1
|
Orriëns LB, van Hulst K, Willemsen MAAP, van den Hoogen FJA, Erasmus CE. Predicting non-response to intraglandular botulinum neurotoxin A injections for drooling in children with neurodevelopmental disabilities. Dev Med Child Neurol 2024; 66:919-930. [PMID: 38140924 DOI: 10.1111/dmcn.15837] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023]
Abstract
AIM To develop robust multivariable prediction models for non-response to (1) submandibular botulinum neurotoxin A (BoNT-A) injections and (2) concurrent submandibular and parotid (four-gland) injections, to guide treatment decisions for drooling in children with neurodevelopmental disabilities, including cerebral palsy. METHOD This was a retrospective cohort study including 262 children (155 males/107 females, median age 7 years 11 months [IQR 5 years 1 month], range 4 years 0 months - 17 years 11 months) receiving submandibular injections and 74 children (52 males/22 females, median age 7 years 7 months [IQR 4 years 3 months], range 4 years 9 months - 18 years 8 months) receiving four-gland injections. Multivariable logistic regression analyses were used to estimate associations between candidate predictors and non-response 8 weeks after injection. RESULTS Ninety-six children (37%) were non-responders to submandibular injections, for which developmental age was the strongest predictor (adjusted odds ratio [aOR] 2.13; 95% confidence interval [CI] 1.02-4.45 for developmental age <4 years or 4-6 years with IQ <70). Other characteristics that showed a trend towards an increased risk of non-response were diagnosis, sex, and head position. Thirty-four children (46%) were non-responders to four-gland injections, for which tongue protrusion (aOR 3.10; 95% CI 1.14-8.43) seemed most predictive, whereas multiple preceding submandibular injections (aOR 0.34; 95% CI 0.10-1.16) showed a trend towards being protective. Predictors were, however, unstable across different definitions of non-response and both models (i.e. submandibular and four-gland) had insufficient discriminative ability. INTERPRETATION Potential predictors of non-response to BoNT-A injections were identified. Nevertheless, the developed prediction models seemed inadequate for guidance of treatment decisions. WHAT THIS PAPER ADDS Developmental age seemed most predictive of non-response to submandibular botulinum neurotoxin A injections. Non-response to concurrent submandibular and parotid injections was best predicted by tongue protrusion and number of previous injections. Multivariable prediction models including these clinical characteristics were unable to discriminate well. Predictors differed when non-response was defined using alternative outcome measures.
Collapse
Affiliation(s)
- Lynn B Orriëns
- Department of Paediatric Neurology, Division of Paediatrics, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Karen van Hulst
- Department of Rehabilitation, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Michèl A A P Willemsen
- Department of Paediatric Neurology, Division of Paediatrics, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Frank J A van den Hoogen
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Corrie E Erasmus
- Department of Paediatric Neurology, Division of Paediatrics, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Nijmegen, the Netherlands
| |
Collapse
|
2
|
Orriëns LB, van Hulst K, van der Burg JJW, van den Hoogen FJA, Willemsen MAAP, Erasmus CE. Comparing the evidence for botulinum neurotoxin injections in paediatric anterior drooling: a scoping review. Eur J Pediatr 2024; 183:83-93. [PMID: 37924348 PMCID: PMC10858158 DOI: 10.1007/s00431-023-05309-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 10/19/2023] [Accepted: 10/24/2023] [Indexed: 11/06/2023]
Abstract
Paediatric anterior drooling has a major impact on the daily lives of children and caregivers. Intraglandular botulinum neurotoxin type-A (BoNT-A) injections are considered an effective treatment to diminish drooling. However, there is no international consensus on which major salivary glands should be injected to obtain optimal treatment effect while minimizing the risk of side effects. This scoping review aimed to explore the evidence for submandibular BoNT-A injections and concurrent submandibular and parotid (i.e. four-gland) injections, respectively, and assess whether outcomes could be compared across studies to improve decision making regarding the optimal initial BoNT-A treatment approach for paediatric anterior drooling. PubMed, Embase, and Web of Science were searched to identify relevant studies (until October 1, 2023) on submandibular or four-gland BoNT-A injections for the treatment of anterior drooling in children with neurodevelopmental disabilities. Similarities and differences in treatment, patient, outcome, and follow-up characteristics were assessed. Twenty-eight papers were identified; 7 reporting on submandibular injections and 21 on four-gland injections. No major differences in treatment procedures or timing of follow-up were found. However, patient characteristics were poorly reported, there was great variety in outcome measurement, and the assessment of side effects was not clearly described. Conclusion: This review highlights heterogeneity in outcome measures and patient population descriptors among studies on paediatric BoNT-A injections, limiting the ability to compare treatment effectiveness between submandibular and four-gland injections. These findings emphasize the need for more extensive and uniform reporting of patient characteristics and the implementation of a core outcome measurement set to allow for comparison of results between studies and facilitate the optimization of clinical practice guidelines. What is Known: • There is no international consensus on which salivary glands to initially inject with BoNT-A to treat paediatric drooling. What is New: • Concluding on the optimal initial BoNT-A treatment based on literature is currently infeasible. There is considerable heterogeneity in outcome measures used to quantify anterior drooling.and clinical characteristics of children treated with intraglandular BoNT-A are generally insufficiently reported. • Consensus-based sets of outcome measures and patient characteristics should be developed and implemented.
Collapse
Affiliation(s)
- Lynn B Orriëns
- Department of Paediatric Neurology, Division of Paediatrics, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Karen van Hulst
- Department of Rehabilitation, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jan J W van der Burg
- Department of Paediatric Rehabilitation, Sint Maartenskliniek, Ubbergen, the Netherlands
- School of Pedagogical and Educational Science, Radboud University Nijmegen, Nijmegen, the Netherlands
| | - Frank J A van den Hoogen
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michèl A A P Willemsen
- Department of Paediatric Neurology, Division of Paediatrics, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Corrie E Erasmus
- Department of Paediatric Neurology, Division of Paediatrics, Donders Institute for Brain, Cognition and Behaviour, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
3
|
Raman S, Yamamoto Y, Suzuki Y, Matsuka Y. Mechanism and clinical use of botulinum neurotoxin in head and facial region. J Prosthodont Res 2023; 67:493-505. [PMID: 36740263 DOI: 10.2186/jpr.jpr_d_22_00238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Botulinum neurotoxin (BoNT) is a biological toxin produced by Clostridium botulinum. BoNT is a potent toxin extensively used in therapeutic interventions. This review provides an updated overview of the mechanisms of action and clinical applications of BoNT in head and facial region. STUDY SELECTION MEDLINE/PubMed searches were conducted using the terms "botulinum neurotoxin" and "dentistry" along with a combination of other related terms. In addition, studies were manually selected from reference lists of the selected articles. RESULTS The Food and Drug Administration in the United States initially approved BoNT to treat strabismus, blepharospasm, and hemifacial spasms. The use of BoNT in dermatology and cosmetics has been widely established and has created a revolution in these fields. Over the years, its applications in various medical specialties have expanded widely. Owing to its safety, efficacy, and long duration of action, it is well-accepted by patients. BoNT/A and BoNT/B are widely used in clinical practice. Several off-label uses of BoNT in the dental fraternity have yielded promising results. We have elaborated on the speculated mechanism of action, dosage, effective sites of injection, and adverse effects of each therapeutic application. The various clinical indications for BoNT include bruxism, myofascial pain, temporomandibular joint dislocation, hemifacial pain, orofacial dystonia, facial paralysis, chronic migraine, and trigeminal neuralgia. CONCLUSIONS BoNT is a safe treatment that can be used effectively, provided that the clinician has adequate knowledge regarding the mechanism, injection techniques, and local and systemic side effects and that it is administered cautiously and purposefully.
