Botulinum toxin A for children with salivary control problems

Use of botox for sialorrhea and dysphagia in the neonatal population

INTRODUCTION

Botox is frequently used for sialorrhea in patients with compromised airways and those with etiologies causing difficulty with secretion management (i.e. strokes, neurologic disorders, etc.). There are no published studies regarding the use of botulinum toxin (BoNT) in the neonate population. We aim to discuss our experience and safety of BoNT use in the neonate population in regards to alleviating secretion management and airway protection.

METHODS

Retrospective review of neonates admitted to the neonatal intensive care unit (NICU) ≤12 months of age who received BoNT injection to submandibular (SMG) and parotid (PG) glands for sialorrhea/dysphagia. BoNT was administered under ultrasound (u/s) guidance by interventional radiology.

RESULTS

6 children were examined. 2 (33 %) were male. Avg NICU stay was 87.5 ± 33.1 days. 2 underwent surgical airway intervention prior to injection. Mean age at initial BoNT was 1.5 ± 0.7 months. Avg weight at injection was 4 ± 1.1 kg. Each PG and SMG were injected in 5/6 cases. Bilateral SMG were unidentified on u/s in 1 case and thus not injected. Dose range injected per gland was 5-15u. 100 % required tube feeds, 50 % with tubes distal to stomach (NJT/NDT). 83 % were completely NPO prior to injection and there was no noted clinical improvement in oral skills post injection. All had noted desats/apneas prior to injection and 83 % had reported decreased events post injection. 50 % had reported decrease O2 requirements and frequent suctioning 2wks after injection, however 2 (33 %) required surgical airway intervention after injection (trach, SGP/MDO). 4/6 (67 %) trialed medical therapy, anticholinergics being the most common. 50 % underwent 2nd injection (age = 6.5 ± 0.3 months) avg. 4.7 ± 0.7mo after 1st injection, and the same 3pts underwent 3rd injection (age = 12.5 ± 2.4 months) avg. 6.1 ± 2.5mo after 2nd injection. 1 pt. had a total 6 injections. There were no injection related complications.

CONCLUSION

BoNT injection is a safe, non-invasive alterative for management of sialorrhea in neonates. Further extensive study needs to be performed to identify the optimal dose per gland in this population.

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

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

Tolerance of salivary gland botulinum toxin A injection under local anesthesia for the treatment of sialorrhea in children: An observational study

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.

Localization of Salivary Glands for Botulinum Toxin Treatment: Ultrasound Versus Landmark Guidance

Background

Sialorrhea is a troublesome symptom in a variety of neurological diseases. Recently, local injection of botulinum toxin into the salivary glands was approved for treatment of sialorrhea, and injection guidance by anatomical landmarks was suggested.

Objective

To compare the accuracy of ultrasound versus previously proposed anatomical landmarks for localizing the salivary glands.

Methods

In a cross-sectional study in 21 adults, landmark positions (LM) of the parotid gland (PG) and the submandibular gland (SG) were identified following published recommendations. The ultrasound position (US) was defined as the position representing the maximum gland thickness. The distance between positions, gland thickness, and optimal injection depth were recorded by US.

Results

Gland thickness differed significantly between LM and US positions (PG, 4 vs. 17.8 mm; P < 0.001; SG, 3.5 vs. 13.6 mm; P < 0.001). The spatial deviation between the recommended LM and identified US positions in the horizontal plane was 21 mm to the posterior direction for the PG and 19.6 mm for the SG. The deviation in vertical orientation was small for both glands; however, there was a positive correlation between the distance from the SG to the mandibular bone with age. The optimal injection depth measured by US was 11.8 mm for the PG and 13.6 mm for the SG. This showed to be positively correlated with the body mass index.

Conclusions

The position of the salivary glands differs from proposed landmarks and depends on the individual age and body weight; therefore, we recommend ultrasound guidance for injection.

