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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Does Stridor HAVE to be Present for Diagnosis of Vocal Cord Dysfunction?

Laryngospasm, the most severe form of vocal cord dysfunction, does include stridor as a symptom. However, a patient can still suffer from vocal cord dysfunction and even laryngospasm without an obvious stridor present.

In order to understand stridor's relationship to vocal cord dysfunction (VCD), one must first understand what exactly is happening anatomically... or skip to the bottom of the article if you already understand the basics.

When a person breathes, the vocal cords move apart allowing air to pass easily through and into the windpipe. When a person talks, the vocal cords come together and vibrate allowing for voice production. [watch video]

Vocal cord dysfunction is when the vocal cords come together (instead of apart) when a person is trying to inhale air. Given the physically smaller airway created by the approximated vocal cords, the patient would typically experience shortness of breath and some wheezing.

Laryngospasm is when the vocal cords come completely together when a patient is trying to breath and stridor is typically produced with attempted strong inhalation against closed vocal cords.

Watch a video showing both types here.

As such, in order for stridor to be produced, TWO things must be present:

1) The vocal cords need to be nearly or completely closed together.
2) There must be strong breathing attempts

If any two elements are absent, stridor will not occur.

For example, if a patient is in a full-fledged laryngospasm attack, but is either breath-holding or making weak attempts at breathing, no stridor will occur.

Conversely, if a patient is suffering from a severe case of vocal cord dysfunction and is breathing hard enough, due to venturi effect against vocal cords that are almost closed (but still open), stridor like sounds may occur.

Venturi effect???

What's that?

In essence, it is a physics concept whereby there is a reduction in pressure when a fluid (or air) flows through a constricted section of a pipe (or airway) in this case.

In essence, the venturi effect as it applies to the voicebox, is a highly localized area of negative pressure created between the vocal cords when a person is breathing fast causing the vocal cords to come together even more... leading to more "sound" with breathing even if the vocal cords are not completely together.

It is perhaps one reason why athletes who suffer from vocal cord dysfunction may sound like they are suffering from laryngospasm during a VCD attack while exercising. Technically, it may not be laryngospasm because the vocal cords are still apart, but due to the venturi effect, causes a functional vocal cord closure leading to aggressive vocal cord vibration and a stridor-like sound production.

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Benign Stridor Often Mistaken for Laryngospasm

Laryngospasm causes a high-pitched squeak or wheezing sound when a person is trying to breath due to abnormal vocal cord movement. Watch video regarding this condition.

Larygnospasm (the most severe form of vocal cord dysfunction) is commonly misdiagnosed as asthma and patients may go for years labelled as asthmatic even though they may not have it at all.

However, though laryngospasm is often the victim of misdiagnosis, there is a condition known as non-organic stridor which is often misdiagnosed as laryngospasm (culprit as well as victim of misdiagnosis).

Here is a video example (watch the movie clip all the way to the end) of a patient with non-organic stridor who was initially misdiagnosed with asthma, than misdiagnosed as having vocal cord dysfunction/laryngospasm before being finally correctly diagnosed with having non-organic stridor.

As you can see, the vocal cords remain apart which immediately rules out the diagnosis of laryngospasm.

What is also apparent is the wheeze or stridor noise is due to vocal cord vibration while they are apart.

The fast moving inhalation/exhalation literally rattles the vocal cord membranes just like a strong wind flaps around an American flag resulting in "noise". No need for the vocal cords to come together to create the noise. The fast moving air does it all by itself.

The existence of non-organic stridor is one of the main reasons why laryngoscopy during a "breathing attack" suspected to be due laryngospasm is so important.

It's also why I have my patients run around my office until they become symptomatic before I perform this exam. Why do an exam when breathing is completely normal???

What is the treatment? Just reassurance... Given it is the fast-moving air that is causing the noise, one simply has to slow the breathing down. No inhalers, no epinephrine, no medications are needed.

For whatever reason, by far the most common patient who suffers from non-organic stridor is a female high school athlete.

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