With a sufficient dose, this acute muscle weakness can result in difficulty speaking, swallowing, and blurred vision. Nervenarzt. The therapeutic effect derives from the ability to minimize muscle tension and enhance muscle relaxation. The following adverse reactions with BOTOX 200 Units were reported at any time following initial injection and prior to re-injection or study exit (median duration of exposure was 44 weeks): urinary tract infections (49%), urinary retention (17%), constipation (4%), muscular weakness (4%), dysuria (4%), fall (3%), gait disturbance (3%), and muscle spasm (2%). Muscle fatigue and shortness of breath can persist for years. Botulinum Toxin, known commonly as 'Botox', is a popular cosmetic and medical treatment designed to reduce the signs of ageing, such as fine lines and wrinkles. Urinary incontinence from detrusor overactivity. The mechanism of action, formulations, clinical use, and safety of botulinum toxin injections for cosmetic indications will be reviewed here. When injected, BTX blocks nerve signals to muscles so they relax. Botulinum toxin, the causal agent of botulism, is employed in therapeutic settings for a number of purposes. Use of anticholinergic drugs after administration of BOTOX may potentiate systemic anticholinergic effects. Jia Z, Lu H, Yang X, Jin X, Wu R, Zhao J, Chen L, Qi Z. [10]Aesthetically this can diminish wrinkles by confined muscle relaxation and smoothing the overlying dermis. Botulinum toxin is a medication used in the management and treatment of therapeutic and cosmetic purposes. On muscle spindles, dystonia and botulinum toxin. Botulinum toxin: mechanisms of action. Patients were followed for an average of 89 days after injection. Douillard FP, Derman Y, Woudstra C, Selby K, Mklin T, Dorner MB, Saxn H, Dorner BG, Korkeala H, Lindstrm M. mBio. Ann Otolaryngol Chir Cervicofac. Arnon SS, Schechter R, Inglesby TV, Henderson DA, Bartlett JG, Ascher MS, Eitzen E, Fine AD, Hauer J, Layton M, Lillibridge S, Osterholm MT, O'Toole T, Parker G, Perl TM, Russell PK, Swerdlow DL, Tonat K., Working Group on Civilian Biodefense. [4]The toxin has also shown effectiveness in other medical conditions, such as strabismus and hypersalivation. Clinical improvement starts within 3-5 days, and patients can expect to have relaxation of the muscle and decreased pain for 6 months. Some of these patients had risk factors including cardiovascular disease. [8]These unfavorable effects can serve up to three months. Initial symptoms of botulism poisoning include difficulty seeing, speaking, and/or swallowing. When the effects of the medication wear off. Botox Cosmetic (onabotulinumtoxinA)." 2022 Jul 26;23(15):8206. doi: 10.3390/ijms23158206. Initial symptoms of botulism poisoning include difficulty seeing, speaking, and/or swallowing. No special precautions are needed for botulism patients in the hospital; as with all patients, standard precautions should be followed. If any of these effects persist or worsen, notify your doctor or pharmacist promptly. Table 18: Adverse Reactions Reported by 3% of BOTOX Treated Pediatric Patients within the First 12 Weeks after Intradetrusor Injection, Study 191622-120. Reported uses of botulinum toxin SPASTICITY Spasticity can lead to significant physical problems including spasms, restricted range of movement, pain, and contractures, as well as functional difficulties including the maintenance of personal hygiene. [5]The neurotoxin formulation onabotulinumtoxin A is amongst the popular cosmetic procedures practiced in America. Would you like email updates of new search results? However, an in vitro study conducted by Solaja et al. After two to three months, the effects start to fade. Recommendations based on this study include: 1) Botulinum toxin injections are recommended for the treatment of adolescents and adults with localized and bothersome simple motor tics when the benefits of treatment outweigh the risks (Level C). Both medical and cosmetic Botox injections last for between three and six months. In: StatPearls [Internet]. [5]Aesthetically, all three serotypes Aforms are used for wrinkles and facial lines. These side effects may go away during treatment as your body adjusts to the medicine. Botulinum toxin is produced by a specific type of bacteria. Plast. Several studies with the BOTOX Cosmetic (onabotulinumtoxinA; Allergan, Inc., Irvine, CA, USA) formulation of botulinum toxin type A (BoNTA) included relapse rates, defined conservatively as return to baseline levels of line severity for two consecutive visits approximately 30 days apart (at repose and maximum contraction). The botulinum toxin contained in Botox can spread to other body areas beyond where it was injected. Botulinum