Randomized controlled trial comparing botulinum vs surgery for drooling in neurodisabilities

OBJECTIVE

To compare the effect of submandibular duct ligation (2-DL) and submandibular botulinum neurotoxin type A (BoNT-A) for drooling in children and adolescents with neurodevelopmental disabilities.

METHODS

A randomized, interventional, controlled, and partly single-blinded study was performed in which submandibular BoNT-A was compared with 2-DL to treat excessive drooling. Main outcomes included a Visual Analog Scale (VAS), drooling quotient (DQ), drooling severity (DS) scale and drooling frequency (DF) scale. Each was obtained at baseline, and 8 and 32 weeks post treatment.

RESULTS

Fifty-seven patients (mean age: 11 years, mean baseline VAS score 7.9, mean baseline DQ 27.3%) were randomized to the 2-DL or BoNT-A group. Four patients were excluded from analyses, leaving 53 patients for intention-to-treat analyses. Response to treatment, defined as a ≥50% reduction in DQ or VAS score, was higher for 2-DL after 32 weeks (63.0% vs 26.9%, p = 0.008). Both VAS score (24.5, p < 0.001) and DQ (-9.3%, p = 0.022) were significantly lower at follow-up after 2-DL vs BoNT-A. The total number of adverse events (p = 0.088, 40.7% vs 19.2%) and postoperative complaints was higher (p < 0.001, mean 9.6 vs 3.6 days) for 2-DL than for BoNT-A.

CONCLUSION

The 2-DL procedure is a more effective treatment for drooling than botulinum toxin, but carries a slightly greater risk of complications and morbidity.

TRIALREGISTERNL IDENTIFIER

NTR3537.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for children and adolescents with neurodevelopmental disabilities and severe drooling, 2-DL compared to a one-time intraglandular BoNT-A injection is more effective at reducing drooling at 32 weeks.

Pediatric leukodystrophies: The role of the otolaryngologist

BACKGROUND

Leukodystrophies consist of degenerative neurogenetic diseases often associated with comorbidities that extend beyond the neurological system. Despite their impacts on patients' quality of life and risks of complications, head and neck symptomology is poorly reported in the literature. The objective of this study was to identify and quantify the main head and neck complaints among a cohort of patients diagnosed with leukodystrophies and define the role of the otolaryngologist as part of a multidisciplinary team for treating these patients.

METHODS

During the First Canadian National Conference on Leukodystrophies held at the Montreal's Children Hospital, a cohort of 12 patients diagnosed with leukodystrophies were recruited and evaluated by a multidisciplinary team. An otolaryngology-focused assessment was done through history and physical examination, and included a screening questionnaire for 23 common otolaryngology issues. If families reported a history of sialorrhea, a validated questionnaire (Drool Quality of Life Assessment Questionnaire (DroolQoL)) was subsequently distributed. Results from the questionnaires were then compiled and analyzed.

RESULTS

Of the 12 recruited patients, 83% (10/12) were known to an otolaryngologist. Drooling affected 67% (8/12) of patients although only 37.5% (3/8) of patients had undergone medical or surgical therapies for this issue. Four patients experienced at least one aspiration pneumonia. 58% (7/12) of the patients had dysphagia, of whom 43% (3/12) were fed exclusively via gastrostomy tube and 28% (2/7) required thickening of feeds. Two patients, despite suspicion of dysphagia and aspiration, had never undergone evaluation. As for otologic issues, it was noted that 25% (3/12) of patients had a history of pressure equalizing tubes (PETs) and one patient had a history of hearing loss.

CONCLUSION

Head and neck comorbidities affect children with leukodystrophies. Therefore, the otolaryngologist should be part of the multidisciplinary team, specifically for the management of dysphagia and sialorrhea.

Managing children with sialorrhoea (drooling): Experience from the first 301 children in our saliva control clinic

OBJECTIVES

Sialorrhoea (drooling) is defined as the involuntary escape of saliva from the mouth. It is considered normal in young children but may cause social problems in older children. Sialorrhoea is frequently seen in children with cerebral palsy, with rates between 10% and 58% and in other neurodevelopmental diseases. Management of these children can be challenging and often requires an individual and stepwise approach. This is a large case series of children managed at the saliva control clinic in Glasgow, Scotland.

