Botulinum neurotoxin type A in the interdisciplinary treatment of sialorrhea in adults and children-update and practice recommendations

Sialorrhea is defined as a chronic excessive flow of saliva from the mouth, often with adverse consequences for health and quality of life of patients. In addition to currently used non-drug treatment and systemic drugs, intraglandular Botulinum Neurotoxin A (BoNT/A) injections have been examined in case studies, controlled trials and clinical practice. Two pivotal Phase III trials recently led to market approval in the USA and EU for IncobotulinumtoxinA [Xeomin®, IncoBoNT/A, Clostridium botulinum neurotoxin type A (150 kD), free from complexing proteins, Merz Pharmaceuticals GmbH] for treatment of chronic sialorrhea in adults and pediatric patients. This review provides a multidisciplinary approach to discuss the current state of sialorrhea therapy as well as benefits and current limitations of BoNT/A injections. A consensus regarding treatment recommendations made available to physicians in Germany in 2022 has now been updated here for presentation to an international audience. This review provides a framework including a flow chart for patient selection, recommendations for dosing and the injection process, as well as a discussion of therapeutic goals, long-term benefits and safety aspects. This review is aimed at supporting physicians in developing multidisciplinary and individualized treatment approaches to achieve optimal benefits for patients.

[Therapy of Sialorrhea with Botulinum Toxin - An Update]

The most important salivary glands are the paired parotid and submandibular glands. Adults produce 1 to 1.5 liters of saliva which are then regularly swallowed. When the act of swallowing is disturbed, salivation occurs. More rarely, the cause can be found in increased saliva production, for example, when caused through medication. Sialorrhea impairs the quality of life substantially and is frequently often socially stigmatizing. Therapy includes conservative measures such as functional dysphagia therapy, oral or transdermal application of anticholinergics, as well as, in selected cases, radiation and surgical measures. Over the last 20 years, local injection of botulinum toxin has been successfully applied in the treatment of this condition. With approval of incobotulinumtoxinA toxin for children and adults, this procedure will become the therapy of choice for chronic sialorrhea. The results of the phase III registration trials have demonstrated high efficacy and good safety of the injection treatment in both children and adults.

[Therapy of Hemifacial Spasm with Botulinum Toxin: an Update]

Injections of botulinum toxin can be viewed by now as the therapy of choice in treating hemifacial spasm (HFS). Each of the three botulinum toxin-A preparations have been approved for this indication in Germany. HFS is a frequent disease characterized by involuntary contractions of the muscles of one half of the face innervated by the facial nerve. The symptoms can be either tonic or clonic, intermittant or permanent. Diagnosis is based purely on clinical observation. A magnetic resonance imagingof the skull is appropriate to demonstrate nerve-vessel contact as most frequent cause and to exclude other pathologies.

Oral health and oral health-related quality of life in patients with oral dystonia indicates their need for dental special care

BACKGROUND

This retrospective study aimed in the evaluation of oral health and oral health-related quality of life (OHRQoL) of patients with oral dystonia (OD).

MATERIAL AND METHODS

Seventeen patients with OD (Meige Syndrome: n=11, Oromandibular Dystonia: n=6) were included, of which seven were examined again at three months after botulinum toxin injection. OHRQoL was assessed by the German short form of oral health impact profile (OHIP G14). Within oral examination, dental parameters, remaining teeth and periodontitis severity were assessed. A matched healthy control (HC) was composed for comparison.

RESULTS

The OD patients had significantly more carious teeth (0.94 ± 1.75 vs. 0; p<0.01), less remaining teeth (15.65 ± 9.89 vs. 22.22 ± 5.91; p=0.01) and higher dental treatment need than the HC (42.9% vs. 0%; p<0.01). The OHIP G14 sum score of 9.47± 9.82 vs. 1.58 ± 2.79 (p<0.01) as well its dimensions psychosocial impact (4.47 ± 6.45 vs. 0.53 ± 1.16; p=0.03) and oral function (4.35 ± 2.98 vs. 0.47 ± 1.34; p<0.01) were clinically relevant and statistically significant higher in OD compared to HC group. No significant differences could be detected at three months after botulinum toxin injection.

