Summary

No to Botulinum Toxin discusses the reasons why I have refused Botox injections for my facial pain. Botulinum Toxin (BTX) is a strong bacterial toxin, created from fermentation of clostridium botulinum. It is ‘a neuromuscular blocking agent that triggers chemical denervation by temporarily suppressing secretion of acetylcholine at major nerve endings; therefore, Botox injections are useful for diseases with increased muscle activity or tension.’ [1]

Facial Pain Disorders

Botulinum Toxin is used in the treatment of many facial pain disorders by producing temporary skeletal muscle relaxation. In Pain Management, Botulinum Toxin has an ‘analgesic effect by reducing muscle hyperactivity.’ [2] I have been offered Botox injections to manage my facial pain, but I have refused the offer of these injections. I will explain my reasons for refusing BTX injections later on the post. Firstly, the following facial pain disorders that are managed with Botox (BTX) injections include;

Oro-Facial Pain

BTX is very effective for the management of Muscular Temporomandibular Joint Disorders (TMD) and hyperactivity of masticatory muscles. Symptoms of TMD include; pain around the jaw, popping and clicking noises when you move your jaw, difficulty opening your mouth, and jaw lock, when you try and open your mouth.

Trigeminal Neuralgia.

Botulinum Toxin A injections are a safe and effective method of management of Trigeminal Neuralgia. ‘Trigeminal Neuralgia (TN) is a painful disorder, which presents as recurrent, unilateral, brief but severe, electric-shock-like pains of rapid onset and duration. It normally remains within Trigeminal dermatomes.’ [3]

Myofascial Pain Syndrome

Myofascial Pain Syndrome (MPS) is a regional pain syndrome, which is characterised by painful points (trigger points) in the masticatory muscle system. Symptoms include pain in the muscle, muscle knots and muscle spasms. ‘Botulinum Toxin blocks the communication between nerves and muscles, and inhibits muscle contractions in the muscles where the painful points are located. This may result in pain relief when injected into the area.’ [4] In summary, Botulinum Toxin helps with both Myofascial Pain Syndrome and TMD. It can be injected into Head and Neck muscles to relax muscle function and spasm.

 Salivary Gland Application

Ultrasound-guided Botulinum Toxin injections are used to treat Sialorrhea, which is excessive salivation or drooling. An injection of Botox into the salivary gland reduces the production of saliva, and thereby the frequency of the patient’s drooling. Patients can develop chewing problems and swallowing difficulties as a side effect from these injections. Sialadenitis is chronic inflammation and swelling of the parotid gland. It is usually caused by obstruction, or a ductal thinning (stenosis.) Botulinum Toxin injections into the parotid gland are known to be effective in temporarily reducing pain and swelling associated with Sialadenitis.

Refusal of Botox

I have been offered BTX injections for my facial pain. The reason that I have refused them is because I do not suffer with any of the above conditions. I have not received any diagnosis, so we do not know what we are treating or dealing with. I do not suffer with Trigeminal Neuralgia, (TN). My symptoms are not congruent with TN. I have no symptoms related to jaw pain or disorder, and the symptoms related to Myofascial Pain Syndrome are not congruent with mine. If I had been diagnosed with any of these disorders, then I would be open to accepting BTX injections, but I have not.

Parotid Gland and Masseter Muscle

I do have a major problem with my left salivary gland, but it is not excessive salivary production or drooling, (Sialorrhea) that I suffer with. The malfunction in my gland has been detected as a thickening of saliva, a thinned duct, hardened tissue and reactive lymph nodes. The parenchyma was Sialolithiasis. I understand that Botox injections slow down the production of saliva, so these injections may temporarily stop the gland swelling, but that would be empirical symptom management, not definitive treatment or long-term cure. After suffering for ten years, and having tried temporary wash outs, I do not wish to return to short term ‘management.’ Additionally, if infection is the underlying cause for my parotid gland disease, then BTX could create further problems.

I understand that Botox injections relax muscle function and spasm, but I do not suffer with overactive masticatory muscles. My left masseter muscle is enlarged, not overactive, and my muscle pain is closely linked to the problem with my parotid gland. A scan done one year after my surgery, showed that there is accessory parotid tissue over the masseter muscle. I have asked many consultants, if the pain in my masseter muscle could be caused by the ongoing problems in my parotid gland. I have received no answer.

