Botulinum toxin to reduce saliva flow: selected indications for ultrasound-guided toxin application into salivary glands

The effect of botulinum neurotoxin A on soft-tissue complications in intraoral reconstructions

BACKGROUND

Intraoral reconstruction has become more common in recent years. Patients may suffer from complications because of hypersalivation. This issue can be overcome with an aid aimed at reducing saliva production. In this study, patients who underwent flap reconstruction were examined. The aim was to compare the complication rates between those who were administered with botulinum neurotoxin type A (BTXA) to the salivary glands before the reconstruction and those who were not.

METHODS

Patients who underwent flap reconstruction between January 2015 and January 2021 were included in the study. The patients were divided into 2 groups. BTXA was applied to the parotid and submandibular glands in the 1st group at least 8 days before the operation to reduce the salivary secretion. BTXA application was not applied to the patients in the 2nd group before the operation.

RESULTS

A total of 35 patients were included in the study. There were 19 patients in group 1 and 16 patients in group 2. The tumor type in both groups was squamous cell carcinoma. For patients in the 1st group, salivary secretion decreased in an average of 3.84 days. In the statistical analysis, no significant difference was found between the groups in terms of age, comorbidity, smoking-complication development, and comorbidity-complication development. When infection was excluded, there was a significant difference in the development of complications between the groups.

CONCLUSIONS

BTXA application before the operation is beneficial to minimize complications in patients who plan to undergo elective intraoral reconstruction.

Botulinum Neurotoxin A in the Treatment of Pharyngocutaneous Fistula after Salvage Surgery in Head and Neck Cancer Patients: Our Preliminary Results

Objective: To analyze the effect of intraparotid injection of botulinum neurotoxin A (BoNT-A) on salivary production and the course of pharyngocutaneous fistula (PCF) in post-radiation therapy salvage surgery. Methods: A total of 13 patients who had undergone total laryngectomy or pharyngolaryngectomy were treated with BoNT-A to both parotid glands, within three days from PCF onset. The salivary flow was evaluated using a subjective rating scale as the percentage of normal function from 0% (no saliva) to 100% (normal saliva flow), before injection, every day for 2 weeks, and once a week for three months. PCFs were monitored daily. Results: Spontaneous closure of PCF occurred in 7/13 (53.84%) cases 13.6 days (range: 7-18) after treatment; 6/13 (46.16%) patients needed revision surgery. Salivary flow significantly decreased in all patients seven days after injection (from 67.2% to 36.4%; p < 0.05). Patients who had undergone either conservative or surgical treatment did not differ in salivary flow before injection, whereas the mean percentages of salivary flow calculated at each time point after injection were different (p < 0.05). Conclusions: BoNT-A contributed to the closure of the fistula in most of our cases. The subjective perception of salivary flow predicted the closure of PCF. The mean time to closure may contribute to establishing the timing of PCF surgical treatment.

Accuracy of non-guided versus ultrasound-guided injections in cervical muscles: a cadaver study

INTRODUCTION

The col-cap concept encouraged neurologists to inject a large group of muscles in the treatment of cervical dystonia. This includes deep muscles such as the obliquus capitis inferior or the semispinalis capitis, and muscles close to vascular or neurological structures such as scalene muscles. Our aim was to determine the accuracy of injections in cervical muscles using ultrasonography (US) or palpation of anatomical landmarks.

METHODS

A mix of paint, gelatin and iodized contrast agent was injected in nine pairs of cervical muscles of human cadavers, according to two injection techniques: US-guided and non-guided. The dye was localized on 1 cm-thick, frozen slices.

RESULTS

A total of 102 muscles was injected in the US-guided group (n = 8). The global accuracy was 88.2%. The lowest accuracy was in the OCI (41.7%); trying to avoid the vertebral artery, injections were too medial. A total of 54 muscles was injected in the non-guided group (n = 3). The global accuracy was 48.0%; moreover, some dye was found in four blood vessels. The embalming process produced texture changes, making difficult the palpation of bony landmarks.

