Objective: Cervical dystonia is the most commonly described dystonia. Since examinations of the muscle using imaging techniques were started [1], the classification of the phenomenological forms in 11 variants has been described: COL CAP Concept (CCC). Among them, the anterior forms (Antecaput [ACa] and Antecollis [ACo]) are the most difficult to treat [2].

Background: The ACo can be treated under imaging (CT, ultrasound) approximately at the 5th neck vertebra by botulinum toxin (BTX) injection [3]. The injection of the ACa is more difficult. Here, the longus capitis muscle (LCa) and the pars obliqua superior of the longus colli (LCo) are often dystonic.

Methods: An inspection of the nasopharynx/oropharynx upon autopsy showed that both muscles are clearly visible after removal of the anterior cervical fascia: LCa lateral, LCo medial [figure1]. To reach the LCa for BTX injection, we propose an endoscopically guided injection under short-acting anaesthesia; the endoscope is passed through the mouth the oropharynx. In the event of an LCa dystonia, you can detect the hypertrophied protruding LCa and LCo at the 1st cervical vertebra.

Results: We examined 15 patients endoscopically for this, who did not suffer from cervical dystonia and found that there was no hypertrophy of the LCa and LCo. In eight patients who suffered from pronounced ACa, we found distinct hypertrophic muscles. Upon inspection of the nasopharynx, such muscle hypertrophy was found on each side: LCa. Two hypertrophic muscles were found on each side in the area of the oropharynx: lateral the LCa and medial the pars obliqua of the LCo [figure2 cannula in LCa]. Depending on whether only the LCa or also the pars superior of the LCo were hypertrophic, we injected 0.3 ml BTX into each of these muscles (corresponds to 60 units of abobotulinum toxin A). In all cases, there was already a clinical weakening of ACa after a few hours, which we attribute to the infiltration of the muscle with the BTX liquid without BTX already having been able to cause an effect.

Conclusions: We recommend using this method for the treatment of ACa, in which case an injection with BTX in the muscles should be carried out only if there is a visible hypertrophy. Literature 1. Reichel, G. BaGa 2011;1:5-12 2. Finsterer J et al J Neurol Sci. 2015;15(355):37-43 3. Flowers JM et al Mov Disord. 2011;26(13):2409-14.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/endoscopic-guided-injection-of-botulinum-toxin-into-the-longus-capitis-muscle-and-into-the-obliquus-superior-part-of-the-longus-colli-muscle-in-dystonic-antecaput/