Intraparotid Injection of Botulinum Toxin A as a Treatment to Control Sialorrhea in Children with Cerebral Palsy

Comparing botulinum toxin and 4-duct ligation for Sialorrhea in children - A systematic review

INTRODUCTION

Sialorrhea or drooling can result in physical and psychosocial complications, such as aspiration and social isolation. Treatment options include botulinum toxin into the salivary glands and 4-duct ligation (i.e., simultaneous ligation of the bilateral parotid and submandibular ducts). This systematic review aimed to compare the efficacy and complication rates of botulinum toxin and 4-duct ligation for the treatment of drooling in children.

METHODS

Following PRISMA guidelines, PubMed, Embase, Web of Science, and Cochrane Library were searched from inception through June 17, 2021 for studies examining the efficacy of botulinum toxin or 4-duct ligation for drooling in children. Data were summarized by pooled counts, percentages, and means. Complication rates were compared by a chi-squared test.

RESULTS

A total of 22 studies (n = 606) examining botulinum toxin and 5 studies (n = 124) examining 4-duct ligation were included. From 12 botulinum toxin studies (n = 211), mean drooling frequency and severity scores was 7.5 at baseline. Mean difference from baseline was -2.6 (n = 92) at 4 weeks follow-up, -2.1 at 8 weeks (n = 41), -2.1 at 12 weeks (n = 56), and - 2.1 at 16 weeks (n = 58). From 4 4-duct ligation studies (n = 103), mean baseline drooling frequency and severity score was 8.4. Mean difference was -3.7 at mean follow-up of 35.6 months (n = 103). Eighteen botulinum studies (n = 343) recorded 53 (15.5 %) complications, including thickened saliva (n = 9), dysphagia (n = 4), and cheek abscesses (n = 4). Four 4-duct ligation studies (n = 108) recorded 25 (23.1 %) complications, including parotid gland swelling (n = 4), aspiration pneumonia (n = 3), and oxygen desaturation (n = 3). There was no statistically significant difference in complication rates between botulinum toxin and four-duct ligation (p = 0.065).

CONCLUSION

Botulinum toxin injection and 4-duct ligation are both effective in improving sialorrhea in children and have comparable complication rates.

Comparing the evidence for botulinum neurotoxin injections in paediatric anterior drooling: a scoping review

Paediatric anterior drooling has a major impact on the daily lives of children and caregivers. Intraglandular botulinum neurotoxin type-A (BoNT-A) injections are considered an effective treatment to diminish drooling. However, there is no international consensus on which major salivary glands should be injected to obtain optimal treatment effect while minimizing the risk of side effects. This scoping review aimed to explore the evidence for submandibular BoNT-A injections and concurrent submandibular and parotid (i.e. four-gland) injections, respectively, and assess whether outcomes could be compared across studies to improve decision making regarding the optimal initial BoNT-A treatment approach for paediatric anterior drooling. PubMed, Embase, and Web of Science were searched to identify relevant studies (until October 1, 2023) on submandibular or four-gland BoNT-A injections for the treatment of anterior drooling in children with neurodevelopmental disabilities. Similarities and differences in treatment, patient, outcome, and follow-up characteristics were assessed. Twenty-eight papers were identified; 7 reporting on submandibular injections and 21 on four-gland injections. No major differences in treatment procedures or timing of follow-up were found. However, patient characteristics were poorly reported, there was great variety in outcome measurement, and the assessment of side effects was not clearly described.   Conclusion: This review highlights heterogeneity in outcome measures and patient population descriptors among studies on paediatric BoNT-A injections, limiting the ability to compare treatment effectiveness between submandibular and four-gland injections. These findings emphasize the need for more extensive and uniform reporting of patient characteristics and the implementation of a core outcome measurement set to allow for comparison of results between studies and facilitate the optimization of clinical practice guidelines. What is Known: • There is no international consensus on which salivary glands to initially inject with BoNT-A to treat paediatric drooling. What is New: • Concluding on the optimal initial BoNT-A treatment based on literature is currently infeasible. There is considerable heterogeneity in outcome measures used to quantify anterior drooling.and clinical characteristics of children treated with intraglandular BoNT-A are generally insufficiently reported. • Consensus-based sets of outcome measures and patient characteristics should be developed and implemented.

Mechanism and clinical use of botulinum neurotoxin in head and facial region

PURPOSE

Botulinum neurotoxin (BoNT) is a biological toxin produced by Clostridium botulinum. BoNT is a potent toxin extensively used in therapeutic interventions. This review provides an updated overview of the mechanisms of action and clinical applications of BoNT in head and facial region.

STUDY SELECTION

MEDLINE/PubMed searches were conducted using the terms "botulinum neurotoxin" and "dentistry" along with a combination of other related terms. In addition, studies were manually selected from reference lists of the selected articles.

RESULTS

The Food and Drug Administration in the United States initially approved BoNT to treat strabismus, blepharospasm, and hemifacial spasms. The use of BoNT in dermatology and cosmetics has been widely established and has created a revolution in these fields. Over the years, its applications in various medical specialties have expanded widely. Owing to its safety, efficacy, and long duration of action, it is well-accepted by patients. BoNT/A and BoNT/B are widely used in clinical practice. Several off-label uses of BoNT in the dental fraternity have yielded promising results. We have elaborated on the speculated mechanism of action, dosage, effective sites of injection, and adverse effects of each therapeutic application. The various clinical indications for BoNT include bruxism, myofascial pain, temporomandibular joint dislocation, hemifacial pain, orofacial dystonia, facial paralysis, chronic migraine, and trigeminal neuralgia.

CONCLUSIONS

BoNT is a safe treatment that can be used effectively, provided that the clinician has adequate knowledge regarding the mechanism, injection techniques, and local and systemic side effects and that it is administered cautiously and purposefully.

