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Oad H, Maltezeanu A, da Silva SD, Daniel SJ. Onabotulinum Toxin A (BoNT-A) for Drooling in Children: A Systematic Review and Meta-Analysis. Laryngoscope 2024; 134:3012-3017. [PMID: 38294288 DOI: 10.1002/lary.31277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 12/19/2023] [Accepted: 12/22/2023] [Indexed: 02/01/2024]
Abstract
INTRODUCTION Sialorrhea, also known as drooling, hypersalivation, or ptyalism, has a significant impact on the medical and psychosocial well-being of children. Onabotulinum toxin A (BoNT-A) is the most commonly used botulinum toxin worldwide for the treatment of sialorrhea in children. OBJECTIVES To conduct a comprehensive systematic review and meta-analysis to assess the clinical efficacy and potential adverse effects of BoNT-A as a treatment for drooling in children. METHODS Cochrane, Embase, and Medline databases were systematically searched (up to May 2023). Out of 535 identified publications, 20 were found eligible for inclusion. A systematic review and meta-analysis were performed to determine the efficacy of BoNT-A treatment in children in reducing the frequency and severity of drooling. RESULTS Out of the 20 studies included, a meta-analysis was conducted on the complete dataset of eight studies involving 131 patients. BoNT-A was found to significantly decrease the severity of drooling in patients with sialorrhea (standardized mean difference [SMD], -2.07; 95% confidence interval [CI], -2.91 to -1.23; p < 0.0001) when compared with the conditions before injections using random-effects models. Six studies out of 20 reported dysphagia as an adverse effect after injection. Other side effects included thickness of saliva and pain at the site of injection. CONCLUSION BoNT-A is a clinically effective therapy that improves drooling severity in children with sialorrhea. Although there were some adverse side effects reported, they were transient and not severe. Future studies are needed to further evaluate the best techniques and to identify the ideal dosages required to achieve the optimal outcomes. Laryngoscope, 134:3012-3017, 2024.
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Affiliation(s)
- Haresh Oad
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Quebec, Canada
| | - Alix Maltezeanu
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Quebec, Canada
| | - Sabrina D da Silva
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Quebec, Canada
| | - Sam J Daniel
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Quebec, Canada
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Ha TAN, Shih MC, Lambert EM. Comparing botulinum toxin and 4-duct ligation for Sialorrhea in children - A systematic review. Am J Otolaryngol 2024; 45:104119. [PMID: 38043299 DOI: 10.1016/j.amjoto.2023.104119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/19/2023] [Indexed: 12/05/2023]
Abstract
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.
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Affiliation(s)
- Tu-Anh N Ha
- Baylor College of Medicine, Bobby R. Alford Department of Otolaryngology, 1977 Butler Boulevard, Houston, TX 77030, USA; Texas Children's Hospital, Department of Surgery, Division of Otolaryngology, Houston, TX, USA
| | - Michael C Shih
- Baylor College of Medicine, Bobby R. Alford Department of Otolaryngology, 1977 Butler Boulevard, Houston, TX 77030, USA; Texas Children's Hospital, Department of Surgery, Division of Otolaryngology, Houston, TX, USA
| | - Elton M Lambert
- Baylor College of Medicine, Bobby R. Alford Department of Otolaryngology, 1977 Butler Boulevard, Houston, TX 77030, USA; Texas Children's Hospital, Department of Surgery, Division of Otolaryngology, Houston, TX, USA.
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Orriëns LB, van Hulst K, van der Burg JJW, van den Hoogen FJA, Willemsen MAAP, Erasmus CE. Comparing the evidence for botulinum neurotoxin injections in paediatric anterior drooling: a scoping review. Eur J Pediatr 2024; 183:83-93. [PMID: 37924348 PMCID: PMC10858158 DOI: 10.1007/s00431-023-05309-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 10/19/2023] [Accepted: 10/24/2023] [Indexed: 11/06/2023]
Abstract
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.
