Dysphagia After Cosmetic Submandibular Gland Botulinum Neurotoxin Type A Injection: A Case Report

Abstract

Highlights: What are the main findings? A healthy woman developed severe acute oropharyngeal dysphagia, including silent aspiration, after receiving cosmetic incobotulinumtoxinA injections to both subman-dibular glands. Videofluoroscopic swallowing study demonstrated marked pharyngeal-phase impairment at 11 days post-injection, with nearly complete resolution by 5 months following dysphagia rehabilitation. What are the implications of the main findings? Even typical cosmetic doses of botulinum toxin to the salivary glands can cause clinically significant swallowing impairment, emphasizing the need for cautious injection technique and consideration of ultrasound guidance to enhance safety. Clinicians performing esthetic botulinum toxin procedures should be aware of this potential complication and recognize early symptoms to ensure timely evaluation and management. Background: Cosmetic injection of botulinum neurotoxin type A (BoNT/A) into the submandibular glands is increasingly performed to enhance jawline contour. Although generally considered safe, unintended diffusion of the toxin can impair pharyngeal musculature and lead to dysphagia. Severe aspiration-prone dysphagia after esthetic submandibular gland injection has rarely been described. Case Presentation: A healthy 37-year-old woman developed acute oropharyngeal dysphagia the day after receiving cosmetic contouring injections with incobotulinumtoxinA (Xeomin®), administered to both submandibular glands (20 units per gland, performed without ultrasound guidance). She presented to our rehabilitation medicine clinic 11 days later with severe difficulty swallowing solids and liquids. Her functional oral intake was severely restricted (Functional Oral Intake Scale [FOIS] score 3), and the Eating Assessment Tool-10 (EAT-10) score was 24. Videofluoroscopic swallowing study (VFSS) demonstrated markedly delayed pharyngeal swallow initiation, reduced palatal elevation, poor airway protection, consistent laryngeal penetration, and silent aspiration of thin liquids (Penetration–Aspiration Scale score 8). She underwent diet modification and structured dysphagia rehabilitation. At three months, repeat VFSS showed substantial improvement, with only occasional penetration of large-volume thin liquids, corresponding to FOIS 5 and EAT-10 score 8. By five months, VFSS confirmed complete resolution of penetration and aspiration with normalization of swallowing physiology, reflected by a FOIS score of 7 and EAT-10 score of 1. Conclusions: This case demonstrates that cosmetic incobotulinumtoxinA injection into the submandibular glands, particularly when performed without ultrasound guidance, can lead to significant oropharyngeal dysphagia. Clinicians performing esthetic lower-face procedures should be aware of this potential complication and ensure timely swallowing evaluation and rehabilitation when symptoms arise. © 2026 by the authors.