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Orriëns LB, van Hulst K, Willemsen MAAP, van den Hoogen FJA, Erasmus CE. Predicting non-response to intraglandular botulinum neurotoxin A injections for drooling in children with neurodevelopmental disabilities. Dev Med Child Neurol 2024; 66:919-930. [PMID: 38140924 DOI: 10.1111/dmcn.15837] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023]
Abstract
AIM To develop robust multivariable prediction models for non-response to (1) submandibular botulinum neurotoxin A (BoNT-A) injections and (2) concurrent submandibular and parotid (four-gland) injections, to guide treatment decisions for drooling in children with neurodevelopmental disabilities, including cerebral palsy. METHOD This was a retrospective cohort study including 262 children (155 males/107 females, median age 7 years 11 months [IQR 5 years 1 month], range 4 years 0 months - 17 years 11 months) receiving submandibular injections and 74 children (52 males/22 females, median age 7 years 7 months [IQR 4 years 3 months], range 4 years 9 months - 18 years 8 months) receiving four-gland injections. Multivariable logistic regression analyses were used to estimate associations between candidate predictors and non-response 8 weeks after injection. RESULTS Ninety-six children (37%) were non-responders to submandibular injections, for which developmental age was the strongest predictor (adjusted odds ratio [aOR] 2.13; 95% confidence interval [CI] 1.02-4.45 for developmental age <4 years or 4-6 years with IQ <70). Other characteristics that showed a trend towards an increased risk of non-response were diagnosis, sex, and head position. Thirty-four children (46%) were non-responders to four-gland injections, for which tongue protrusion (aOR 3.10; 95% CI 1.14-8.43) seemed most predictive, whereas multiple preceding submandibular injections (aOR 0.34; 95% CI 0.10-1.16) showed a trend towards being protective. Predictors were, however, unstable across different definitions of non-response and both models (i.e. submandibular and four-gland) had insufficient discriminative ability. INTERPRETATION Potential predictors of non-response to BoNT-A injections were identified. Nevertheless, the developed prediction models seemed inadequate for guidance of treatment decisions. WHAT THIS PAPER ADDS Developmental age seemed most predictive of non-response to submandibular botulinum neurotoxin A injections. Non-response to concurrent submandibular and parotid injections was best predicted by tongue protrusion and number of previous injections. Multivariable prediction models including these clinical characteristics were unable to discriminate well. Predictors differed when non-response was defined using alternative outcome measures.
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Affiliation(s)
- Lynn B Orriëns
- Department of Paediatric Neurology, Division of Paediatrics, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Karen van Hulst
- Department of Rehabilitation, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Michèl A A P Willemsen
- Department of Paediatric Neurology, Division of Paediatrics, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Frank J A van den Hoogen
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Corrie E Erasmus
- Department of Paediatric Neurology, Division of Paediatrics, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Nijmegen, the Netherlands
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Delsing CPA, Adriaansens C, van Hulst K, Erasmus CE, van den Hoogen FJA. Long-term effects of submandibular gland excision on drooling in children with neurodevelopmental disorders: A cross-sectional study. Int J Pediatr Otorhinolaryngol 2023; 164:111377. [PMID: 36403383 DOI: 10.1016/j.ijporl.2022.111377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/31/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022]
Abstract
AIM Submandibular gland excision (SMGE) is suitable for the management of drooling in patients with non-progressive neurodisabilities. We aimed to investigate the long-term effects of SMGE. METHOD Patients who had SMGE between 2007 and 2018 were included. Main outcomes were a Visual Analogue Scale (VAS), Drooling Severity (DS), and Drooling Frequency (DF) collected at baseline, 8 weeks, 32 weeks and with a median of 313 weeks after SMGE (long-term). Secondary outcomes were satisfaction with the procedure, Drooling Quotient (DQ) and adverse events (AEs). RESULTS We included thirty-five patients in the long-term analysis with a mean age of 14.5 years. A baseline VAS score of 80.4 was found, which improved on the long-term (mean difference -21.8, t(26) = 4.636, p < 0.0005)). DS and DF decreased significantly at the long-term compared to baseline (Z = -4.361, p < 0.0001 for DS, Z = -3.065, p = 0.002 for DF). Twenty-three out of 35 (66%) patients would recommend the procedure to peers. INTERPRETATION This study indicates a long-term stable effect on drooling after SMGE in patients with anterior drooling. Recurrence of drooling occurs due to unknown reasons, nevertheless most caregivers and/or patients are still satisfied and would recommend the procedure to others.