CONCLUSIONS

Our results indicate that US-guided injections are more accurate than non-guided injections in most cervical muscles.

The ectopic accessory parotid system with congenital cheek fistula: An overview and current update

OBJECTIVE

This review attempts to provide a comprehensive, updated overview of the ectopic accessory parotid system (EAPS) from clinical and developmental perspectives and investigates its eligibility to be included in the oculo-auriculo-vertebral spectrum (OAVS).

REVIEW METHODS

Results of the keyword-based search in the PubMed/MEDLINE, Google Scholar, LILACS, and Cochrane Library were subjected to the given inclusion and exclusion criteria that corroborated with the definition of EAPS. Eleven records were shortlisted, their full texts studied and references cross-checked. Finally, 10 articles collectively describing 16 patients were considered for review.

RESULTS

The average age of presentation was 8.33 years, with 44% of the patients aged below 5 years. Boys were affected 1.67 times more. The cheek fistula was always unilateral, with marginal left predilection. About 94% of the patients were of East Asian descent, chiefly from China and India. Thirteen children had preauricular appendages, mostly ipsilateral, with occasional ipsilateral mandibular hypoplasia (25%). The ectopic parotid was anterolateral to the masseter, lateral to buccinator, and inferior to the Stensen duct. Complete surgical removal of the EAPS (intraoral approach) or transposing the fistula into the oral cavity formed the mainstay of treatment.

CONCLUSION

The EAPS is a rare craniofacial anomaly presenting with a saliva-draining cheek fistula, associated with ipsilateral preauricular appendages (microtia) and occasional mandibular hypoplasia. Speculative developmental theories suggest dysmorphogenesis of the first two pharyngeal arches, clinically and embryologically relating it with OAVS. This review summarizes the clinical aspects, and establishes isolated EAPS as a mild but discrete phenotype of OAVS irrespective of the presence of other congenital stigmata. Laryngoscope, 127:1351-1360, 2017.

Safety and Efficacy of Botulinum Toxin to Preserve Gland Function after Radiotherapy in Patients with Head and Neck Cancer: A Prospective, Randomized, Placebo-Controlled, Double-Blinded Phase I Clinical Trial

This prospective, randomized, placebo-controlled, double-blinded phase I clinical trial investigates safety and efficacy of botulinum toxin (BoNT) to preserve gland function after radiotherapy in patients with head and neck cancer. Twelve patients with advanced head and neck cancer were injected with BoNT into the submandibular glands prior to primary radiochemotherapy. Six patients received BoNT/A and 6 patients BoNT/A and B, half of each subgroup into their left and the other half into their right gland. As an internal control, sodium chloride was injected into the respective contralateral gland (placebo). For the evaluation of the salivary gland function, technetium pertechnetate salivary gland scintigraphy was performed before and after the end of radiotherapy. BoNT/A and B were well tolerated. Analysis of the scintigraphic data revealed no statistically significant difference between BoNT and placebo regarding the scintigraphic uptake difference (pBoNT/A = 0.84 and pBoNT/A-B = 0.56 for BoNT/A vs. placebo and BoNT/A-B vs. placebo, respectively). We also found no significant difference in treatment between BoNT and placebo in terms of salivary excretion fraction (pBoNT/A = 0.44; pBoNT/A-B = 0.44). This study demonstrates that BoNT can be safely combined with radiochemotherapy. Dosing and timing of BoNT injection should be further investigated for efficacy analysis.

Association of onabotulinum toxin A treatment with salivary pH and dental caries of neurologically impaired children with sialorrhea

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.

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

INTRODUCTION AND OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Salivary gland diseases in children

Salivary gland diseases in children are rare, apart from viral-induced diseases. Nevertheless, it is essential for the otolaryngologist to recognize these uncommon findings in children and adolescents and to diagnose and initiate the proper treatment.

The present work provides an overview of the entire spectrum of congenital and acquired diseases of the salivary glands in childhood and adolescence. The current literature was reviewed and the results discussed and summarized.