Comparative Efficacy of Botulinum Toxin in Salivary Glands vs. Oromotor Therapy in the Management of Sialorrhea in Cerebral Palsy Impact on Sleep Quality

Aims

The aim of this study was to compare the effects of intraglandular abobotuliniumtoxinA application and oromotor therapy in the management of sialorrhea in patients with cerebral palsy and its effect on sleep quality.

Methods

A comparative study (n = 134), mean age 7.1 years (± 3.9 years) was performed in pediatric patients, between the efficacy of abobotuliniumtoxinA in salivary glands and oromotor therapy (JT), with a control group receiving exclusive oromotor therapy (EOMT). Demographic variables, as well as Gross Motor Function Classification System (GMFCS), Drooling Severity and Frequency Scale (DSFS), Sleep Disturbance Scale for Children (SDSC) and Eating and Drinking Ability Classification System (EDACS) were analyzed in 134 patients considering two measurements 6 months apart. Statistical analysis was developed between both groups.

Results

The greatest improvement in safety and efficacy of swallowing were those in the JT group with initial levels of EDACS IV and V. Both therapies result in favorable changes of all subscales means of SDSC, with joint therapy showing the greater benefit (p = 0.003) over EOMT (p = 0.06), especially for Sleep Breathing Disorders and Disorders of initiating and maintaining sleep (p < 0.01 vs. p = 0.07). No major adverse effects were found, only those expected from the application of the toxin, such as pain, mild, and transient local inflammation.

Interpretation

A correlation between frequency and intensity of sialorrhea, with the frequency of sleep disorders and dysphagia was found. Conventional EOMT proved to be useful, improving the safety and efficacy of swallowing, sialorrhea and sleep disorder, however it can be enhanced with the application of abobotuliniumtoxinA.

Botulinum Toxin Injections for Treatment of Drooling in Children with Cerebral Palsy: A Systematic Review and Meta-Analysis

Background: We aimed to review and analyse the effectiveness and safety of botulinum toxin type A (BoNT-A) injections for drooling in children with cerebral palsy. Data sources: We searched the EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) databases from inception to January 2020. Methods: We included randomized controlled trials and observational studies which (1) involved children with cerebral palsy, (2) used BoNT-A for control of drooling, and (3) provided quantitative evaluations of drooling before and after intervention with BoNT-A. Results: Twenty-one trials met the inclusion criteria. Most studies showed that BoNT-A injections are safe and efficacious as a treatment for drooling in children with cerebral palsy. Four trials had sufficient data to pool the results for the meta-analysis. Both the drooling quotient (p = 0.002) and drooling Ffrequency and severity scale (p = 0.004) supported this conclusion. Conclusion: BoNT-A injections are a safe, reversible, effective treatment for drooling control in children with cerebral palsy that can offer effectiveness for more than 3 months with few side effects. The dosage of BoNT-A should not exceed 4 units/kg. Further studies are required to determine the optimal dosage and target glands.

A critical review of incobotulinumtoxinA in the treatment of chronic sialorrhea in pediatric patients

INTRODUCTION

Sialorrhea, also known as hypersalivation, ptyalis, or drooling, results in physical and psychosocial complications that may have a significant negative impact on quality of life for both the patient and their caregiver. The goal of pharmacological treatment is to reduce excessive salivary flow, while maintaining a moist and healthy oral cavity; until recently, however, few of the agents used to treat chronic sialorrhea have been approved in pediatric patients.

AREAS COVERED

This article summarizes early evidence for the use of botulinum neurotoxin A formulations in the treatment of children/adolescents with chronic sialorrhea, and findings of the recently completed phase III trial of incobotulinumtoxinA in this indication. Alternative therapies are also briefly discussed.

EXPERT OPINION

IncobotulinumtoxinA is the first botulinum neurotoxin A to be approved for the treatment of chronic sialorrhea in children and adults, following the results of phase III trials that demonstrate the efficacy and safety of the drug in these patients. The authors expect that the positive findings will result in updates to clinical guidelines for the treatment of children with chronic sialorrhea.

ABBREVIATIONS

AE, adverse event; AESI, adverse event of special interest; BoNT/A, botulinum neurotoxin A; CI, confidence interval; CP, cerebral palsy; DIS, drooling impact scale; DQ, drooling quotient; DSFS, Drooling Severity and Frequency Scale; GICS, Global Impression of Change Scale; LS, least squares; mTDS, modified Teacher's drooling scale; NR, not reported; PD, Parkinson's disease; SAE, serious adverse event; SE, standard error; SIAXI, Sialorrhea in Adults Xeomin Investigation; SIPEXI, Sialorrhea Pediatric Xeomin Investigation; SNAP-25, synaptosomal associated protein-25; TBI, traumatic brain injury; TDS, Teacher Drooling Scale; USA, United States of America; uSFR, unstimulated Salivary Flow Rate; VAS, visual analog scale.

Sialorrhea & aspiration control - A minimally invasive strategy uncomplicated by anticholinergic drug tolerance or tachyphylaxis

OBJECTIVE

Sialorrhea complicated by aspiration is a primary source of morbidity and mortality in neurologically impaired children. Anticholinergics are an effective treatment option, but have traditionally been considered only adjuncts due to tachyphylaxis and drug tolerance. Similarly, Botox-A^® salivary gland injections are also considered adjunctive due to the need to repeat treatment every 3 months. This retrospective case series assessed these two adjunctive strategies used in combination as definitive minimally invasive primary treatment.

METHODS

112 subjects diagnosed with sialorrhea and treated at UPMC Children's Hospital of Pittsburgh between 2004 and 2011 were identified. Charts were carefully reviewed for pertinent information regarding the treatment of their sialorrhea and related outcomes.