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Affiliation(s)
- Corinne P A Delsing
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Centre, Philips Van Leijdenlaan 15 (route 377), Postbus 9101, Nijmegen, 6500 HB, the Netherlands.
| | - Carleen Adriaansens
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Centre, Philips Van Leijdenlaan 15 (route 377), Postbus 9101, Nijmegen, 6500 HB, the Netherlands
| | - Karen van Hulst
- Department of Rehabilitation, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Corrie E Erasmus
- Department of Pediatric Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Frank J A van den Hoogen
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Centre, Philips Van Leijdenlaan 15 (route 377), Postbus 9101, Nijmegen, 6500 HB, the Netherlands
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Nguyen J, Ongkasuwan J, Anand G, Lambert EM. Combined laryngeal cleft injection laryngoplasty and salivary botulinum toxin for saliva aspiration. Laryngoscope Investig Otolaryngol 2022; 7:1194-1199. [PMID: 36000049 PMCID: PMC9392396 DOI: 10.1002/lio2.823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 04/06/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives Children with type I laryngeal clefts and sialorrhea can have posterior drooling, aspiration of oral secretions, and respiratory complications. Laryngeal cleft injection laryngoplasty (LCIL) and salivary botulinum injections (Sal‐Bot) have been used separately for short‐term treatment of type I laryngeal clefts and sialorrhea. Our goal was to evaluate combined LCIL and Sal‐Bot and create recommendations for further treatment based on response to initial treatment. Methods Retrospective chart review of nine patients who underwent direct laryngoscopy and bronchoscopy with combined LCIL and Sal‐Bot from 2012 to 2019. Charts were reviewed for patient characteristics, response to treatment, and pre and post‐op hospitalizations. Subsequent procedures were performed depending on efficacy of initial treatments. Results Nine patients were identified. All had pre‐existing neurologic conditions, gastrostomy tubes, and a history of coughing and choking on secretions. Only one patient was able to feed orally (purees). 1 U/kg of botulinum toxin per gland was injected into each parotid and submandibular gland. The average units of botulinum toxin injected was 67 U. The mean laryngeal cleft injection volume was 0.35 cc. Subsequent treatment was based on timing of symptomatic improvement and individual patient factors. Five patients had respiratory‐related hospitalizations in year preceding the procedures (median 1.5, range 1–10). Three (60%) had a reduction in respiratory‐related hospitalization 1 year post procedure (median 1, range 1–3). One patient died during the follow up period due to continued chronic respiratory failure. Conclusions This is the first study of combined laryngeal cleft injection laryngoplasty and botulinum toxin injections for patients with posterior laryngeal penetration and aspiration of oropharyngeal secretions. We highlight strategies for choosing subsequent procedures based on response to initial treatment. Level of Evidence 4.
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Affiliation(s)
- Justin Nguyen
- Department of Otolaryngology: Head and Neck Surgery Baylor College of Medicine Houston Texas USA
| | - Julina Ongkasuwan
- Department of Otolaryngology: Head and Neck Surgery Baylor College of Medicine Houston Texas USA
- Division of Pediatric Otolaryngology, Department of Surgery Texas Children's Hospital Houston Texas USA
| | - Grace Anand
- Division of Pediatric Otolaryngology, Department of Surgery Texas Children's Hospital Houston Texas USA
| | - Elton M. Lambert
- Department of Otolaryngology: Head and Neck Surgery Baylor College of Medicine Houston Texas USA
- Division of Pediatric Otolaryngology, Department of Surgery Texas Children's Hospital Houston Texas USA
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Bekkers S, de Bock S, van Hulst K, Kok SE, Scheffer ART, van den Hoogen FJA. The medium to long-term effects of two-duct ligation for excessive drooling in neurodisabilities, a cross-sectional study. Int J Pediatr Otorhinolaryngol 2021; 150:110894. [PMID: 34474251 DOI: 10.1016/j.ijporl.2021.110894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/31/2021] [Accepted: 08/20/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study aims to evaluate the medium to long-term (1-12 years) effectiveness of two-duct ligation (2-DL) in patients with nonprogressive neurodisabilities. METHODS Main outcomes included a Visual Analogue Scale (VAS), Drooling Severity (DS) and Drooling Frequency (DF), collected at baseline, 32 weeks postintervention and 1-12 years postintervention. Secondary outcomes were adverse events (AEs), and satisfaction. RESULTS Forty-two patients were analyzed (mean age 17 years, mean baseline VAS 82). VAS decreased significantly from baseline to long-term (n = 30. Mean difference -36.5, CI -47.0 to -26.0, p ≤ 0.001; -26.1, CI -36.2 to -15.9, p ≤ 0.001). However, long-term VAS significantly increased compared to VAS at 32 weeks (+10.4, CI 1.0-19.8, p = 0.031). Out of 42 patients, 64% would recommend 2-DL to peers. CONCLUSION There is a significant subjective 2-DL effect on drooling severity in the medium to long-term as reported by patients and caregivers, but there is also a certain degree of recurrence in this time span, and 33% of the patients required subsequent treatment. However, the majority of patients and/or caregivers would recommend 2-DL to peers.