Besides congenital diseases of the salivary glands in children, the main etiologies of viral and bacterial infections, autoimmune diseases and tumors of the salivary glands were considered. In addition to the known facts, new developments in diagnostics, imaging and therapy, including sialendoscopy in obstructive diseases and chronic recurrent juvenile sialadenitis were taken into account. In addition, systemic causes of salivary gland swelling and the treatment of sialorrhoea were discussed. Although salivary gland diseases in children are usually included in the pathology of the adult, they differ in their incidence and some­times in their symptoms. Clinical diagnostics and especially the surgical treatment are influenced by a stringent indications and a less invasive strategy. Due to the rarity of tumors of the salivary glands in children, it is recommended to treat them in a specialized center with greater surgical experience.

Altogether the knowledge of the differential diagnoses in salivary gland diseases in children is important for otolaryngologists, to indicate the proper therapeutic approach.

Botulinum toxin in the treatment of drooling in tetraplegic patients with brain injury

Objective

To investigate the effect of botulinum toxin type A (BTA) injection into the salivary gland and to evaluate the changes of drooling in varied postures in tetraplegic patients with brain injury.

Methods

Eight tetraplegic patients with brain injury were enrolled. BTA was injected into each parotid and submandibular gland of both sides under ultrasonographic guidance. Drooling was measured by a questionnaire-based scoring system for drooling severity and frequency, and the sialorrhea was measured by a modified Schirmer test for the patients before the injection, 3 weeks and 3 months after the injection. Drooling was evaluated in each posture, such as supine, sitting, and tilt table standing, and during involuntary mastication, before and after the injection.

Results

The severity and frequency of drooling and the modified Schirmer test improved significantly at 3 weeks and 3 months after the injection (p<0.05). Drooling was more severe and frequent in tilt table standing than in the sitting position and in sitting versus supine position (p<0.05). The severity of drooling was significantly increased in the patients with involuntary mastication (p<0.05).

Conclusion

Salivary gland injection of BTA in patients with tetraplegia resulting from brain injury who had drooling and sialorrhea could improve the symptoms for 3 months without complications. The severity and frequency of drooling were dependent on posture and involuntary mastication. Proper posture and involuntary mastication of the patients should be taken into account in planning drooling treatment.

Botulinum toxin type A on oral health in treating sialorrhea in children with cerebral palsy: a randomized, double-blind, placebo-controlled study

Intrasalivary gland injection of botulinum toxin type A is known to treat sialorrhea effectively in children with cerebral palsy. However, oral health may be compromised with escalating dose. In this randomized, double-blind, and placebo-controlled pilot trial, the authors aim to determine the therapeutic effect of low-dose, ultrasonography-controlled botulinum toxin type A injection to bilateral parotid and submandibular glands on oral health in the management of sialorrhea. Twenty children diagnosed with cerebral palsy were randomly assigned to 2 groups. The treatment group received botulinum toxin type A injections, whereas the control received normal saline in the same locations. The authors evaluated subjective drooling scales, salivary flow rate, and oral health (salivary compositions and cariogenic bacterial counts). A significant decrease was found in salivary flow rate at the 1- and 3-month follow-up in the botulinum toxin-treated group. The authors suggest that current protocol can effectively manage sialorrhea while maintaining oral health.

Thickened saliva after effective management of drooling with botulinum toxin A

AIM

The aim of this study was to evaluate the rheological properties of saliva after submandibular botulinum toxin type A (BoNT-A) injections.

METHOD

We enrolled 15 children (11 males and six females; age range 3-17 y, mean age 9 y 10 mo) diagnosed with spastic (n=9) or dyskinetic (n=6) quadriplegic cerebral palsy (CP); Gross Motor Function Classification System level IV or V; and two children with intellectual disability (IQ<70) who experienced moderate to severe drooling. Salivary flow rate and drooling quotient were measured at baseline and at different times after BoNT-A injections up to 24 weeks. The mucin concentration of saliva was analysed before and after BoNT-A treatment.

