demographics, bladder condition parameters, and treatment outcomes were analyzed. Logistic regression and receiver operating characteristic curve analyses were performed to identify predictors of treatment success. Of the 118 patients, 71 (60.1%) showed satisfactory treatment outcomes after the injection. Post-injection status, bladder management, and injection frequency varied significantly among patients with satisfactory and unsatisfactory treatment outcomes. Age, bladder compliance, intravesical pressure, and bladder contractility were indicators of satisfactory outcomes. The first sensation of bladder filling of ≤263 mL, intravesical pressure of ≤28, and bladder contractility index of ≥14 were highly correlated with satisfactory outcomes. A urethral sphincter BoNT-A injection shows promise in managing dysuria in patients with SCI. Understanding bladder condition parameters and patient demographics helps optimize patient selection for this intervention. Further studies are needed to validate these findings and refine treatment protocols.

Botulinum toxin for bruxism treatment: a nationwide study among oral and maxillofacial surgeons in Germany.

INTRODUCTION: This study aimed to evaluate the use of botulinum toxin (BTX) for the treatment of bruxism in oral and maxillofacial surgery in Germany. MATERIAL AND METHODS: A dynamic online questionnaire comprising 7 to 25 questions was formulated to gather general and specific information regarding using BTX to treat bruxism. The questionnaire underwent internal and external assessments for validation. Subsequently, it was distributed to 906 oral and maxillofacial surgeons (OMFS) affiliated with the German Association for Oral and Maxillofacial Surgery (DGMKG). Weekly reminders were dispatched over four weeks to enhance response rates. Participation in the study was voluntary and anonymized. Descriptive methods were employed for data analysis. RESULTS: 107 OMFS participated in the study, yielding a response rate of 11.81%. On average, 17 patients with bruxism were per month, with 4 of these patients receiving BTX therapy. BTX administration was frequently accompanied by splints and physiotherapy (35.51% of participants). Botox® (Allergan) was the preferred BTX preparation, utilized by 40.79% and reconstituted with saline by 92.11% of participants. The masseter muscles were primarily targeted for BTX treatment (67.57% of participants), averaging 29 BTX (Allergan-) units per side. Injection points for each masseter muscle typically amounted to six per side, preferred by 30.67% of participants. Follow-up assessments post-BTX treatment were conducted regularly, predominantly after four weeks, by 36% of participants. In 8% of cases, additional BTX injections were necessary due to inadequate outcomes. Side effects were reported in 4% of cases, commonly manifesting as a non-disturbing reduction in bite force. Most participating OMFS (61.84%) using BTX for bruxism therapy regarded bruxism treatment with BTX as evidence-based. Notably, 97.37% of respondents expressed their willingness to recommend BTX-based bruxism treatment to their colleagues. Overall, the efficacy of BTX therapy for bruxism was rated as good (53.95%) and very good (40.79%). CONCLUSION: The use of BTX for the management of bruxism among OMFS in Germany has demonstrated efficacy. Substantial variances in certain facets of bruxism treatment employing BTX have been observed. CLINICAL RELEVANCE: Additional research endeavors are warranted to comprehensively investigate distinct elements of BTX therapy for bruxism, including the optimal dosage of BTX units and the precise localization of injection sites across various muscles.

Clinical Conditions Targeted by OnabotulinumtoxinA in Different Ways in Medicine.