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Affiliation(s)
- Stijn Bekkers
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Sanne de Bock
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Karen van Hulst
- Department of Rehabilitation, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands
| | - Saskia E Kok
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Arthur R T Scheffer
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frank J A van den Hoogen
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
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Bekkers S, Pruijn IMJ, van der Burg JJW, van Hulst K, Kok SE, Delsing CP, Scheffer ART, van den Hoogen FJA. Surgery versus botulinum neurotoxin A to reduce drooling and improve daily life for children with neurodevelopmental disabilities: a randomized controlled trial. Dev Med Child Neurol 2021; 63:1351-1359. [PMID: 33997959 PMCID: PMC8597158 DOI: 10.1111/dmcn.14924] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 11/28/2022]
Abstract
AIM To compare the effect of bilateral submandibular duct ligation and botulinum neurotoxin A (BoNT-A) on drooling severity and its impact on daily life and care in children and adolescents with moderate-to-severe drooling. METHOD This was a randomized, interventional, controlled trial in which 53 children and adolescents (31 males, 22 females, mean age 11y, range 8-22y, SD 2y 10mo) with cerebral palsy (58.5%) or other non-progressive developmental disorders (41.5%) were randomized to BoNT-A (n=26) or bilateral submandibular duct ligation (n=27). A parent questionnaire on the severity of drooling in specific positions and daily activities and the impact of drooling on daily life and care was filled out at baseline and 8 and 32 weeks posttreatment. RESULTS Both BoNT-A and bilateral submandibular duct ligation had a positive effect on daily care, damage to electronic equipment and/or furniture, social interactions, and self-esteem. However, bilateral submandibular duct ligation had a significant greater and longer-lasting short- (8wks) and medium-term (32wks) effect on daily care, reducing damage to electronic devices, and improving social interactions and satisfaction with life in general. INTERPRETATION This randomized controlled trial confirms reduced drooling by both BoNT-A and bilateral submandibular duct ligation, but provides new evidence on improved well-being through a reduction in drooling. Even though there is a greater risk of complications and morbidity after bilateral submandibular duct ligation, compared to BoNT-A there was a significantly greater and longer-lasting positive effect on most outcomes. What this paper adds Bilateral botulinum neurotoxin A (BoNT-A) and submandibular duct ligation had a positive effect on the well-being of individuals with moderate-to-severe drooling. Bilateral submandibular duct ligation had a greater effect on the impact of drooling during daily care than BoNT-A. Bilateral submandibular duct ligation reduced damage to electronic devices and improved social interactions and satisfaction with life.