RESULTS

Over half of the subject undergoing BTX-A injections were able to reduce their dosage of anticholinergics after receiving injection (58%, n = 28 for glycopyrrolate users and 61%, n = 20 for scopolamine users). Subjects experienced a significant reduction in days spent in the hospital in the year following Botox-A^® injection (P-Value = 0.03), and the number of pneumonia episodes in the year following injection (P-Value = 0.04).

CONCLUSION

Patients treated effectively with both BTX-A injections into their salivary glands and anticholinergics developed neither tachyphylaxis nor drug tolerance with up to 9.6 years of continuous treatment. During the year following combined therapy, patients' average length hospital stay was reduced by a full week and the number of pneumonia episodes was statistically decreased. The failure rate of combined therapy was below that reported for any other intervention or combination of interventions in the literature. Finally, patients did not require BTX-A re-injection at the reported frequency. We hypothesize that anticholinergic medications competitively block acetylcholine attachment to post-synaptic receptors while BTX-A inhibits acetylcholine release at the pre-synaptic terminal, tachyphylaxis/drug tolerance mechanisms resulting in up-regulation of post-synaptic receptors are disrupted. Although salivary production may increase in the year following BTX-A injection, there is enough remaining activity at a molecular level to inhibit release of acetylcholine allowing salvage with anticholinergic medications at tolerable dosages.

Incobotulinumtoxin A for Sialorrhea in Neurological Disorders: A Real-Life Experience

Botulinum toxin type A is one of the most useful treatments of sialorrhea in neurological disorders. Evidence for the use of incobotulinumtoxin A (inco-A) in the treatment of sialorrhea is limited. Thirty-six patients with sialorrhea were treated with infiltrations of inco-A into both parotid glands. The severity of sialorrhea was evaluated by the Drooling Severity Scale (DSS), and the Drooling Frequency Scale (DFS). Patients’ perceptions of clinical benefit were recorded via the Patient Global Impression of Improvement (PGI-I) scale. Following treatment, there was a significant difference in both the DFS and the DSS (p < 0.001). Clinical benefits on the basis of the PGI-I were present in up to 90% of patients.

Botulinum Toxin Injection to the Salivary Glands for the Treatment of Sialorrhea with Chronic Aspiration

Objectives

Chronic aspiration of salivary secretions can cause major pulmonary morbidity in neurologically impaired patients. Many treatments are proposed to address these problems, some with significant side effects. Botulinum toxin type A injection into the salivary glands is known to reduce salivary flow without major complications. Few reports exist regarding the use of this treatment in the prevention of recurrent aspiration pneumonia. We studied the effects of this treatment for patients with recurrent aspiration pneumonia.

Methods

We performed a chart review of 12 patients, ranging in age from 7 months to 37 years, treated with botulinum toxin injections at a single tertiary care institution. A caregiver telephone questionnaire was also administered. The numbers of pulmonary infections and hospitalizations before and after the initiation of treatment were compared.

Results

Nine of 12 patients reported improvement in the numbers of hospitalizations and pulmonary infections following botulinum toxin injections. Reduction in the use of anticholinergic medication and reduced pulmonary toilet requirements were also noted. There were no complications of treatment.

Conclusions

Botulinum toxin injection into the salivary glands can be effective in reducing pulmonary morbidity in many neurologically impaired patients. This relatively simple technique offers an alternative to the use of anticholinergic medication and may obviate the need for more invasive surgical treatment in certain patients.

Histological and immunohistochemical findings of the action of botulinum toxin in salivary gland: systematic review

The treatment of sialorrhea is necessary for the constant risks posed by hypersalivation. A new therapeutic option comes up with the application of botulinum toxin in salivary glands. However, little is known about its mechanism of action in glandular tissue. Based on the above, this work had the objective to systematically review the literature about the action of botulinum toxin on submandibular and parotid salivary glands tissues. Electronic search was performed in databases of great relevance for this study (PubMed, SciELO, HighWire, Crossref, Scopus, Science Direct, MEDLINE, OLDMEDLINE, Serials Database, NLM Catalog, LILACS and IBECS). Inclusion and exclusion criteria for articles were established, and a total number of 14 articles were selected and used. There are few publications that clarify how the salivary gland acini behave with application of botulinum toxin. Although, the immunohistochemical findings were consistent among authors, showing weak immunoreactivity in glands treated with botulinum toxin. Histometric data are divergent, requiring more detailed studies to answer the questions about the efficacy and safety of botulinum toxin in salivary glands.

Botulinum Toxin a in the Treatment of Sialorrhea

Objective:

To review the efficacy and safety of botulinum toxin A (BTX) in the treatment of sialorrhea.

Data Sources:

A PubMed search and reference list review was performed to find clinical trials on BTX in the treatment of sialorrhea. The search was limited to English-language trials involving human subjects. Articles from 1965 to October 2006 were searched, using key words botulinum, botulinum toxin, Botox, sialorrhea, saliva, salivary gland, and drooling.

Study Selection And Data Extraction:

Reports of 15 studies were found on BTX in the treatment of sialorrhea in human subjects. Four controlled trials are presented in detail, and 11 uncontrolled studies are summarized.

Data Synthesis:

One controlled trial found that BTX caused significant reductions in patients' severity and frequency of drooling compared with placebo. Another found significant saliva reductions in the treatment group receiving the highest dose of BTX but found no subjective improvement compared with the placebo group. A third study comparing BTX with placebo found significant improvements in subjective and objective measures of drooling in the treatment group. A fourth controlled trial found significant reductions from baseline levels of drooling after patients received BTX injections. Similar efficacy was found between the BTX and scopolamine treatment groups.

Conclusions:

Evidence indicates that BTX is a safe and effective treatment for sialorrhea. More research is needed to determine the ideal dose, injection location, and technique of BTX injections.