OnabotulinumtoxinA (BT-A) is used in different medical fields for its beneficial effects. BT-A, a toxin originally produced by the bacterium Clostridium botulinum, is widely known for its ability to temporarily paralyze muscles by blocking the release of acetylcholine, a neurotransmitter involved in muscle contraction. The literature continually reports new hypotheses regarding potential applications that do not consider blockade of acetylcholine release at the neuromuscular junction as a common pathway. In this opinion article, it is our aim to investigate the different pathway targets of BT-A in different medical applications. First of all, the acetylcholine effect of BT-A is used to reduce wrinkles for cosmetic purposes, in the treatment of urological problems, excessive sweating, temporomandibular joint disorders, obesity, migraine, spasticity in neurological diseases, and in various cases of muscle overactivity such as cervical dystonia, blepharospasm, and essential head tremor. In another potential pathway, glutamate A, CGRP, and substance P are targeted for pain inhibition with BT-A application in conditions such as migraine, trigeminal neuralgia, neuropathic pain, and myofascial pain syndrome. On the other hand, as a mechanism different from acetylcholine and pain mediators, BT-A is used in the treatment of hair loss by increasing oxygenation and targeting transforming growth factor-beta 1 cells. In addition, the effect of BT-A on the apoptosis of cancer cells is also known and is being developed. The benefits of BT-A applied in different doses to different regions for different medical purposes are shown in literature studies, and it is also emphasized in those studies that repeating the applications increases the benefits in the long term. The use of BT-A continues to expand as researchers discover new potential therapeutic uses for this versatile toxin.

A New Method in Dealing With Children's Condylar Fracture by Botulinum Toxin A Injection in Lateral Pterygoid Muscle.

Condylar is one of the most vulnerable sites to be traumatized in pediatric mandible fracture, while temporomandibular joint ankylosis might be the most severe complication of condylar fracture in children. There exists a long-time controversy on the treatment of condylar fractures in children. Considering the risk of facial nerve injury and a certain probability of absorption or even ankylosis after open reduction and internal fixation (ORIF) of condylar fractures, a series of nonsurgical approaches are preferred in cases without severe malocclusion or shortening of the ramus. Our treatment plan was carried out through combining procedures of Botulinum toxin A injection in lateral pterygoid muscle with ORIF of para symphyseal fracture; subsequently, a conservative way of the occlusal splint with elastic traction was performed. Three patients of bilateral or unilateral condylar fractures, aged between 2 y and 6 y, were involved in this treatment. After more than 1 year's follow-up, the occlusion was satisfactory in all patients. Condylar remodeling was approximately complete in 3 months, and no unwanted complications were observed. We may expect this method to offer a new idea when dealing with children's condylar fracture.

Comparison of quality of life after bladder augmentation in patients previously treated with intradetrusor botulinum toxin A for neurogenic detrusor overactivity.

PURPOSE: To compare the quality of life (QoL) in the same patients first treated with botulinum toxin A (BTA) injections for neurogenic detrusor overactivity (NDO) and then with bladder augmentation (BA). METHOD: Retrospective study of patients who had BA after BTA treatment between January 2012 and December 2022. Qualiveen Short Form questionnaires and a 7-level Likert/PGI-I scale to answer the question "How would you describe your quality of life after surgery compared to when you felt your best with BTA injections?" were collated and analyzed. RESULTS: Fifty-two BAs for neurogenic bladder (NDO or low compliance) were performed in patients with a median age of 43years [33; 52] previously treated with BTA. After a median follow-up of 33.5 [13.8; 54.3] months, the median Qualiveen-SF global score after BA was significantly higher than that obtained at best BTA efficacy (1.63 [1; 2.63] vs. 2.63 [1.88; 3], P=0.012), as were the scores for the fear, constraints/restrictions and limitations/inconvenience domains. The median PGI-I score was +3 [2; 3] (truly better QoL) and 85.4% of patients reported a QoL after BA superior to the best QoL under BTA. CONCLUSION: BA provides a greater range of QoL improvement than BTA injection for patients who have experienced both treatments. Long-lasting effects and absence of need to perform iterative retreatment were the main reasons.

Comparison of outcome of botulinum toxin injection with and without glyceryl trinitrate in chronic anal fissure in terms of post operative pain and healing.