Cure Not Management

Botulinum Toxin injections are effective pain management for some facial pain syndromes. However, BTX is a temporary suppressant, not a definitive cure. It is common for pain to return three to six months after the injection. Abnormality has been detected in the soft tissue and muscle in my left cheek, and around my left eye. That abnormality needs diagnosing and treating, not suppressing with ‘symptom management.’

Facial pain syndromes can be very heterogeneous and need individual diagnosis and treatment.

Head and Face Medicine, BioMedCentral.com

Finding A Cause

I clarify in This is Not Chronic Pain, the difference between pain conditions that need ‘managing,’ and pain conditions where there is an aetiology, (cause) and which need treatment. My facial pain is not chronic pain, which just needs managing. I have ‘managed’ my facial pain with oral antibiotics for ten years. The pathology thus far found, pushes for the need to identify a cause for my facial pain, so that I can receive the correct treatment.

My left-sided facial pain involves a left diseased parotid gland, severe periocular pain, left ear pain, and left-sided head pain. Pathology found includes a collapsed levitator on my eyelid (left ptosis), parenchymal damage in my parotid gland, reactive lymph nodes, masseter enlargement and buccal fat pad abnormality. There have also been consistent raises with my white blood count, particularly my neutrophils.

Diagnose Me First

Infection is the suspected aetiology for my facial pain. Botulinum Toxin is not a recommended treatment for soft tissue infections. If I am suffering with a soft tissue infection, Botulinum Toxin could make my symptoms worse. It is imperative, therefore that I receive a diagnosis before injecting Botox Willy-nilly into my face. It is not clear what we are treating. I do not, therefore, want a dangerous chemical injected into my face, without receiving a diagnosis first.

Botulism

I will also not accept Botox injections because of the significant risk of Botulism. Botulism is when the toxin, Clostridium Botulinum, attacks the muscles. This can result in a serious bacterial infection, that can cause life-threatening illness. The symptoms of Botulism begin in the muscles and eyes of the face. They include, drooping eyelid (ptosis), loss of facial expression, drooling, reduced gag reflex and breathing difficulty. I already have a drooping eyelid, (left ptosis) as part of my condition, and I suffered with severe loss of facial expression, following my superficial parotidectomy in 2018. I am not, therefore, opening myself up to the risk of Botulism, on top of what I am already suffering with. No way.

 

‘Facial pain, alone or combined with other symptoms, is a symptom situated at a cross point where several disciplines meet; Ophthalmologists, Ear-Nose-Throat, internal medicine and neurosurgeons. Key message: Caregivers should “think outside of the box” and refer to other disciplines when indicated. If not, a correct diagnosis can be delayed and unnecessary treatments might be given.’

Facial Pain- A Review and Proposal for a Pragmatic Diagnostic Approach- Research Gate

References

[1] Lew, MF; Review of FDA- Approaches of Botulinum Toxins, including Data Efficacy in Pain Reduction, National Library of Medicine, PubMed, November, 2022

[2] Woo, SS; Application of Botulinum Toxin in Pain Management, National Library of Medicine, PubMed Central, March, 2011

[3] Rubis A; The Use of Botulinum Toxin A in the Management of Trigeminal Neuralgia; A Systemic Literature Review. Journal of Oral & Maxillo Facial Research (JOMR), April, 2020

[4] Atallah A and Silva EMK; Botulinum Toxin for Myofascial Pain Syndrome in Adults, Cochrane Library, National Library of Medicine, PubMed Central, July, 2014

Recommended Articles

Facial Pain: A Comprehensive Review

Botulinum Toxin in Pain Management

Botulinum Toxin For Pain Relief?

Myofascial Pain Disorder- An Overview.

The Use Of Botulinum Toxin A in the Treatment of Muscular Temporomandibular Joint Disorders- PubMed (nih.gov)

Botulism: Types, Causes, Symptoms and Treatments

Ultrasound-Guided Botulinum Toxin Injections for the Treatment of Drooling

Improvement of Chronic Facial Pain with the Help of Botulinum Toxin