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Affiliation(s)
- Lynn B Orriëns
- Department of Paediatric Neurology, Division of Paediatrics, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Karen van Hulst
- Department of Rehabilitation, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jan J W van der Burg
- Department of Paediatric Rehabilitation, Sint Maartenskliniek, Ubbergen, the Netherlands
- School of Pedagogical and Educational Science, Radboud University Nijmegen, Nijmegen, the Netherlands
| | - Frank J A van den Hoogen
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michèl A A P Willemsen
- Department of Paediatric Neurology, Division of Paediatrics, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Corrie E Erasmus
- Department of Paediatric Neurology, Division of Paediatrics, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
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Ban MJ, Ryu CH, Woo JH, Lee YC, Lee DK, Kwon M, Hong YT, Lee GJ, Byeon HK, Choi SH, Lee SW. Guidelines for the Use of Botulinum Toxin in Otolaryngology From the Korean Society of Laryngology, Phoniatrics and Logopedics Guideline Task Force. Clin Exp Otorhinolaryngol 2023; 16:291-307. [PMID: 37905325 DOI: 10.21053/ceo.2023.00458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 10/25/2023] [Indexed: 11/02/2023] Open
Abstract
The Korean Society of Laryngology, Phoniatrics and Logopedics created a task force to establish clinical practice guidelines for the use of botulinum toxin (BT) in otolaryngology. We selected 10 disease categories: spasmodic dysphonia, essential vocal tremor, vocal fold granuloma, bilateral vocal fold paralysis, Frey's syndrome, sialocele, sialorrhea, cricopharyngeal dysfunction, chronic sialadenitis, and first bite syndrome. To retrieve all relevant papers, we searched the CORE databases with predefined search strategies, including Medline (PubMed), Embase, the Cochrane Library, and KoreaMed. The committee reported 13 final recommendations with detailed evidence profiles. The guidelines are primarily aimed at all clinicians applying BT to the head and neck area. In addition, the guidelines aim to promote an improved understanding of the safe and effective use of BT by policymakers and counselors, as well as in patients scheduled to receive BT injections.
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Affiliation(s)
- Myung Jin Ban
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Chang Hwan Ryu
- Department of Otorhinolaryngology-Head and Neck Surgery, National Cancer Center, Goyang, Korea
| | - Joo Hyun Woo
- Department of Otorhinolaryngology-Head and Neck Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Young Chan Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Dong Kun Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Dong-A University College of Medicine, Busan, Korea
| | - Minsu Kwon
- Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Tae Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
| | - Gil Joon Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyung Kwon Byeon
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Seung Ho Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Won Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
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Heikel T, Patel S, Ziai K, Shah SJ, Lighthall JG. Botulinum Toxin A in the Management of Pediatric Sialorrhea: A Systematic Review. Ann Otol Rhinol Laryngol 2023; 132:200-206. [PMID: 35176902 PMCID: PMC9834812 DOI: 10.1177/00034894221078365] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Botulinum toxin A is known to be effective and safe in managing sialorrhea in pediatric patients; however, there is no consensus on a protocol for optimal injection sites and appropriate dosing for injection. METHODS This review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol. PubMed, EMBASE, and other databases were queried to identify articles that evaluated botulinum toxin type A for the treatment of sialorrhea in the pediatric population. A total of 405 studies were identified. After applying inclusion and exclusion criteria, 31 articles were included for review. RESULTS A total of 14 studies evaluated 2-gland injections, and 17 studies evaluated 4-gland injections. Of the 31 studies included, one study assessed incobotulinumtoxinA (Xeomin®) the remaining all used onabotulinumtoxinA (Botox®). For 2-gland injection studies, a combined total of 899 participants were reviewed, where 602 participants received 50 units into their submandibular glands, while 262 participants received 30 to 50 units. Among 4-gland injection studies, there was a combined total of 388 participants, with the most prevalent dosage utilized being 60 to 100 units in 230 participants, followed by 100 units total in 77 participants. The most common adverse event was dysphagia which resolved in nearly all cases. Three studies aimed to examine 2-gland versus 4-gland injections, with 2 of the studies concluding 4-gland injection was superior. CONCLUSIONS The strength of evidence suggests that the dosing of 50 units total of onabotulinumtoxinA to the submandibular glands is safe and effective in the pediatric population. For 4-gland injections, bilateral submandibular and parotid gland injections of 60 to 100 units total is the safe and effective dosage. There is no substantial evidence comparing 4-gland injections to 2-gland injections, but research thus far suggests 4-gland injections to be superior. Future study is needed to evaluate incobotulinumtoxinA and abobotulinumtoxinA dosages in the pediatric population.
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Affiliation(s)
- Tiffany Heikel
- Department of Otolaryngology—Head and
Neck Surgery, The Pennsylvania State University, Milton S. Hershey Medical Center,
Hershey, PA, USA
| | - Shivam Patel
- The Pennsylvania State University,
College of Medicine, Hershey, PA, USA
| | - Kasra Ziai
- Department of Otolaryngology—Head and
Neck Surgery, The Pennsylvania State University, Milton S. Hershey Medical Center,
Hershey, PA, USA
| | - Sejal J. Shah
- Department of Anesthesiology and
Perioperative Medicine, The Pennsylvania State University, Milton S. Hershey Medical
Center, Hershey, PA, USA
| | - Jessyka G. Lighthall
- Facial Plastic and Reconstructive
Surgery, Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State
University, Milton S. Hershey Medical Center, Hershey, PA, USA
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Marquez-Vazquez JF, Arellano-Saldaña ME, Rojas-Martinez KN, Carrillo-Mora P. Comparative Efficacy of Botulinum Toxin in Salivary Glands vs. Oromotor Therapy in the Management of Sialorrhea in Cerebral Palsy Impact on Sleep Quality. FRONTIERS IN REHABILITATION SCIENCES 2022; 3:875235. [PMID: 36188909 PMCID: PMC9397995 DOI: 10.3389/fresc.2022.875235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/27/2022] [Indexed: 11/13/2022]
Abstract
AimsThe 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.MethodsA 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.ResultsThe 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.InterpretationA 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.
