UNASSIGNED: Masseter hypertrophy presents as unilateral or bilateral swellings over the ramus and angle of the mandible. It is caused by malocclusion, clenching, TMJ disorders, etc and alters facial symmetry, leading to discomfort and negative cosmetic impact in many patients, making this a popular request for aesthetic and functional correction.
UNASSIGNED: This case report involves injecting Botulinum toxin into 6 equidistant bulging points on the masseter. Standardized photography and clinical parameters were used to assess facial contour and masseter muscle thickness at baseline and successive follow ups.
UNASSIGNED: Significant masseteric bulk reduction was observed in subsequent follow ups.
UNASSIGNED: The 6-point technique was found to be an effective treatment modality for Botox injection in masseteric hypertrophy. The clinical method to quantify prognosis was easy and economical.

BACKGROUND: Hemifacial spasm represents segmental myoclonus of muscles innervated by the facial nerve, which is usually and successfully treated with botulinum toxin. Botulinum toxin (BTX) acts as an acetylcholine release inhibitor at presynaptic cholinergic junctions and therefore is considered contraindicated (or administrable with caution) in patients with neuromuscular disorders like Myasthenia Gravis (MG). Moreover, to date, the association of hemifacial spasm and ocular MG is extremely rare and only a few cases have been described.
METHODS: We report the case of a 73 years old man with a 3-year history of ocular MG who developed a left hemifacial spasm. The patient underwent hemispasm, treatment with BTX type A (abobotulinum toxin-A, total dose of 50 IU) that resulted in safe and successful 6 months re-evaluation.
CONCLUSIONS: Our results suggest that in selected cases with concomitant MG and conditions characterized by orbicularis oculi spasms or hemispasm, BTX therapy may not be contraindicated and could be given at longer intervals due to prolonged effects.

Lesch-Nyhan syndrome is a genetic metabolic disorder often involving dystonia and self-mutilating behavior. This case report describes a 13-year-old boy with Lesch-Nyhan syndrome and self-mutilating behavior who received botulinum toxin injections to his bilateral masseter muscles after failing multiple other treatments. Following injections, the patient had reduction in self-biting, along with improvements in speech, mastication and feeding observed in speech therapy. Botulinum toxin injections to the masseters may help to improve oromotor function and reduce self-mutilating behaviors in children with Lesch-Nyhan syndrome who have failed more conservative treatments, providing opportunity for improved functional status and patient safety. Further investigation is indicated to establish optimal dosing. Additionally, the mechanism for the reduction of self-mutilating behavior is unclear and justifies additional investigation.

OBJECTIVE: To investigate changes in hemiparetic gait parameters after treatment of elbow flexor spasticity with botulinum neurotoxin (BoNT) injection and adjunctive casting.
METHODS: Prospective case series.
METHODS: Ten participants with spasticity secondary to acquired brain injury (8 stroke, 2 traumatic brain injury).
METHODS: Participants received BoNT injections for their spastic elbow flexors under ultrasound guid-ance. Two weeks post-injection, an elbow stretching cast was applied for 1 week.
METHODS: Assessments using the Modified Ashworth Scale (MAS), Tardieu scale V1 angle of arrest at slow speed and V3 angle of catch at fast speed, 2-min walk test (2MWT), Edinburgh Gait Score scale (EGS) and video gait analysis for step-length symmetry were conducted pre-BoNT injection (t0) and at cast removal (t1). Goal attainment scale (GAS) was used to assess changes in spasticity and gait 3 months post-injection (t2).
RESULTS: At t1, participants showed a mean increase of 16.7° (p < 0.01) on the Tardieu Scale V3 and a mean reduction of 0.5 points on the MAS (p < 0.05). There was also a mean reduction on EGS of 2.7 points (p < 0.05), and a mean increase on 2MWT of 3.1 m (p < 0.05). On the GAS, all participants report-ed impro-ved gait at t2 and 80% reported a decrease in spasticity.
CONCLUSIONS: Combining BoNT injection with casting for treatment of elbow flexor spasticity without treat-ing the lower limb may improve hemiparetic gait parameters.