CONCLUSIONS

Patients with OD suffer from more dental diseases and have a worse OHRQoL than HC. Dental special care appears recommendable and should be fostered by everyone, who is involved in the treatment of patients with OD.

[Planning and design of European prospective randomized trial on the value of drain in parotidectomy]

INTRODUCTION

There are no valid clinical studies on the value of wound drains in parotid surgery. The aim of the current trial is to analyze the influence of the closed wound drain (redon) on the incidence of postoperative complications such as bleeding, wound healing problems, infection, as well as salivary cyst and fistula after superficial or partial parotidectomy.

METHODS

A European-wide multicenter prospective randomized study was planned. The study protocol was prepared by the leading study center (ENT University Hospital Cologne) in cooperation with the ENT University Hospitals Jena and Göttingen. The calculation of the number of cases was carried out with G*Power. The study includes test persons with an indication for parotidectomy for a benign tumor without known coagulation disorder or ongoing anticoagulation. Preoperative randomization and data management is software-supported (REDCap 9.1.24, Vanderbilt University).

RESULTS

The study has been approved by the leading ethics committee in 10/2019 and is open since 04/2019. Currently, nine (9) ENT hospitals are participating in the study, 6 of them in Germany and 3 in Austria. Enrollment of patients is ongoing in 7 centers. With a calculated follow-up-to-treat population of 800 test persons, the planned duration of the study is 4 years.

CONCLUSIONS

The Redon-study is the first prospective randomized study worldwide to investigate the effect of a drain in parotidectomy. In order to achieve the recruitment goal within the planned time frame, the participation of further specialized study centers is needed. We also encourage all ENT physicians to make their patients aware of the Redon study, inform them about the possibility of participating in the study and refer them to one of the participating centers.

Shallow whole genome sequencing of adenoid cystic carcinomas of the salivary glands identifies specific chromosomal aberrations related to tumor progression

BACKGROUND AND PURPOSE

Adenoid cystic carcinomas (ACC) are characterized by high rate of local recurrence and late distant metastasis. Chromosomal changes in the evolution from primary tumors to metastatic disease of ACC have not been appointed. Here we investigated the chromosomal alterations of 53 primary tumors from ACC patients with different progressive states by shallow whole genome sequencing to identify potential new markers for metastatic spread.

METHODS

Illumina paired-end libraries were generated using DNA from the primary tumor of 53 ACC patients. Fragmented DNA was end-repaired, A-tailed and multiplex sequencing adapters were ligated. Sequence data were mapped to HG19 and a copy-number analysis was conducted using the QDNAseq R package (version 1.10.0). Outliers were removed and data was smoothed by applying the circular binary segmentation algorithm implemented in the R package copynumber version 1.22.0. A modified chromosomal instability (CNI) score was used to analyze deletions and amplifications.

RESULTS

Cluster analysis of the whole genome sequencing revealed that the frequency of chromosomal aberrations were increased in ACC with local recurrence and distant metastases in comparison to ACC patients with no metastatic spread. Specifically, chromosome 6 and 12 and exclusively the entire chromosome 4 showed an increased frequency of chromosomal alterations with tumor progression.

CONCLUSION

Our data show a molecular evolution from primary tumors to local recurrences and distant metastases and pinpoint the critical chromosomal regions involved in this process. These regions should be in the focus of the search for therapeutic targets of progressive ACC.

