Botulinum Toxin Type A in Red Ear Syndrome and a Novel Multi-nerve Injection Paradigm: A Case Report

Red ear syndrome (RES) is a rare, poorly understood disorder characterized by episodic ear erythema and pain. Its pathophysiology remains unclear, with proposed associations to migraine, erythromelalgia, and rosacea. Existing treatments are often ineffective, emphasizing the need for novel approaches. We describe a 33-year-old male with bilateral, non-headache RES refractory to standard therapies. A novel botulinum toxin type A (BoNT-A) injection paradigm, targeting both sensory and autonomic innervation, was implemented. Although episode frequency remained unchanged, the patient experienced significant reductions in pain intensity, episode duration, and improvement in quality of life.