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Affiliation(s)
| | | | | | - Paul Carrillo-Mora
- Neuroscience Research Division, Instituto Nacional de Rehabilitación LGII, Tlalpan, México
- *Correspondence: Paul Carrillo-Mora
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Hung SA, Liao CL, Lin WP, Hsu JC, Guo YH, Lin YC. Botulinum Toxin Injections for Treatment of Drooling in Children with Cerebral Palsy: A Systematic Review and Meta-Analysis. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121089. [PMID: 34943284 PMCID: PMC8700360 DOI: 10.3390/children8121089] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/06/2021] [Accepted: 11/15/2021] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Shang-An Hung
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (S.-A.H.); (W.-P.L.); (Y.-H.G.)
| | - Chung-Lun Liao
- School of Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
| | - Wei-Pin Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (S.-A.H.); (W.-P.L.); (Y.-H.G.)
| | - Jason C. Hsu
- International Ph.D. Program in Biotech and Healthcare Management, College of Management, Taipei Medical University, Taipei 110, Taiwan;
| | - Yao-Hong Guo
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (S.-A.H.); (W.-P.L.); (Y.-H.G.)
| | - Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (S.-A.H.); (W.-P.L.); (Y.-H.G.)
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
- Correspondence:
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Berweck S, Bonikowski M, Kim H, Althaus M, Flatau-Baqué B, Mueller D, Banach MD. Placebo-Controlled Clinical Trial of IncobotulinumtoxinA for Sialorrhea in Children: SIPEXI. Neurology 2021; 97:e1425-e1436. [PMID: 34341153 PMCID: PMC8520391 DOI: 10.1212/wnl.0000000000012573] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 07/06/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To investigate the efficacy and safety of repeated injections of incobotulinumtoxinA (incoBoNT/A) for treatment of chronic sialorrhea (drooling) associated with neurologic disorders (e.g., cerebral palsy, traumatic brain injury) or intellectual disability in children and adolescents in a prospective phase III study (SIPEXI [Sialorrhea Pediatric Xeomin Investigation]). METHODS The study enrolled 2- to 17-year-old patients with sialorrhea due to neurologic disorders or intellectual disability. Patients received body weight-dependent doses of incoBoNT/A (20-75 U). A main period with 1 injection cycle (placebo-controlled, double-blind, 6- to 17-year-olds) was followed by an open-label extension with up to 3 further cycles. An additional cohort of 2- to 5-year-olds received active treatment throughout the study. Coprimary endpoints were the change in unstimulated salivary flow rate (uSFR) from baseline to week 4 and the carers' Global Impression of Change Scale (GICS) rating at week 4. Adverse events were recorded. RESULTS In the main period, 220 patients aged 6-17 years were randomized and treated (148 patients in incoBoNT/A group, 72 patients in placebo group). A total of 35 patients aged 2-5 years received incoBoNT/A (no placebo). A total of 214 patients aged 6-17 years and 33 patients aged 2-5 years continued treatment in the open-label extension period. For the 6- to 17-year-olds, a significant difference between incoBoNT/A and placebo was seen in mean uSFR decrease (difference -0.06 g/min; p = 0.0012) and the carers' GICS rating (difference 0.28 points; p = 0.032) at week 4, in favor of active treatment. The secondary endpoints consistently supported these results. A sustained benefit was observed during the extension. Incidences of adverse events were comparable between incoBoNT/A and placebo and did not increase notably with repeated injections. The most common adverse events were respiratory infections. Efficacy and safety were also favorable in the uncontrolled cohort of 2- to 5-year-olds. DISCUSSION Both co-primary efficacy endpoints were reached and superiority of incoBoNT/A over placebo was confirmed. IncoBoNT/A (up to 75 U, up to 4 cycles) is an effective and well-tolerated treatment for sialorrhea associated with neurologic disorders in children. TRIAL REGISTRATION INFORMATION Clinicaltrials.gov: NCT02270736 (clinicaltrials.gov/ct2/show/results/NCT02270736); EU Clinical Trials Register: 2013-004532-30 (clinicaltrialsregister.eu/ctr-search/search?query=2013-004532-30). CLASSIFICATION OF EVIDENCE This study provides Class I evidence that injection of incobotulinumtoxinA decreases drooling in children aged 6 to 17 years with neurologic disorders.