toxin as a biological weapon: medical and public health management. Common (1% to 10%): Fatigue, asthenia, fever, Frequency not reported: Focal facial paralysis, syncope, exacerbation of myasthenia gravis, Postmarketing reports: Hypoacusis, hypoesthesia, malaise, radiculopathy, tinnitus[Ref], Common (1% to 10%): Pruritus, skin tightness, Frequency not reported: Diffuse skin rash, Postmarketing reports: Alopecia (including madarosis), hyperhidrosis, pruritus, skin rash, erythema multiforme, dermatitis psoriasiform, psoriasiform eruption[Ref], Common (1% to 10%): Flu syndrome, infection, Frequency not reported: Immunogenicity (formation of neutralizing antibodies to botulinum toxin type A which may reduce the effectiveness of therapy)[Ref], 1. Seek medical care or call 911 at once if you have the following serious side effects: This document does not contain all possible side effects and others may occur. [8], The human LD50for inhalation botulism is 1 to 3 ng/kg body mass. Timely administration of antitoxin minimizes further nerve damage by the toxin, but it cannot reverse paralysis that has already occurred. Identify the mechanism of action of Botulinum toxin. [2]Clostridium botulinum is a spore-forming, gram-positive, anaerobic bacterium. Needle-related pain and/or anxiety may result in vasovagal responses (including syncope, hypotension), which may require appropriate medical therapy. 1996;113(2):73-8. Bethesda, MD 20894, Web Policies Temporary drooping eyelids (ptosis). In addition, if the botulinum toxin is . Distant spread of toxin effects - The effects of onabotulinumtoxinA and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects. We examined its effect on quality of life and other person-centred perspectives. However, only small, weaker doses of botulinum toxin are used to reduce facial wrinkles. Adverse Events of Botulinum Toxin Type A in Facial Rejuvenation: A Systematic Review and Meta-Analysis. However, it may be associated with more severe signs and symptoms [see WARNINGS AND PRECAUTIONS]. [2] Infection with the bacterium causes the disease botulism. Botulinum Toxin: Pharmacology and Therapeutic Roles in Pain States. Change of stretch reflex threshold in spasticity: effect of botulinum toxin injections. Botulinum toxin is least effective when: Used alone in large deviations Restrictive or mechanical strabismus (e.g. Symptoms associated with flu-like symptoms (e.g., nausea, fever, myalgia) have been reported after treatment. [4]All four types are approved globally for treating spasmodic torticollis, a condition that can cause fixed head posturing or abnormal head movements. Dysphagia and symptomatic general weakness may be attributable to an extension of the pharmacology of BOTOX resulting from the spread of the toxin outside the injected muscles [see WARNINGS AND PRECAUTIONS]. [18][12], These treatments are in addition to supportive therapy. The most common adverse reactions in patients who received BOTOX 6 U/kg and less than a total dose of 200 U in Study 191622-120 were urinary tract infection (UTI), bacteriuria and hematuria. Several in vitro and in vivo studies have reported the effect of botulinum toxin (BT) on tumour tissue in the prostate. [Ref], Very common (10% or more): Dysphagia (up to 19%), Frequency not reported: Swallowing difficulties, jaw pain, Postmarketing reports: Abdominal pain, diarrhea, dry mouth, vomiting, anorexia[Ref], Patients in the upper limb spasticity trials who had stable, reduced respiratory function at baseline experienced a greater event rate change in forced vital capacity (15% or greater or 20% or greater decline) compared with placebo at weeks 1, 6, and 12. sharing sensitive information, make sure youre on a federal Before Check with your physician for additional information about side effects. Localized pain, infection, inflammation, tenderness, swelling, erythema, and/or bleeding/bruising may be associated with the injection. Arq Neuropsiquiatr. [13]Allergic reactions are amongst the rare reported adverse effects. 2022 Aug 11. doi: 10.1007/s00115-022-01369-0. Botulinum toxin (BT) has been perceived as a lethal threat for many centuries. The current use of botulinum toxin. Botulinum toxin has a longer duration of its action once administered. There have been spontaneous reports of death, sometimes associated with dysphagia, pneumonia, and/or other significant debility or anaphylaxis, after treatment with botulinum toxin [see WARNINGS AND PRECAUTIONS]. Accessibility Such patients should be treated as quickly as possible. 