METHODS

A chart review of all children attending the saliva control clinic between 2006 and June 2012 was performed. This was to ensure that all children would have long term follow up (3 years minimum). Drooling severity was assessed on the child's first attendance at clinic, and at review following a treatment option, using the Teacher Drooling Scale (TDS).

RESULTS

The total number of children attending this clinic was 301, of which 274 had adequate records for inclusion in the study. 176 (64%) were male. The mean age was 7.3 (median 5) years. In terms of development 35 (13%) of children were developing normally and 50 (18%) had general developmental delay. There were 105 (38%) children with cerebral palsy. The final management of sialorrhoea in these children was simple reassurance and advice for 34 (12%), speech and language therapy for 62 (23%) anticholinergics in 90 patients (33%), botox for 30 (11%) and surgery for 71 (26%) children. The rate of non-tolerance of anticholinergics is 30%; 90 of the 298 children tried on anticholinergics had side effects leading to the treatment being stopped. The average teachers drooling score was 4.24 before clinic and 1.59 after clinic. Satisfactory results were achieved in 215 (78%) of children.

CONCLUSION

Our data illustrates that effective patient management requires all treatment options to be available, including speech therapy, medications, botulinum toxin and surgery. This is one of the larger case series of children attending a saliva control clinic.

Safety of Ultrasound-Guided Botulinum Toxin Injections for Sialorrhea as Performed by Pediatric Otolaryngologists

OBJECTIVE

To evaluate incidence of complications and hospital readmission as a result of ultrasound-guided botulinum toxin injections to manage sialorrhea.

STUDY DESIGN

Case series with chart review.

SETTING

Children's Hospital of Wisconsin.

SUBJECTS AND METHODS

A case series with chart review was performed of all cases of ultrasound-guided injection of botulinum toxin by pediatric otolaryngologists from March 5, 2010, to September 26, 2014,. Primary outcomes included complications such as dysphagia, aspiration pneumonia, and motor paralysis. Secondary outcomes included hospitalization, intubation, and nasogastric tube placement.

RESULTS

There were 48 patients, 111 interventions, and 306 intraglandular injections identified. Botulinum toxin type A and type B were utilized in 4 and 107 operative interventions, respectively. Type A was injected into 4 parotid and 4 submandibular glands, utilizing doses of 20 U per parotid and 30 U per submandibular gland. Type B was injected into 98 parotid and 200 submandibular glands, with average dosing of 923 U per parotid and 1170 U per submandibular gland, respectively. There were 2 instances of subjectively worsening of baseline dysphagia that self-resolved. No cases were complicated by aspiration pneumonia or motor paralysis. No patients required hospital readmission, intubation, or nasogastric tube placement.

CONCLUSION

Prior published data indicated 16% complication incidence with ultrasound-guided injection of botulinum toxin. Our study found a low complication rate (0.6%) with ultrasound-guided injections of botulinum toxin to manage sialorrhea, without cases of aspiration pneumonia or motor paralysis. Of 306 intraglandular injections, there were 2 cases of worsening baseline subjective dysphagia that self-resolved.

Botulinum Toxin Confers Radioprotection in Murine Salivary Glands

PURPOSE

Xerostomia is a common radiation sequela, which has a negative impact on the quality of life of patients with head and neck cancer. Current treatment strategies offer only partial relief. Botulinum toxins (BTX) have been successfully used in treating a variety of radiation sequelae such as cystitis, proctitis, fibrosis, and facial pain. The purpose of this study was to evaluate the effect of BTX on radiation-induced salivary gland damage.