Collapse
Affiliation(s)
- Swarnalakshmi Raman
- Department of Stomatognathic Function and Occlusal Reconstruction, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Yumiko Yamamoto
- Department of Bacteriology, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Yoshitaka Suzuki
- Department of Stomatognathic Function and Occlusal Reconstruction, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Yoshizo Matsuka
- Department of Stomatognathic Function and Occlusal Reconstruction, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| |
Collapse
|
4
|
Hung SA, Liao CL, Lin WP, Hsu JC, Guo YH, Lin YC. Botulinum Toxin Injections for Treatment of Drooling in Children with Cerebral Palsy: A Systematic Review and Meta-Analysis. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121089. [PMID: 34943284 PMCID: PMC8700360 DOI: 10.3390/children8121089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/06/2021] [Accepted: 11/15/2021] [Indexed: 11/16/2022]
Abstract
Background: We aimed to review and analyse the effectiveness and safety of botulinum toxin type A (BoNT-A) injections for drooling in children with cerebral palsy. Data sources: We searched the EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) databases from inception to January 2020. Methods: We included randomized controlled trials and observational studies which (1) involved children with cerebral palsy, (2) used BoNT-A for control of drooling, and (3) provided quantitative evaluations of drooling before and after intervention with BoNT-A. Results: Twenty-one trials met the inclusion criteria. Most studies showed that BoNT-A injections are safe and efficacious as a treatment for drooling in children with cerebral palsy. Four trials had sufficient data to pool the results for the meta-analysis. Both the drooling quotient (p = 0.002) and drooling Ffrequency and severity scale (p = 0.004) supported this conclusion. Conclusion: BoNT-A injections are a safe, reversible, effective treatment for drooling control in children with cerebral palsy that can offer effectiveness for more than 3 months with few side effects. The dosage of BoNT-A should not exceed 4 units/kg. Further studies are required to determine the optimal dosage and target glands.
Collapse
Affiliation(s)
- Shang-An Hung
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (S.-A.H.); (W.-P.L.); (Y.-H.G.)
| | - Chung-Lun Liao
- School of Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
| | - Wei-Pin Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (S.-A.H.); (W.-P.L.); (Y.-H.G.)
| | - Jason C. Hsu
- International Ph.D. Program in Biotech and Healthcare Management, College of Management, Taipei Medical University, Taipei 110, Taiwan;
| | - Yao-Hong Guo
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (S.-A.H.); (W.-P.L.); (Y.-H.G.)
| | - Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (S.-A.H.); (W.-P.L.); (Y.-H.G.)
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
- Correspondence:
| |
Collapse
|
5
|
Berweck S, Bonikowski M, Kim H, Althaus M, Flatau-Baqué B, Mueller D, Banach MD. Placebo-Controlled Clinical Trial of IncobotulinumtoxinA for Sialorrhea in Children: SIPEXI. Neurology 2021; 97:e1425-e1436. [PMID: 34341153 PMCID: PMC8520391 DOI: 10.1212/wnl.0000000000012573] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 07/06/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To investigate the efficacy and safety of repeated injections of incobotulinumtoxinA (incoBoNT/A) for treatment of chronic sialorrhea (drooling) associated with neurologic disorders (e.g., cerebral palsy, traumatic brain injury) or intellectual disability in children and adolescents in a prospective phase III study (SIPEXI [Sialorrhea Pediatric Xeomin Investigation]). METHODS The study enrolled 2- to 17-year-old patients with sialorrhea due to neurologic disorders or intellectual disability. Patients received body weight-dependent doses of incoBoNT/A (20-75 U). A main period with 1 injection cycle (placebo-controlled, double-blind, 6- to 17-year-olds) was followed by an open-label extension with up to 3 further cycles. An additional cohort of 2- to 5-year-olds received active treatment throughout the study. Coprimary endpoints were the change in unstimulated salivary flow rate (uSFR) from baseline to week 4 and the carers' Global Impression of Change Scale (GICS) rating at week 4. Adverse events were recorded. RESULTS In the main period, 220 patients aged 6-17 years were randomized and treated (148 patients in incoBoNT/A group, 72 patients in placebo group). A total of 35 patients aged 2-5 years received incoBoNT/A (no placebo). A total of 214 patients aged 6-17 years and 33 patients aged 2-5 years continued treatment in the open-label extension period. For the 6- to 17-year-olds, a significant difference between incoBoNT/A and placebo was seen in mean uSFR decrease (difference -0.06 g/min; p = 0.0012) and the carers' GICS rating (difference 0.28 points; p = 0.032) at week 4, in favor of active treatment. The secondary endpoints consistently supported these results. A sustained benefit was observed during the extension. Incidences of adverse events were comparable between incoBoNT/A and placebo and did not increase notably with repeated injections. The most common adverse events were respiratory infections. Efficacy and safety were also favorable in the uncontrolled cohort of 2- to 5-year-olds. DISCUSSION Both co-primary efficacy endpoints were reached and superiority of incoBoNT/A over placebo was confirmed. IncoBoNT/A (up to 75 U, up to 4 cycles) is an effective and well-tolerated treatment for sialorrhea associated with neurologic disorders in children. TRIAL REGISTRATION INFORMATION Clinicaltrials.gov: NCT02270736 (clinicaltrials.gov/ct2/show/results/NCT02270736); EU Clinical Trials Register: 2013-004532-30 (clinicaltrialsregister.eu/ctr-search/search?query=2013-004532-30). CLASSIFICATION OF EVIDENCE This study provides Class I evidence that injection of incobotulinumtoxinA decreases drooling in children aged 6 to 17 years with neurologic disorders.
Collapse
Affiliation(s)
- Steffen Berweck
- From the Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology (S.B.), Schoen Klinik, Vogtareuth; Department of Pediatric Neurology and Developmental Medicine (S.B.), LMU Center for Children with Medical Complexity-Integrated Social Pediatric Center, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Movement Analysis Lab, Neuro Rehabilitation Department (M.B.), Mazovian Neuropsychiatry Center LLC, Warsaw, Poland; Pediatric Rehabilitation Medicine at the Department of Rehabilitation & Regenerative Medicine (H.K.), Columbia University Irving Medical Center/New York Presbyterian Hospital, New York; Merz Pharmaceuticals GmbH (M.A., B.F.-B.), Frankfurt am Main, Germany; Kantar Health (D.M.), Munich, Germany; and Department of Neurology (M.D.B.), Jagiellonian University, Krakow, Poland.