2000. Potential adverse effects following the use of botulinum toxin around the eye include ecchymosis, ptosis, diplopia, midfacial weakness, lagophthalmos, and dry eye. Botulism causes flaccid paralysis, which begins in the muscles of the head and neck and progresses to the muscles of the trunk and extremities. As a bioweapon, botulinum toxin can be transmitted in airborne or foodborne methods. This study indicated that topical botulinum toxin was able to elicit an effect of the function of the eccrine glands, typically located in the mid-reticular dermis.12 Adverse events included local tingling sensations, redness at the site, and excessive dryness of the skin where the cream was applied. Botulism Web page. The muscles relax, reducing unwanted wrinkles. Botox (onabotulinumtoxinA) is an injectable neuro-toxin used for the treatment of chronic migraines, limb spasticity, axillary hyperhidrosis, cervical dystonia, strabismus, and blepharospasm. [13]Eyelid ptosis transpires with the introduction of botulinum toxin is introduced into the glabella, procerus, and corrugator muscles with unintended dispersion into the levator orbicularis muscle. For example: In neck dystonia people can experience difficulties swallowing headache, neck pain, back pain, pain in your arms or legs; cold symptoms such as stuffy nose, sneezing, sore throat; increased sweating in areas other than the underarms; or. is approximately 20 Units/nanogram of neurotoxin protein complex. 2005 Mar;63(1):180-5. doi: 10.1590/s0004-282x2005000100035. Death usually results from flaccid paralysis of lung muscles. "Product Information. When this medication is used for overactive bladder, side effects such as urinary tract infections, burning/painful urination, fever, or difficulty urinating may occur. Botulinum toxins are a class of medications used to treat muscle stiffness or spasms. Padda IS, Tadi P. Botulinum Toxin. Check with your physician for additional information about side effects. Table 15: Proportion of Patients Experiencing Urinary Tract Infection Following an Injection in Double-Blind, Placebo-Controlled Clinical Trials in OAB According to History of Diabetes Mellitus. 96. The following adverse reactions to BOTOX (onabotulinumtoxinA) for injection are discussed in greater detail in other sections of the labeling: Because clinical trials are conducted under widely varying conditions, the adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. Porta M. A comparative trial of botulinum toxin A and methylprednisolone for the treatment of myofascial pain syndrome and pain from chronic muscle spasm. (See CDC Isolation Precautions Guidelines.). Table 17: Adverse Reactions Reported in a Post Approval Study (NDO-3) by >2% of BOTOX Treated Patients and More Frequent than in Placebo-Treated Patients Within the First 12 Weeks after Intradetrusor Injection. * Elevated PVR not requiring catheterization. Many people know botulinum toxin for its power to treat wrinkles. [3][4]Serotype A is of three sorts; serotype B is one. These differences from placebo were not statistically significant, but noticeable. Most dysphagia was reported as mild or moderate, however, dyspnea accompanied dysphagia in about 20% of these cases. Last updated on Aug 30, 2022. 77, 242-248 (2016). In one Phase 3 study and the open-label extension study in patients with pediatric lower limb spasticity, neutralizing antibodies developed in 2 of 264 patients (0.8%) treated with BOTOX for up to 5 treatment cycles. Jackson JL, Kuriyama A, Hayashino Y. Botulinum toxin A for prophylactic treatment of migraine and tension headaches in adults: a meta-analysis. The incidence of UTI increased in patients who experienced a maximum post-void residual (PVR) urine volume >200 mL following BOTOX injection compared to those with a maximum PVR <200 mL following BOTOX injection, 44% versus 23%, respectively. Moreira S, Silva R, Carrageta DF, Alves MG, Seco-Rovira V, Oliveira PF, de Lourdes Pereira M. Int J Mol Sci. Why isn't botulism food poisoning common? [11] bruising, bleeding, pain, redness, or swelling where the injection was given. Botulism ("BOT-choo-liz-um") is a rare but serious illness caused by a toxin that attacks the body's nerves and causes difficulty breathing, muscle paralysis, and even death. Luvisetto S, Gazerani P, Cianchetti C, Pavone F. Botulinum Toxin Type a as a Therapeutic Agent against Headache and Related Disorders. 100 U of powder form in 1 to 8 mL of saline. The most frequently reported adverse reactions following injection of BOTOX in pediatric patients 2 to 17 years of age with upper limb spasticity appear in Table 22. Direct central nervous system effects are not observed, since BT does not cross the blood-brain barrier and since it is inactivated during its retrograde axonal transport. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. The https:// ensures that you are connecting to the *Includes upper respiratory tract infection and viral upper respiratory tract infection. The 3 known cases of inhalational botulism, which occurred after a laboratory accident, caused symptoms approximately 72 hours after exposure. The half-life differs among the serotypes and relies on when the SNARE protein regains function and releases neurotransmitter acetylcholine. [2][11][3][12][8]SNARE proteins also play an identified role in neurons recognized to release glutamate and substance R. Their actions are to release bradykinin, prostaglandins, histamine, and serotonin, which are proinflammatory mediators. Botulism poisoning does not cause fever. Studies by scholars have shown that the effects of botulinum toxin A usually occur 2 to 3 days after injection, and the paralytic effect reaches its maximum after 2 weeks and lasts for about 2.5 months, after which time the effect gradually decreases. A study using safety surveillance data of botulinum toxin found significant associations between its use and antidepressant effects, across several indications and different injection sites, according to the study's authors.. Their results show that the antidepressant effect of botulinum toxin "administered for various indications goes beyond the control of the intended disease states and . inability to close the eyelids completely, irritation of the cornea (colored portion) of the eyes, turning outward or inward of the edge of the eyelids, heavy bleeding from the place where the shot was given, eye pointing upward or downward instead of straight ahead. Although botulinum toxin A injections for the treatment of provoked vestibulodynia did not improve pain during tampon use, it did have a positive effect on sexual function and . Who suffers more frequently from migraine headaches? Botulism Antitoxin Heptavalent (BAT), an antitoxin produced by Cangene Corporation of Canada, contains antibodies to 7 botulinum toxin types. Botulism is not transmitted from person to person. Botulinum toxin therapy of strabismus is a medical technique used sometimes in the management of strabismus, . [1] Clinicians have used this neurotoxin in practice since late 1970. In a study of blepharospasm patients who received an average dose per eye of 33 Units (injected at 3 to 5 sites) of the currently manufactured BOTOX, the most frequently reported adverse reactions were ptosis (21%), superficial punctate keratitis (6%), and eye dryness (6%). Managing the care of patients prescribed botulinum toxin for therapeutic purposes requires excellent communication between the patient and an interprofessional team of healthcare providers. uneven eyebrows dry eyes excessive tearing Injections around the mouth may result in a "crooked" smile or drooling. The approximate conversion factor is 1:2.5 to 1:5 between Botox and Dysport; and 1:1 between Botox and Xeomin. All 4 of these patients responded to BOTOX therapy at the time of the positive antibody test. Field M, Splevins A, Picaut P, van der Schans M, Langenberg J, Noort D, Snyder, Foster K. AbobotulinumtoxinA (Dysport. Presenting symptoms include difficulty swallowing, hoarseness in voice, slurred or slow speech, double vision, and descending flaccid paralysis. Dev Med Child Neurol. The data reflect the patients whose test results were considered positive for neutralizing activity to BOTOX in a mouse protection assay or negative based on a screening ELISA assay or mouse protection assay. In pediatric patients treated for upper limb spasticity, upper respiratory tract infections were reported more frequently compared with placebo (17% [6 units/kg]; 10% [3 Units/kg]; 9% [placebo]). Godoy IR, Donahue DM, Torriani M. Botulinum Toxin Injections in Musculoskeletal Disorders. Design: A multi-centre, randomized, double-blind, placebo-controlled study. Most side effects are usually temporary and should fade within a few days. Castelo M, Marques RE, Duarte GS, Rodrigues FB, Ferreira J, Sampaio C, Moore AP, Costa J. Botulinum toxin type A therapy for cervical dystonia. There is no antitoxin, to date, for type H botulism. Disabil Rehabil. Botulism toxin as a biological weapon: medical and public health management. However, 3 of these patients developed clinical resistance after subsequent treatment, while the fourth patient continued to respond to BOTOX therapy for the remainder of the study. Carbamate Pesticides: Shedding Light on Their Impact on the Male Reproductive System. In 2003, the FDA approved human botulinum immune globulin (BabyBIG) for the treatment of infant botulism. Some side effects of onabotulinumtoxinA may occur that usually do not need medical attention. This document does not contain all possible side effects and others may