Therapy of Sialorrhea with Botulinum Neurotoxin

Botulinum neurotoxin (BoNT) is considered the treatment of choice for various symptoms and diseases such as focal dystonia and focal spasticity. The effects of BoNT on the salivary glands have also been known for years, but their use was limited because of a lack of approval studies. Now the indication of sialorrhea is approved in some countries for incobotulinumtoxinA, such as the USA and Europe, and therapy could also become the treatment of choice. According to the pivotal study, a dose of 100 units of incobotulinumtoxinA, which is divided into the parotid and submandibular glands, is recommended. RimabotulinumtoxinB is approved in the USA only. To define the value of this therapy, we must consider anatomy, physiology, and available therapies. Therapy includes conservative measures such as functional dysphagia therapy, oral or transdermal application of anticholinergics, and, in selected cases, radiotherapy and surgical procedures. A combination of different approaches is optional. On the basis of the evidence and clinical experience, BoNT injections will be the first line of pharmacotherapy for chronic sialorrhea.

[Therapy of sialorrhea with botulinum toxin]

The most important salivary glands are the paired parotid and submandibular glands. Adults produce 1 to 1.5 liters of saliva which are then regularly swallowed. When the act of swallowing is disturbed, salivation occurs. More rarely, the cause can be found in increased saliva production, for example, when caused through medication. Sialorrhea impairs the quality of life substantially and is frequently often socially stigmatizing. Therapy includes conservative measures such as functional dysphagia therapy, oral or transdermal application of anticholinergics, as well as, in selected cases, radiation and surgical measures. Over the last 20 years local injection of botulinum toxin has been successfully applied in the treatment of this condition. With approval of this therapy by the European agencies, this measure will become the therapy of choice for pronounced therapy-resistant sialorrhea.

[Hypersalivation - Update of the S2k guideline (AWMF) in short form]

Hypersalivation describes a relatively excessive salivary flow, which wets the patient himself and his surroundings. It may result because of insufficient oro-motor function, dysphagia, decreased central control and coordination. This update presents recent changes and innovation in the treatment of hypersalivation.Multidisciplinary diagnostic and treatment evaluation is recommended already at early stage and focus on dysphagia, saliva aspiration, and oro-motor deficiencies. Clinical screening tools and diagnostics such as fiberoptic endoscopic evaluation of swallowing generate important data on therapy selection and control. Many cases profit from swallowing therapy programmes in order to activate compensation mechanisms as long compliances is given. In children with hypotonic oral muscles, oral stimulation plates can induce a relevant symptom release because of the improved lip closure. The pharmacologic treatment improved for pediatric cases as glycopyrrolate fluid solution (Sialanar^®) is now indicated for hypersalivation within the E. U. The injection of botulinum toxin into the salivary glands has shown safe and effective results with long lasting saliva reduction. Here, a phase III trial is completed for Incobotulinum toxin A and, in the U. S., is indicated for the treatment of adult patients with chronic hypersalivation. Surgical treatment should be reserved for isolated cases. External radiation is judged as a safe and effective therapy when using modern 3 D techniques to minimize tissue damage. Therapy effects and symptom severity has to be followed, especially in cases with underlying neurodegenerative disease.

[Therapy of Hemifacial Spasm with Botulinum Toxin]

Hemifacial spasm (HFS) is a frequent disorder characterized by involuntary contractions of those muscles innervated by the facialis nerve on one side of the face. The symptoms can appear as tonic or clonic, intermittent or permanent. Diagnosis is based purely on clinical observation. Differential diagnosis should rely on cranial MRI, which can demonstrate a pathological contact between the nerves and vessels and exclude alternative causation. Often, the symptoms are not marked so that therapy may not be necessary. The therapy of choice is an injection of botulinum toxin to reduce the underlying pathological activity. As an alternative, decompression operation according to Jannetta can be considered, although it is frequently rejected by patients.

Deep neck infections: A single-center analysis of 63 cases

BACKGROUND AND PURPOSE

With the use of antibiotic therapy, the incidence of deep neck infections has decreased in recent decades. The aim of this investigation was to review the clinical course and the management of deep neck infections in our department, compare them to the experiences of the common literature and identify predisposing factors for lethal complications.

MATERIAL AND METHODS

In this single-center analysis, 63 patients with deep neck infections were treated surgically. The following clinical data were analyzed and compared: age, gender, laboratory data, spatial manifestation, therapeutic modalities, comorbidities, length of hospitalization and complications.

