Friday, January 25, 2008

Botox Deaths (and the real story)

The news reports from January 24, 2008—in typical news fashion—are shocking: Death from Botox! [<--see the Reuters article] As always, though, the devil is in the details and those are conspicuously absent from these news articles. Just today I had a patient in the office expressing her fear over the idea of getting "botulism" from injections for her forehead wrinkles. "It's all over the news," she exclaimed, which is what prompted me to post this quick blog entry. Here's my take on the story and what you should understand about these news reports. Botox (botulinum toxin type A) from Allergan is used for much more than just wrinkles. For many years, and long before it was approved for cosmetic use, Botox was and is used for the treatment of muscle tension disorders. Prominent among these are its use in a vocal cord disorder called spasmodic dysphonia and for a neck muscle disorder called cervical dystonia ("wry neck"). In both instances, Botox is injected into these hyperactive muscles to weaken them, generally to the suffering patient's great satisfaction.

So I suspect, based on the reports, that none of these tragic deaths were among patients receiving Botox Cosmetic for their facial wrinkles. Rather, I would bet, those who died were patients receiving injections on their neck muscles and vocal cords.

Take, for example, the case of vocal cord injections. Most people think their vocal cords are primarily for speaking, but their most important function is protecting the airway (the windpipe and lungs) from food, liquids, saliva, etc., from going down the wrong way. We all have experienced when that critical reflex doesn't work, such as when we're eating and laughing at the same time: we choke and cough violently.

But imagine the patient who's received a little too much Botox in their vocal cords during treatment for their voice disorder. As the paralysis kicks in, they become unable to protect their airway. This provides the perfect setting for conditions known as aspiration pneumonia or chemical pneumonitis from food, liquids, secretions, etc. getting into the lungs. These are potentially fatal complications.

Or consider the situation where a child with cervical dystonia needs his or her neck muscles relaxed: a small neck, a big muscle (the sternocleidomastoid muscle), and distorted anatomy from the twisted neck. In addition, larger quantities of Botox are needed to relax a big muscle like this. But just fractions of an inch from it lies the esophagus though which we swallow...and which is basically a long tubular muscle.

If enough Botox is injected around the esophageal or pharyngeal muscles of the throat, the resulting paralysis can make swallowing difficult or impossible. And where does that food go when it won't go down the esophagus? It obstructs the esophagus or spills into the airway, possibly choking the patient.

So could Botox migrate from the forehead muscles (frontalis muscle), frown lines (corrugator supercilii and procerus muscles), or crow's feet (orbicularis muscle) far enough and in sufficient quantity to cause death? The short answer is "No."*

*Of course, there's always a caveat. If the person injecting you is using illegal botulinum toxin and accidentally injects about 100,000 times (!) the usual dose, you could end up on a ventilator for a few months.

[FYI: the LD50 of botulinum toxin for adult humans is estimated at about 3000 units (LD50 is the "lethal dose 50%", or the dose required to kill 50% of subjects receiving a given toxin). Typical cosmetic doses are about 5 to 40 units of Botox...a pretty safe margin, I must say.]


  • You'll find that the media love the stories about how something that everyone loves or wants actually gives you cancer or hemorrhoids... Botox is no different. Take everything with a grain of salt for sure.
    BTW: Love docs that blog.

    By Anonymous Botox Patient, at June 28, 2010 at 6:36:00 PM EDT  

  • Thanks! And you're right.

    It's really crazy how hardly a day goes by that there isn't some story about Botox and its hazards. Most are wildly overblown if not flat out wrong.

    It's a great product. It works. And gosh darn it, people like it! :-)

    By Blogger David C. Pearson, M.D., at June 28, 2010 at 6:57:00 PM EDT  

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