Standardization of sternocleidomastoid for botulinum toxin applications*

Abstract

Objectives: Botulinum toxin is frequently applied to the sternocleidomastoid muscle (SCM) for torticollis treatment. During

this application, bulb of the jugular vein located under SCM makes the interventions unsafe. Also, injecting the botulinum

toxin into the infrahyoid muscles which lie under SCM may cause hoarseness and swallowing disorders. The aim of this study

was to describe the most reliable and appropriate botulinum toxin injection sites to the SCM to avoid injury to neighboring

neurovascular structures and adjacent muscles.

Methods: In ten male cadavers, SCM was evaluated in three equal segments (upper, middle and lower). Muscle width and thickness

at the center of each segment were measured. In one male cadaver, colored latex was injected according to the results of

the measurements.

Results: The respective mean width of upper, medial and lower segments were 33.15 (23–41) mm, 36.45 (28–45) mm and,

39.35 (15–50) mm, respectively. The mean thickness of upper, medial and lower segments were 5.29 (3.87–7.68) mm, 5.89

(3.56–8.32) mm and 3.60 (0.69–7.75) mm, respectively. There was no significant difference between the right and left sides.

The thickest part of the muscle was the middle part, and the lower part was the thinnest. When the colored latex injected cadaver

was dissected, the center of the muscle was observed as colored, while the neighboring structures were avoided. The thickest

and safest part of SCM for the botulinum toxin injections was the middle part.

Conclusion: Knowing the thickness of SCM will make the botulinum toxin applications to this muscle safer and easier.

Keywords

• botulinum toxin; muscle thickness; sternocleidomastoid; swallowing disorder; torticollis

References

1. 1. Hanagasi HA. Cervical dystonia and botulinum toxin treatment. Nöropsikiyatri Arflivi 2006;43:27–30.
2. 2. Tomczak KK, Rosman NP. Torticollis. J Child Neurol 2013;28:365– 78.
3. 3. Bledsoe IO, Comella CL. Botulinum toxin treatment of cervical dystonia. Semin Neurol 2016;36:47–53.
4. 4. Bhidayasiri R. Treatment of complex cervical dystonia with botulinum toxin: involvement of deep-cervical muscles may contribute to suboptimal responses. Parkinsonism Relat Disord 2011;17:S20–4.
5. 5. Borodic GE, Joseph M, Fay L, Cozzolino D, Ferrante RJ. Botulinum A toxin for the treatment of spasmodic torticollis: dysphagia and regional toxin spread. Head Neck 1990;12:392–9.
6. 6. Scott AB. The role of botulinum toxin type A in the management of strabismus. In: Scientific and therapeutic aspects of botulinum toxin. Brin MF, Hallett M, Jankovic J, editors. Philadelphia (PA): Lippincott Williams and Wilkins; 2002. p. 189–95.
7. 7. Comella CL. Cervical dystonia: treatment with botulinum toxin serotype A as Botox or Dysport. In: Scientific and therapeutic aspects of botulinum toxin. Brin MF, Hallett M, Jankovic J, editors. Philadelphia (PA): Lippincott Williams and Wilkins; 2002. p. 359– 364.
8. 8. Blitzer A, Zalvan C, Gonzalez-Yanez O, Brin MF. Botulinum toxin type A injections for the management of the hyperfunctional larynx. In: Brin MF, Hallet M, Jankovic J, editors. Scientific and therapeutic aspects of botulinum toxin. Philadelphia (PA): Lippincott Williams and Wilkins; 2002. p.207–16.

9. 9. Brin MF, Binder W, Blitzer A. Botulinum toxin type A BOTOX for pain and headache. In: Brin MF, Hallett M, Jankovic J, editors. Scientific and therapeutic aspects of botulinum toxin. Philadelphia (PA): Lippincott Williams and Wilkins; 2002. p. 233–50.
10. 10. Schwartz MFB. Botulinum toxin A therapy for temporomandibular disorders. In: Brin MF, Hallett M, and Jankovic J, editors. Scientific and therapeutic aspects of botulinum toxin. Philadelphia (PA): Lippincott Williams and Wilkins; 2002. p. 259.
11. 11. Tintner RJJ. Botulinum toxin type A in the management of oromandibular dystonia and bruxism. In: Brin MF, Hallett M, and Jankovic J, Editors. Scientific and therapeutic aspects of botulinum toxin. Philadelphia (PA): Lippincott Williams and Wilkins; p. 343–50.
12. 12. Stephan S, Wang TD. Botulinum toxin: clinical techniques, applications, and complications. Facial Plast Surg 2011;27:529–39.
13. 13. Shaari CM, George E, Wu BL, Biller HF, Sanders I. Quantifying the spread of botulinum toxin through muscle fascia. Laryngoscope 1991;101:960–4.
14. 14. Anderson TJ, Rivest J, Stell R, Steiger MJ, Cohen H, Thompson PD, Marsden CD. Botulinum toxin treatment of spasmodic torticollis. J R Soc Med 1992;85: 524–9.
15. 15. Hong JS, Sathe GG, Niyonkuru C, Munin MC. Elimination of dysphagia using ultrasound guidance for botulinum toxin injections in cervical dystonia. Muscle Nerve 2012;46:535–9.
16. 16. Arts IM, Pillen S, Schelhaas HJ, Overeem S, Zwarts MJ. Normal values for quantitative muscle ultrasonography in adults. Muscle Nerve 2010;41:32–41.
17. 17. Park SY, Kim MJ, Kim MG, Lee SJ, Kim SH, Ok SY, Kim SI. Changes in the relationship between the right internal jugular vein and an anatomical landmark after head rotation. Korean J Anesthesiol 2011;61:107–11.
18. 18. Proverbio MR, Lamba M, Rossi A, Siani P. Early diagnosis and treatment in a child with foodborne botulism. Anaerobe 2016;39: 189–92.
19. 19. Ye JF, Lee JH, An XC, Lin CH, Yue B, Han SH. Anatomic localization of motor entry points and accurate regions for botulinum toxin injection in the flexor digitorum superficialis. Surg Radiol Anat 2011;33:601–7.
20. 20. Lee JH, Lee BN, Han SH, An XC, Chung RH. The effective zone of botulinum toxin A injections in the sternocleidomastoid muscle. Surg Radiol Anat 2011;33:185–90.
21. 21. Delnooz CC, Veugen LC, Pasman JW, Lapatki BG, van Dijk JP, van de Warrenburg BP. The clinical utility of botulinum toxin injections targeted at the motor endplate zone in cervical dystonia. Eur J Neurol 2014;21:1486–98.
22. 22. Loukas M, Louis RG Jr, Childs RS. Anatomical examination of the recurrent artery of Heubner. Clin Anat 2006;19:25–31.
23. 23. Apaydin N, Uz A, Evirgen O, Loukas M, Tubbs RS, Elhan A. The phrenico-esophageal ligament: an anatomical study. Surg Radiol Anat 2008;30:29–36.