RESULTS

There was a predominance of male patients (58.7%) and a mean age of 57.9 years. The most common symptoms at diagnosis were sore throat (96.8%) and neck swelling (92.0%). Cardio/pulmonary diseases and diabetes mellitus were the most common comorbidities. There was a significantly longer hospital stay for patients with diabetes mellitus. The most common manifestation was a parapharyngeal abscess in 24 patients (38.1%), followed by peri-/retrotonsillar infections in 19 patients (30.2%). In 29 patients, a multiple space infection was observed, with a significantly longer duration of hospitalization and a higher rate of complications. The main life-threatening complication was the development of airway obstruction in 20 patients (31.7%), who all received a tracheostomy. The duration of hospitalization for patients with complications was significantly longer.

CONCLUSION

Close attention must be paid to the management of patients with deep neck infections, especially patients with diabetes mellitus and cardio/pulmonary diseases or patients with multiple space infections.

[Treatment of laryngeal dystonia with botulinum toxin]

The treatment of laryngeal dystonias with botulinum toxin is successful. Every patient suffering from a laryngeal dystonia should be assured of high quality therapeutic intervention. Therefore it is important to establish general standards by experts in this field. In this connection, we want to focus here on different relevant aspects of laryngeal dystonias. This includes new aspects in etiology, anatomical landmarks for the injection, standards in diagnostics and therapy and finally open issues needing discussion.

Frontalis suspension surgery to treat patients with blepharospasm and eyelid opening apraxia: long-term results

Blepharospasm may be accompanied by eyelid opening apraxia (EOA) reducing the efficacy of botulinum toxin (BT) therapy. The frontalis suspension operation (FSO) is then the only effective treatment option available. We want to report the first long-term results with FSO. We studied 15 patients with blepharospasm and EAO unresponsive to BT therapy (9 females, 6 males, age 61.9 ± 11.5 years). FSO was performed by applying 2 polytetrafluoroethylene threads (PTFE, Gore-Tex^®) per eye connecting the frontalis muscle to the upper eye lid. Tension of the two carrés was set to produce a palpebral fissure width of 2-3 mm. Therapy outcome was monitored by a quality-of-life questionnaire (QoL-Q) and a self-assessment calendar reviewing postoperative days 0-9 (T1), 10-89 (T2), 90-179 (T3), 180-365 (T4), and >365 days (T5). Altogether, 40 FSO were performed. Postoperatively, all patients reported improved eyelid opening, 4 (27%) complete remission of symptoms. At T1, this improvement was 74.6 ± 26.4% on the self-assessment scale, after 1 year 68.2 ± 27.5%. Throughout the observation period (T1-T5), the improvement was 71.9 ± 25.6%. All 19 items on the QoL-Q (except for presence of involuntary eye lid closure) showed postoperative improvement. Adverse effects included circumscript upper eyelid haematomas, suture extrusion, suture granuloma, lacrimation, and infections. In all patients, BT therapy had to be continued to treat orbicularis oculi contractions. Our first long-term results demonstrate that FSO is a benign procedure producing robust and stable therapeutic effects on EOA in blepharospasm.

Bilateral Changes in Cortical Motor Representation of the Tongue after Unilateral Peripheral Facial Paralysis: Evidence from Transcranial Magnetic Stimulation

Motor evoked potentials of the lingual muscles due to focal cortical transcranial magnetic stimulation were investigated in 5 patients with unilateral total facial paralysis with regard to amplitude as a function of the coil position on the interaural line. Maximum bilateral responses could be obtained at mean stimulus positions of about 6 to 8 cm lateral to the vertex. In comparison with healthy subjects, the patient group had significantly smaller mediolateral calculated centers for ipsilateral and contralateral responses. At the optimum stimulus positions, the patients' mean motor evoked potential amplitudes were significantly lower than those in healthy subjects. These alterations could be observed on both cortical hemispheres, but were more pronounced for the hemisphere contralateral to the side of facial paralysis. Thus, we provide strong evidence of bilateral changes in lingual cortical motor representation following facial paralysis with an invasion of the facial motor area by the tongue motor representation.