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Affiliation(s)
- Steffen Berweck
- From the Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology (S.B.), Schoen Klinik, Vogtareuth; Department of Pediatric Neurology and Developmental Medicine (S.B.), LMU Center for Children with Medical Complexity-Integrated Social Pediatric Center, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Movement Analysis Lab, Neuro Rehabilitation Department (M.B.), Mazovian Neuropsychiatry Center LLC, Warsaw, Poland; Pediatric Rehabilitation Medicine at the Department of Rehabilitation & Regenerative Medicine (H.K.), Columbia University Irving Medical Center/New York Presbyterian Hospital, New York; Merz Pharmaceuticals GmbH (M.A., B.F.-B.), Frankfurt am Main, Germany; Kantar Health (D.M.), Munich, Germany; and Department of Neurology (M.D.B.), Jagiellonian University, Krakow, Poland.
| | - Marcin Bonikowski
- From the Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology (S.B.), Schoen Klinik, Vogtareuth; Department of Pediatric Neurology and Developmental Medicine (S.B.), LMU Center for Children with Medical Complexity-Integrated Social Pediatric Center, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Movement Analysis Lab, Neuro Rehabilitation Department (M.B.), Mazovian Neuropsychiatry Center LLC, Warsaw, Poland; Pediatric Rehabilitation Medicine at the Department of Rehabilitation & Regenerative Medicine (H.K.), Columbia University Irving Medical Center/New York Presbyterian Hospital, New York; Merz Pharmaceuticals GmbH (M.A., B.F.-B.), Frankfurt am Main, Germany; Kantar Health (D.M.), Munich, Germany; and Department of Neurology (M.D.B.), Jagiellonian University, Krakow, Poland
| | - Heakyung Kim
- From the Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology (S.B.), Schoen Klinik, Vogtareuth; Department of Pediatric Neurology and Developmental Medicine (S.B.), LMU Center for Children with Medical Complexity-Integrated Social Pediatric Center, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Movement Analysis Lab, Neuro Rehabilitation Department (M.B.), Mazovian Neuropsychiatry Center LLC, Warsaw, Poland; Pediatric Rehabilitation Medicine at the Department of Rehabilitation & Regenerative Medicine (H.K.), Columbia University Irving Medical Center/New York Presbyterian Hospital, New York; Merz Pharmaceuticals GmbH (M.A., B.F.-B.), Frankfurt am Main, Germany; Kantar Health (D.M.), Munich, Germany; and Department of Neurology (M.D.B.), Jagiellonian University, Krakow, Poland
| | - Michael Althaus
- From the Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology (S.B.), Schoen Klinik, Vogtareuth; Department of Pediatric Neurology and Developmental Medicine (S.B.), LMU Center for Children with Medical Complexity-Integrated Social Pediatric Center, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Movement Analysis Lab, Neuro Rehabilitation Department (M.B.), Mazovian Neuropsychiatry Center LLC, Warsaw, Poland; Pediatric Rehabilitation Medicine at the Department of Rehabilitation & Regenerative Medicine (H.K.), Columbia University Irving Medical Center/New York Presbyterian Hospital, New York; Merz Pharmaceuticals GmbH (M.A., B.F.-B.), Frankfurt am Main, Germany; Kantar Health (D.M.), Munich, Germany; and Department of Neurology (M.D.B.), Jagiellonian University, Krakow, Poland
| | - Birgit Flatau-Baqué
- From the Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology (S.B.), Schoen Klinik, Vogtareuth; Department of Pediatric Neurology and Developmental Medicine (S.B.), LMU Center for Children with Medical Complexity-Integrated Social Pediatric Center, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Movement Analysis Lab, Neuro Rehabilitation Department (M.B.), Mazovian Neuropsychiatry Center LLC, Warsaw, Poland; Pediatric Rehabilitation Medicine at the Department of Rehabilitation & Regenerative Medicine (H.K.), Columbia University Irving Medical Center/New York Presbyterian Hospital, New York; Merz Pharmaceuticals GmbH (M.A., B.F.-B.), Frankfurt am Main, Germany; Kantar Health (D.M.), Munich, Germany; and Department of Neurology (M.D.B.), Jagiellonian University, Krakow, Poland
| | - Daniela Mueller
- From the Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology (S.B.), Schoen Klinik, Vogtareuth; Department of Pediatric Neurology and Developmental Medicine (S.B.), LMU Center for Children with Medical Complexity-Integrated Social Pediatric Center, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Movement Analysis Lab, Neuro Rehabilitation Department (M.B.), Mazovian Neuropsychiatry Center LLC, Warsaw, Poland; Pediatric Rehabilitation Medicine at the Department of Rehabilitation & Regenerative Medicine (H.K.), Columbia University Irving Medical Center/New York Presbyterian Hospital, New York; Merz Pharmaceuticals GmbH (M.A., B.F.-B.), Frankfurt am Main, Germany; Kantar Health (D.M.), Munich, Germany; and Department of Neurology (M.D.B.), Jagiellonian University, Krakow, Poland