| | - Marcin Bonikowski
- From the Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology (S.B.), Schoen Klinik, Vogtareuth; Department of Pediatric Neurology and Developmental Medicine (S.B.), LMU Center for Children with Medical Complexity-Integrated Social Pediatric Center, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Movement Analysis Lab, Neuro Rehabilitation Department (M.B.), Mazovian Neuropsychiatry Center LLC, Warsaw, Poland; Pediatric Rehabilitation Medicine at the Department of Rehabilitation & Regenerative Medicine (H.K.), Columbia University Irving Medical Center/New York Presbyterian Hospital, New York; Merz Pharmaceuticals GmbH (M.A., B.F.-B.), Frankfurt am Main, Germany; Kantar Health (D.M.), Munich, Germany; and Department of Neurology (M.D.B.), Jagiellonian University, Krakow, Poland
| | - Heakyung Kim
- From the Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology (S.B.), Schoen Klinik, Vogtareuth; Department of Pediatric Neurology and Developmental Medicine (S.B.), LMU Center for Children with Medical Complexity-Integrated Social Pediatric Center, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Movement Analysis Lab, Neuro Rehabilitation Department (M.B.), Mazovian Neuropsychiatry Center LLC, Warsaw, Poland; Pediatric Rehabilitation Medicine at the Department of Rehabilitation & Regenerative Medicine (H.K.), Columbia University Irving Medical Center/New York Presbyterian Hospital, New York; Merz Pharmaceuticals GmbH (M.A., B.F.-B.), Frankfurt am Main, Germany; Kantar Health (D.M.), Munich, Germany; and Department of Neurology (M.D.B.), Jagiellonian University, Krakow, Poland
| | - Michael Althaus
- From the Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology (S.B.), Schoen Klinik, Vogtareuth; Department of Pediatric Neurology and Developmental Medicine (S.B.), LMU Center for Children with Medical Complexity-Integrated Social Pediatric Center, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Movement Analysis Lab, Neuro Rehabilitation Department (M.B.), Mazovian Neuropsychiatry Center LLC, Warsaw, Poland; Pediatric Rehabilitation Medicine at the Department of Rehabilitation & Regenerative Medicine (H.K.), Columbia University Irving Medical Center/New York Presbyterian Hospital, New York; Merz Pharmaceuticals GmbH (M.A., B.F.-B.), Frankfurt am Main, Germany; Kantar Health (D.M.), Munich, Germany; and Department of Neurology (M.D.B.), Jagiellonian University, Krakow, Poland
| | - Birgit Flatau-Baqué
- From the Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology (S.B.), Schoen Klinik, Vogtareuth; Department of Pediatric Neurology and Developmental Medicine (S.B.), LMU Center for Children with Medical Complexity-Integrated Social Pediatric Center, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Movement Analysis Lab, Neuro Rehabilitation Department (M.B.), Mazovian Neuropsychiatry Center LLC, Warsaw, Poland; Pediatric Rehabilitation Medicine at the Department of Rehabilitation & Regenerative Medicine (H.K.), Columbia University Irving Medical Center/New York Presbyterian Hospital, New York; Merz Pharmaceuticals GmbH (M.A., B.F.-B.), Frankfurt am Main, Germany; Kantar Health (D.M.), Munich, Germany; and Department of Neurology (M.D.B.), Jagiellonian University, Krakow, Poland
| | - Daniela Mueller
- From the Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology (S.B.), Schoen Klinik, Vogtareuth; Department of Pediatric Neurology and Developmental Medicine (S.B.), LMU Center for Children with Medical Complexity-Integrated Social Pediatric Center, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Movement Analysis Lab, Neuro Rehabilitation Department (M.B.), Mazovian Neuropsychiatry Center LLC, Warsaw, Poland; Pediatric Rehabilitation Medicine at the Department of Rehabilitation & Regenerative Medicine (H.K.), Columbia University Irving Medical Center/New York Presbyterian Hospital, New York; Merz Pharmaceuticals GmbH (M.A., B.F.-B.), Frankfurt am Main, Germany; Kantar Health (D.M.), Munich, Germany; and Department of Neurology (M.D.B.), Jagiellonian University, Krakow, Poland
| | - Marta Dagmara Banach
- From the Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology (S.B.), Schoen Klinik, Vogtareuth; Department of Pediatric Neurology and Developmental Medicine (S.B.), LMU Center for Children with Medical Complexity-Integrated Social Pediatric Center, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany; Movement Analysis Lab, Neuro Rehabilitation Department (M.B.), Mazovian Neuropsychiatry Center LLC, Warsaw, Poland; Pediatric Rehabilitation Medicine at the Department of Rehabilitation & Regenerative Medicine (H.K.), Columbia University Irving Medical Center/New York Presbyterian Hospital, New York; Merz Pharmaceuticals GmbH (M.A., B.F.-B.), Frankfurt am Main, Germany; Kantar Health (D.M.), Munich, Germany; and Department of Neurology (M.D.B.), Jagiellonian University, Krakow, Poland
| |
Collapse
|
6
|
Effectiveness and safety of botulinum toxin in comparison with surgery for drooling in paediatric patients with neurological disorders: a systematic review. Br J Oral Maxillofac Surg 2021; 60:e691-e701. [DOI: 10.1016/j.bjoms.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 10/27/2021] [Indexed: 11/21/2022]
|
7
|
Jost WH, Steffen A, Berweck S. A critical review of incobotulinumtoxinA in the treatment of chronic sialorrhea in pediatric patients. Expert Rev Neurother 2021; 21:1059-1068. [PMID: 34516331 DOI: 10.1080/14737175.2021.1979959] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Sialorrhea, also known as hypersalivation, ptyalis, or drooling, results in physical and psychosocial complications that may have a significant negative impact on quality of life for both the patient and their caregiver. The goal of pharmacological treatment is to reduce excessive salivary flow, while maintaining a moist and healthy oral cavity; until recently, however, few of the agents used to treat chronic sialorrhea have been approved in pediatric patients. AREAS COVERED This article summarizes early evidence for the use of botulinum neurotoxin A formulations in the treatment of children/adolescents with chronic sialorrhea, and findings of the recently completed phase III trial of incobotulinumtoxinA in this indication. Alternative therapies are also briefly discussed. EXPERT OPINION IncobotulinumtoxinA is the first botulinum neurotoxin A to be approved for the treatment of chronic sialorrhea in children and adults, following the results of phase III trials that demonstrate the efficacy and safety of the drug in these patients. The authors expect that the positive findings will result in updates to clinical guidelines for the treatment of children with chronic sialorrhea. ABBREVIATIONS AE, adverse event; AESI, adverse event of special interest; BoNT/A, botulinum neurotoxin A; CI, confidence interval; CP, cerebral palsy; DIS, drooling impact scale; DQ, drooling quotient; DSFS, Drooling Severity and Frequency Scale; GICS, Global Impression of Change Scale; LS, least squares; mTDS, modified Teacher's drooling scale; NR, not reported; PD, Parkinson's disease; SAE, serious adverse event; SE, standard error; SIAXI, Sialorrhea in Adults Xeomin Investigation; SIPEXI, Sialorrhea Pediatric Xeomin Investigation; SNAP-25, synaptosomal associated protein-25; TBI, traumatic brain injury; TDS, Teacher Drooling Scale; USA, United States of America; uSFR, unstimulated Salivary Flow Rate; VAS, visual analog scale.
Collapse
Affiliation(s)
| | - Armin Steffen
- Department for Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Steffen Berweck
- Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology, Schön Klinik, Vogtareuth, Germany.,Department of Pediatric Neurology and Developmental Medicine, LMU Center for Children with Medical Complexity - Integrated Social Pediatric Center, Dr. Von Hauner Children's Hospital, Ludwig Maximilians-University, Munich, Germany
| |
Collapse
|
8
|
Submandibular duct transposition for drooling in children: A Casuistic review and evaluation of grade of satisfaction. Int J Pediatr Otorhinolaryngol 2018; 113:58-61. [PMID: 30174011 DOI: 10.1016/j.ijporl.2018.07.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/15/2018] [Accepted: 07/15/2018] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Drooling of saliva is the unintentional loss of saliva from the mouth resulting in excess pooling of saliva in the anterior portion of the oral cavity. It is considered normal in infants and usually resolves itself by 15-18 months of age. It is a common problem in pediatric patients with cerebral palsy or other neurological disorders. Drooling interferes with speech, impairs oral hygiene and contributes to oral dermatitis, aspiration pneumonias and fluid electrolyte imbalances. It has a profoundly negative impact on quality of life and contributes to social exclusion, self-esteem problems and significant discomfort, especially amongst school-aged children. In addition, it can present a serious challenge for caregivers. Various approaches to manage this condition have been described in the literature. Submandibular duct relocation allows salivary flow and is the surgical approach undertaken by the authors. OBJECTIVES The aim of this study is to share our experience with the surgical approach to drooling children and to evaluate clinical outcomes and long-term caregiver satisfaction outcomes. METHODS The authors conducted a retrospective study with a review of the medical records of 43 children and adolescents who had been submitted to submandibular duct relocation in the Centro Hospitalar Tondela-Viseu, between January 2003 and December 2017. The authors analyzed the clinical history, bibs used per day before and after surgery, and caregivers' satisfaction was assessed by interview using a questionnaire. The results of this procedure, technical considerations and outcomes are presented in this work. RESULTS Forty-three patients (15 girls and 28 boys), between the ages of 3 and 18 at time of surgery (mean age of 9), underwent bilateral submandibular duct transposition for drooling. All children have neurological disorders, with cerebral palsy being the predominant diagnosis. The majority were hospitalized for 1-2 days and no surgical complications were observed. The number of bib or clothing changes fell from more than ten in 23 patients (53%) pre-operatively to less than five in 33 patients (77%) post-operatively. 30% of caregivers were satisfied and 53% were very satisfied with the results of surgery. CONCLUSIONS The results of this study show that submandibular duct relocation is an effective method in the resolution of uncontrolled drooling in children, contributing to the improvement of children's quality of life. The degree of satisfaction with the surgical results is in agreement with the published international studies, proving once again the effectiveness of the surgical technique implemented in our Hospital.
