Borodic G E, Joseph M, Fay L, Cozzolino D, Ferrante R J
Department of Ophthalmology and Otolaryngology, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Boston.
Head Neck. 1990 Sep-Oct;12(5):392-9. doi: 10.1002/hed.2880120504.
Chemodenervation of cervical muscles with botulinum A toxin, although useful in treating spasmodic torticollis, has been associated with dysphagia. Retrospective analysis of dose and injection site (sternomastoid vs. posterior cervical muscle groups) in 26 patients (49 injections) suggested that dysphagia was related to the quantity of toxin injected into the sternomastoid muscle: dysphagia, median 150 IU (7 injections); and no dysphagia, median 100 IU (42 injections; p = 0.026 Wilcoxon test). In a prospective study (31 injections to 24 patients), limiting the dose administered to the sternomastoid to 100 IU, substantially reduced the incidence of dysphagia (0 of 31, p = 0.27, Fisher's exact test). Denervation of human orbicularis muscle fibers, 5 weeks to 4 months after injection of botulinum A toxin for the treatment of blepharospasm, was successfully demonstrated by intense, diffuse acetylcholinesterase staining. A weight-adjusted dose similar to that given for torticollis was injected into longissimus dorsi muscle in 6 albino rabbits. Using the acetylcholinesterase stain as a marker, a diffusion gradient was noted over a distance of 30 to 45 mm from the point of injection and in contralateral muscle 15 to 25 mm from this point. Thus, denervation was demonstrated to occur within a definable area which crossed anatomic barriers, such as fascia and bone. These clinical and laboratory data suggest that dysphagia following botulinum toxin therapy results from toxin spread to pharyngeal musculature from the sternocleidomastoid injection site. Limiting of the injection dose to 100 IU or less to the sternomastoid substantially decreases the incidence of this complication.
用A型肉毒毒素对颈部肌肉进行化学去神经支配，尽管在治疗痉挛性斜颈方面有用，但一直与吞咽困难有关。对26例患者（49次注射）的剂量和注射部位（胸锁乳突肌与颈后肌群）进行回顾性分析表明，吞咽困难与注入胸锁乳突肌的毒素量有关：有吞咽困难者，中位数为150国际单位（7次注射）；无吞咽困难者，中位数为100国际单位（42次注射；Wilcoxon检验，p = 0.026）。在一项前瞻性研究中（对24例患者进行31次注射），将注入胸锁乳突肌的剂量限制在100国际单位，可大幅降低吞咽困难的发生率（31次注射中0例出现吞咽困难，Fisher精确检验，p = 0.27）。在注射A型肉毒毒素治疗眼睑痉挛后5周至4个月，通过强烈、弥漫性的乙酰胆碱酯酶染色成功证实了人眼轮匝肌纤维的去神经支配。对6只白化兔的背最长肌注射了与治疗斜颈时所用相似的按体重调整的剂量。以乙酰胆碱酯酶染色作为标记，在距注射点30至45毫米的距离内以及距该点15至25毫米的对侧肌肉中观察到了扩散梯度。因此，证明去神经支配发生在一个可界定的区域内，该区域跨越了解剖屏障，如筋膜和骨骼。这些临床和实验室数据表明，肉毒毒素治疗后出现的吞咽困难是由于毒素从胸锁乳突肌注射部位扩散到咽部肌肉组织所致。将胸锁乳突肌的注射剂量限制在100国际单位或更低可大幅降低这种并发症的发生率。