Objectives: To compare the outcome of botulinum toxin injection with and without glyceryl trinitrate with respect to postoperative pain and healing in the treatment of anal fissures. METHODS: The prospective, comparative study was conducted at the Department of General Surgery, Mayo Hospital, Lahore, Pakistan, from September 1, 2021, to August 31, 2022, and comprised adult chronic anal fissure patients of either gender. They were randomised using the lottery method into group A which received botulinum toxin injection, and group B which received botulinum toxin injection plus 1g of 0.2% topical glyceryl trinitrate cream. Post-operative pain was measured 24 hours after the procedure using the visual analogue scale. Healing was assessed by examining the wound for the appearance of granulation tissue 4 weeks post-procedure. Data was analysed using SPSS 26. RESULTS: Of the 88 patients, 44(50%) were in group A; 32(72.7%) males and 12(27.3%) females with mean age 33.91±14.8 years. There were 44(50%) patients in group B; 35(79.5%) males and 9(20.5%) females with mean age range 36.33±14.9 years. The mean postoperative pain at 24 hours in group A was 4.67±1.16 and it was 3.06±0.65 in group B (p=0.009). In group A, 23(69.7%) patients showed complete healing at 4 weeks compared to 30(90.9%) in group B (p=0.030). CONCLUSIONS: Botulinum toxin injection with glyceryl trinitrate could be considered as first line of treatment for chronic anal fissure in patients who refuse surgery and with previous sphincter surgery.

Comparison of smile attractiveness in cases with gummy smile treated with botulinum toxin and maxillary impaction surgery: A retrospective study.

This study aimed to compare the smile's attractiveness in patients submitted to the treatment of gummy smiles with botulinum toxin or maxillary impaction surgery. The retrospective sample comprised 26 patients divided into two groups: Group 1 (BTX): 13 patients (12 females and 1 male) with a mean age of 28.06 years (s.d. = 6.09) and mean gingival exposure during smile of 5.18 mm (s.d. = 1.51) treated with botulinum toxin; Group 2 (SURGICAL): 13 patients (9 females and 4 males) with a mean age of 30.59 years (s.d. = 5.72) and mean gingival exposure during smile of 5.21 mm (s.d. = 1.55) treated with orthognathic maxillary impaction surgery. The group of evaluators comprised 317 participants, divided into 143 orthodontists (85 females and 58 males) with a mean age of 41.40 (s.d. = 9.30); 62 dentists (47 female and 15 male) with a mean age of 35.44 (s.d. = 10.44), and 112 lay people (74 female and 38 male) with a mean age of 46, 91 (s.d. = 10.11) in a questionnaire on Google Forms. Without knowing the therapy used, the evaluators assigned scores to the photographs of the posed smile taken before (T1) and after (T2) treatment. Intergroup comparison of smile attractiveness was performed using the t-independent, one-way ANOVA, and Tukey tests. There was a significant improvement in smile attractiveness with treatment in both groups; however, the improvement was significantly better in the surgical group than in the BTX group. Orthodontists rated smile attractiveness significantly higher than dentists and laypersons for the final phase of the BTX and surgical groups. There was a significant improvement in the smile attractiveness with botulinum toxin application and orthodontic-surgical treatment. However, orthognathic surgery promoted a greater improvement in smile attractiveness than the application of botulinum toxin.

Bladder instillations vs onabotulinumtoxinA injection for interstitial cystitis/bladder pain syndrome: a randomized clinical trial.