Botulinum toxin (BTX) is also well-known as Botox is produced by a gram-positive anaerobic bacterium called Clostridium botulinum. Generally, clinical manifestations of BTX can be observed after consumption of contaminated food, from colonization of the infant gastrointestinal tract, as well as following the infection of the wound to this bacterium. There are seven types of this neurotoxin labeled as A, B, C (C1, C2), D, E, and F. Human botulinum is caused by types A, B, E and rarely F. The most common clinical symptoms of BTX in cosmetic goals are cervical dystonia, severe primary axillary hyperhidrosis, strabismus, neurogenic detrusor over-activity, chronic migraine, upper limb spasticity and blepharospasm. Botox has a wide range of therapeutic uses and occasionally patients receiving this treatment may experience botulism symptom including local and even distant and autonomic symptoms. Despite the efficacies of Botox in treatment of myriad neurologic and cosmetic conditions, it may carry some risk of sever adverse effects which may be the result of local or systemic spreading of the drug. Our patient was a 22 years old man who received Botox for axillary hyperhidrosis after two weeks, when most of generalized complications of botulinum toxin appeared. This case was introduced for being aware of dangerous complication of Botox. Pyridostigmine could relieve symptoms of the patient.

BACKGROUND: The latest news shows several cases of contaminated heroin that is found in different parts all over Europe. This information can be helpful for the emergency doctors to find the correct diagnosis of wound botulism in patients who are intravenous drug users.
METHODS: We describe a case of a 40-year-old man who presented to the emergency department in 2016. He suffered from mild dysarthria, diplopia, dysphagia and ptosis since two days. The CT-scan of the cerebrum and the liquor were without any pathological results. We found out that the patient is an intravenous drug user and the clinical examination showed an abscess in the left groin. So we treated him with the suspected diagnosis of wound botulism. In the emergency operation we split the abscess, made a radical debridement and complementary treated him with a high dose of penicillin g and two units of botulism antitoxin. The suspected diagnosis was confirmed a few days later by finding the Toxin B in the abscess and in the patient\'s serum. In the following days the neurological symptoms decreased and the wound healing was without any complications. The patient left the hospital after nine days; the antibiotic therapy with penicillin g was continued for several days. In a following examination, 14 days after the patient\'s discharge of the hospital, no further symptoms were found and the abscess was treated successfully without any problems.
CONCLUSIONS: Because wound botulism is a very rare disease it can be challenging to the attending physician. This case shows a fast treatment with full recovery of the patient without any further disabilities, which can be used for the future.

OBJECTIVE: IncobotulinumtoxinA is used for treating certain movement disorders but lacks published clinical data on use in chronic migraine.
METHODS: This retrospective case series was performed by using electronic chart reviews on patients receiving incobotulinumtoxinA for migraine at the Veterans Affairs San Diego Healthcare System between September 2013 and March 2014. Patients were administered 150 units each, with similar methods used for onabotulinumtoxinA injections.
RESULTS: A total of 21 patients were included in the analysis. Patients were 40 years old on average, 67% white, and 52% female. Patients had trialed an average of 4.19 oral prophylactic agents for migraine with 43% having previous history of onabotulinumtoxinA use and 29% having a history of traumatic brain injury. Patients reported a decrease in headache days per month (19.1 vs 9.1; P < 0.001) and headache intensity (8.3 vs 4.1; P < 0.001) after incobotulinumtoxinA injections. Most patients experienced an improvement in headache frequency and/or intensity (81.8%). The duration of action for these patients averaged 81.9 days (median, 70 days).
CONCLUSIONS: Significant improvements in headache frequency and intensity were observed. Chronic migraine is not an indication approved by the US Food and Drug Administration for incobotulinumtoxinA; however, the drug\'s effectiveness was documented in this small patient population.

BACKGROUND: Infantile botulism is the result of ingestion of Clostridium botulinum spores, and is the most common form of infection with botulism in the United States. Ninety percent of cases occur in infants <6 months old. The infants typically present with vague symptoms such as hypotonia and poor feeding. This article reports an infant with confirmed infantile botulism that presented to the Emergency Department (ED) with complaints of decreased feeding and absence of bowel movements for >1 week.
OBJECTIVE: Review a case of infantile botulism, its diagnosis, and treatment.
METHODS: A 4-month-old healthy Caucasian male presented to the ED with a 6-day history of decreased feeding after referral from the pediatrician. He had not had a bowel movement for 9 days, and his parents were also concerned about increasing weakness, as he was no longer able to hold his head up on his own. In the ED, he was minimally interactive. His vital signs were within normal limits, and he had hypoactive bowel sounds and decreased tone throughout. He was admitted to the Children\'s Hospital and eventually transferred to the Pediatric Intensive Care Unit requiring intubation and mechanical ventilation. The botulism immunoglobulin was administered, and a diagnosis was confirmed with positive botulinum toxin in the stool samples. Full recovery was made by the infant.
CONCLUSIONS: Awareness of the symptoms of botulism and a high degree of clinical suspicion is needed to make a prompt diagnosis.

Hemimasticatory spasm is a rare neuromuscular disorder where the patient experiences involuntary, painful spasm of muscles of mastication. Only 15 cases have been reported in literature. We present a case which was treated unconventionally with satisfactory outcome.