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Surgical intervention is rarely required for acute fissures in children, and symptoms from an acute fissure often resolve within 10-14 days of conservative medical management.

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Cordivari et al (2001) reported the findings of 14 patients with "dystonic clenched fist" (3 with cortico-basal ganglionic degeneration, 7 with Parkinson's disease, and 4 with dystonic-complex regional pain syndrome) who were treated with botulinum toxin A (BTXA, Dysport).

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In a 6-month follow-up study, Giannantoni et al (2011) examined the effect of intra-detrusor injection of 100 U botulinum toxin type A in patients with Parkinson's disease (PD) and refractory detrusor overactivity.

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Topical 2 per cent diltiazem ointment used as an agent for chemical sphincterotomy for chronic anal fissure offers significant healing rates but does not have a significant side-effect profile, which may aid compliance to treatment.

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The authors concluded that physicians need to be aware of this possible complication, consider alternate injection techniques and antiseptic preparation before injection.

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The AAN's assessment on the use of botulinum neurotoxin in the treatment of movement disorders (Simpson et al, 2008b) stated that botulinum neurotoxin should be considered a treatment option for essential hand tremor in those patients who fail treatment with oral agents.

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Endoscopic injection of botulinum toxin is presently the best studied treatment option but many questions remain unanswered.

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