| | - Marta Dagmara Banach
- From the Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology (S.B.), Schoen Klinik, Vogtareuth; Department of Pediatric Neurology and Developmental Medicine (S.B.), LMU Center for Children with Medical Complexity-Integrated Social Pediatric Center, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Movement Analysis Lab, Neuro Rehabilitation Department (M.B.), Mazovian Neuropsychiatry Center LLC, Warsaw, Poland; Pediatric Rehabilitation Medicine at the Department of Rehabilitation & Regenerative Medicine (H.K.), Columbia University Irving Medical Center/New York Presbyterian Hospital, New York; Merz Pharmaceuticals GmbH (M.A., B.F.-B.), Frankfurt am Main, Germany; Kantar Health (D.M.), Munich, Germany; and Department of Neurology (M.D.B.), Jagiellonian University, Krakow, Poland
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Jost WH, Steffen A, Berweck S. A critical review of incobotulinumtoxinA in the treatment of chronic sialorrhea in pediatric patients. Expert Rev Neurother 2021; 21:1059-1068. [PMID: 34516331 DOI: 10.1080/14737175.2021.1979959] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
| | - Armin Steffen
- Department for Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Steffen Berweck
- Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology, Schön Klinik, Vogtareuth, Germany.,Department of Pediatric Neurology and Developmental Medicine, LMU Center for Children with Medical Complexity - Integrated Social Pediatric Center, Dr. Von Hauner Children's Hospital, Ludwig Maximilians-University, Munich, Germany
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10
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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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11
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Corrêa LB, Basso MB, Sousa-Pinto B, Coelho Leal S. Oral health effects of botulinum toxin treatment for drooling: a systematic review. Med Oral Patol Oral Cir Bucal 2021; 26:e172-e180. [PMID: 33340083 PMCID: PMC7980293 DOI: 10.4317/medoral.24101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 11/30/2020] [Indexed: 11/19/2022] Open
Abstract
Background Drooling is a major morbidity in several neurological diseases. Intraglandular botulinum neurotoxin (BoNT) injections have been used to manage this condition. However, by decreasing salivary flow, BoNT injections may result in an increased risk of caries and other oral adverse effects. In this study, we aimed to assess whether, in patients with drooling, intraglandular BoNT injections are associated with increased dental caries development, modifications on salivary composition (oral pH, buffering capacity and osmolality) and cariogenic bacterial load.
Material and Methods We performed a systematic review, searching PubMed, CENTRAL, Web of Science, and Scopus for all experimental and observational studies reporting on adverse effects of intraglandular BoNT injections in patients with drooling. Primary study selection, quality assessment, and data extraction were independently performed by two researchers. No studies were excluded based on their language, publication status or date of publication. Studies’ quality was based on revised Cochrane Risk of Bias tools. Meta-analysis was not performed.
Results We retrieved 1025 studies, of which 5 were included. Two studies were two randomized controlled trials and three quasi-experimental studies. None of the included studies found BoNT injections to be associated with dental caries development or with significant reductions in oral pH. One of the included primary studies even observed an increase in salivary buffer capacity. One study found an increase in Lactobacilli counts. As for the risk of bias, two studies were classified as having a critical risk, two as high risk and one as having some concerns.
Conclusions Currently, there is no evidence that, in patients with drooling, BoNT injections associate with increased risk of dental caries or disturbances in oral pH or salivary buffering capacity. However, the included primary studies had important limitations and differences in their methodologies. Key words:Neurological diseases, drooling, sialorrhea, botulinum toxin, oral health, caries, saliva.