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Affiliation(s)
- Stijn Bekkers
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
| | - Ineke M J Pruijn
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
| | - Jan J W van der Burg
- Department of Pediatric RehabilitationSint MaartenskliniekNijmegenthe Netherlands,School of Pedagogical and Educational ScienceRadboud UniversityNijmegenthe Netherlands
| | - Karen van Hulst
- Department of RehabilitationRadboud University Medical CenterDonders Institute for Brain, Cognition and BehaviourNijmegenthe Netherlands
| | - Saskia E Kok
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
| | - Corinne P Delsing
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
| | - Arthur R T Scheffer
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
| | - Frank J A van den Hoogen
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
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Delsing CP, Bekkers S, Erasmus CE, van Hulst K, van den Hoogen FJ. Posterior drooling in children with cerebral palsy and other neurodevelopmental disorders. Dev Med Child Neurol 2021; 63:1093-1098. [PMID: 33844298 DOI: 10.1111/dmcn.14888] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 12/14/2022]
Abstract
AIM To evaluate the effect of botulinum neurotoxin A (BoNT-A) injections, submandibular gland excision (SMGE), and bilateral submandibular duct ligation (2DL) for the control of posterior drooling in children with neurological impairment. METHOD In a retrospective cohort, children with neurological impairment (e.g. cerebral palsy) treated between 2000 and 2016 were identified. Mean age at time of surgery was 9 years (range 1-21y). The primary outcome was posterior drooling severity by a visual analogue scale (VAS; 0-10) at baseline, 8-weeks, and 32-weeks follow-up. The secondary outcome was lower respiratory tract infections during the follow-up period. RESULTS Ninety-two patients (out of 475; 47 males, 45 females) were identified. They were undergoing three different treatments: BoNT-A (n=63), SMGE (n=16), and 2DL (n=13). A significant reduction in VAS over time was observed in the total group of 92 patients. After SMGE, VAS decreased significantly from 6.82 (SD 3.40) at baseline to 2.29 (SD 1.93) at 8 weeks, and 2.17 (SD 2.58) at 32 weeks (F[2.34]=11.618, p<0.001). There was no significant decrease after both BoNT-A and 2-DL. INTERPRETATION Posterior drooling is an unfamiliar, potentially life-threatening condition that is treatable with medication, BoNT-A injections, or surgery. Although all treatments reduced signs and symptoms of posterior drooling, there is a greater effect after SMGE compared to BoNT-A and 2-DL. What this paper adds Submandibular gland excision has better results for posterior drooling than botulinum toxin A or submandibular duct ligation.
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Affiliation(s)
- Corinne Pa Delsing
- Department of Otorhinolaryngology-Head and Neck Surgery, Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Stijn Bekkers
- Department of Otorhinolaryngology-Head and Neck Surgery, Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Corrie E Erasmus
- Department of Pediatric Neurology, Donders Institute for Medical Neurosciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Karen van Hulst
- Department of Rehabilitation, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Frank Ja van den Hoogen
- Department of Otorhinolaryngology-Head and Neck Surgery, Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
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Bekkers S, Leow TYS, Van Hulst K, Orriëns LB, Scheffer ART, Van Den Hoogen FJA. Repeated onabotulinum neurotoxin A injections for drooling in children with neurodisability. Dev Med Child Neurol 2021; 63:991-997. [PMID: 33772779 PMCID: PMC8359949 DOI: 10.1111/dmcn.14872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 11/28/2022]
Abstract
AIM To evaluate the effect of repeated onabotulinum neurotoxin A injections for the treatment of drooling in children with neurodisabilities. METHOD This was a retrospective cohort study, in which the first, second, and third onabotulinum neurotoxin A injection were compared within children treated between 2000 and 2020. Primary outcomes included drooling quotient, visual analogue scale (VAS), and treatment success defined as ≥50% reduction in drooling quotient and/or VAS 8 weeks after treatment. Each outcome was obtained at baseline and 8 weeks posttreatment. RESULTS Seventy-seven children were included (mean age at first injection: 8y 3mo, SD 3y 7mo, range 3-17y; 44 males, 33 females; 51.9% with cerebral palsy, 45.5% wheelchair-bound). The objective (drooling quotient) and subjective (VAS) effect after the second injection was lower compared to the first injection. The third injection showed less objective and significantly less subjective effect compared to the first injection. An overall success rate of 74.0%, 41.6%, and 45.8% were found for the first, second, and third injection respectively. INTERPRETATION Although onabotulinum neurotoxin A remained effective throughout the entire treatment course, there is less effect of subsequent onabotulinum neurotoxin A injections compared to the first. Although there might be a loss of effect after repeated injections, there is continued improvement for most children. What this paper adds Repeated injections show a diminished treatment effect after the second injection. A continued improvement is seen in most patients.