BACKGROUND: Interstitial cystitis (IC)/bladder pain syndrome (BPS) is an unpleasant sensation related to the bladder with lower urinary tract symptoms lasting more than 6 weeks, unrelated to an otherwise identifiable cause. The etiology is likely multifactorial including urothelial abnormalities, neurogenic pain upregulation, and potentially bladder and vaginal microbiome alterations. Despite treatment effectiveness of both bladder instillations and intradetrusor onabotulinumtoxinA injection for this condition, a head-to-head comparison has not been performed. OBJECTIVE: To compare the efficacy of bladder instillations and intradetrusor onabotulinumtoxinA injection for treatment of IC/BPS. STUDY DESIGN: Patients with O'Leary-Sant (OLS) questionnaire scores of ≥6, meeting clinical criteria for IC/BPS, and desiring procedural management were randomized to bladder instillations or intradetrusor onabotulinumtoxinA injection. The primary outcome was the difference in OLS scores at 2 months posttreatment between groups. Secondary outcomes included evaluation of sexual function, physical/mental health status, pain, patient satisfaction, treatment perception, retreatment, and adverse event rates. RESULTS: Forty-seven patients were analyzed with 22 randomized to bladder instillations and 25 to onabotulinumtoxinA injection. There were no differences in demographic and clinical characteristics between groups. From baseline to 2 months posttreatment, there was a decrease in OLS subscales in all patients (Interstitial Cystitis Symptom Index [ICSI] -6.3 (confidence interval [CI] -8.54, -3.95), P<.0001; Interstitial Cystitis Problem Index [ICPI] -5.9 (CI -8.18, -3.57), P<.0001). At 2 months posttreatment, patients in the onabotulinumtoxinA group had significantly lower OLS scores compared to those in the bladder instillation group (ICSI 6.3±4.5 [onabotulinumtoxinA] vs 9.6±4.2 [instillation], P=.008; ICPI 5.9±5.1 [onabotulinumtoxinA] vs 8.3±4.0 [instillation], P=.048). The difference in OLS scores between groups did not persist at 6 to 9 months posttreatment. There were no statistically significant differences between baseline and posttreatment time points for the remaining questionnaires. Eight percent of patients who received onabotulinumtoxinA injection experienced urinary retention requiring self-catheterization. Patients who underwent onabotulinumtoxinA injection were significantly less likely to receive retreatment within 6 to 9 months compared to patients who received bladder instillations (relative risk 13.6; 95% CI, 1.92-96.6; P=.0002). There were no differences between groups regarding patient satisfaction, perception of treatment convenience, or willingness to undergo retreatment. CONCLUSION: Both onabotulinumtoxinA injection and bladder instillations are safe, effective treatments for patients with IC/BPS, with significant clinical improvement demonstrated at 2 months posttreatment. Our findings suggest that intradetrusor onabotulinumtoxinA injection is a more effective procedural treatment for this condition than bladder instillation therapy and associated with decreased rates of retreatment.

Decompression Surgery in Elderly Patients with Hemifacial Spasm Refractory to Botulinum Toxin.

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.

Long-Term Effects of Botulinum Toxin A Versus Incisional Surgery for Management of Partially Accommodative Esotropia in Children: Comparison of Three Approaches.

PURPOSE: To compare the effect of bilateral medial rectus injection of botulinum toxin A (BTX-A), bilateral medial rectus muscle recession surgery (BMR rc), or unilateral medial rectus muscle recession combined with lateral rectus muscle resection surgery (R&R), in the management of partially accommodative esotropia (PAET) in children. DESIGN: Retrospective comparative clinical study. METHODS: The study cohort included 98 patients diagnosed with PAET who had BTX-A injection or incisional surgery between December 2014 and January 2023. The main outcome measures included motor and sensory results as well as complications. Follow-up was at least 12 months for all patients. RESULTS: There were 28 patients in the BTX-A group, 45 in the R&R group, and 25 in the BMR rc group. The motor success rates at distance and near fixation respectively were 50% (14/28) and 54% (15/28) in the BTX-A group, which were lower than that of the R&R group (78% [35/45], 84% [38/45]) and the BMR rc group (72% [18/25], 84% [21/25]) (P = .042 for near and P = .006 for distance). For patients with onset age <2.5 years old, there was no statistical difference amongst the 3 surgical approaches (P = .656). For patients with onset age ≥2.5 years, the motor success rate of the R&R group (81% [26/32]) and the BMR rc group (88% [14/16]) was higher than that in the BTX-A group (38% [5/13]; P = .004). There was no statistical difference in sensory outcomes for patients regardless of onset age or treatment methods (P > .05 for all). During follow-up, 4% (2/45) of patients in the R&R group and 20% (5/25) in the BMR rc group developed consecutive exotropia; no patient in the BTX-A group was overcorrected (P = .017). CONCLUSIONS: Bilateral medial rectus muscle injection with BTX-A in patients with PAET is a safe, accessible, and low-cost alternative. Although motor success rates were higher, overall, in patients treated with incisional surgery, for patients with earlier age of onset (≤ 2.5 years old), BTX-A injection may be preferred to incisional surgery. In older children treated with unilateral recession-resection surgery, fewer developed consecutive exotropia.

