Abstract Committee Review

The abstract has significantly improved following the revision. However, it may still be challenging for readers to discern how much of the observed effect can be attributed to the additional injected muscles (see below), as opposed to the longus capitis and longus cervicis. This raises a further question: if previous injection cycles targeting these more superficial muscles failed to produce a noticeable effect, what is the rationale for continuing to include them? Please clarify these questions.

11.4

Thank you so much for all your help.

Please, forward my response to the responsible reviewer:

"I would like to begin by expressing my sincere gratitude for the opportunity to resubmit my abstract and for the time and attention you have devoted to reviewing it.

With regard to your thoughtful and valid observations, please allow me to address them as follows:

• Due to the word-limit constraint, I was unable to fully elaborate on the rationale underlying the selection of the muscles. It is standard practice in our clinic to perform needle electromyography of the muscles you mentioned when assessing dysphonic patients and, since they were activated , these muscles were therefore targeted primarily to address the patient’s complaints of dysphonia and pain.
• According to the most recent literature on the subject, none of these muscles are implicated in the dystonic pattern exhibited by the patient (anterocollis/anterocaput), however, the longus colli and longus capitis are. I have added a paragraph to the abstract to clarify this point.
• Should you consider it preferable for the sake of clarity, I would be pleased to revise this section of the manuscript to include only the longus colli and longus capitis muscles, as these have been identified as responsible for the patient’s abnormal posture.

Once again, I wish to express my appreciation for your valuable feedback and for the opportunity to improve my work. Please do not hesitate to contact me should any further clarification be required."

Yours sincerely,

Caio Gomes

I am very sorry to hear that. If I may, I would like to offer a few remarks regarding your very pertinent observations:

• Regarding the assessment: we used a range of motion comparison (before and after injection). I do have the corresponding photographs of these measurements, but due to an oversight on my part, they were unfortunately not included with the rest of the paper.
• As mentioned, in the abstract we state that EMG evaluation was performed prior to injection. After confirming muscle activation, we used the same point of access and depth to reach and inject the deeper layer muscles.

I took the liberty of rewriting the abstract with your insightful comments in mind. I would be very grateful if you could kindly review it again.

With the kindest regards,

Caio Gomes

In the case presented, there is no description of which specific muscles were previously targeted, apart from a general reference to superficial and deep muscles. The current treatment with BTX-A was performed using the anatomical landmark technique, which does not allow for documentation confirming that the injections reached the longus colli or longus capitis. Furthermore, no objective measurements were used to assess the effect of the treatment.

Injection of the longus colli and longus capitis can be crucial in managing antecollis and anterocapitis. However, the anatomical landmark technique is not recommended for these muscles due to the difficulty in ensuring accurate targeting.