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Affiliation(s)
- Stijn Bekkers
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud Institute for Health SciencesNijmegenthe Netherlands
| | - Theresa YS Leow
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud Institute for Health SciencesNijmegenthe Netherlands
| | - Karen Van Hulst
- Department of RehabilitationRadboud University Medical CenterDonders Institute for Brain, Cognition and BehaviourNijmegenthe Netherlands
| | - Lynn B Orriëns
- Department of RehabilitationRadboud University Medical CenterDonders Institute for Brain, Cognition and BehaviourNijmegenthe Netherlands
| | - Arthur RT Scheffer
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud Institute for Health SciencesNijmegenthe Netherlands
| | - Frank JA Van Den Hoogen
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud Institute for Health SciencesNijmegenthe Netherlands
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Toulemonde P, Maltezeanu A, Broucqsault H, Fayoux P. Tolerance of salivary gland botulinum toxin A injection under local anesthesia for the treatment of sialorrhea in children: An observational study. Eur Ann Otorhinolaryngol Head Neck Dis 2021; 139:77-81. [PMID: 34217684 DOI: 10.1016/j.anorl.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The main objective of this study was to assess tolerance of botulinum toxin A injection into the salivary glands under local anesthesia in a pediatric population. Secondary endpoints comprised efficacy and side-effects. MATERIAL AND METHODS A retrospective observational study included children treated between January 2013 and March 2020 for sialorrhea and/or pharyngeal salivary congestion. Children were identified from the botulinum toxin A injection database. The study included 162 injection sessions in 55 children. Injections were performed under local anesthesia with nitrous oxide, after clinical location of the site. Epidemiological and clinical data, injection tolerance on the FLACC scale, treatment response and complications were recorded. RESULTS For submandibular gland injections, pain was absent in 81 cases, mild in 64, moderate in 4 and intense in 1. In parotid gland injections, pain was absent in 45 cases, mild in 89, moderate in 17 and intense in 1. Injection tolerance was significantly poorer (P<0.005) in parotid than submandibular glands. Seventy-seven percent of the injections had a positive effect on sialorrhea. Fifteen patients presented transient adverse events: mainly dysphagia and paradoxical increase in sialorrhea. CONCLUSION Salivary gland botulinum toxin A injections in under local anesthesia were well-tolerated, safe and effective for children with sialorrhea and/or pharyngeal salivary congestion.
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Affiliation(s)
- P Toulemonde
- Service ORL et Chirurgie Cervico-Faciale Pédiatrique, Hôpital Jeanne de Flandre, Avenue Eugène Avinée, 59000 Lille, France
| | - A Maltezeanu
- Service ORL et Chirurgie Cervico-Faciale Pédiatrique, Hôpital Jeanne de Flandre, Avenue Eugène Avinée, 59000 Lille, France
| | - H Broucqsault
- Service ORL et Chirurgie Cervico-Faciale Pédiatrique, Hôpital Jeanne de Flandre, Avenue Eugène Avinée, 59000 Lille, France
| | - P Fayoux
- Service ORL et Chirurgie Cervico-Faciale Pédiatrique, Hôpital Jeanne de Flandre, Avenue Eugène Avinée, 59000 Lille, France.
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Schild SD, Timashpolsky A, Ballard DP, Horne S, Rosenfeld RM, Plum AW. Surgical Management of Sialorrhea: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2021; 165:507-518. [PMID: 33494642 DOI: 10.1177/0194599820985165] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Chronic sialorrhea commonly occurs in patients with neurodevelopmental disorders. While conservative management can provide sufficient symptom control, surgical intervention is often required. One of the most common procedures utilized is submandibular gland excision (SMGE), with or without parotid duct ligation or rerouting (PDL or PDR). This study aims to compare these surgical approaches and their outcomes. DATA SOURCES PubMed, Web of Science, and Embase. REVIEW METHODS This systematic review includes studies of patients with chronic sialorrhea treated with SMGE alone or SMGE plus PDR or PDL and reports on postintervention outcomes and complications. Two independent investigators assessed study eligibility, rated quality, and extracted data for analysis. A random effects model was used for meta-analysis of pooled data. RESULTS Of 3186 studies identified, 21 met inclusion criteria, with 708 patients: 103 underwent SMGE alone (15%); 299 (42%), SMGE and PDL; and 306 (43%), SMGE plus PDR. Overall, a majority of patients had significant improvement, with very good to excellent control of symptoms after surgery: SMGE, 82% (95% CI, 73%-89%); SMGE and PDL, 79% (95% CI, 73%-85%); and SMGE and PDR, 85% (95% CI, 75%-92%). Importantly, there was no significant difference in outcomes with the addition of PDL or PDR. Reported complications included sialocele, parotitis, dental caries, and dry mouth. CONCLUSION Our systematic review identified consistent positive outcomes with SMGE for patients with chronic sialorrhea but no additional benefit when PDR or PDL was performed as a concurrent procedure.
