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Pain and Spine Medicine

Atypically Severe and Rapid Onset Dysphagia Following Stellate Ganglion Block with Onabotulinum Toxin A (Botox): A Case Report

Friday, October 24, 2025
8:00 AM - 9:15 AM MT
Location: Kiosk 4

    Primary Author(s)

  • ML

    Michael Leff, MD

    Resident Physician
    Sidney Kimmel Medical College At Thomas Jefferson University/TJUH PM&R Program
    PHILADELPHIA, Pennsylvania

    • Poster Presenter(s)

  • Helen Xia, MD

    Resident Physician
    Sidney Kimmel Medical College At Thomas Jefferson University/TJUH PM&R Program
    Philadelphia, Pennsylvania

    • Co-Author(s)

  • KH

    Kimberly Heckert, MD

    Clinical Associate Professor
    Thomas Jefferson University
    Haddonfield, New Jersey

  • KF

    Kristofer Feeko, DO

    Associate Professor Rehabilitation Medicine
    Thomas Jefferson University PM&R Program
    Philadelphia, Pennsylvania

  • JM

    Jeffrey Mojica, DO

    Assistant Professor of Anesthesiology & Perioperative Medicine
    Thomas Jefferson University
    Philadelphia, Pennsylvania

  • MM

    Marisa Moreta, DO

    Assistant Professor
    Thomas Jefferson University Hospital
    Philadelphia, Pennsylvania

Disclosure(s):
Helen Xia, MD: No financial relationships to disclose
Case Diagnosis: 46 year old woman with chronic pain from traumatic right ulnar nerve injury developed acute and severe dysphagia following stellate ganglion nerve injection with onabotulinumtoxinA.

Case Description or Program Description: Patient developed severe dysphagia 12 hours after right stellate ganglia nerve block with lidocaine/bupivacaine and 50 units of onabotulinumtoxinA. Symptoms included inability to tolerate oral intake, manage oral secretions, and a muffled voice, prompting hospital presentation.

Setting: Inpatient hospital

Assessment/Results: Neck ultrasound and computed tomography showed no focal collections. Nasal endoscopy displayed normal vocal cord mobility. Videofluoroscopic Swallow Study (VFSS) demonstrated profound pharyngoesophageal dysphagia.
She required percutaneous endoscopic gastrotomy tube placement 11 days after symptom onset. 8 days later, dysphagia mildly improved with scant tolerance of thin liquids and improved vocal quality. Repeat VFSS showed mild-moderate dysphagia, and she was discharged home. 40 days after symptom onset, she still utilized her gastrostomy tube for adequate nutrition and medications.

Discussion (relevance): Acute and severe dysphasia after stellate ganglia block with onabotulinumtoxinA requires a comprehensive neurologic workup, as reported cases are typically mild and require multiple days to develop. The vagus nerve lies adjacent to the stellate ganglia, and injury is consistent with symptomatology and VFSS findings. The patient’s symptoms were attributed to either onatobulinumntoxinA-related paralysis of pharyngoesophageal muscles and/or direct nerve injury. Should symptoms persist, electrodiagnosis could aid in further diagnosis, but with slow and steady improvement, was not yet recommended. OnabotulinumtoxinA for stellate ganglion blocks is not approved by the FDA.

Conclusions: This case demonstrates more severe dysphagia than reported in literature following stellate ganglion block with onabotulinumtoxinA, with fast onset of symptoms suggesting nerve injury over onabotulinumtoxinA spread. It adds to extremely sparse diagnostic and prognostic evidence of severe dysphagia following interventional procedures. It also serves as an educational exercise, applying pharmacodynamics, neck neuroanatomical relationships, and dysphagia pathophysiology to critically evaluate the differential diagnosis.