[Submandibular gland resection for the management of sialorrhea in paediatric patients with cerebral palsy and unresponsive to type A botullinum toxin. Pilot study]

BACKGROUND

Sialorrhoea has a prevalence of between 10% and 58% in patients with cerebral palsy. Amongst the invasive treatments, botulinum toxin-A injections in submandibular and parotid glands and various surgical techniques are worth mentioning. There are no studies in Mexico on the usefulness of surgery to manage sialorrhoea.

OBJECTIVE

To evaluate the usefulness of submandibular gland resection in improving sialorrhoea in patients with cerebral palsy and with a poor response to botulinum toxin.

MATERIAL AND METHODS

Experimental, clinical, self-controlled, prospective trial was conducted to evaluate the grade of sialorrhoea before surgery, and 8, 16 and 24 weeks after. Statistical analysis was performed using a non-parametric repetitive measure assessment, considering a p < 0.05 as significant. Complications and changes in salivary composition were evaluated.

RESULTS

Surgery was performed on 3 patients with severe sialorrhoea, and 2 with profuse sialorrhoea, with mean age of 10.8 years. The frequency and severity of sialorrhoea improved in the 5 patients, with mean of 76.7 and 87.5% improvement, respectively. The best results were seen after 6 months of surgery, with a statistically significant difference between the preoperative stage and 6 months after the procedure (p = 0.0039, 95% CI). No significant differences were observed in complications, increase in periodontal disease or cavities, or salivary composition.

CONCLUSIONS

Submandibular gland resection is an effective technique for sialorrhoea control in paediatric patients with cerebral palsy, with a reduction in salivary flow greater than 80%. It has a low chance of producing complications compared to other techniques. It led to an obvious decrease in sialorrhoea without the need to involve other salivary glands in the procedure.

Ultrasound-Guided Botulinum Toxin Type A Salivary Gland Injection in Children for Refractory Sialorrhea: 10-Year Experience at a Large Tertiary Children's Hospital

BACKGROUND

Sialorrhea is problematic for neurologically impaired children, and botulinum toxin A salivary gland injection has been reported as effective in reducing sialorrhea. This article assesses the success and safety of ultrasound-guided weight-based botulinum toxin A injection for the management of sialorrhea in children.

METHODS

A total of 111 patients (63 males; 48 females; average age 7 years) with refractory sialorrhea were treated with ultrasound-guided botulinum toxin type A salivary gland injections (144 procedures) from July 1, 2004, to July 1, 2014, using a single weight-based protocol. Patient history, procedural records, and clinical follow-up documents were retrospectively reviewed. Clinical data were compared with reported effectiveness and complications using odds ratios.

RESULTS

A total of 144 procedures were performed in 111 patients with refractory sialorrhea. Cerebral palsy was the most common underlying etiology for sialorrhea (29%), whereas others included encephalopathy (5%), anoxic brain injury (4%), and a variety of chromosomal anomalies (5%). There was a 100% technical success rate. Overall treatment effectiveness was 68%. Repeat injections were not associated with increased clinical success. No procedure-related deaths or major complications were identified; the minor complication rate was less than 2%.

CONCLUSIONS

The protocol used for ultrasound-guided injection of botulinum toxin A proved to be safe and effective in children suffering from sialorrhea. Image guidance technique may lead to a reduction in rates of adverse events reported in other series. Subsequent procedures do not improve upon initial efficacy.

Botulinum Toxin A and B in sialorrhea: Long-term data and literature overview

INTRODUCTION AND OBJECTIVES

In recent years, Botulinum Toxin has been shown to be efficacious and safe in the treatment of sialorrhea, but scanty data are available on its long term use. The aim of this study was to investigate adverse events, discriminate differences in safety, and evaluate the efficacy of long-term use of both abobotulinumtoxinA and rimabotulinumtoxinB ultrasound-guided injections for sialorrhea in a retrospective trial. Moreover we review the literature on this topic.

PATIENTS AND METHODS

Consecutive patients with severe sialorrhea and receiving at least two ultrasound-guided intrasalivary glands abobotulinumtoxinA 250 U or rimabotulinumtoxinB 2500 U injections were included. Clinical and demographic data were collected. Safety and tolerability were assessed on the basis of patients' self-reports. Efficacy was assessed by recording the duration of benefit and by the Drooling Severity Scale and Drooling Frequency Scale 4 weeks after intervention. A review of literature was performed using 'Botulinum Toxin' and/or 'drooling' and/or 'sialorrhea' and/or 'hypersalivation' as keywords.

RESULTS

Sixty-five patients (32 Amyotrophic Lateral Sclerosis and 33 Parkinson's Disease) were treated in a total of 317 sessions (181 rimabotulinumtoxinB and 136 abobotulinumtoxinA). Both serotypes induced a clear-cut benefit in 89% of injections. Mean benefit duration was 87 days (range 30-240), similar for abobotulinumtoxinA and rimabotulinumtoxinB but significantly shorter in Amyotrophic Lateral Sclerosis group compared to Parkinson's Disease (p < 0.001). Older age was positively correlated to benefit duration (p = 0.003). Botulinum Toxin-related and injection-related side effects complicated respectively 8,2% and 1,5% of treatments. The only Botulinum Toxin-related adverse event was a change of saliva thickness, mostly rated mild to moderate and more frequent in Amyotrophic Lateral Sclerosis patients (p = NS).

CONCLUSIONS

Both 250 U abobotulinumtoxinA and 2500 U rimabotulinumtoxinB administered by ultrasound-guided intrasalivary gland injection are safe and effective in treating sialorrhea, even in long-term follow-up. Older age is significantly associated with longer benefit duration. Parkinson's Disease patients showed a more favorable safety-efficacy ratio than did Amyotrophic Lateral Sclerosis patients, due to lower adverse events (p = NS) and longer benefit duration (p < 0.001).