Successful Treatment of Autophonia with Botulinum Toxin: Case Report

Objectives:

We sought to treat autophonia due to a patulous eustachian tube using botulinum toxin.

Methods:

Because we assumed that the patulous eustachian tube was caused by abnormal activity of paratubal muscles (tensor and levator veli palatini muscles and salpingopharyngeus muscle), paralysis was performed via injection of botulinum toxin type A in a 45-year-old female professional musician who had had chronic unilateral autophonia for 20 years. In addition to a patient interview, an endoscopic examination of the nasopharynx (posterior rhinoscopy), ear microscopy, and impedance audiometry were performed to verify the diagnosis and the outcome after treatment.

Results:

The autophonia disappeared 1 week after treatment. Normalized tympanic ventilation was verified by impedance audiometry after 8 weeks. The period of symptom relief was 9 months.

Conclusions:

The administration of botulinum toxin type A provides a new option in the treatment of patulous eustachian tube. The reliability of this method and the effect of repeated injections remains to be proved in future studies.

Large Intraosseous Hemangioma of the Temporal Bone in a Child

Hemangiomas of the temporal bone are extremely uncommon tumors, predominantly arising in the area of the geniculate ganglion and the internal auditory canal and affecting mainly middle-aged adults. We present a 6-year-old boy who had suffered from recurrent infections of the left ear associated with a slight conductive hearing loss, but without facial nerve dysfunction. Using high-resolution computed tomography and gadolinium-enhanced magnetic resonance imaging, we detected an unusually large 32 × 32 × 24-mm mass of the left temporal bone occupying the entire mastoid. Histopathologically, a capillary hemangioma was diagnosed. The tumor was removed surgically by a transmastoid approach. We present a thorough review of the literature, focusing on the clinical and radiologic features, as well as the pathogenesis of intratemporal vascular lesions.

Strategies for treatment of dystonia

Treatment of dystonias is generally symptomatic. To produce sufficient therapy effects, therefore, frequently a multimodal and interdisciplinary therapeutic approach becomes necessary, combining botulinum toxin therapy, deep brain stimulation, oral antidystonic drugs, adjuvant drugs and rehabilitation therapy including physiotherapy, occupational therapy, re-training, speech therapy, psychotherapy and sociotherapy. This review presents the recommendations of the IAB-Interdisciplinary Working Group for Movement Disorders Special Task Force on Interdisciplinary Treatment of Dystonia. It reviews the different therapeutic modalities and outlines a strategy to adapt them to the dystonia localisation and severity of the individual patient. Hints to emerging and future therapies will be given.

Frontalis suspension surgery to treat patients with essential blepharospasm and apraxia of eyelid opening-technique and results

INTRODUCTION

We describe the results of 15 patients suffering from essential blepharospasm with apraxia of eyelid opening who underwent frontalis suspension surgery.

MATERIAL AND METHODS

Patients with apraxia of eyelid opening and unresponsive to botulinum toxin injections were studied. Bilateral frontalis suspension surgery was performed (sling operation) using polytetrafluoroethylene (Gore-Tex®) sutures. The patients reported the degree of improvement using a subjective rating scale to evaluate the benefit of the operation at two times after surgery (0-10 days and 180-360 days).

RESULTS

The patients reported a high degree of subjective improvement. In the early postoperative period (0-10 days) the mean degree of subjective improvement was 74.6% (standard deviation (SD) 26.4%). At 180-360 days after surgery the mean improvement was 70.0% (SD 26.7%). Small hematomas of the upper lid occurred postoperatively in all patients. Other complications were suture extrusions (9.1%), suture granulomas (6.1%), lacrimation (5.0%) and local infections (7.5%). Postoperatively, all patients needed additional botulinum toxin injections for optimal outcome.