Collapse
|
9
|
Job A, Naina P, Syed KA, Thomas M, John M, Varghese AM. Validation of a drooling questionnaire in Indian children with cerebral palsy. Int J Pediatr Otorhinolaryngol 2018; 112:55-60. [PMID: 30055740 DOI: 10.1016/j.ijporl.2018.06.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/17/2018] [Accepted: 06/17/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Drooling of saliva is a common problem in children with cerebral palsy. In addition to causing impairment in articulation, drooling also affects socialization, interpersonal relationships and integration into society for these children. There are various methods to assess drooling which measure directly the amount of saliva drooled. However the most convenient and popular method is the use of questionnaires which are mostly western based and need slight modification for the Indian scenario Aim-Validation of a modified questionnaire for the assessment of drooling in children with cerebral palsy. METHOD The modified questionnaire was administered to parents of children with cerebral palsy willing to participate in the study. The drooling score was compared with objective tests, namely cotton pad test and drooling quotient. Internal consistency was assessed using the Cronbach's alpha, test retest reliability by Intraclass Correlation and sensitivity analysis by the Receiver operating characteristic curve. RESULTS The modified questionnaire was found to be easy to administer. The Cronbach's alpha coefficient was between 0.867 and 0.879 which implies a high degree on internal consistency. The intraclass correlation and the test retest reliability was found to be statistically significant with a p value < 0.001 which show that the questionnaire was highly reliable for repeat administration as well as administration by different investigators. The ROC Area was found to be 0.94 with a standard error of 0.02 with a 95% confidence interval of 0.88-0.99, which suggests that the score has great specificity, closer agreement between specificity and sensitivity and excellent precision. CONCLUSION Our modified questionnaire was easy to administer, highly reliable and valid with high internal consistency. A score of 24 on the questionnaire was found to be the most sensitive and specific point to discriminate between the mild and severe droolers in children with cerebral palsy.
Collapse
Affiliation(s)
- Anjana Job
- -Department of ENT, Christian Medical College, Vellore, 632004, India
| | - P Naina
- -Department of ENT, Christian Medical College, Vellore, 632004, India.
| | - Kamran Asif Syed
- -Department of ENT, Christian Medical College, Vellore, 632004, India
| | - Maya Thomas
- -Department of Neurological Sciences, Christian Medical College, Vellore, 632004, India
| | - Mary John
- -Department of ENT, Christian Medical College, Vellore, 632004, India
| | | |
Collapse
|
10
|
Burch E, Lubeley L, Murakami J. Percutaneous Salivary Gland Ablation using Ethanol in a Rat Model. J Oral Maxillofac Res 2018; 8:e3. [PMID: 29435205 PMCID: PMC5806040 DOI: 10.5037/jomr.2017.8403] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 12/29/2017] [Indexed: 11/16/2022]
Abstract
Objectives Sialorrhea is a common health and psychosocial problem for children with neuromuscular dysfunction secondary to a variety of disorders such as cerebral palsy. Current accepted treatments include the injection of botulinum toxin into the submandibular glands for temporary symptom relief. The purpose of this study is to demonstrate the feasibility of percutaneous ethanol injection for longer lasting salivary gland ablation in an animal model. Material and Methods Twenty rats were used in this study. In each rat, 98% ethanol was injected into the right submandibular gland under ultrasound guidance. No intervention was performed on the left gland, which served as the control. Ten rats were sacrificed and glands evaluated at three weeks, with the remaining 10 rats sacrificed and evaluated at three months. Unpaired, 1-tailed T-tests were used to analyse the data. Results Ethanol injections induced a significant and sustained reduction in salivary gland size. Treated glands were 41% smaller by mass than untreated controls in the 10 rats sacrificed at three weeks (P < 0.001). Treated glands were 43% smaller by mass than untreated controls in the 10 rats sacrificed at three months (P < 0.001). Qualitative histologic analysis demonstrated extensive parenchymal damage, inflammation, and fibrosis at both three week and three month time points. Conclusions Using a rat model, we demonstrated dramatic and sustained submandibular gland damage after percutaneous injection of ethanol.
Collapse
Affiliation(s)
- Emma Burch
- Department of Radiology, Nationwide Children's Hospital, Columbus, OhioUSA
| | - Lacey Lubeley
- Department of Radiology, Nationwide Children's Hospital, Columbus, OhioUSA
| | - James Murakami
- Department of Radiology, Nationwide Children's Hospital, Columbus, OhioUSA
| |
Collapse
|
11
|
Factors in the Efficacy, Safety, and Impact on Quality of Life for Treatment of Drooling with Botulinum Toxin Type A in Patients with Cerebral Palsy. Am J Phys Med Rehabil 2017; 96:68-76. [PMID: 28099276 DOI: 10.1097/phm.0000000000000525] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of botulinum toxin A (BoNT-A) injected in both submandibular and parotid versus only in parotid glands as a treatment for drooling in patients with spastic and dyskinetic cerebral palsy (CP), including an assessment of impact on quality of life (QoL) based on items from the International Classification of Functioning, Disability, and Health (ICF) core set. DESIGN Forty patients with CP 18 years or older (mean, 21.8 years) participated in a prospective, single-center, randomized controlled interventional study. All participants were classified as Gross Motor Function Classification System level III or higher and all had significant drooling as defined in prior studies. One group (group A) was treated with 100 U of BoNT-A, and another group (group B) served as control. In the treatment group, all patients first received combined parotid and submandibular injections, and then parotid injections only. The main outcome variables were a postinjection decrease in the drooling quotient (DQ) of 50% or more, total flow of 30% or more, and QoL as assessed by a set of 10 items related to drooling from the ICF. RESULTS The proportion of patients who achieved at least 50% reduction in DQ was 45% in group A versus 0.0% in group B; 0.0% (P = 0.0012); and of those who achieved at least 30% reduction in total flow was 90% in group A versus 10% in group B (P < 0.0001). Within group A, 42.1% of the dyskinetic patients versus 58.0% of the spastic ones showed 50% or better response in DQ, which is not a statistically significant difference (P = 0.8045). With regard to ICF questions, group A showed statistically significant improvements in several related items. There did not seem to be a significant difference in overall response for providing parotid-only injections. Additional correlations and uncommon adverse effect experiences are also reviewed. CONCLUSION Botulinum toxin A injection of the salivary glands is frequently effective and generally safe for the treatment of drooling in patients with either spastic or dyskinetic CP, both in objective measurement of saliva production and subjective symptoms related to the condition. There does not seem to be a significant advantage of injecting both submandibular and parotid glands over injecting parotid glands alone.
Collapse
|
12
|
Kok SE, van der Burg JJW, van Hulst K, Erasmus CE, van den Hoogen FJA. The impact of submandibular duct relocation on drooling and the well-being of children with neurodevelopmental disabilities. Int J Pediatr Otorhinolaryngol 2016; 88:173-8. [PMID: 27497408 DOI: 10.1016/j.ijporl.2016.06.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/23/2016] [Accepted: 06/25/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the impact of a reduction in drooling after bilateral submandibular duct relocation (SMDR) with sublingual gland excision on daily life and care, as well as social and emotional consequences in children and adolescents with neurodevelopmental disabilities. METHODS This prospective cohort study included 72 children and adolescents (46 males, 26 females) with moderate to severe drooling, and their caregivers. Mean age at the time of surgery was 15 years 2 months (SD 4y 3mo). Fifty-two children were diagnosed with cerebral palsy and 20 had other non-progressive developmental disabilities. A caregiver questionnaire to document the impact of drooling on daily care and economic consequences, social interaction and emotional development and self-esteem was administered before, and 8 and 32 weeks after surgery. RESULTS Following bilateral SMDR the mean Visual Analogue Scale (VAS, 0-100) scores demonstrated a significant (p < 0.001) reduction in the severity of drooling from 81 at baseline to 28 and 36 after 8 and 32 weeks, respectively. This was accompanied by a decrease in the amount of daily care required and reduced economic consequences. In addition, an increase in social contact with other children and adults was reported by caregivers after surgery. CONCLUSION Bilateral SMDR with sublingual gland excision provides a significant positive reduction in daily care of children suffering from drooling. Caregivers also report positive changes in their child's social interaction and sense of self-esteem.