occur. Botulinum toxins pose a major threat as biological weapons because they are extremely potent and lethal; some of the toxins are relatively easy to produce and transport; and people with botulism require prolonged intensive hospital care. 42: 116-121. The incidence rates of these adverse effects in 2058 adults who received a total of 3650 injections for horizontal strabismus was 17%. Bossi P, Tegnell A, Baka A, et al. Some clinical data already exist, but only little is known on a cellular level. Although not all of these side effects may occur, if they do occur they may need medical attention. . Table 14 presents the most frequently reported adverse reactions in double-blind, placebo-controlled clinical trials for overactive bladder occurring within 12 weeks of the first BOTOX treatment. There are a few drugs that facilitate acetylcholine release, including tetraethylammonium and 4-aminopyridine. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them: Applies to onabotulinumtoxinA: injectable powder for injection. Bronchitis has been reported more frequently in patients treated for upper limb spasticity (3% vs 1%) compared with placebo. Focal facial paralysis, syncope, and exacerbation of myasthenia gravis have also been reported after treatment of blepharospasm. The table below presents the most frequently reported adverse reactions within 12 weeks of injection. Allergan Inc. 2. [Ref], Deaths as a complication of severe dysphagia have been reported with botulinum toxin. trauma, chronic thyroid eye disease) Secondary strabismus due to excessive muscle resection or muscle slippage Alphabetical patterns (A, V, X syndromes), dissociated vertical deviation (DVD) and chronic paralytic strabismus Studies suggest thatbotulinum neurotoxin serotype A has themost prolonged half-life. In the Multiple Sclerosis (MS) patients enrolled in the double-blind, placebo-controlled trials, the MS exacerbation annualized rate (i.e., number of MS exacerbation events per patient-year) was 0.23 for BOTOX and 0.20 for placebo. Presenting symptoms include difficulty swallowing, hoarseness in voice, slurred or slow speech, double vision, and descending flaccid paralysis. *Elevated PVR not requiring catheterization. In 99 pediatric patients who had a negative baseline result for binding antibodies or neutralizing antibodies and had at least one evaluable post-baseline value from one randomized double-blind study and one double-blind extension study, no patients developed neutralizing antibodies after receiving 50 Units to 200 Units of BOTOX. [20][21][22][23]The interprofessional team approach, customized to the particular indication, will enhance patient outcomes with Botulinum toxin while mitigating potential adverse events. In a series of 5587 injections, retrobulbar hemorrhage occurred in 0.3% of cases. Kattimani V, Tiwari RVC, Gufran K, Wasan B, Shilpa PH, Khader AA. Review interprofessional team strategies for improving care coordination and communication to advance Botulinum toxin and improve outcomes. Botulinum toxin as a biological weapon: medical and public health management. These providers include a primary care clinician, a neurologist, a gynecologist, a urologist, and a nurse with their respective therapeutic uses for chronic migraine, post-stroke pain, cervical dystonia, and urinary incontinence from detrusor overactivity. Botulinum toxin prices vary according to the manufacturer and supplier; doctors can expect to pay up to $1200 per 100 units. Herd CP, Tomlinson CL, Rick C, Scotton WJ, Edwards J, Ives N, Clarke CE, Sinclair A. Botulinum toxins for the prevention of migraine in adults. Unable to load your collection due to an error, Unable to load your delegates due to an error. Severe headache, confusion, slurred speech, arm or leg weakness, trouble walking, loss of coordination, feeling unsteady, very stiff muscles, high fever, profuse sweating, or tremors. Abstract. The following adverse events with BOTOX 100 Units were reported at any time following initial injection and prior to re-injection or study exit (median duration of exposure was 51 weeks): urinary tract infections (39%), bacteriuria (18%), urinary retention (17%), residual urine volume* (17%), dysuria (9%), and hematuria (5%). Some dosage forms listed on this page may not apply to the brand name Botox. But. The incidence of ptosis has been reported to be dependent on the location of the injected muscles, 1% after inferior rectus injections, 16% after horizontal rectus injections and 38% after superior rectus injections. [4]There are three forms of serotype A and one form of serotype B. Source: FDA's Foodborne Pathogenic Microorganisms and Natural Toxins Handbook: Clostridium botulinum. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Swallowing and breathing difficulties can be life threatening and there have been reports of death. Although this means routine injections, it also means that Botulinum toxin injections do not have any permanent side effects. Animal models suggest that inhaling 0.7-0.9 g of aerosolized botulinum toxin would be enough to kill a standard weight person (70 kg or 154 lbs). Medically reviewed by Philip Thornton, DipPharm. The lack of effects on pericranial muscle tension precludes We recruited 20 patients with a diagnosis of chronic to suppose a modulating effect on trigeminal nociception migraine treated with type A botulinum toxin every 3 by the inhibition of the neuromuscular synapse. . The current hypothesis is that botulinum toxin works on altering sensory input in the central nervous system in addition to its effects on the neuromuscular junction. Botox Patient Information is supplied by Cerner Multum, Inc. and Botox Consumer information is supplied by First Databank, Inc., used under license and subject to their respective copyrights. Unless otherwise noted, all information presented in this article is derived from the following 2 sources: Botulism is a serious, but rare, paralytic illness caused by neurotoxins (botulinum toxin) produced by the common bacterium, Clostridium botulinum, which is found throughout the world in soil and ocean sediment. This is not a complete list of side effects and others may occur. months. New onset or recurrent seizures have also been reported, typically in patients who are predisposed to experiencing these events. 2001;285(8):1059-1070. http://jama.ama-assn.org/cgi/content/full/285/8/1059. Severe worsening of migraine requiring hospitalization occurred in approximately 1% of BOTOX treated patients in Study 1 and Study 2, usually within the first week after treatment, compared to 0.3% of placebo-treated patients. In higher amounts, it can be poisonous. There are no adequate studies of Botox in pregnant women and it has not been evaluated in nursing mothers. See below for a comprehensive list of adverse effects. However, only small, weaker doses of botulinum toxin are used to reduce facial wrinkles. Cot TR, Mohan AK, Polder JA, Walton MK, Braun MM. Botulinum toxins pose a major threat as biological weapons: A deliberate release of botulinum toxin could be in the form of an aerosolized weapon or contamination of the food or water supply with C. botulinum or botulinum toxin. We comply with the HONcode standard for trustworthy health information. Rarely, if the injection is not performed properly, the risorius muscle may be paralyzed, leading to an asymmetric smile. Botulinum toxins Distal esophageal spasm Drug-related side effects and adverse reactions Esophageal motility disorders Lower esophageal sphincter ASJC Scopus subject areas Gastroenterology Fingerprint Dive into the research topics of 'Complications of botulinum toxin injections for treatment of esophageal motility disorders'. It can reduce sweat production by blocking cholinergic innervation of eccrine sweat glands. In Canada - Call your doctor for medical advice about side effects. [2][1][6]The neurotoxin is a beneficial and useful alternative pain remedy and should be considered for those that do not yield desirable results to opioid treatment. [Level 5]. Other adverse reactions that occurred more frequently in the BOTOX group compared to the placebo group at a frequency less than 1% and potentially BOTOX related include: vertigo, dry eye, eyelid edema, dysphagia, eye infection, and jaw pain. You may report side effects to Health Canada at 1-866-234-2345. Botulinum (neuro)toxin A (BoNT) is widely used in the field of plastic and reconstructive surgery. Euro Surveillance. A release of aerosolized botulinum toxin would likely result in an outbreak of acute flaccid paralysis (sudden, profound muscle weakness) among persons in the same geographic area who have had no obvious common dietary exposure. Without treatment, death results from airway obstruction (paralysis of pharyngeal and upper airway muscles) and respiratory failure (paralysis of diaphragm and accessory breathing muscles). Most commonly, botulinum toxin can be injected into the wrong muscle group or with time spread from the injection site, causing temporary paralysis of unintended muscles. the before and after pictures of the effects of botulinum toxin that you see on social media are a true story. Botox is administered by injection and dosing depends on the condition that it is used for. Antibiotics are of no use, except in the case of wound botulism and then only as an adjunct to surgical wound care. 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