Botox Injection Severe Side Effects Treatment

Side effects from botox injections are not uncommon and even expected to some degree in the region where the injection was performed. For example, when botox is injected into the voicebox for spasmodic dysphonia, normal and expected side effects include hoarseness and dysphagia.

However, in very rare instances, more severe side effects may occur that may even appear to be life-threathening including stridor, shortness of breath, profound difficulty swallowing, etc.

In such situations, beyond supportive care and ruling out more serious conditions like a heart attack, treatment with pyridostigmine can be quite effective in alleviating if not outright reversing the severe botox side effects.

Pyridostigmine is a drug that prevents the body from breaking down the chemical mediator (acetylcholine) that causes muscle contraction. Given botox works by preventing the release of acetylcholine, it makes sense that by preventing the body from breaking this hormone down, more of it is around to activate the muscle.

Put simply, pyridostigmine increases acetylcholine levels to counteract the botox effect of decreasing acetylcholine leading to a net zero effect theoretically. But does it work that way? According to one research paper, it certainly appears to do so!

In cases of stridor due to bilateral vocal cord paralysis or other severe side effect, an initial treatment of 300 mg of pyridostigmine x 2 doses separated by 6 hours followed by 30 mg 3x per day is recommended. Symptom improvement occurs fairly rapidly.

In less dire situations, simply starting a patient on pyridostigmine 30 mg 3x per day without an initial loading dose is sufficient.

Otherwise, behavioral support alone is recommended for less severe botox side effects.

Reference:

Pyridostigmine for Reversal of Severe Sequelae From Botulinum Toxin Injection. Journal of Voice. 2014 Jul 5. pii: S0892-1997(14)00091-5. doi: 10.1016/j.jvoice.2014.04.010. [Epub ahead of print]

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Treatment for Vocal Tremor

Vocal tremor is characterized by a rhythmic undulating vocal quality whenever talking, much akin to vibrato that can not be turned off. In the past, it was felt that use of botulinum toxin type A (botox) to treat vocal tremor was not possible nor realistic given the multiple muscle groups involved. This is in contrast to dystonias of the voice (i.e., spasmodic dysphonia) where only one muscle group is involved and is readily and easily treated with botox injections to the affected vocal cord muscle.

However over the past few years, several research papers have been produced that show that botox CAN alleviate (though not eliminate) vocal tremor both objectively and subjectively, though more than one site may need to be injected in order to produce vocal tremor relief. Such muscle sites include thyroarytenoid muscle, ventricularis muscle, lateral cricoarytenoid muscle, interarytenoid muscle, cricothyroid muscle, and strap muscles.

All these muscle sites are easily accessible either via, endoscopic guidance and/or EMG guidance alone. Indeed, physicians who already perform botox injections for spasmodic dysphonia should also be able to inject all the other muscle groups just as easily. [watch video]

Typically, "horizontal" vocal tremor is treated with thyroarytenoid, ventricularis, interarytenoid, and/or lateral cricoarytenoid muscle botox injections.

"Vertical" vocal tremor is treated with strap muscle botox injections.

Dosages are similar to that given to treat spasmodic dysphonia.

SO... for patients suffering from vocal tremor who do not respond well to oral medications (propranolol, primidone), consider botox injections!

Be aware that botox injections to treat vocal tremor may not be covered by insurance.

References:
A new paradigm for the management of essential vocal tremor with botulinum toxin. Laryngoscope. 2013 Apr 1. doi: 10.1002/lary.24073. [Epub ahead of print]

Botulinum toxin type A for treating voice tremor. Arch Neurol. 2004 Sep;61(9):1416-20.

Botulinum toxin for essential tremor of the voice with multiple anatomical sites of tremor: a crossover design study of unilateral versus bilateral injection. Laryngoscope. 2000 Aug;110(8):1366-74.

Tremor laryngeal dystonia: treatment of the lateral cricoarytenoid muscle. Ann Otol Rhinol Laryngol. 2004 May;113(5):349-55.

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Fake Botox Being Sold to US Physicians: FDA Sends Warning

It is not just patients trying to save money when purchasing medications from online pharmacies located in Canada. It's doctors as well when it comes to expensive drugs like Botox made by Allergan which costs a physician practice $550 per vial (2012 price)... but if purchased from Canada, may cost hundreds less.

Unfortunately, just like prescription drugs purchased outside the US, foreign-purchased Botox may be a product that is potentially unapproved, counterfeit, unsafe, or ineffective. Indeed, medical practices that purchase and administer such illegally obtained and unapproved medications from foreign sources are placing patients at risk and potentially depriving them of proper treatment.

To address this dangerous practice, the FDA has alerted more than 350 medical practices that they may have received unapproved medications, including unapproved versions of Botox from foreign-based suppliers, especially from Canada.

Disclaimer! Our practice has ALWAYS purchased Botox directly from Allergan, the maker of Botox, and have never purchased Botox from a third party supplier, whether US-based or not, past and present.

The ones the FDA specifically listed on a watch-list of sorts under the umbrella of online Canada Drugs include:

• Quality Specialty Products (QSP)
• A+ Health Supplies
• QP Medical
• Bridewater Medical
• Clinical Care

Per the FDA, "many, if not all, of the products sold and distributed by these suppliers have not been approved by FDA. Therefore, FDA cannot confirm that the manufacture and handling of these products follow U.S. regulations or that these medications are safe and effective for their intended uses."

The FDA has also publicly released the names of physicians and physician groups who have purchased from these online sources... public humiliation in order to persuade a change?

However, it may not be just public humiliation, but even jail-time for one physician in a particularly egregious case (Botox not meant for human use was deliberately and knowingly injected).

It's not just doctors, but even medical institutions on the list (ie, University of SW Texas Medical Center).