Collapse
Affiliation(s)
- Saskia E Kok
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500HB, Nijmegen, The Netherlands.
| | - Jan J W van der Burg
- Department of Social Sciences/Pedagogical and Educational Sciences, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500HB, Nijmegen, The Netherlands; Department of Pediatric Rehabilitation, St. Maartenskliniek, Hengstdal 3, 6574 NA, Ubbergen, The Netherlands.
| | - Karen van Hulst
- Department of Rehabilitation, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500HB, Nijmegen, The Netherlands.
| | - Corrie E Erasmus
- Department of Pediatric Neurology, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500HB, Nijmegen, The Netherlands.
| | - Frank J A van den Hoogen
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500HB, Nijmegen, The Netherlands.
| |
Collapse
|
13
|
Chaléat-Valayer E, Porte M, Buchet-Poyau K, Roumenoff-Turcant F, D'Anjou MC, Boulay C, Bernard JC, Touzet S. Management of drooling in children with cerebral palsy: A French survey. Eur J Paediatr Neurol 2016; 20:524-31. [PMID: 27155820 DOI: 10.1016/j.ejpn.2016.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 03/29/2016] [Accepted: 04/10/2016] [Indexed: 10/21/2022]
Abstract
AIM To characterise children with cerebral palsy (CP) and pathological drooling in France, and to describe care pathways, assessment and treatment. METHOD A transversal, observational, descriptive survey of the practices and opinions of 400 health professionals potentially involved in the care of children with CP, was carried out nationally across France in 2013. RESULTS The response rate was 36%. Seventy-five questionnaires were returned and analysed (52%). A small proportion of children were specifically treated for drooling (<25%). Assessments were carried out in 75% of cases and 91% of professionals prescribed treatments. Use of assessment tools varied widely. The most common treatment was oro-facial rehabilitation (95% of professionals), followed by anticholinergic drugs (Scopolamine(®)) (94%) botulinum toxin injections (BT) (66%) and surgery (34%). Scopolamine was considered to be less effective than BT and to have more side effects. CONCLUSION The rate of pathological drooling in children with CP is likely underestimated and under treated in France. There is a lack of knowledge regarding assessment tools. Aside from rehabilitation, current practice is to prescribe medication as the first-line treatment, however professionals consider that BT is more effective and has less side effects.
Collapse
Affiliation(s)
- E Chaléat-Valayer
- Centre Médico-Chirurgical de Réadaptation des Massues Croix-Rouge française, 69322 Lyon Cedex 05, France.
| | - M Porte
- Centre Hospitalier Universitaire de Nîmes, 30029, France.
| | - K Buchet-Poyau
- Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Lyon F-69003, France.
| | - F Roumenoff-Turcant
- Centre Médico-Chirurgical de Réadaptation des Massues Croix-Rouge française, 69322 Lyon Cedex 05, France.
| | - M C D'Anjou
- Coordination SSR Pédiatrique Hôpital Nord, Saint Etienne 42055, France.
| | - C Boulay
- Service de Neurologie Pédiatrique, CHU Timone Enfants, 13385 Marseille, France.
| | - J C Bernard
- Centre Médico-Chirurgical de Réadaptation des Massues Croix-Rouge française, 69322 Lyon Cedex 05, France.
| | - S Touzet
- Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Lyon F-69003, France; Universite de Lyon, EA 7425 Health Services and Performance Research (HESPER), Lyon F-69008, France.
| |
Collapse
|
14
|
Sillanpää S, Sipilä M, Numminen J, Rautiainen M. The Experience of Treating Drooling with Repeated Botulinum Toxin Injections. ORL J Otorhinolaryngol Relat Spec 2015; 77:333-8. [PMID: 26418063 DOI: 10.1159/000439175] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 08/03/2015] [Indexed: 11/19/2022]
Abstract
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.
Collapse
Affiliation(s)
- Saara Sillanpää
- Department of Otorhinolaryngology, Head and Neck Surgery, Tampere University Hospital and School of Medicine, University of Tampere, Tampere, Finland
| | | | | | | |
Collapse
|
15
|
Cardona I, Saint‐Martin C, Daniel SJ. Effect of recurrent onabotulinum toxin a injection into the salivary glands: An ultrasound measurement. Laryngoscope 2015. [DOI: 10.1002/lary.25222] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Isabel Cardona
- Department of Otolaryngology–Head & Neck SurgeryMontreal Children's HospitalMcGill University Health CenterMontreal Quebec Canada
| | - Christine Saint‐Martin
- Department of Pediatric Medical ImagingMontreal Children's HospitalMcGill University Health CenterMontreal Quebec Canada
| | - Sam J. Daniel
- Department of Otolaryngology–Head & Neck SurgeryMontreal Children's HospitalMcGill University Health CenterMontreal Quebec Canada
| |
Collapse
|
16
|
Xu H, Shan XF, Cong X, Yang NY, Wu LL, Yu GY, Zhang Y, Cai ZG. Pre- and Post-synaptic Effects of Botulinum Toxin A on Submandibular Glands. J Dent Res 2015; 94:1454-62. [PMID: 26078423 DOI: 10.1177/0022034515590087] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Intraglandular injection of botulinum toxin type A (BoNT/A) is an effective treatment for sialorrhea. Despite numerous experimental and clinical studies on inhibition of saliva section by BoNT/A, the proteolysis of synaptosomal-associated protein 25 (SNAP-25) following BoNT/A treatment has not yet been confirmed in the salivary gland after injection of BoNT/A. More important, it is not known whether BoNT/A exerts a direct effect in acinar cells. Here, we show that injection of BoNT/A into the rat submandibular gland (SMG) decreased salivary flow in a dose-dependent manner; the inhibitory effect lasted at least 4 wk, and salivary flow recovered to normal levels by 12 wk. During the inhibitory period, SMG neurons and synapses expressed lower levels of full-length SNAP-25, and cleavage of SNAP-25 was observed, as indicated by detection of reduced molecular weight SNAP-25 using Western blotting. In addition, the water channel aquaporin 5 (AQP5) was downregulated and abnormally distributed in rat SMG after injection of BoNT/A. The direct effects of BoNT/A on AQP5 expression and distribution were assessed in vitro to exclude the influence of BoNT/A-induced inhibitory neurotransmission. In stable GFP-AQP5-transfected SMG-C6 cells, treatment with BoNT/A reduced the cell surface protein level of AQP5 in a dose- and time-dependent manner without affecting total AQP5 protein expression. Cell surface biotinylation and immunofluorescence demonstrated translocation of AQP5 from the membrane to the cytoplasm, which was confirmed by decreased levels of AQP5 protein in the membrane fraction and increased levels in the cytoplasmic fraction, suggestive of AQP5 redistribution. Taken together, these results indicated that BoNT/A reversibly decreased saliva secretion in rat SMGs through not only the presynaptic SNAP-25 cleavage but also the postsynaptic AQP5 redistribution. These data provide the first evidence for a direct effect of BoNT/A on the salivary gland.
Collapse
Affiliation(s)
- H Xu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, China
| | - X F Shan
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, China
| | - X Cong
- Department of Physiology and Pathophysiology, Peking University Health Science Centre and Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, China
| | - N Y Yang
- Department of Pediatric Dentistry, Beijing Stomatological Hospital, Capital Medical University, Beijing, China
| | - L L Wu
- Department of Physiology and Pathophysiology, Peking University Health Science Centre and Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, China
| | - G Y Yu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, China
| | - Y Zhang
- Department of Physiology and Pathophysiology, Peking University Health Science Centre and Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, China
| | - Z G Cai
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, China
| |
Collapse
|
17
|
Şen A, Arpaci B. Effects of Repeated Botulinum Toxin Treatment for Sialorrhea in Patients with Parkinson's Disease. Noro Psikiyatr Ars 2015; 52:69-72. [PMID: 28360679 DOI: 10.5152/npa.2015.7477] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 02/01/2014] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION To evaluate the efficacy and adverse effects of repeated onabotulinumtoxinA (BoNT-A) treatment in patients suffering from Parkinson's disease (PD) with sialorrhea. METHODS A retrospective analysis of 16 patients with sialorrhea treated with BoNT-A at our movement disorders outpatient clinic was conducted from February 2009 to September 2013. A patient with adult cerebral palsy and a patient with PD who received only a single application were excluded. BoNT-A was injected into the parotid glands without ultrasound guidance. Pre-treatment sialorrhea severity was quantified according to the Drooling Frequency and Severity Scale (DFSS). The efficacy was evaluated four weeks after BoNT-A injections using DFSS and according to the subjective assessment of the patients and/or caregivers. RESULTS The mean age of the patients was 70.00±9.82 years and the mean follow-up duration was 18.78±10.37 months. Totally, 37 applications were performed. The mean BoNT-A total dose was 34.35±6.41 units. The mean scores of DFSS before and after injections were 7.00±1.03 and 3.21±0.89, respectively (p<0.001). Efficacy was 100%, and the mean experienced sialorrhea improvement was 71.78±12.95%. We found a significant difference between the first and last application in the mean duration of efficacy (17.28±9.21 weeks and 18.03±9.02 weeks, respectively, p=0.001). We did not observe side effects in this study group. CONCLUSION Repeated injections of BoNT-A are safe and effective in treating sialorrhea in patients with PD. Based on our results, it seems that there is a maintenance of efficacy after a three-year period and an increase in the mean duration of efficacy with the number of injections. Further prospective clinical studies with larger number of patients and more longer duration of follow-up are needed to confirm our results.