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Affiliation(s)
- L-B Corrêa
- MEDCIDS - Department of Community Medicine Information and Decision Sciences Faculty of Medicine, University of Porto Rua Dr. Plácido da Costa, 4200-450, Porto, Portugal
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Khajuria S, Ng KF, Jefferson RJ. What is the effectiveness and safety of different interventions in the management of drooling in children with cerebral palsy? Arch Dis Child 2020; 105:906-910. [PMID: 32606035 DOI: 10.1136/archdischild-2020-319309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Sujata Khajuria
- Community Paediatrics, St. Mary's Hospital, Northamptonshire NHS Foundation Trust, Kettering, Northamptonshire, UK
| | - Khuen Foong Ng
- Department of Paediatrics, University Hospitals of Leicester NHS Trust, Leicester, UK
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Steffen A, Jost W, Bäumer T, Beutner D, Degenkolb-Weyers S, Groß M, Grosheva M, Hakim S, Kahl KG, Laskawi R, Lencer R, Löhler J, Meyners T, Rohrbach-Volland S, Schönweiler R, Schröder SC, Schröder S, Schröter-Morasch H, Schuster M, Steinlechner S, Urban R, Guntinas-Lichius O. Hypersalivation: update of the German S2k guideline (AWMF) in short form. J Neural Transm (Vienna) 2019; 126:853-862. [DOI: 10.1007/s00702-019-02000-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/27/2019] [Indexed: 12/11/2022]
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Pharmacological interventions for treating sialorrhea associated with neurological disorders: A mixed treatment network meta-analysis of randomized controlled trials. J Clin Neurosci 2018; 51:12-17. [DOI: 10.1016/j.jocn.2018.02.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 02/04/2018] [Indexed: 11/19/2022]
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Botulinum neurotoxin A injection for the treatment of epiphora with patent lacrymal ducts. J Fr Ophtalmol 2018; 41:343-349. [PMID: 29681465 DOI: 10.1016/j.jfo.2017.11.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 10/30/2017] [Accepted: 11/09/2017] [Indexed: 10/17/2022]
Abstract
HEADINGS Retrospective longitudinal study to evaluate the efficacy of botulinum neurotoxin A (BoNT/A) therapy for epiphora with patent lacrimal ducts. BACKGROUND/PURPOSE BoNT/A has been used since 2000 in axillary hyperhidrosis to reduce sweat secretion. Some isolated cases of hyperlacrimation or crocodile tear syndrome have been treated with BoNT/A on this basis. We report our experience in the treatment of tearing despite patent lacrimal ducts by BoNT/A injection into the lacrimal gland. METHODS We reviewed qualitative and quantitative criteria to evaluate the degree of improvement of epiphora after BoNT/A injections in the palpebral lobe of the lacrimal gland in patients referred for epiphora despite patent lacrimal ducts between 2009 and 2016. Epiphora was graded using a functional questionnaire, Munk score and Schirmer test performed before and after the injections. Side effects were recorded. RESULTS Sixty-five palpebral lacrimal glands of forty-two patients with epiphora despite patent lacrimal ducts, of mean age 65 years, sex ratio 0.8, were treated with BoNT/A (IncobotulinumtoxinA, XEOMIN®, MERZ Pharma France) from April 2009 to April 2016. The etiology of the epiphora was represented by 56 paroxysmal lacrimal hypersecretion, 2 crocodile tear syndrome and 7 facial palsies. No conventional medical or surgical treatment had been effective in these cases. The technique of injection, dilution and dosage of BoNT/A were specific. We re-injected 33/65 cases a second time upon patient request due to recurrence of epiphora, 16/65 cases three times, 8/65 cases four times, 6/65 cases five times and 3/65 six times. The Schirmer's test measured a decrease of lacrimal secretion in 51/65 glands (78%) after the first botulinum neurotoxin injection. Side effects were limited to ptosis in 2 cases (3%) and six patients (9%) with rapidly regressing diplopia. Two patients experienced immediate lacrimal gland hematoma (3%) with no sequelae. The authors describe the injection techniques, the dosage, the volume and concentration of BoNT/A. CONCLUSION Patients with intractable epiphora despite patent lacrimal ducts can be effectively treated with BoNT/A (IncobotulinumtoxinA) injection into the palpebral lobe of the lacrimal gland. Most of the patients (80%) were very satisfied with few side effects (hematoma, ptosis or mild diplopia lasting from 3 days to 3 weeks). More studies are needed to delineate which types of epiphora can be treated with BoNT A.
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16
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Does Botulinum neurotoxin type A treatment for sialorrhea change oral health? Clin Oral Investig 2016; 21:795-800. [DOI: 10.1007/s00784-016-1826-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 04/17/2016] [Indexed: 12/12/2022]
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Ferraz Dos Santos B, Dabbagh B, Daniel SJ, Schwartz S. Association of onabotulinum toxin A treatment with salivary pH and dental caries of neurologically impaired children with sialorrhea. Int J Paediatr Dent 2016; 26:45-51. [PMID: 25726732 DOI: 10.1111/ipd.12156] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sialorrhea is a common manifestation of several neurological disorders. The use of intraglandular onabotulinum toxin A (OBTXA) injection has been recognized to effectively treat sialorrhea. As OBTXA injection reduces salivary flow rate and alters salivary quality, its use may have a detrimental effect on oral health. AIM To examine the effect of OBTXA injection on caries experience and salivary pH of neurologically impaired children with sialorrhea. DESIGN Twenty-five children receiving OBTXA treatment and 25 control children were enrolled in the study. Whole saliva was collected to determine salivary pH. All participants underwent an interview on their dietary habits. Dental clinical examinations were carried out to evaluate caries experience and oral hygiene level. RESULTS Overall, mean salivary pH value was significantly lower in the OBTXA group (6.92 ± 0.77) compared with the control group (7.36 ± 0.70). Caries activity was significantly higher in the OBTXA group (P = 0.01). The regression analyses showed a significant association between OBTXA treatment and salivary pH value (P = 0.03). Results from the logistic regression show that dental caries was significantly associated with OBTXA treatment (OR = 1.73, CI = 1.14-27.3). CONCLUSIONS The study showed an intricate relationship between OBTXA treatment and oral findings. Hence, special dental care should be given to children receiving OBTXA treatment.