METHODS AND MATERIALS

We used a previously established model for murine salivary gland irradiation (IR). The submandibular glands (SMGs) of C5BL/6 mice (n=6/group) were injected with saline or BTX 72 hours before receiving 15 Gy of focal irradiation. Saliva flow was measured 3, 7, and 28 days after treatment. The SMGs were collected for immunohistochemistry, confocal microscopy, and Western blotting. A cytokine array consisting of 40 different mouse cytokines was used to evaluate cytokine profiles after radiation treatment.

RESULTS

Irradiated mice showed a 50% reduction in saliva flow after 3 days, whereas mice preinjected with BTX had 25% reduction in saliva flow (P<.05). Cell death detected by TUNEL staining was similar in SMG sections of both groups. However, neutrophil infiltrate, detected by myeloperoxidase staining, was 3-fold lower for the BTX treated mice. A cytokine array showed a 2-fold upregulation of LPS-induced chemokine (LIX/CXCL5) 3 days after IR. BTX pretreatment reduced LIX levels by 40%. At 4 weeks after IR, the saline (control) group showed a 40% reduction in basal SMG weight, compared with 20% in the BTX group. Histologically, BTX-pretreated glands showed relative preservation of acinar structures after radiation.

CONCLUSIONS

These data suggest that BTX pretreatment ameliorates radiation-induced saliva dysfunction. Moreover, we demonstrate a novel role for CXCL5 in the acute phase of salivary gland damage after radiation. These results carry important clinical implications for the treatment of xerostomia in patients with head and neck cancer.

The use of botulinum toxin B in the treatment of a post-traumatic sialocele in a 4-year-old child: A case report

Parotid sialoceles are bothersome complications of parotidectomy and penetrating injury to the parotid gland. Though typically self-limited and responsive to conservative management, they can be particularly difficult to manage in the pediatric population where even conservative interventions are less well tolerated. We present the case of a 4-year-old child with a post-traumatic parotid sialocele that was successfully managed with a single injection of botulinum toxin B. To our knowledge, this is the first reported case of the use of botulinum toxin for this purpose in the pediatric population.

The Experience of Treating Drooling with Repeated Botulinum Toxin Injections

Botulinum toxin A (BTX-A) injections to the salivary glands are effective in the treatment of drooling, and complications are rare. However, there are only a few previous reports on the long-term use of BTX-A injections. This study retrospectively analyzes our experience of treating drooling with repeated BTX-A injections in patients with neurodegenerative diseases. All patients who received repeated BTX-A injections to the submandibular glands at Tampere University Hospital in 2004-2013 were included in the analysis. Six patients, aged from 6 to 21 years, were included in the study, and a total of 41 bilateral BTX-A injections were administered to their submandibular glands. The average number of injections per patient was 6 (range: 3-11). The average interval between the injections was 9.8 months (range: 4-18), and 95% (39/41) of the injections were performed with good response. The complication rate of the BTX-A injections was 2.4% (1/41), since one of the patients had swallowing problems after an injection. BTX-A injections to the submandibular glands are effective and have a low morbidity rate, and repeated injections can be recommended as long-term treatment of drooling.

The option of sonographic guidance in Botulinum toxin injection for drooling in Parkinson's disease

Parkinson's disease is a syndrome that frequently includes drooling, i.e., the involuntary spillage of saliva over the lip margin. Such drooling places a severe burden on both the health and the quality of life of Parkinsonian patients. Its origin lies in the impairment of oral motor control and swallowing associated with Parkinson's disease. It can be treated surgically or conservatively by reducing the production of saliva in the salivary glands, to which the parotid and submandibular glands make the greatest contribution. Botulinum neurotoxins A and B, administered to these glands, are in increasing use as treatment for drooling from various causes including Parkinson's disease. Wide knowledge was gathered about preferred drugs, dosages, injection sites and injection-guiding techniques, albeit without providing evidence-based guidance or a clear rationale for the mode of action of the medication or any information about further influential or predictive factors for safety and efficacy. However, it is essential that the relevant glands be targeted accurately; although this can be done by using anatomical landmarks, the use of sonographic guidance seems preferable. In the hands of a trained injector, sonography is a quick and non-invasive imaging technique.