RESULTS

Both submandibular salivary flow rate (baseline 0.38 mL/min; 24 wks after injection 0.26 mL/min) and drooling quotient (baseline 42.5%; 24 wks 28.80%) were substantially reduced, with a concomitant increase in mucin concentration within 8 weeks after BoNT-A injection (from 0.612 to 1.830 U/mL). The parents of nine children observed thickened saliva. Swallowing and chewing were problematic in seven children. Two of these children needed treatment with mucolytics because of pooling of thickened saliva in the throat.

INTERPRETATION

When making decisions about the use of BoNT-A, the risk of problems with masticatory and swallowing functions as a result of thickening of saliva after BoNT-A treatment should be taken into account.

Botulinum toxin B as an effective and safe treatment for neuroleptic-induced sialorrhea

RATIONALE

Severe sialorrhea is a common, potentially stigmatizing and disabling side-effect of neuroleptic drugs such as clozapine. Sialorrhea also occurs in neurological disorders such as Parkinson's disease (PD). For neurological diseases, several studies have demonstrated botulinum toxin type B to be a safe and effective treatment.

OBJECTIVES

To evaluate the treatment effects, tolerance, and duration of treatment-induced effects of botulinum toxin type B (Neurobloc) in the context of neuroleptic-induced sialorrhea (group 1) or PD-associated drooling (group 2) in a double-blind, placebo-controlled trial.

METHODS

Nine patients (four from group 1; five from group 2) with severe sialorrhea received injections into the salivary glands with either botulinum toxin type B or placebo and were followed over 16 weeks.

RESULTS

We found large effect sizes for improvement of sialorrhea in patients treated with botulinum toxin type B, whereas the improvement of sialorrhea in those receiving placebo was only small. No patient reported any side effects. Reduction of sialorrhea lasted for 8 to 16 weeks after a single injection.

CONCLUSIONS

Like for PD, botulinum toxin type B represents an effective and safe treatment for neuroleptic-induced sialorrhea with a treatment effect of 8 to 16 weeks.

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.

Novel treatment of first bite syndrome using botulinum toxin type A

BACKGROUND

First bite syndrome is the development of pain in the parotid region after the first bite of each meal and can be seen after surgery of the parapharyngeal space. The purpose of this study is to evaluate the efficacy of intraglandular injection of botulinum toxin type A (BTA) in patients with first bite syndrome.

METHODS

Five patients with first bite syndrome developed after head and neck surgery were treated by injection of BTA into parotid gland. All patients completed a 4-item quality-of-life survey with a 10-point response scale designed to measure outcome of intraglandular injection of BTA.

RESULTS

The first bite syndrome without or with sialogogue and degree of interference with daily activity with or without eating or drinking improved significantly at 1 and 3 month after injection (p < .05).

CONCLUSION

The BTA injection into affected parotid gland produces a decrease in the severity of first bite syndrome and improves the patient's quality of life.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

Botulinum toxin therapy: a tempting tool in the management of salivary secretory disorders

PURPOSE

The aim of the study was to investigate the feasibility and effectiveness of botulinum toxin therapy in salivary secretory disorders.

MATERIALS AND METHODS

We treated 24 patients with botulinum neurotoxin type A for drooling, salivary fistulas, sialoceles, recurrent parotitis, and Frey's syndrome; each parotid gland and submandibular gland received 25 to 60 and 10 to 40 mouse units, respectively, per session. All the patients other than those with Frey's syndrome underwent, for diagnostic purpose, color Doppler ultrasonography (Hitachi H 21; frequency, 7.5 MHz, Scanner, Kashiwa, Japan), and Minor's test was carried out for gustatory sweating; pretreatment magnetic resonance sialography (Philips Gyroscan Intera, Eindhoven, The Netherlands) and sialoendoscopy were also performed in selected cases. The follow-up included clinical and ultrasonographic examinations and Minor's test.

RESULTS

A clinical improvement was observed in all patients: complete clinical recovery in 12, subtotal in 6, and partial in 6. A self-assessment test suggested the cessation of sweating by the 10th day in most patients with Frey's syndrome. Botulinum toxin lost its effectiveness approximately after 4 months, requiring further administrations especially for drooling. No major side effects were observed with the exception of transitory paresis of the lower branch of the facial nerve in a patient with concomitant autonomic diabetic neuropathy.