Relevance of intraglandular injections of Botulinum toxin for the treatment of sialorrhea in children with cerebral palsy: a review

BACKGROUND

After the age of 4 years, drooling becomes pathological and impacts the quality of life of children with cerebral palsy. Intraglandular injection of Botulinum toxin is one of the treatments available to limit this phenomenon.

AIMS

The objectives of this review were to validate the efficacy of Botulinum toxin injections for drooling in children with cerebral palsy, determine recommendations and identify potential side effects.

METHODS

We conducted a literature review from 2001 in the following databases: Embase, Pubmed and Cochrane using the keywords: sialorrhea, drooling, hypersalivation, Botulinum toxin, cerebral palsy and children. Only the articles evaluating the efficacy of Botulinum toxin in children with cerebral palsy over the age of 4 were researched.

RESULTS

Eight studies were found: 2 case studies, 3 open and non-controlled studies and 3 randomized controlled trials. Efficacy results in this indication are quite encouraging and the use of BTX injections is safe but the overall level of evidence of these studies was quite low.

CONCLUSION

However, intraglandular injection of Botulinum toxin has a place among the therapeutic array available for the management of sialorrhea in this population even if no standardized protocol is available yet.

Surgical management of chronic sialorrhea in pediatric patients: 10-year experience from one tertiary care institution

BACKGROUND

Chronic sialorrhea is a common problem for pediatric patients with disorders that affect swallowing. While many patients are successfully treated with medical therapies such as Robinul and Scopolamine, a number of such children are not able to tolerate the side effects of these medications. In these cases, surgical treatments can include Botulinum toxin A (Botox) injections into the major salivary glands, sublingual or submandibular gland excision (SMGE), submandibular duct ligation, parotid duct ligation (PDL), or any combination of the above procedures. The purpose of this study is to report on the 10-year experience with the surgical management of chronic sialorrhea at one tertiary care institution, and compare the efficacy of open surgical procedures versus Botox injections for reduction in salivary flow.

METHODS

A retrospective chart review identified 27 pediatric patients with chronic sialorrhea; 21 of whom underwent Botox injections and 15 of whom underwent surgical procedures. Preoperative and follow-up clinic notes were reviewed to determine the level and severity of drooling as well as the effectiveness of sialorrhea reduction, as assessed by the Teacher Drooling Scale (TDS).

RESULTS

42% of those receiving Botox injections reported a reduction in drooling, with the average pre- and post-Botox TDS of 4.3 and 3.9, respectively (p=0.02 by the Wilcoxon signed rank test). Nine of the patients receiving Botox injections (43%) required multiple injections, with an average duration of effect of 3.9 months, and 7 patients (33%) eventually required surgery. All of the children who underwent surgery (7 bilateral SMGE with PDL, 6 SMGE only, and 2 PDL only) experienced a reduction in drooling, with average pre- and post-operative TDS of 4.5 and 2.2, respectively. This reduction was significant by the Wilcoxon signed rank test (p=0.001).

CONCLUSIONS

The ten-year experience at our institution demonstrates the safety, efficacy and long-term control of drooling in the patients undergoing surgery for intractable sialorrhea.

Salivary gland botulinum toxin injections for drooling in children with cerebral palsy and neurodevelopmental disability: a systematic review

AIM

The aim of this paper was to systematically review the efficacy and safety of botulinum toxin (BoNT) injections to the salivary glands to treat drooling in children with cerebral palsy and neurodevelopmental disability.

METHOD

A systematic search of The Cochrane Central Register of Controlled Trials, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE, and the Physiotherapy Evidence Database (PEDro) was conducted (up to 1 October 2011). Data sources included published randomized controlled trials (RCTs) and prospective studies.

RESULTS

Sixteen studies met inclusion criteria. Three outcome measures support the effectiveness of BoNT for drooling. One RCT found an almost 30% reduction in the impact of drooling on patients' lives, as measured by the Drooling Impact Scale (mean difference -27.45; 95% confidence interval [CI] -35.28 to -19.62). There were sufficient data to pool results on one outcome measure, the Drooling Frequency and Severity Scale, which supports this result (mean difference -2.71; 95% CI -4.82 to -0.60; p<0.001). There was a significant reduction in the observed number of bibs required per day. The incidence of adverse events ranged from 2 to 41%, but was inconsistently reported. One trial was terminated early because of adverse events.

INTERPRETATION

BoNT is an effective, temporary treatment for sialorrhoea in children with cerebral palsy. Benefits need to be weighed against the potential for serious adverse events. More studies are needed to address the safety of BoNT and to compare BoNT with other treatment options for drooling.

Drooling: are botulinum toxin injections into the major salivary glands a good treatment option?

There are several treatment options available for drooling; botulinum toxin injections into the major salivary glands are one. There is no consensus as to how many and which glands should be injected. A research project on this topic was terminated because of adverse effects. Individual results and the adverse effects are described and discussed in this article. Six individuals with cerebral palsy were randomly allocated to 2 treatment groups, with five individuals receiving ultrasound-guided injections to parotid and submandibular glands and one receiving injections to the submandibular glands only. Reduction of observed drooling was registered in 3, while 4 patients reported subjective improvement (Visual Analog Scale). Two participants reported adverse effects, including dysphagia, dysarthria, and increased salivary viscosity. Injections with botulinum toxin can be a useful treatment option but there is a risk of adverse effects. Multidisciplinary evaluation and informed discussions with patients/caregivers are important factors in the decision-making process.

Effect of botulinum toxin type a on morphology of salivary glands in patients with cerebral palsy

Objective

To investigate the effect of botulinum toxin type A (BTXA) on drooling and the morphologic change of the salivary gland in patients with cerebral palsy.