Collapse
Affiliation(s)
- Aysu Şen
- Department of Neurology, Bakırköy Prof. Dr. Mazhar Osman Neurological Disorders Training and Research Hospital, Istanbul, Turkey
| | - Baki Arpaci
- Department of Neurology, Bakırköy Prof. Dr. Mazhar Osman Neurological Disorders Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
18
|
Abbas F, Farid R, Nada I, El-Sharnouby M. Evaluation of ethanolamine oleate sclerotherapy on the submandibular glands of canines as a potential therapy for sialorrhea. Int J Pediatr Otorhinolaryngol 2013; 77:351-5. [PMID: 23246419 DOI: 10.1016/j.ijporl.2012.11.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 11/15/2012] [Accepted: 11/18/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sialorrhea can have major negative effects on the physical and social well-being. Sclerotherapy may be useful in patients with sialorrhea by decreasing the amount of saliva production. The aim of this study was to test the effect of ethanolamine oleate (EO) in an experimental model as a preliminary step for its application in humans. METHODS Histopathological and morphometric analysis of submandibular glands from thirteen dogs was preformed. A total of 25 glands were injected with 1ml of 2.5% EO (n=5), 1ml of 5% EO (n=5), 5ml of 2.5% EO (n=5) and 5ml of 5% EO (n=5). Five glands were used as control. RESULTS EO significantly induced a dose dependent scaring of the gland ending in lobular transformation (salivary gland cirrhosis). Morphometric measurements showed that 1ml of 2.5% or 5% EO significantly induced fibrosis compared to normal glands (p=0.014 and 0.021, respectively). Fibrosis significantly increased and was more apparent when a dose of 5ml of 2.5% EO or 5% EO were injected [by semi-quantitative evaluation (p=0.016 and 0.002, respectively) and morphometric measurements (p=0.016 and 0.008, respectively)]. This scarring effect was significantly associated with reduction of area of acinar cells when a dose of 1ml-5%, 5ml-2.5% or 5ml-5% EO were applied (p=0.03. 0.012 and 0.004, respectively). Moreover, ductal injury was only significant when a dose of 5ml of 5% EO was used (p=0.034). This dose and concentration (i.e. 5ml-5% EO) had a significant synergetic effect [p=0.0119]. CONCLUSION In this model, treatment with EO proved to permanently reduce the acinar area through induction of progressive, irreversible and dose dependant scarring (medical sialoadenectomy).
Collapse
Affiliation(s)
- F Abbas
- ENT Department, Faculty of Medicine, Misr University for Science and Technology, 6th of October city, Giza, Egypt
| | | | | | | |
Collapse
|
19
|
Sidebottom A, May J, Madahar A. Role of botulinum toxin A injection into the submandibular salivary glands as an assessment for the subsequent removal of the submandibular glands in the management of children with sialorrhoea. Br J Oral Maxillofac Surg 2013; 51:113-6. [DOI: 10.1016/j.bjoms.2012.03.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 03/27/2012] [Indexed: 11/27/2022]
|
20
|
Use of botulinum neurotoxin A in uncontrolled salivation in children with cerebral palsy: a pilot study. Int J Oral Maxillofac Surg 2012; 41:1540-5. [DOI: 10.1016/j.ijom.2012.09.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 07/23/2012] [Accepted: 09/18/2012] [Indexed: 11/20/2022]
|
21
|
Abstract
BACKGROUND Drooling is a common problem for children with cerebral palsy (CP). This can be distressing for these children as well as for their parents and caregivers. The consequences of drooling include risk of social rejection, damp and soiled clothing, unpleasant odour, irritated chapped skin, mouth infections, dehydration, interference with speech, damage to books, communication aids, computers, and the risk of social isolation (Blasco 1992; Van der Burg 2006). A range of interventions exist that aim to reduce or eliminate drooling. There is a lack of consensus regarding which interventions are most effective for children with CP. OBJECTIVES (1) To evaluate the effectiveness and safety of interventions aimed at reducing or eliminating drooling in children with cerebral palsy. (2) To provide the best available evidence to inform clinical practice. (3) To assist with future research planning. SEARCH METHODS We searched the following databases from inception to December 2010 : Cochrane Central Register of Controlled Trials (CENTRAL); Medline via Ovid; EMBASE; CINAHL; ERIC; Psych INFO; Web of Science; Web of Knowledge; AMED; SCOPUS; Dissertation Abstracts.We searched for ongoing clinical trials in the Clinical Trials web site (http://clinicaltrials.gov.) and in the Current Controlled Trials web site (http://www.controlled-trials.com/). We hand searched a range of relevant journals and conference proceeding abstracts. SELECTION CRITERIA Only randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were included. DATA COLLECTION AND ANALYSIS Data were extracted independently by MW, MS and LP and differences resolved through discussion. MAIN RESULTS Six studies were eligible for inclusion in the review. Four of these studies were trials using botulinum toxin-A (BoNT-A) and two were trials on the pharmacological interventions, benztropine and glycopyrrolate. No RCTs or CCTs were retrieved on surgery, physical, oro-motor and oro-sensory therapies, behavioural interventions, intra-oral appliances or acupuncture. In the studies eligible for review, there was considerable heterogeneity within and across interventions and a meta-analysis was not possible. A descriptive summary of each study is provided. All studies showed some statistically significant change for treatment groups up to 1 month post intervention. However, there were methodological flaws associated with all six studies. AUTHORS' CONCLUSIONS It was not possible to reach a conclusion on the effectiveness and safety of either BoNT-A or the pharmaceutical interventions, benztropine and glycopyrrolate. There is insufficient evidence to inform clinical practice on interventions for drooling in children with CP. Directions for future research are provided.
Collapse
Affiliation(s)
- Margaret Walshe
- Clinical Speech and Language Studies,Trinity College Dublin, Dublin 2, Ireland.
| | | | | |
Collapse
|
22
|
Rodwell K, Edwards P, Ware RS, Boyd R. Salivary gland botulinum toxin injections for drooling in children with cerebral palsy and neurodevelopmental disability: a systematic review. Dev Med Child Neurol 2012; 54:977-87. [PMID: 22946706 DOI: 10.1111/j.1469-8749.2012.04370.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM The aim of this paper was to systematically review the efficacy and safety of botulinum toxin (BoNT) injections to the salivary glands to treat drooling in children with cerebral palsy and neurodevelopmental disability. METHOD A systematic search of The Cochrane Central Register of Controlled Trials, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE, and the Physiotherapy Evidence Database (PEDro) was conducted (up to 1 October 2011). Data sources included published randomized controlled trials (RCTs) and prospective studies. RESULTS Sixteen studies met inclusion criteria. Three outcome measures support the effectiveness of BoNT for drooling. One RCT found an almost 30% reduction in the impact of drooling on patients' lives, as measured by the Drooling Impact Scale (mean difference -27.45; 95% confidence interval [CI] -35.28 to -19.62). There were sufficient data to pool results on one outcome measure, the Drooling Frequency and Severity Scale, which supports this result (mean difference -2.71; 95% CI -4.82 to -0.60; p<0.001). There was a significant reduction in the observed number of bibs required per day. The incidence of adverse events ranged from 2 to 41%, but was inconsistently reported. One trial was terminated early because of adverse events. INTERPRETATION BoNT is an effective, temporary treatment for sialorrhoea in children with cerebral palsy. Benefits need to be weighed against the potential for serious adverse events. More studies are needed to address the safety of BoNT and to compare BoNT with other treatment options for drooling.