[Botulinum toxin in male lower urinary tract symptoms (LUTS): What can we expect?] / Botulinumtoxin bei Symptomen des unteren Harntraktes beim Mann ("male LUTS"): Was darf man erwarten?

During the last two decades botulinum toxin has also conquered urology. Botulinum toxin reduces the contractility and sensitivity of the detrusor muscle and relieves pain. It is therefore a promising drug whose use in men also appears promising. The following article highlights the practical relevance of botulinum toxin for male lower urinary tract symptoms (LUTS). But first of all, a distinction must be made between use in male LUTS due to benign prostate syndrome (BPS) and use in cases of overactive bladder (OAB) alone. A differentiated diagnosis and treatment of male LUTS is therefore essential.

Nerve Block Guided by Anatomic Landmarks Only Reduces Pain in Botulinum Toxin Type A Treatment for Glabellar and Forehead Wrinkles.

BACKGROUND: Botulinum toxin type A is widely used to treat glabellar and forehead wrinkles, but the pain caused by multiple injections often deters patients from receiving long-term treatment. Despite several methods used to alleviate this pain, consistency and effectiveness remain a challenge. Therefore, this study aimed to evaluate the effectiveness and safety of nerve block guided by anatomic landmarks only in reducing pain associated with botulinum toxin type A injections. PATIENTS AND METHODS: Between 2018 and 2022, the study enrolled 90 patients divided into 3 groups: the nerve block group (n = 30), the lidocaine cream group (n = 30), and the control group (n = 30). In the nerve block group, a landmarks-based technique was used to perform the nerve block. The study collected general information and comorbidities, and recorded pain at each point and time spent on preparation and treatment for each patient's forehead and glabellar area on each side. Patient-reported outcomes and complications were followed up at 2, 4, and 12 weeks after the injections. RESULTS: The nerve block group had significantly lower total pain scores in all regions compared to the lidocaine cream and control groups (P < 0.01). There were no significant differences in patient-reported outcomes between the groups at any follow-up point. Additionally, the complication rates related to injection were low and comparable among the 3 groups. CONCLUSIONS: Nerve block guided by anatomic landmarks only is a safe, effective, and consistent approach to reduce pain during botulinum toxin type A treatment for glabellar and forehead lines. This technique may offer advantages over other methods used to alleviate the pain associated with these injections.

Botulinum toxin-A as a treatment option for refractory idiopathic trigeminal neuralgia of the ophthalmic branch: a case report and literature review.

Trigeminal neuralgia is one of the most common neurological pains affecting the head and neck and is associated with severe, lancinating, electrical pain episodes. The maxillary and mandibular branches are usually affected. The ophthalmic branch is rarely involved and, when present, it requires a comprehensive workup to rule out major conditions. Pharmacotherapy and surgery are the most common treatment options for this condition. Systemic medications may pose a wide range of side effects and effectiveness may decrease over time while surgery has inherent complications. Injectable onabotulinum toxins have been utilized for various applications in medicine and dentistry. There is, however, limited data on their use for the management of refractory trigeminal neuralgia of the ophthalmic branch. We present the case of a 58-year-old male diagnosed with refractory idiopathic trigeminal neuralgia affecting the ophthalmic branch, which was unresponsive to standard care and successfully managed with onabotulinum toxin type A. This treatment should be considered in cases of refractory trigeminal neuralgia prior to surgery. We reviewed the relevant literature concerning the application of Onabotulinum toxin A for managing trigeminal neuralgia of the ophthalmic branch. This case report and review aim to enlighten the application of Onabotulinum toxin A for managing refractory trigeminal neuralgia of the ophthalmic branch. Our case report and review show that Onabotulinum toxin A could be used for managing TN of the ophthalmic branch.