Method

Eight cerebral palsy patients suffering from severe drooling participated in this study. BTXA was injected into both submandibular and parotid glands under intravenous sedation and with ultrasound guidance (1 unit/gland/kg: maximum 100 units) in an outpatient or inpatient procedure. The severity of drooling was measured before injection and 3 weeks after injection using the Teacher Drooling Scale, the Drooling Score-severity, frequency and the Visual Analog Scale. To investigate the morphologic change of the salivary glands, the size of salivary glands were measured before injection and 3 weeks after injection using computed tomography of the neck. The measurement values were analyzed by Wilcoxon signed rank test.

Results

Statistically significant improvements were shown in all three parameters for assessing the severity of drooling after BTXA injections (p<0.05). Size of the salivary glands were significantly decreased at 3 weeks after BTXA injection (p<0.05).

Conclusion

Salivary gland injection with BTXA could be a useful treatment method to reduce drooling in patients with cerebral palsy and decreased size of salivary glands may partially explain the mechanism.

Botox(®) to reduce drooling in a paediatric population with neurological impairments: a Phase I study

BACKGROUND

The treatment of drooling in a paediatric population with neurological impairments is clinically challenging. Surgery is considered invasive, while behaviour modification techniques, correction of situational factors and oral-motor therapy do not always produce sustained improvement. In recent years the use of Botox® to decrease drooling has been investigated.

AIMS

To review the clinical data from a Drooling Treatment Project for children with neurological impairments and to establish the validity of the drooling severity and frequency rating scales, establishing Phase I-level information about the therapeutic use of submandibular salivary gland injections of Botox® in various contexts.

METHOD & PROCEDURES

A retrospective, explanatory design was used to review the data. Nine children, seven with cerebral palsy and two with operculum syndrome, ranging in age from 5 to 17 years (mean = 9;3 years) were included. Drooling was assessed by qualified speech-language therapists using drooling rating scales, in five different situations and at different time points pre- and post-Botox® injection up to 6 months. Quantitative and qualitative analyses were computed. Parents'/primary caregivers' perceptions of drooling and treatment with Botox® were also considered using an interview form and a quality of life questionnaire.

OUTCOMES & RESULTS

Statistically significant reductions in drooling with large effect sizes were obtained in the communicating and general appearance situations. There was a difference in the pattern of response between the children with cerebral palsy and those with operculum syndrome. Discrepancies between the parents and the speech-language therapists regarding the context of drooling reduction were found. Most parents/primary caregivers felt their children's lives and their own had improved following the Botox® injection and would repeat the treatment. The drooling rating scales were a valid method to assess drooling in a clinical situation.

CONCLUSIONS & IMPLICATIONS

In the clinical setting of the Drooling Treatment Project, the results indicated that the context in which drooling occurs is an important factor and suggested the value of considering the situational context when making drooling judgments. Further, there was a difference in the pattern of response between the children with cerebral palsy and those with operculum syndrome, suggesting that aetiology may be involved in the response to Botox®.

Botulinum toxin type B for sialorrhoea in children with cerebral palsy: a randomized trial comparing three doses

AIM

The aim of the present study was to evaluate the efficacy and safety of three doses of botulinum toxin type B (BoNT-B) in reducing persistent sialorrhoea in children with cerebral palsy (CP).

METHOD

Children with CP and refractory sialorrhoea were randomized to one of four groups: a control group and three experimental groups receiving a low (1500 mouse units [MU]), medium (3000 MU), or high (5000 MU) dose of BoNT-B respectively, into bilateral salivary glands. Drooling was measured using the Thomas-Stonell rating scale, and the weight and the number of bibs used per day were counted in all children at baseline, 4, and 12 weeks after BoNT-B injection.

RESULTS

Twenty-seven children (15 males, 12 females; mean age 7 y 10 mo, SD 1 y 6 mo; range 5-15 y) were randomized into a control (seven children: four males, three females) and experimental groups receiving low (six children: four males, two females), medium (seven children: four males, three females), and high (seven children: three males, four females) doses of BoNT-B respectively. All children had mixed neurological disorders consisting of spastic paraparesis, tetraparesis, dystonic movements, and ataxia. Gross Motor Function Classification System levels ranged from III to V, and all children had moderate or severe intellectual disability. Estimated means with their standard errors (SEM) of drooling were at baseline, 4, and 12 weeks respectively, as follows: control group, 12.1 (2.1), 11.9 (2.1), 11.8 (2.2), p for trend 0.992; low dose group, 13.8 (2.3), 11.4 (2.3), 13.9 (2.3), p for trend 0.952; medium dose group, 13.9 (2.1), 6.7 (2.1), 7.1 (2.1) p for trend 0.008; and for the high dose group 14.4 (2.1), 5.0 (2.1), 5.6 (2.1), p for trend 0.002. Side effects included dense saliva, xerostomia, and difficulty in swallowing, and were more frequent in the high-dose group.

INTERPRETATION

A 3000 MU injection of BoNT-B into the salivary glands significantly improved the frequency and severity of sialorrhoea in children with CP. The lower dose was ineffective, and the higher dose produced no greater benefit and more side effects.

Ultrasound-guided botulinum toxin injections for treatment of drooling

OBJECTIVES

To evaluate the efficacy of treatment of drooling by ultrasound-guided botulinum toxin injection of the salivary glands and to determine the optimal modalities of this procedure.

PATIENTS AND METHODS

This study is a retrospective review of patients treated for drooling by injection of 100 units of Botox(®) into the parotid and submaxillary glands between 2002 and 2008. Efficacy was evaluated by a quality of life questionnaire six weeks after the injections.

RESULTS

One hundred and eleven injection sessions were performed in 70 patients aged one to 84 years with a beneficial effect in 66% of cases. The most effective protocol was injection of 20 units of botulinum toxin into each submaxillary gland and 30 units of toxin into each parotid gland.