Collapse
Affiliation(s)
- Kate Rodwell
- Queensland Paediatric Rehabilitation Service, The Royal Children's Hospital, Herston, Brisbane, Australia.
| | | | | | | |
Collapse
|
23
|
Botulinum toxin therapy: its use for neurological disorders of the autonomic nervous system. J Neurol 2012; 260:701-13. [DOI: 10.1007/s00415-012-6615-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 07/06/2012] [Accepted: 07/09/2012] [Indexed: 11/26/2022]
|
24
|
Jeung IS, Lee S, Kim HS, Yeo CK. Effect of botulinum toxin a injection into the salivary glands for sialorrhea in children with neurologic disorders. Ann Rehabil Med 2012; 36:340-6. [PMID: 22837969 PMCID: PMC3400873 DOI: 10.5535/arm.2012.36.3.340] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 04/19/2012] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine the 9 month period effect of botulinum toxin A (BoNT-A) injection into the salivary gland in children with neurologic disorders and sialorrhea by qualified parent/caregiver-administered questionnaires. METHOD A total of 17 patients (age 7.6±4.24 years) were enrolled in this study. The degree of sialorrhea was assessed at the baseline, 2 weeks, 1, 2, 4, 6 and 9 months after injection. The Drooling Count (DC) was assessed as an objective measurement. The Drooling Frequency and Severity Scale (DFS) and the Teacher Drooling Scale (TDS) were evaluated as a subjective measurement. BoNT-A (0.5 unit/kg) was injected into each submandibular and parotid gland under ultrasonography-guidance. RESULTS DC, DFS and TDS showed significant improvement at 2 weeks, 1, 2, 4, 6, and 9 months follow-up (p<0.05). Twelve of 17 cases (70.5%) showed more than 50% reduction in DC from the baseline value. CONCLUSION Ultrasonography-guided BoNT-A injection into the submandibular and parotid gland was a safe and effective method to treat sialorrhea in children with neurologic disorders.
Collapse
Affiliation(s)
- In Seuk Jeung
- Department of Rehabilitation Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu 700-712, Korea
| | | | | | | |
Collapse
|
25
|
Erasmus CE, van Hulst K, Scheffer ART, van Limbeek J, van den Hoogen FJA, Rotteveel JJ, Jongerius PH. What could predict effectiveness of Botulinum Toxin to treat drooling: a search for evidence of discriminatory factors on the level of body functions or structures. Eur J Paediatr Neurol 2012; 16:126-31. [PMID: 21783393 DOI: 10.1016/j.ejpn.2011.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 02/22/2011] [Accepted: 06/16/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND The treatment of drooling is important to families that experience the daily impact and research to elucidate clinical factors that play a role in the outcome of drooling treatment should be encouraged. AIM To define clinical factors that influence therapy outcome of submandibular Botulinum Toxin (BoNT-A) injections for drooling. METHODS Prospectively collected data of 128 children with cerebral palsy were evaluated; 80 spastic and 48 dyskinetic movement disorder, mostly Gross Motor Function Classification System III and higher; over 70% had an IQ <70. In addition, 23 fully ambulant children with exclusively intellectual disability were treated for drooling by ultrasound-guided injections of BoNT-A into the submandibular glands. Salivary flow rates and drooling quotients were measured at baseline and at 8 weeks after injection. Extensive information about the oral motor performance was gathered. Successful clinical response was defined as a 50% reduction of the baseline Drooling Quotient; 85 children were responsive to BoNT-A and 66 children unresponsive. RESULTS Five nominated clinical factors that possibly could influence saliva reduction (head position, lip seal, voluntary control over the tongue, control of voluntary movement functions, and mental age) did not influence the responsiveness to BoNT-A. INTERPRETATION Other variables need to be considered to predict the outcome of BoNT-A treatment. This article describes the first attempt to reveal the contribution of body functions and structures to the outcome of BoNT-A submandibular injections.
Collapse
Affiliation(s)
- Corrie E Erasmus
- Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behavior, Department of Paediatric Neurology, Nijmegen, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
BACKGROUND Drooling is a common problem for children with cerebral palsy (CP). This can be distressing for these children as well as for their parents and caregivers. The consequences of drooling include risk of social rejection, damp and soiled clothing, unpleasant odour, irritated chapped skin, mouth infections, dehydration, interference with speech, damage to books, communication aids, computers, and the risk of social isolation (Blasco 1992; Van der Burg 2006). A range of interventions exist that aim to reduce or eliminate drooling. There is a lack of consensus regarding which interventions are most effective for children with CP. OBJECTIVES (1) To evaluate the effectiveness and safety of interventions aimed at reducing or eliminating drooling in children with cerebral palsy. (2) To provide the best available evidence to inform clinical practice. (3) To assist with future research planning. SEARCH METHODS We searched the following databases from inception to December 2010 : Cochrane Central Register of Controlled Trials (CENTRAL); Medline via Ovid; EMBASE; CINAHL; ERIC; Psych INFO; Web of Science; Web of Knowledge; AMED; SCOPUS; Dissertation Abstracts.We searched for ongoing clinical trials in the Clinical Trials web site (http://clinicaltrials.gov.) and in the Current Controlled Trials web site (http://www.controlled-trials.com/). We hand searched a range of relevant journals and conference proceeding abstracts. SELECTION CRITERIA Only randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were included. DATA COLLECTION AND ANALYSIS Data were extracted independently by MW, MS and LP and differences resolved through discussion. MAIN RESULTS Six studies were eligible for inclusion in the review. Four of these studies were trials using botulinum toxin-A (BoNT-A) and two were trials on the pharmacological interventions, benztropine and glycopyrrolate. No RCTs or CCTs were retrieved on surgery, physical, oro-motor and oro-sensory therapies, behavioural interventions, intra-oral appliances or acupuncture. In the studies eligible for review, there was considerable heterogeneity within and across interventions and a meta-analysis was not possible. A descriptive summary of each study is provided. All studies showed some statistically significant change for treatment groups up to 1 month post intervention. However, there were methodological flaws associated with all six studies. AUTHORS' CONCLUSIONS It was not possible to reach a conclusion on the effectiveness and safety of either BoNT-A or the pharmaceutical interventions, benztropine and glycopyrrolate. There is insufficient evidence to inform clinical practice on interventions for drooling in children with CP. Directions for future research are provided.
Collapse
Affiliation(s)
- Margaret Walshe
- Clinical Speech and Language Studies,TrinityCollegeDublin,Dublin 2, Ireland.
| | | | | |
Collapse
|
27
|
Erasmus CE, Scheffer ART, van Hulst K, van Limbeek J, van den Hoogen FJA, Rotteveel JJ, Jongerius PH. Does motor performance matter in botulinum toxin efficacy for drooling? Pediatr Neurol 2011; 45:95-9. [PMID: 21763949 DOI: 10.1016/j.pediatrneurol.2011.02.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 02/28/2011] [Indexed: 10/18/2022]
Abstract
The aim of this study was to define factors that influence therapy outcome of submandibular botulinum toxin injections for drooling in children with cerebral palsy or mental disability. We postulated that differences in response may be explained by the variation of dysfunctions in the various cerebral palsy subtypes. Prospectively collected data were evaluated of 80 spastic and 48 dyskinetic children, of whom 70% had an IQ of <70. In addition, the data of 23 fully ambulant children with mental disability only were examined. Flow and Drooling Quotient were assessed at baseline and at 8 weeks after injection. After treatment, both the Drooling Quotient and submandibular flow decreased in all children. Morbidity associated with the procedure was limited. Ninety-three children responded to botulinum. Decrease of submandibular flow in these children was associated with reduction of parotid flow. In those who did not respond to therapy, spread across all 3 diagnostic classifications, parotid flow increased after injection. Response failure is characterized by increased parotid flow after injection; however, the precise role of parotid flow in therapy failure remains unclear. We cannot predict who will respond to botulinum toxin to treat drooling.