CONCLUSION

Frontalis suspension surgery is a minimally invasive and effective treatment option for apraxia of eyelid opening in patients with essential blepharospasm unresponsive to botulinum toxin injections alone.

[Changes in dose and injection pattern in the botulinum toxin long-term therapy of facial dyskinesis]

BACKGROUND

Rare information exists about comparative long-term observations of patients with facial movement disorders. This retrospective analysis deals with the course of different parameters of injection over the time.

METHODS

In this study we compared the development of long-term botulinum toxin treatments of patients with blepharospasm, hemifacial spasm and synkinesis. 80 patients (n=30 blepharospasm, n=31 hemifacial spasm, n=19 synkinesis), who had at least 10 consultations for BTA-injections, were included in the retrospective analysis. The development for each entity in total dosage, increase in the number of injection points and change in dosages for each point were evaluated.

RESULTS

The over-all dosage in all 3 clinical disorders and for each single disease itself increased continuously over the time. The amount of injection points increased in the treatment of hemifacial spasm and synkinesis. The dosage per point increased most in blepharospasm between the 1. and 25. injection, but was distinctly lower in patients with hemifacial spasm and synkinesis. The increase in dosage in blepharospasm is therefore, in contrast to the other indications, mostly caused by an increase in dosage per point. In patients with hemifacial spasm and synkinesis the escalation of dosage is mainly caused by an increase of the number of injection points.

CONCLUSION

These new aspects of the dynamic in the treatment with botulinum toxin enable the physician to understand better the dynamic of these diseases, to optimize treatment protocols.

[Rhinorrhea following laryngectomy : Treatment with botulinum toxin type A.]

After laryngectomy, the transport of intranasal secretions is often inadequate due to the lack of the nasal ventilation. Consequently, persistent and disruptive anterior rhinorrhea may occur. We report the case of a 61-year-old man who had recently undergone a laryngectomy and who was successfully treated with bilateral injections of botulinum toxin into the anterior portion of the inferior turbinates. After treatment, rhinorrhea was clearly reduced. Therefore, symptomatic treatment of anterior rhinorrhea with local injections of botulinum toxin type A should be considered as an option to improve the quality of life in laryngectomized patients.

[Hypersalivation - inauguration of the S2k Guideline (AWMF) in short form]

Hypersalivation describes a relatively excessive salivary flow, which wets the patient himself and his surroundings. It may result because of insufficient oro-motor function, dysphagia, decreased central control and coordination. This reduces social interaction chances and burdens daily care. Multidisciplinary diagnostic and treatment evaluation is recommended already at early stage and focus on dysphagia, and saliva aspiration. Therefore, a multidisciplinary S2k guideline was developed. Diagnostic tools such as fiberoptic endoscopic evaluation of swallowing and videofluoroscopic swallowing studies generate important data on therapy selection and control. Especially traumatic and oncologic cases profit from swallowing therapy programmes in order to activate compensation mechanisms. In children with hypotonic oral muscles, oralstimulation plates can induce a relevant symptom release because of the improved lip closure. In acute hypersalivation, the pharmacologic treatment with glycopyrrolate and scopolamine in various applications is useful but its value in long-term usage critical. The injection of botulinum toxin into the salivary glands has shown safe and effective results with long lasting saliva reduction. Surgical treatment should be reserved for isolated cases. External radiation is judged as ultima ratio. Therapy effects and symptom severity has to be followed, especially in neurodegenerative cases. The resulting xerostomia should be critically evaluated by the responsible physician regarding oral and dental hygiene.

Aneurysm of the superficial temporal artery following parotid gland surgery--case report and review of the literature

Possible complications of parotid gland surgery are numerous, just as the reasons for aneurysms of the superficial temporal artery. The occurrence of such an aneurysm as a consequence of parotidectomy, however, has so far only been published once. Here, we report of an aneurysm of the superficial temporal artery following parotid gland surgery. It presented as a pulsating mass in the preauricular region. Combining clinical examination, duplex ultrasound, and CT scan, the diagnosis was readily established and treated with a circumscribed revision at low risk and without complications.