CONCLUSION

The treatment of drooling by Botox(®) injections into salivary glands is effective. The authors propose ultrasound-guided injection of both submaxillary glands and both parotid glands. These injections can be repeated in the case of recurrence of drooling.

Botulinum toxin assessment, intervention and aftercare for paediatric and adult drooling: international consensus statement

Many individuals with neurological problems or anatomical abnormalities of the jaw, lips or oral cavity may drool, which can impact on health and quality of life. A thorough evaluation of the patient's history, examination of the oral region by a speech pathologist and, in individuals over 3 years, a dental examination is warranted. Questionnaires with established validity such as the Drooling Impact Scale are useful assessment tools. A hierarchical approach to treatment is taken from least invasive therapies, such as speech pathology, to more invasive, such as injection of botulinum neurotoxin type-A (BoNT-A) into the salivary glands (parotid and submandibular). The wishes of the individual and their carer are crucial considerations in determining the suitability of the intervention for the patient. In the presence of dysphagia and cerebral palsy (CP), careful assessment is required prior to the injection of BoNT-A. Favourable responses to intervention include a reduction in the secretion of saliva and in drooling, as well as psychosocial improvements. BoNT-A is usually well tolerated, although potential side effects should be discussed with the patient and carer.

Pediatric rehabilitation: 1. Common medical conditions in children with disabilities

OBJECTIVE

This self-directed learning module focuses on the physiatric management of the common morbidities associated with pediatric traumatic brain injury and cerebral palsy. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to enhance the learner's knowledge regarding current physiatric management of complications related with pediatric traumatic brain injury and cerebral palsy.

Outcome measures used in studies of botulinum toxin in childhood cerebral palsy: a systematic review

This literature review uses the International Classification of Functioning, Disability and Health to describe the quality and variety of the studies of botulinum toxin in children with cerebral palsy since 2001. Articles were identified via electronic query and then reviewed for strength of evidence and classification of outcome measures. The distribution of levels of evidence for the 63 articles was I (n = 8), II (n = 12), III (n = 21), and IV (n = 22). One or more measurements were used in the International Classification of Functioning, Disability and Health domains of body structure and function (47 papers), activity (47 papers), participation (12 papers), and environmental/personal factors (10 papers). A total of 67% of all outcomes demonstrated a significant difference (I 49%, II 39%, III 74%, IV 88%). This review illustrates that few studies provide a high level of evidence and that outcomes focus on arenas such as spasticity or range of motion rather than activity or participation domains such as walking.

Botulinum toxin A injection of salivary glands in children with drooling and chronic aspiration

PURPOSE

To review outcomes of ultrasound (US)-guided percutaneous submandibular gland injection of botulinum toxin A (BTX-A) in the treatment of drooling and chronic aspiration.

MATERIALS AND METHODS

A 3-year retrospective review was performed of 220 US-guided salivary gland injections in 36 patients. There were 21 male patients and 15 female patients with an age range of 1.4 to 19.8 years (mean, 8.6 y) and a weight range of 7.8 to 73 kg (mean, 24.4 kg). The mean pretreatment analysis period was 48 months and the mean follow-up period was 21 months. The study group was divided into groups with anterior (n = 9) and posterior (n = 27) drooling, with those with both (n = 10) included in the posterior group.

RESULTS

All procedures were technically successful. Bilateral submandibular injections were performed in 34 procedures and bilateral submandibular and parotid injections were performed in 38 procedures. Of the 27 patients with posterior drooling, improvement occurred in 24 patients (88%), no improvement was seen in two (8%), and one (4%) was lost to follow-up. Of the nine patients with anterior drooling, six (66%) showed improvement, there was no response in two (22%), and one (12%) was lost to follow-up. The total number of hospitalizations for respiratory issues and presumed aspiration pneumonia decreased by 56.4% per year in the patients with posterior drooling. There was one procedure-related complication: an episode of self-limited oral bleeding.

CONCLUSION

Salivary gland BTX-A injection for salivary control shows promising results in decreasing saliva production and frequency of respiratory symptoms in children with drooling and chronic aspiration.

Control of salivary secretions in esophageal atresia with laryngeal cleft using Botulinum toxin Type A

A baby born with esophageal atresia and a laryngeal cleft is presented. Retained salivary secretions and aspiration were a constant management problem whilst the baby was waiting for delayed primary repair of the atresia. The use of anticholinergic agents resulted in thickening of secretions which were difficult to suction and ultimately led to increasing respiratory compromise. Intraglandular salivary gland injection of Botulinum toxin type A was performed using ultrasound guidance. The mean daily salivary flow output prior to treatment was 59 ml. On glycopyrrolate the mean daily salivary output on glycopyrrolate was 16 ml. After Botulinum injection the mean daily salivary output was 7 ml in the 3 weeks after injection. Over the next 14 weeks this increased to 34 ml. There were no adverse effects or significant thickening of secretions after BTX injection. This is the first reported use of Botulinum toxin injection in the management of salivary aspiration in esophageal atresia with laryngeal cleft.

Botulinum toxin in the management of sialorrhoea: a systematic review

Sialorrhoea can be a significant problem in both adults and children and can cause both physical and psychosocial problems. Botulinum toxin has enjoyed an emergence in the treatment of sialorrhoea, a systematic review of the evidence for botulinum toxin reveals two randomised controlled trials (RCTs) and four other trials that fulfilled our inclusion criteria. Both RCTs demonstrate the effectiveness of botulinum toxin in the management of sialorrhoea. There was no clear evidence for one antigenic type of botulinum toxin over another and minimal evidence for the optimal dose of botulinum toxin for each antigenic type. No advantage is conferred in using ultrasound guidance in injecting the glands. None of the RCTs or other studies directly compared submandibular versus parotid injection or directly compared botulinum toxin against surgery. Minor side effects were reported in one of the RCTs but overall botulinum toxin is a safe, minimally invasive and effective means in the treatment of sialorrhoea with the potential to become the treatment of choice. Our review demonstrates that further randomised controlled trials are required to more fully evaluate this new modality of treatment.