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Affiliation(s)
- Beatriz Ferraz Dos Santos
- Division of Dentistry, Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Basma Dabbagh
- Division of Dentistry, Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Sam J Daniel
- Department of Otolaryngology, Head and Neck Surgery, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Stephane Schwartz
- Division of Dentistry, Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, Quebec, Canada
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Petracca M, Guidubaldi A, Ricciardi L, Ialongo T, Del Grande A, Mulas D, Di Stasio E, Bentivoglio AR. Botulinum Toxin A and B in sialorrhea: Long-term data and literature overview. Toxicon 2015; 107:129-40. [PMID: 26327120 DOI: 10.1016/j.toxicon.2015.08.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 08/17/2015] [Accepted: 08/24/2015] [Indexed: 12/14/2022]
Abstract
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).
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Affiliation(s)
- Martina Petracca
- Institute of Neurology, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Arianna Guidubaldi
- Institute of Neurology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lucia Ricciardi
- Institute of Neurology, Università Cattolica del Sacro Cuore, Rome, Italy; Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, London, United Kingdom
| | - Tàmara Ialongo
- Institute of Neurology, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Delia Mulas
- Institute of Neurology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Enrico Di Stasio
- Institute of Biochemistry and Clinical Biochemistry, Università Cattolica del Sacro Cuore, Rome, Italy
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Møller E, Pedersen SA, Vinicoff PG, Bardow A, Lykkeaa J, Svendsen P, Bakke M. Onabotulinumtoxin A Treatment of Drooling in Children with Cerebral Palsy: A Prospective, Longitudinal Open-Label Study. Toxins (Basel) 2015; 7:2481-93. [PMID: 26134257 PMCID: PMC4516924 DOI: 10.3390/toxins7072481] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 06/14/2015] [Accepted: 06/19/2015] [Indexed: 11/16/2022] Open
Abstract
The aim of this prospective open-label study was to treat disabling drooling in children with cerebral palsy (CP) with onabotulinumtoxin A (A/Ona, Botox®) into submandibular and parotid glands and find the lowest effective dosage and least invasive method. A/Ona was injected in 14 children, Mean age 9 years, SD 3 years, under ultrasonic guidance in six successive Series, with at least six months between injections. Doses and gland involvement increased from Series A to F (units (U) per submandibular/parotid gland: A, 10/0; B, 15/0; C, 20/0; D, 20/20; E, 30/20; and F, 30/30). The effect was assessed 2, 4, 8, 12, and 20 weeks after A/Ona (drooling problems (VAS), impact (0–7), treatment effect (0–5), unstimulated whole saliva (UWS) flow and composition)) and analyzed by two-way ANOVA. The effect was unchanged–moderate in A to moderate–marked in F. Changes in all parameters were significant in E and F, but with swallowing problems ≤5 weeks in 3 of 28 treatments. F had largest VAS and UWS reduction (64% and 49%). We recommend: Start with dose D A/Ona (both submandibular and parotid glands and a total of 80 U) and increase to E and eventually F (total 120 U) without sufficient response.
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Affiliation(s)
- Eigild Møller
- Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen DK-2200, Denmark.
- Department of Neurology, Bispebjerg University Hospital, Copenhagen DK-2400, Denmark.
| | - Søren Anker Pedersen
- Departments of Pediatrics and Radiology, Hvidovre University Hospital, Hvidovre DK-2650, Denmark.
| | - Pablo Gustavo Vinicoff
- Departments of Pediatrics and Radiology, Hvidovre University Hospital, Hvidovre DK-2650, Denmark.
| | - Allan Bardow
- Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen DK-2200, Denmark.
| | - Joan Lykkeaa
- Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen DK-2200, Denmark.
| | - Pia Svendsen
- Gerbrandskolen, Copenhagen Municipal Dental Service, Copenhagen DK-2300, Denmark.
| | - Merete Bakke
- Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen DK-2200, Denmark.
