Orbital Cellulitis and Abscess After Botulinum Toxin Injection: A Case Report

Infections involving the orbit and periorbita, while frequent, have the potential of being life-threatening. Orbital cellulitis is an infection of the soft tissues of the periorbita as they invade past the orbital septum.¹ The major symptoms of orbital cellulitis include eyelid edema, erythema, chemosis, and proptosis with or without ophthalmoplegia.² Untreated, orbital cellulitis may progress to a subperiosteal abscess, an orbital abscess, or cavernous sinus thrombosis.³ This can also progress to osteomyelitis of the frontal bone, septic thrombophlebitis, as well as other intracranial complications.⁴ This condition commonly occurs from bacterial invasion from adjacent structures. More than 90% of cases arise from the migration of bacteria from the sinuses.⁵ However, less common etiologies also include odontogenic and traumatic sources as well as iatrogenic procedures such as injections. Among those, botulinum toxin (Botox) injections around the periorbita represent a rare but important cause of orbital cellulitis.⁶

Botox is a neurotoxin produced by Clostridium botulinum and has been used to treat various conditions including blepharospasm, hemifacial spasm, temporomandibular dysfunction, headaches, and complex pain.⁷ Injection of Botox is the most common cosmetic procedure with more than 3 million injections per year performed worldwide.⁸ Although generally safe, complications may occur if the sterile technique is compromised or the injection is improperly administered. Complications of Botox include injection site side effects, allergic reactions, and technique-dependent side effects.⁸ In this report, we discuss a case of a 37-year-old patient who presents with severe orbital cellulitis complicated by abscess formation likely secondary to Botox injections.

A 37-year-old presented to the emergency department in Thunder Bay, Ontario, Canada, for increased swelling and redness around her left eye. Thirteen days prior, she received Nuceiva botulinum toxin injections in her forehead, glabella, and lateral to medial upper eyelid by a nurse practitioner. She had received a total of 6 units around each periorbital area divided into 3 equal doses in the lateral canthal area, the midline, and the medial canthal area. She had received multiple injections from this same nurse practitioner in the past without any complications. At the time of her injection, she did not have any other infections and was in good health. She did not experience any other issues with this injection such as bleeding or trauma. Otherwise, she does have a history of hypothyroidism that is well controlled and has had multiple cosmetic procedures including a rhinoplasty and blepharoplasty.

At her presentation, she had fevers and significant progressive periorbital swelling but no vision changes. The erythema and swelling slowly progressed over the course of 6 days prior to her presentation. She had no upper respiratory tract infection (URTI) symptoms or difficulties breathing. A computed tomography (CT) scan was done and showed signs consistent with extensive periorbital cellulitis extending past the orbital septum with no signs of abscess (Figure 1). There were no signs of sinusitis. She was started on piperacillin/tazobactam and transferred to Victoria Hospital in London, Ontario, for further assessment by the Otolaryngology-Head and Neck Surgery team.

Upon arrival, her cellulitis progressed (Figure 2), and clindamycin was added. The swelling involved the left periorbita and the left cheek. She had full extra-ocular movement with no diplopia, normal intra-ocular pressure, and no relative afferent pupillary defect. Nasopharyngoscopy did not reveal any purulence in the middle meatus or any signs of sinusitis. She had normal cranial nerve testing for cranial nerves III, IV, V, and VII. Her white blood cell count at that time was 22, and her C-reactive protein level was 250. The ophthalmology team assessed her as well and did not find any disk edema, retinal involvement, or optic nerve involvement.

As per the recommendation of the infectious disease team, her clindamycin was stopped after 48 hours. Her left periorbital swelling and erythema continued to improve over the coming days. Her C-reactive protein and white blood cell count were decreasing steadily. She was switched to oral amoxicillin-clavulanate and oral doxycycline on post-admission day 10 (Figure 3). Unfortunately, her swelling worsened slightly after this, but vision and extra-ocular movement are still normal. An ultrasound was done to assess for any fluid collection, and she was found to have developed a 3.0 × 5.5 × 1.0 cm periorbital abscess. The Otolaryngology-Head and Neck surgery team then drained his abscess at the bedside under ultrasound guidance using an 18-gauge needle; no cuts in the skin were made. In total, 7 cc of purulent discharge was drained and sent for fluid culture, which did not grow any bacteria. The following day another attempt was made, and another 3 cc of purulent discharge was aspirated.

She continued to improve clinically and biochemically after that. She was discharged on post-admission day 13. At that time, her C-reactive protein was 50 and her white blood cell count was 12. She was afebrile for multiple days and feeling well. Her vision was at baseline, and she had full extra-ocular movements. Her periorbital edema and erythema had significantly improved. She was discharged on 2 weeks of amoxicillin-clavulanate and doxycycline. By the time her course of antibiotics had finished, her erythema and edema had completely resolved.

This report presents the rare case of a young woman developing orbital cellulitis that is complicated by a soft tissue abscess following Botox injections. This patient initially presented with symptoms and signs consistent with orbital cellulitis without sinusitis and went on to develop a soft tissue abscess requiring aspiration despite being on appropriate antibiotic treatment.

The progression of this case highlights the importance of early antibiotic treatment as well as close monitoring to assess for the formation of an abscess. The most frequently seen signs and symptoms of an orbital abscess formation include restricted ocular movements with pain, proptosis, periorbital erythema, vision changes, fever, and diplopia.⁹ In cases of a developing abscess, prompt aspiration and drainage are crucial to relieve the pressure and prevent optic nerve compression, which can lead to permanent vision loss. As in this case, ocular ultrasonography can provide information on the formation of a superficial abscess without the risk of radiation exposure.¹⁰ However, a CT or magnetic resonance imaging (MRI) can also be used to determine the disease’s initial extent or assess for any intracranial extension. In cases of an orbital abscess, about half of patients are expected to make a complete recovery, whereas the other half may still experience vision deterioration or persistent movement restrictions in the long term.⁹

This case highlights that although Botox is generally safe, devastating sequela may arise in rare situations. It is therefore important to mitigate those risks by applying a strict aseptic technique during injection as well as inform patients of potential risks and signs and symptoms to watch for. Our recommendation is to prepare a tray with the expected dosing and the instruments needed before the start of the procedure. It is also important to avoid contamination while preparing the patient for the treatment. Make-up should be removed by using saline or a cleanser, and an antiseptic solution such as alcohol or chlorhexidine should be applied to the areas needing treatment. Given the increasing popularity of Botox injections, providers need to understand all the risks associated with the procedures, however uncommon. This study will contribute to the growing body of literature on serious adverse events that can arise from Botox injections.

This case reports on a young woman who developed a serious ocular infection secondary to Botox injections. This highlights the rare but serious complications of orbital cellulitis and soft tissue abscesses following these injections. It also underscores the importance of early antibiotic treatment for orbital cellulitis and close monitoring for the development of an abscess. In patients with an abscess, prompt aspiration or drainage is necessary to prevent progression and to relieve the pressure around the optic nerve.