CONCLUSIONS

Our findings suggest that botulinum toxin therapy is valid for the nonsurgical management of patients with salivary secretory disorders; the use of color Doppler ultrasonographic monitoring warrants the safety of the procedure.

Chemocauterization of congenital fistula from the accessory parotid gland

Congenital sialo-cutaneous fistula arising from the accessory parotid gland is extremely rare. Although the fistula tract can be successfully excised after making a skin incision along the skin tension line around the fistula opening, a facial scar inevitably remains. We here report a case of sialo-cutaneous fistula that was treated with chemocauterization with trichloroacetic acid (TCA). TCA cauterization is an easy and effective option for the treatment of congenital fistula from an accessory parotid gland, especially from the aesthetic point of view.

Intraglandular application of botulinum toxin leads to structural and functional changes in rat acinar cells

BACKGROUND AND PURPOSE

Intraglandular injection of botulinum toxin (BoNT) leads to a transient denervation of the submandibular gland and this is associated with reduced salivary secretion. The purpose of the present study was to verify whether temporary acinar atrophy occurs simultaneously with chemical denervation of the glands.

EXPERIMENTAL APPROACH

Tissue specimens of the right submandibular gland taken from 18 Wistar rats after intraglandular injection of BoNT A, BoNT B, or a combination of both were examined. As a sham control, an equivalent volume of saline was injected into the left submandibular gland. Morphometric measurements, immunohistochemistry, electron microscopy and western blot analysis were used to analyse the morphological and functional changes of the denervated glands.

KEY RESULTS

Morphological and ultrastructural analyses of the cell organelles and secretory granula showed a clear atrophy of the acini, which was more prominent in glands injected with the combination of BoNT/A and B. Morphometric measurements of the glandular acini revealed a significant reduction of the area of the acinar cells after injection of BoNT (P=0.031). The expression of amylase was significantly reduced in BoNT treated glands.

CONCLUSIONS AND IMPLICATIONS

Intraglandular application of BoNT induces structural and functional changes of the salivary glands indicated by glandular atrophy. These effects may be due to glandular denervation induced by the inhibition of the soluble N-ethylmaleimide-sensitive fusion protein attachment protein receptors (SNAREs) involved in acetylcholine release at the neuroglandular junction and also specially inhibition of those involved in exocytosis of the granula of the acinar cells.

The voice and laryngeal dysfunction in stroke: a report from the Neurolaryngology Subcommittee of the American Academy of Otolaryngology-Head and Neck Surgery

OBJECTIVE

Stroke is the third leading cause of death in the United States, behind heart disease and cancer. It affects as many as 5% of the population over 65 years old, and this number is growing annually due to the aging population. A significant portion of stroke patients that initially survive are faced with the risk of aspiration, as well as quality-of-life issues relating to impaired communication. The goal of this paper is to define the scope of practice in otolaryngology for these patients, and to review pertinent background literature.

STUDY DESIGN

Consensus report and retrospective literature review.

RESULTS

Otolaryngology involvement in these patients is critical to their rehabilitation, which often requires an interdisciplinary team of specialists. This committee presentation explores epidemiological data regarding the impact of stroke and its complications on hospitalizations. A pertinent review of neuroanatomy as it relates to laryngeal function is also discussed. State-of-the-art diagnostic and therapeutic procedures are presented.

CONCLUSION

There is a well-defined set of diagnostic and therapeutic options for laryngeal dysfunction in the stroke patient.

SIGNIFICANCE

Otolaryngologists play a critical role in the interdisciplinary rehabilitation team.

