Laryngeal Botox injection is a common procedure for the treatment of Spasmodic Dysphonia and tremor. Complications are rare and can include breathy voice, swallowing issues and skin bruising. Bleeding post injections, requiring surgical interventions, are exceedingly rare occurrences. Care givers must plan accordingly when patients at risk present for injections and must be prepared to treat these complications when they arise.
We present a case of a 76 yo patient with adductor spasmodic dysphonia, psoriatic arthritis, lupus anticoagulant and prior CVA who presented for her follow up Botox injection. She had multiple previous injections without incident. During the procedure the patient was asked to hum gently to insure proper placement with an EMG signal. The patient elevated her larynx, inferiorly displacing the needle slightly. The needle was replaced in the proper position, and the injection was completed. The patient had hemoptysis when exiting the waiting room about 10 minutes post injection. Evaluation with stroboscope revealed a small perforating bleeder just inferior to the anterior commissure. The patient was sent to the ED where nebulized TXA was administered without benefit. Patient was taken to the OR where the active perforating bleeder was cauterized with a pinpoint laryngeal cautery. Patients anticoagulants were held and the patient was discharged the next morning.
The anterior commissure is a region of dense vascularity with terminal branches of the inferior laryngeal artery and branches of the superior laryngeal artery. These fine perforating vessels extend anteriorly to the subglottic mucosa and anterior tracheal wall where protective perichondrium is limited. Precautions with the anticoagulated patient must be considered, such as holding the anticoagulants prior to injection. Laryngeal movement must be minimized during the procedure to avoid post operative bleeding. The area immediately below the anterior commissure should also be avoided if possible.