Botulinum toxin treatment of sialorrhea: comparing different therapeutic preparations

In recent years, a number of potential new therapeutic indications of botulinum toxin injections have emerged, amongst which sialorrhea has attracted considerable attention. Based on open-label and controlled studies, botulinum toxin can be used to improve sialorrhea in patients with Parkinson's disease, parkinsonian syndromes, motor neuron disease and cerebral palsy. The toxin can be injected blindly based on anatomic landmarks of the salivary glands, or localization can be facilitated by use of ultrasound guidance. There are few reported adverse effects. However, many more carefully designed, controlled studies are still required to address the specific questions related to selection of patients, the optimal injection technique, the appropriate dose of botulinum toxin and its long-term effects.

Drooling in children with cerebral palsy: effect of salivary flow reduction on daily life and care

The purpose of this study was to investigate the effect of salivary flow reduction on daily life and provision of care in children with cerebral palsy (CP). Parents of children with CP were asked to fill in a questionnaire on the impact of drooling on the daily life of their children and their families and the data were then analyzed. Forty-five children with severe drooling (28 males, 17 females; mean age 9y 5mo [SD 3y 7mo]; range 3 to 16y) were monitored before and after receiving medication (scopolamine and botulinum toxin) to reduce salivary flow. Type of CP included hypotonia (n = 1), spastic paresis (n = 27), and mixed motor disorders with spastic and dyskinetic paresis (n = 17). Eight children were independently ambulant and 37 children were wheelchair users. Thirty-four children had learning disability with a developmental age of below 6 years. Six participants dropped out of the study; data on 39 children were analyzed. Results showed that anticholinergic agents effectively reduced salivary flow. Drooling diminished substantially and this was accompanied by a significant reduction in care needs, making daily care less demanding. The amount of reported damage to communication devices and computers decreased. In addition to the evaluation of primary variables, such as the salivary flow rate, investigation of impact of drooling on daily life provides useful information about the outcome of treatment for reduction in drooling.

Botulinum Toxin Type A Injections to Salivary Glands: Combination With Single Event Multilevel Chemoneurolysis in 2 Children With Severe Spastic Quadriplegic Cerebral Palsy

We describe 2 children with severe spastic quadriplegic cerebral palsy (CP) who have significant drooling and frequent aspiration pneumonia. They underwent simultaneous botulinum toxin type A (BTX-A) injections to salivary glands for drooling and prevention of aspiration pneumonia along with single-event multilevel chemoneurolysis (SEMLC) with BTX-A and 5% phenol for severe diffuse spasticity. There was significant improvement in drooling, frequency of aspiration pneumonia, and spasticity without adverse effect. BTX-A injections into the salivary glands, in addition to SEMLC, for these 2 children with medically complicated severe spastic quadriplegic CP, were safe and highly successful procedures, which improved their health-related quality of life.

Drooling of saliva: A review of the etiology and management options

Drooling of saliva appears to be the consequence of a dysfunction in the coordination of the swallowing mechanism, resulting in excess pooling of saliva in the anterior portion of the oral cavity and the unintentional loss of saliva from the mouth. Drooling can produce significant negative effects on physical health and quality of life, especially in patients with chronic neurological disabilities. Various approaches to manage this condition have been described in the literature, including oral motor therapy, behavior modification via biofeedback, orofacial regulation therapy, drug therapy, radiotherapy, and surgical treatments. Minimally invasive modalities, such as injection of botulinum toxin, photocoagulation, and acupuncture, have also been reported. This article provides a comprehensive and thorough overview of drooling, with an emphasis on understanding its etiologies and modalities of treatment.

Controlling sialorrhoea: a review of available treatment options

Sialorrhoea (drooling or excessive salivation) is a common symptom of many neurological diseases (e.g., amyotropic lateral sclerosis, cerebral palsy and Parkinson's disease) and otolaryngologic diseases (tumours of upper aerodigestive tract). It is mostly caused by poor oral and facial muscle control in patients with swallowing dysfunction (secondary sialorrhoea). However, some cases of sialorrhoea are due to hypersecretion of saliva. These cases represent so-called primary sialorrhoea.

Treating sialorrhea with transdermal scopolamine. Exploiting a side effect to treat an uncommon symptom in cancer patients

INTRODUCTION

Sialorrhea is a distressing symptom accompanying oral cancer and many heterogeneous cancer-related conditions (chemotherapy-induced nausea, bowel subocclusion, pharmacologic side effects), but its incidence is low in cancer patients. Conversely, it is frequent in patients with neurological damage, and some therapeutic options have been attempted such as botulinum toxins, anticholinergic agents, and surgical procedures.

CASE REPORT

We report the case of an 80-year-old woman with peritoneal carcinomatosis and bowel subocclusion, suffering from distressing nausea and sialorrhea that rapidly improved using transdermal scopolamine. No relevant side effects occurred during the treatment, and the reduction of the abnormal salivation allowed the recovery of oral feeding.

CONCLUSIONS

Anticholinergic drugs are classified as secondary options in the treatment of sialorrhea of patients with Parkinson's disease or cerebral palsy, owing to the relevant side effects occurring during prolonged treatments. However, they could be useful in cancer patients with bowel subocclusion, as the reduction of gastrointestinal secretions and intestinal motility (frequent side effects of anticholinergic drugs) could be effective in controlling nausea, vomiting, and abdominal pain. Moreover, the transdermal or sublingual route of administration can be of some interest, avoiding other more invasive parenteral approaches.