Source:
Letters to Doctors about Risks of Purchasing Unapproved Versions of Botox and Other Medications from Foreign or Unlicensed Suppliers. FDA 12/19/12

FDA warns doctors of counterfeit Botox. Fox News 12/24/12

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Julie Andrews and Her "Botched Throat Surgery"

It has already been well-publicized that the former singing sensation Julie Andrews underwent some type of throat surgery in 1997 after which she never regained her phenomenal 4-octave voice thus relegating her to more conventional roles of being an actress without the singing. This "botched throat surgery" per Julie Andrews lead to a lawsuit that was ultimately settled.

It is unknown precisely what type of (presumed) vocal cord pathology was present as well as what type of surgical approach was used to try and fix it. In a recent interview, she stated:

"The operation that I had left me without a voice and without a certain piece of my vocal chords"

However, given her aggressive and active singing career prior to surgery, she probably had vocal cord nodules, a benign growth that occurs due to vocal overuse, a situation not uncommon with professional singers.

Vocal cord nodules are most always due to excessive voice use leading to "callous" formation on the vocal cord lining, much like shoveling dirt will eventually lead to callous formation on the hands.

Traditional standard of care management of vocal cord nodules is voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). However, resolution of nodules with such behavior focused treatment takes months. However, although it takes a while for the nodules to resolve with this treatment method, they typically do not come back.

For patients who are more "impatient" for results (not unusual with professional singers whose livelihoods depend on singing), there are more aggressive ways to address vocal cord nodules with possible resolution within weeks. However, the caveat is if the underlying voice behavior that led to nodule formation in first place is not addressed, the vocal cord nodule WILL recur after initial resolution/improvement. Furthermore, as with any more invasive treatments to obtain a "quick fix", scar formation may occur leading to permanent voice changes, usually for the worse which obviously happened with Julie Andrews.

What are some of these more invasive treatments beyond voice therapy? To reiterate, these procedures also have a high risk of recurrence if underlying abusive voice behavior that led to the nodule formation in first place is not first addressed.

• Surgical excision can be performed, but can lead to permanent scar formation during the healing process that can lead to persistent irreversible hoarseness.

• Botox injection can also be pursued which causes a "partial" vocal cord paralysis preventing the repetitive trauma in the region of the vocal cord nodule.

• Steroid injection to the vocal cord nodule(s) can possibly resolve or reduce the nodule resulting in improved vocal quality within weeks. Such local injection technique has mainly been performed in the treatment of spasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis. Watch a video how a "local injection" to the vocal cord can be performed (video shows injection of vocal cord granuloma rather than nodule, but overall approach is identical).

Read more about vocal cord nodules here.

Source:
Julie Andrews' Voice Isn't Coming Back, But She's Not Staying Silent. Huffington Post 12/5/12

PUBLIC LIVES; Julie Andrews Sues Throat Surgeon. NYT 12/15/99

Julie Andrews Settles Lawsuit Against Doctors. ABC News 9/7/12

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Steroid Injection to Eliminate Vocal Cord Nodules

Vocal cord nodules are most always due to excessive voice use leading to "callous" formation on the vocal cord lining, much like shoveling dirt will eventually lead to callous formation on the hands.

Traditional standard of care management of vocal cord nodules is voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). However, resolution of nodules with such behavior focused treatment takes months. However, although it takes a while for the nodules to resolve with this treatment method, they typically do not come back.

For patients who are more "impatient" for results, there are more aggressive ways to address vocal cord nodules with resolution within weeks. However, the caveat is if the underlying voice behavior that led to nodule formation in first place is not addressed, the vocal cord nodule WILL recur after initial resolution/improvement.

Recently, there have been several studies that have shown that steroid injection directly into vocal cord nodule can resolve or reduce the nodule resulting in improved vocal quality within weeks. Such local injection technique has mainly been performed in the treatment of spasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis.

In the most recent study published Oct 2011, researchers have found that in a group of 80 patients, 44% had complete resolution of the nodule and another 49% had improvement within 4 weeks after injection of the nodule with Kenalog 40. 8% had recurrence of the nodule after initial improvement due to persisting in a high voice-use occupation. 4 patients suffered vocal cord atrophy and 2 patients developed a white plaque that resolved spontaneously 1-2 months after injection.

Watch a video how a "local injection" to the vocal cord can be performed (video shows injection of vocal cord granuloma rather than nodule, but overall approach is identical).

Beyond voice therapy and steroid injections, there are other ways of dealing with vocal cord nodules, but also have a high risk of recurrence if underlying abusive voice behavior that led to the nodule formation in first place is not first addressed.

• Surgical excision can be performed, but can lead to permanent scar formation during the healing process that can lead to persistent hoarseness.

• Botox injection can also be pursued which causes a "partial" vocal cord paralysis preventing the repetitive trauma in the region of the vocal cord nodule.

Read more about vocal cord nodules here.

References:
Local steroid injection via the cricothyroid membrane in patients with a vocal nodule. Arch Otolaryngol Head Neck Surg. 2011;137(10):1011-1016. doi:10.1001/archoto.2011.168

Steroid injection to vocal nodules using fiberoptic laryngeal surgery under topical anesthesia. Eur Arch Otorhinoloaryngol. 2004. 261(9):489-492.

Laryngeal steroid injection. Curr Opin Otolarngol Head Neck Surg. 2009. 17(6): 424-426.

Office Steroid Injections of the Larynx. Laryngoscope. 2006. 116(10):1735-1739.

Percutaneous corticosteroid injection for vocal fold polyp. Arch Otolaryngol Head Neck Surg. 2009. 135(8):776-780.

Intracordal injection of dexamethasone. Pract Otorhinoloaryngol (Basel). 1964. 57(3):496-500.

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