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Affiliation(s)
- Sam D Schild
- State University of New York, Brooklyn, New York, USA
| | | | | | - Sylvia Horne
- State University of New York, Brooklyn, New York, USA
| | | | - Ann W Plum
- State University of New York, Brooklyn, New York, USA
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Bekkers S, van Ulsen KJ, M M Adang E, R T Scheffer A, J A van den Hoogen F. Cost-effectiveness of botulinum neurotoxin A versus surgery for drooling: a randomized clinical trial. Dev Med Child Neurol 2020; 62:1302-1308. [PMID: 32706122 PMCID: PMC7589433 DOI: 10.1111/dmcn.14636] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2020] [Indexed: 11/27/2022]
Abstract
AIM This study compared the cost-effectiveness of botulinum neurotoxin A (BoNT-A) injections with two-duct ligation of the submandibular glands as treatment for severe drooling after one treatment cycle. METHOD The study was part of a larger, partly single-blinded, randomized clinical trial (trialregister.nl identifier NTR3537). Data were collected between 2012 and 2017. Evaluation was at 32 weeks after one treatment cycle. Fifty-seven patients with cerebral palsy or other neurological, non-progressive disorders and severe drooling classified as having a drooling frequency ≥3 or a drooling severity ≥2, in whom conservative treatment was deemed ineffective, were randomized to treatment by BoNT-A or two-duct ligation. An incremental cost-effectiveness ratio (ICER) was calculated using the success rates as the measure of benefit. Treatment success was defined as a decrease ≥50% from baseline to 32 weeks in the subjective visual analogue scale for the severity of drooling or the objective drooling quotient. RESULTS Fifty-three patients were analysed (22 females, 31 males; mean age 11y, range 8-22y). Average costs for one treatment cycle, which included one BoNT-A injection, were €1929 (standard error 62) for BoNT-A and €3155 (standard error 99) for two-duct ligation. Treatment success was in favour of two-duct ligation (63% vs 27%; number needed to treat 3). The ICER was €34 per 1% gain in treatment success in favour of two-duct ligation versus BoNT-A. INTERPRETATION The additional cost of two-duct ligation is to some extent offset by a larger treatment success rate compared with BoNT-A. WHAT THIS PAPER ADDS Botulinum neurotoxin A (BoNT-A) is less expensive per percentage of success than two-duct ligation. The additional cost of two-duct ligation over BoNT-A is offset by greater treatment success.
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Affiliation(s)
- Stijn Bekkers
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
| | - Kim J van Ulsen
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
| | - Eddy M M Adang
- Department for Health Evidence RehabilitationRadboud University Medical CenterNijmegenthe Netherlands
| | - Arthur R T Scheffer
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
| | - Frank J A van den Hoogen
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
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An evaluation of predictors for success of two-duct ligation for drooling in neurodisabilities. J Neurol 2020; 267:1508-1515. [PMID: 32025794 PMCID: PMC7184040 DOI: 10.1007/s00415-020-09735-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 10/26/2022]
Abstract
BACKGROUND Drooling is dependent on various clinical variables. However, while drooling proves refractory to two-duct ligation in 40% of patients, predictors for treatment success are sparse and to date there is little evidence why some respond well while others are non-responders. We aim to find predictors for treatment success and study the effectiveness of two-duct ligation for drooling in neurodisabilities. METHODS Fifty-four patients with moderate to severe drooling who had undergone two-duct ligation were screened for inclusion. Four patients were excluded due to missing or unreliable primary outcomes. The average age at the time of surgery was 12 years. Predictors were evaluated for treatment success which was defined as ≥ 50% visual analog scale for severity of drooling and/or drooling quotient reduction from baseline. Treatment effect was measured after 8 and 32 weeks compared to baseline. RESULTS Age (more mature), adequate posture (no anteflexion), and normal speech are predictors for treatment success. Compared to baseline, drooling quotient was significantly lower at 8 (difference 18.6%, 95% confidence interval 12.3-24.9%) and 32 weeks (difference 10.1%, 95% confidence interval 3.9-16.4%). Compared to baseline, visual analog scale was significantly lower at 8 (difference 45.0, 95% confidence interval 37.0-52.9) and 32 weeks (difference 32.9, 95% confidence interval 25.0-40.7). CONCLUSIONS Age, adequate posture, and a normal speech are predictors for treatment success, are easily determined pre-operatively, and help the clinician providing patient-specific probability of treatment success. There is a significant subjective and objective decrease of drooling after two-duct ligation.
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