Symptomatic treatment of multiple sclerosis. Multiple Sclerosis Therapy Consensus Group (MSTCG) of the German Multiple Sclerosis Society

Besides immunomodulation and immunosuppression, the specific treatment of symptoms is an essential component of the overall management of multiple sclerosis (MS). Symptomatic treatment is aimed at the elimination or reduction of symptoms impairing the functional abilities and quality of life of the affected patients. Moreover, with symptomatic treatment the development of a secondary physical impairment due to an existing one may be avoided. Many therapeutic techniques as well as different drugs are used for the treatment of MS symptoms, but only a few of them have been investigated, especially in MS patients, and are approved by the national health authorities. Despite an overwhelming number of publications, only a few evidence-based studies exist and consensus reports are very rare, too. Therefore, it seemed necessary to develop a consensus statement on symptomatic treatment of MS comprising existing evidence-based literature as well as therapeutic experience of neurologists who have dealt with these problems over a long time. This consensus paper contains proposals for the treatment of the most common MS symptoms: disorders of motor function and coordination, of cranial nerve function, of autonomic, cognitive, and psychological functions as well as MS-related pain syndromes and epileptic seizures.

Botulinum toxin in the management of sialorrhoea: a systematic review

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

Botulinum toxin treatment of sialorrhea: comparing different therapeutic preparations

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

Botulinum toxin type A for drooling in Parkinson's disease: A double-blind, randomized, placebo-controlled study

To investigate the safety and efficacy of botulinum toxin type A (BoNTX) treatment to reduce sialorrhea in Parkinson's disease (PD), a double-blind, randomized, placebo-controlled study enrolled 32 PD patients complaining of excessive drooling. Patients received either 50 U Botox in each parotid gland or placebo without using ultrasound guidance. Subjects treated with BoNTX experienced a reduction in both drooling frequency and familial and social disability (TimexGroup effect: P<0.01), as well as in saliva production (Time x Group effect: P<0.0001). No adverse events were recorded. BoNTX injections are safe and effective treatment for the management of PD-related drooling.

Botulinumtoxin A zur Therapie traumatischer Speichelfisteln

Injury of salivary gland tissue in the head and neck, as the result of extensive trauma, can often be overlooked on initial examination. In two case reports, the primary treatment and further follow-up of injuries of the head resulting in a parotid-maxillary sinus fistula as well as a fistula between the skin and sublingual gland are illustrated. The successful use of botulinum toxin in the treatment of traumatic salivary gland fistulas is documented in both cases. Alternative diagnostic and treatment measures of salivary gland fistulas are discussed. Surgical repair of salivary fistulas as primary treatment should be carefully considered. Treatment of a salivary fistula with the injection of botulinum toxin is possibly advantageous compared to spontaneous fistula closure. The injection of botulinum toxin shortens fistula closure time, is minimally invasive, effective and tolerable for the patient.

Immunohistochemical investigations of the influence of botulinum toxin A on the immunoreactivity of nNOS in the parotid gland of the rat

PURPOSE

We wanted to prove the hypothesis that local injections of botulinum toxin A have an influence on the immunoreactivity of neuronal nitric oxide synthase (nNOS) in parotid glands of adult rats.

MATERIALS AND METHODS

Our group carried out immunohistochemical reaction of neuronal nitric oxide synthase (nNOS) in the parotid gland of female adult Wistar rats, in native (untreated) glands and after intraglandular injection of botulinum toxin A under general anesthesia. The immunoreactivity of nNOS was investigated on different times after injection.

RESULTS

Compared with the untreated glands, there was a significant decrease of nNOS in the treated organs that became stronger with extended toxin exposure time. After our laboratory in a pilot study had already shown in general a decrease of nNOS immunoreactivity after injection of botulinum toxin A into the cephalic salivary glands of the rat, the present study shows more explicit data on the effect of botulinum toxin A injection on a higher number of examined parotid glands and analyzes a time course of the effect duration.

CONCLUSIONS

In our study, it was shown that botulinum toxin A had an influence on the immunoreactivity of neuronal nitric oxide synthase (nNOS) in parotid glands. Participation of nitric oxide (NO) in the regulation of secretion from the parotid gland of the rat seems to be likely. It might be assumed that the influence of botulinum toxin A on nNOS in the parotid gland of the rat is able to explain the sometimes longer duration of toxin effect at the neuroglandular junction than at the motor endplate.

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

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

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

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