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Relevance of intraglandular injections of Botulinum toxin for the treatment of sialorrhea in children with cerebral palsy: a review. Eur J Paediatr Neurol 2014; 18:649-57. [PMID: 24931915 DOI: 10.1016/j.ejpn.2014.05.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 04/15/2014] [Accepted: 05/13/2014] [Indexed: 11/20/2022]
Abstract
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.
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[Contribution of botulinum toxin to maxillo-facial surgery]. ACTA ACUST UNITED AC 2013; 114:72-8. [PMID: 23838244 DOI: 10.1016/j.revsto.2013.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 11/06/2012] [Accepted: 01/04/2013] [Indexed: 11/21/2022]
Abstract
Botulinum toxin has a wide range of use in maxillo-facial surgery due to its action on muscles, on the glandular system, and against pain. It already has been given several market authorizations as indicated for: blepharospasm, spasmodic stiff neck, and glabellar lines. Furthermore, several studies are ongoing to prove its effectiveness and usefulness for many other pathologies: treatment of pain following cervical spine surgery; action on salivary glands after trauma, hypertrophy, or hyper-salivation; analgesic action (acknowledged but still being experimented) on neuralgia, articular pain, and keloids scars due to its anti-inflammatory properties. Botulinum toxin injections in the cervico-facial area are more and more used and should be to be correctly assessed.
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Lakraj AA, Moghimi N, Jabbari B. Sialorrhea: anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins (Basel) 2013; 5:1010-31. [PMID: 23698357 PMCID: PMC3709276 DOI: 10.3390/toxins5051010] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 04/09/2013] [Accepted: 04/24/2013] [Indexed: 12/14/2022] Open
Abstract
Sialorrhea or excessive drooling is a major issue in children with cerebral palsy and adults with neurodegenerative disorders. In this review, we describe the clinical features, anatomy and physiology of sialorrhea, as well as a review of the world literature on medical treatment using Yale University’s search engine; including but not limited to Medline and Erasmus. Level of drug efficacy is defined according to the guidelines of American Academy of Neurology. Current medical management is unsatisfactory. Topical agents (scopolamine and tropicamide) and oral agents (glyccopyrolate) combined render a level B evidence (probably effective); however, this treatment is associated with troublesome side effects. Double-blind and placebo-controlled studies of botulinum toxin (BoNT) provide a level A evidence for type B (two class I studies; effective and established) and both overall and individual B level of evidence for OnabotulinumtoxinA (A/Ona) and AbobotulinumtoxinA (A/Abo); these are probably effective. For IncobotulinumtoxinA (A/Inco), the level of evidence is U (insufficient) due to lack of blinded studies. Side effects are uncommon; transient and comparable between the two types of toxin. A clinical note at the end of this review comments on fine clinical points. Administration of BoNTs into salivary glands is currently the most effective way of treating sialorrhea.
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Affiliation(s)
- Amanda Amrita Lakraj
- Department of Neurology, Yale School of Medicine, 15 York Street LLCI-920 New Haven, CT 06520, USA; E-Mail:
| | - Narges Moghimi
- Department of Neurology, Case Western Reserve University; Cleveland, OH 44106, USA; E-Mail:
| | - Bahman Jabbari
- Department of Neurology, Yale School of Medicine, 15 York Street LLCI-920 New Haven, CT 06520, USA; E-Mail:
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-203-737-2464; Fax: +1-203-737-1122
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Use of botulinum neurotoxin A in uncontrolled salivation in children with cerebral palsy: a pilot study. Int J Oral Maxillofac Surg 2012; 41:1540-5. [DOI: 10.1016/j.ijom.2012.09.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 07/23/2012] [Accepted: 09/18/2012] [Indexed: 11/20/2022]
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Rodwell K, Edwards P, Ware RS, Boyd R. Salivary gland botulinum toxin injections for drooling in children with cerebral palsy and neurodevelopmental disability: a systematic review. Dev Med Child Neurol 2012; 54:977-87. [PMID: 22946706 DOI: 10.1111/j.1469-8749.2012.04370.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Kate Rodwell
- Queensland Paediatric Rehabilitation Service, The Royal Children's Hospital, Herston, Brisbane, Australia.
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26
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Botulinum toxin therapy: its use for neurological disorders of the autonomic nervous system. J Neurol 2012; 260:701-13. [DOI: 10.1007/s00415-012-6615-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 07/06/2012] [Accepted: 07/09/2012] [Indexed: 11/26/2022]
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Nordgarden H, Østerhus I, Møystad A, Asten P, Johnsen ULH, Storhaug K, Loven JØ. Drooling: are botulinum toxin injections into the major salivary glands a good treatment option? J Child Neurol 2012; 27:458-64. [PMID: 21940695 DOI: 10.1177/0883073811419365] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Hilde Nordgarden
- National Resource Centre for Oral Health in Rare Medical Conditions, Lovisenberg Diakonale Hospital, Oslo, Norway.
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