[Botulinum toxin for the treatment of spastic entropion. Case report]

Spastic entropion is a rare condition that predominantly affects older people. We report on a 74-year-old dementia patient who was successfully treated by botulinum toxin injections into the lower eyelid, thereby avoiding lid correction surgery. For patients with an increased risk of eyelid surgery, symptomatic therapy comprising botulinum toxin injections to the lower eyelid should be considered as an alternative treatment.

Botulinum toxin treatment of salivary fistulas following parotidectomy: follow-up results

BACKGROUND

Salivary fistulas are a well-known sequel of parotidectomy, and successful treatment with botulinum toxin has been demonstrated in individual cases. Here, we report on 12 patients with fistulas treated following parotidectomy for various indications.

METHODS AND RESULTS

Injection of botulinum toxin type A into the residual gland tissue was the initial treatment. After early intervention (within 6 weeks after development of the fistula), only one fistula remained (9 of 10 fistulas treated early only with botulinum toxin). One patient with early intervention did not want to wait for the botulinum toxin treatment to take effect and demanded early surgical revision, which was successful. In one patient with a permanent fistula, botulinum toxin treatment began 420 days after the operation and was unsuccessful. No side effects were evident after the treatment.

CONCLUSION

In summary, botulinum toxin injections into the parotid tissue remaining after surgery appear to be an effective treatment for salivary fistulas following parotidectomy.

[Botulinum toxin to treat sweat caused sequelae in patients with hearing aids, active middle ear implants and cochlear implants]

The production of sweat in the temporal skin region may be a serious problem for patients with hearing aids, active middle ear implants or cochlear implants. We report on two patients suffering from a loss of function of their hearing aid and a reduction of the "wear comfort" of an active middle ear implant. The patients underwent intracutaneous botulinum toxin (BTX) treatment of the temporal skin region. In both patients a distinct improvement of their complaints occurred, enabling them to use their hearing aids and active middle ear implants continuously. BTX injections are suited to improve sweat-caused complaints in patients with hearing aids, active middle ear implants and cochlear implants.

Diseases of the salivary glands in infants and adolescents

BACKGROUND

Diseases of the salivary glands are rare in infants and children (with the exception of diseases such as parotitis epidemica and cytomegaly) and the therapeutic regimen differs from that in adults. It is therefore all the more important to gain exact and extensive insight into general and special aspects of pathological changes of the salivary glands in these age groups. Etiology and pathogenesis of these entities is still not yet fully known for the age group in question so that general rules for treatment, based on clinical experience, cannot be given, particularly in view of the small number of cases of the different diseases. Swellings of the salivary glands may be caused by acute and chronic inflammatory processes, by autoimmune diseases, by duct translocation due to sialolithiasis, and by tumors of varying dignity. Clinical examination and diagnosis has also to differentiate between salivary gland cysts and inflammation or tumors.

CONCLUSION

Salivary gland diseases are rare in childhood and adolescence. Their pattern of incidence differs very much from that of adults. Acute and chronic sialadenitis not responding to conservative treatment requires an appropriate surgical approach. The rareness of salivary gland tumors is particularly true for the malignant parotid tumors which are more frequent in juvenile patients, a fact that has to be considered in diagnosis and therapy.

Minimally invasive application of botulinum toxin A in patients with idiopathic rhinitis

Background

Nasal hypersecretion due to idiopathic rhinitis can often not be treated sufficiently by conventional medication. Botulinum toxin A (BTA) has been injected into the nasal mucosa in patients with nasal hypersecretion with a reduction of rhinorrhea lasting for about 4 to 8 weeks. Since the nasal mucosa is well supplied with glands and vessels, the aim of this study was to find out if the distribution of BTA in the nasal mucosa and a reduction of nasal hypersecretion can also be reached by a minimally invasive application by sponges without an injection.

Methods

Patients were randomly divided into two groups. The effect of BTA (group A, C, D) or saline as placebo (group B) was investigated in 20 patients with idiopathic rhinitis by applying it with a sponge soaked with BTA (40 units each nostril) or saline. Subgroups C and D contained these patients of group A and B who did not improve in symptoms one week after the original treatment (either BTA or saline) who then received the alternative medication. Changes of symptoms (rhinorrhea, nasal obstruction) were scored by the patients in a four point scale and counted (consumption of tissues, sneezing) in a diary. The patients were followed up weeks 1, 2, 4, 8 and 12.

Results

There was a clear reduction of the amount of secretion in group A compared to group B, C and D. This did not correlate with the tissue consumption, which was comparably reduced in group A and B, but reduced less in group C and D. Sneezing was clearly reduced in group A but comparably unchanged in group B and C and increased in group D. Nasal congestion remained unchanged.

Conclusion

In some patients with therapy-resistant idiopathic rhinitis BTA applied with a sponge is a long-lasting and minimal invasive therapy to reduce nasal hypersecretion.

Reduction of Salivary Flow With Botulinum Toxin: Extended Report on 33 Patients with Drooling, Salivary Fistulas, and Sialadenitis

OBJECTIVES/HYPOTHESIS

The aim of the study was the evaluation of the clinical data of 33 patients who had had drooling attributable to various diseases, salivary fistulas, and sialadenitis and had been treated with injection of botulinum toxin type A (Botox). A controlled follow-up study documenting efficiency, possible side effects, and duration of the effect of treatment was also performed.

STUDY DESIGN

Retrospective clinical evaluation.

METHODS

Thirty-three patients with drooling attributable to head and neck carcinoma, neurodegenerative diseases, stroke, or idiopathic hypersalivation or with salivary fistula or chronic sialadenitis received injections of 20 to 65 U botulinum toxin type A into salivary glands under sonographic control. The entire salivary flow rate and the output per minute of the salivary analytes thiocyanate, total protein, alpha-amylase, acid phosphatase, kallikrein, and immunoglobulin A were measured at various times before and after injection. The patients were examined with regard to severity of their symptoms, including sonographic control investigation of their cephalic salivary glands.

RESULTS

Twenty-six patients (79% of all patients) reported a distinct improvement of their symptoms after toxin injection. Seven patients noted a return of high salivation rates and requested a second injection after 4 to 7 months. Duration of toxin effect varied widely among individuals. In general, salivary flow rates and thiocyanate output dropped sharply within 1 week after injection and had increased again after a period of 12 to 16 weeks. Conversely, amylase outputs increased during this period, whereas the outputs of the other analytes remained roughly constant. Sonography did not reveal any major changes in salivary gland parenchyma, and side effects were not noted.

CONCLUSION

Reduction of salivary flow in patients with drooling, salivary fistulas, or chronic sialadenitis by local injection of botulinum toxin type A into the salivary glands proved to be a dependable therapy for these disorders, as shown in the present extended report on 33 patients. Side effects were not observed. The effect of toxin application lasted for approximately 3 months. Based on their results, the authors recommend botulinum toxin injection as the therapy of choice in patients with the problem of drooling.

The use of botulinum toxin in head and face medicine: an interdisciplinary field

Background

In this review article different interdisciplinary relevant applications of botulinum toxin type A (BTA) in the head and face region are demonstrated.

Patients with head and face disorders of different etiology often suffer from disorders concerning their musculature (example: synkinesis in mimic muscles) or gland-secretion.

This leads to many problems and reduces their quality of life. The application of BTA can improve movement disorders like blepharospasm, hemifacial spasm, synkinesis following defective healing of the facial nerve, palatal tremor, severe bruxism, oromandibular dystonias hypertrophy of the masseter muscle and disorders of the autonomous nerve system like hypersalivation, hyperlacrimation, pathological sweating and intrinsic rhinitis.

Conclusion

The application of botulinum toxin type A is a helpful and minimally invasive treatment option to improve the quality of life in patients with head and face disorders of different quality and etiology. Side effects are rare.