Collapse
Affiliation(s)
- Corrie E Erasmus
- Department of Pediatric Neurology, Radboud University Nijmegen Medical Centre/Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
28
|
Flu-like symptoms following botulinum toxin therapy. Toxicon 2011; 58:1-7. [DOI: 10.1016/j.toxicon.2011.04.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 04/24/2011] [Accepted: 04/27/2011] [Indexed: 01/12/2023]
|
29
|
Wu KPH, Ke JY, Chen CY, Chen CL, Chou MY, Pei YC. Botulinum toxin type A on oral health in treating sialorrhea in children with cerebral palsy: a randomized, double-blind, placebo-controlled study. J Child Neurol 2011; 26:838-43. [PMID: 21551374 DOI: 10.1177/0883073810395391] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
Collapse
Affiliation(s)
- Katie Pei-Hsuan Wu
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | | | | | | | | | | |
Collapse
|
30
|
Breheret R, Bizon A, Jeufroy C, Laccourreye L. Ultrasound-guided botulinum toxin injections for treatment of drooling. Eur Ann Otorhinolaryngol Head Neck Dis 2011; 128:224-9. [PMID: 21600865 DOI: 10.1016/j.anorl.2010.12.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 12/13/2010] [Accepted: 12/19/2010] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate the efficacy of treatment of drooling by ultrasound-guided botulinum toxin injection of the salivary glands and to determine the optimal modalities of this procedure. PATIENTS AND METHODS This study is a retrospective review of patients treated for drooling by injection of 100 units of Botox(®) into the parotid and submaxillary glands between 2002 and 2008. Efficacy was evaluated by a quality of life questionnaire six weeks after the injections. RESULTS One hundred and eleven injection sessions were performed in 70 patients aged one to 84 years with a beneficial effect in 66% of cases. The most effective protocol was injection of 20 units of botulinum toxin into each submaxillary gland and 30 units of toxin into each parotid gland. CONCLUSION The treatment of drooling by Botox(®) injections into salivary glands is effective. The authors propose ultrasound-guided injection of both submaxillary glands and both parotid glands. These injections can be repeated in the case of recurrence of drooling.
Collapse
Affiliation(s)
- R Breheret
- Service d'oto-rhino-laryngologie et de chirurgie cervicofaciale, CHU d'Angers, 20, rue de Savoie, 49100 Angers, France.
| | | | | | | |
Collapse
|
31
|
Reddihough D, Erasmus CE, Johnson H, McKellar GMW, Jongerius PH. Botulinum toxin assessment, intervention and aftercare for paediatric and adult drooling: international consensus statement. Eur J Neurol 2011; 17 Suppl 2:109-21. [PMID: 20633182 DOI: 10.1111/j.1468-1331.2010.03131.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Many individuals with neurological problems or anatomical abnormalities of the jaw, lips or oral cavity may drool, which can impact on health and quality of life. A thorough evaluation of the patient's history, examination of the oral region by a speech pathologist and, in individuals over 3 years, a dental examination is warranted. Questionnaires with established validity such as the Drooling Impact Scale are useful assessment tools. A hierarchical approach to treatment is taken from least invasive therapies, such as speech pathology, to more invasive, such as injection of botulinum neurotoxin type-A (BoNT-A) into the salivary glands (parotid and submandibular). The wishes of the individual and their carer are crucial considerations in determining the suitability of the intervention for the patient. In the presence of dysphagia and cerebral palsy (CP), careful assessment is required prior to the injection of BoNT-A. Favourable responses to intervention include a reduction in the secretion of saliva and in drooling, as well as psychosocial improvements. BoNT-A is usually well tolerated, although potential side effects should be discussed with the patient and carer.
Collapse
Affiliation(s)
- D Reddihough
- Developmental Medicine, Royal Children's Hospital, Parkville, Victoria, Australia.
| | | | | | | | | | | |
Collapse
|
32
|
Lee ZI, Park DH, Jo DH, Choi WD, Byun SD. Effects of Botulinum Toxin A Injection into Salivary Glands of Patients with Brain Lesion Suffering from Posterior Drooling. BRAIN & NEUROREHABILITATION 2011. [DOI: 10.12786/bn.2011.4.2.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Zee Ihn Lee
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Korea
| | - Dong Hwi Park
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Korea
| | - Dong Hyun Jo
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Korea
| | - Won-Duck Choi
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Korea
| | - Seung Deuk Byun
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Korea
| |
Collapse
|
33
|
Scheffer ART, Erasmus C, VAN Hulst K, VAN Limbeek J, Rotteveel JJ, Jongerius PH, van den Hoogen FJA. Botulinum toxin versus submandibular duct relocation for severe drooling. Dev Med Child Neurol 2010; 52:1038-42. [PMID: 20561006 DOI: 10.1111/j.1469-8749.2010.03713.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM Botulinum neurotoxin type A (BoNT-A) has been described as an effective intervention for drooling and is being increasingly adopted. However, its effectiveness compared with established treatments is still unknown. We undertook a within-participants observational study to examine this. METHOD An historic cohort was formed of 19 children and young adults (10 males, nine females) with severe drooling who underwent BoNT-A injections followed by surgical re-routing of the submandibular duct at least 6 months later. Mean age at time of admission was 11 years 5 months (range 5-17 y) and mean age at the time of surgery was 14 years (range 6-23 y). Fifteen children were diagnosed with bilateral cerebral palsy (CP), three with unilateral CP, and one with non-progressive developmental delay. Gross Motor Function Classification System levels were the following: level I, n=1; level II, n=2; level III, n=7; level IV, n=6; and level V, n=3). The primary outcome was the drooling quotient, which was assessed before each intervention and 8 and 32 weeks thereafter. A multivariate analysis of variance of repeated measures was performed, with the measurement points as the within-participant variables. RESULTS The drooling quotient was reduced to a greater extent after surgery than after BoNT-A administration (p=0.001). Compared with a baseline value of 28, the mean drooling quotient 8 weeks after surgery was 10, and 32 weeks after surgery was 4 (p<0.001). Among the group treated with BoNT-A, the drooling quotient showed a significant reduction from a baseline value of 30 to 18 after 8 weeks (p=0.02), and a continued but diminished effect after 32 weeks (drooling quotient 22; p=0.05). INTERPRETATION Both interventions are effective, but surgery provides a larger and longer-lasting effect.
Collapse
Affiliation(s)
- Arthur R T Scheffer
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | | | | | | | | | | | | |
Collapse
|
34
|
Kim CT, Moberg-Wolff E, Trovato M, Kim H, Murphy N. Pediatric rehabilitation: 1. Common medical conditions in children with disabilities. PM R 2010; 2:S3-S11. [PMID: 20359677 DOI: 10.1016/j.pmrj.2009.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Accepted: 12/09/2009] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This self-directed learning module focuses on the physiatric management of the common morbidities associated with pediatric traumatic brain injury and cerebral palsy. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to enhance the learner's knowledge regarding current physiatric management of complications related with pediatric traumatic brain injury and cerebral palsy.
Collapse
Affiliation(s)
- Chong Tae Kim
- Department of PM&R, University of Pennsylvania, School of Medicine, 3405 Civic Center Boulevard, Philadelphia, PA 19096, USA.
| | | | | | | | | |
Collapse
|
35
|
Baird MW, Vargus-Adams J. Outcome measures used in studies of botulinum toxin in childhood cerebral palsy: a systematic review. J Child Neurol 2010; 25:721-7. [PMID: 19808988 DOI: 10.1177/0883073809346846] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This literature review uses the International Classification of Functioning, Disability and Health to describe the quality and variety of the studies of botulinum toxin in children with cerebral palsy since 2001. Articles were identified via electronic query and then reviewed for strength of evidence and classification of outcome measures. The distribution of levels of evidence for the 63 articles was I (n = 8), II (n = 12), III (n = 21), and IV (n = 22). One or more measurements were used in the International Classification of Functioning, Disability and Health domains of body structure and function (47 papers), activity (47 papers), participation (12 papers), and environmental/personal factors (10 papers). A total of 67% of all outcomes demonstrated a significant difference (I 49%, II 39%, III 74%, IV 88%). This review illustrates that few studies provide a high level of evidence and that outcomes focus on arenas such as spasticity or range of motion rather than activity or participation domains such as walking.
Collapse
Affiliation(s)
- Micah W Baird
- Division of Pediatric Rehabilitation, Departments of Pediatrics and Physical Medicine & Rehabilitation, Cincinnati Children's Hospital Medical Center, University of Cinncinati College of Medicine, Cincinnati, Ohio 45229, USA.
| | | |
Collapse
|
36
|
Wittekindt C, Burmeister H, Guntinas-Lichius O. Diagnostik und Therapie von Speicheldrüsenerkrankungen. DER PATHOLOGE 2009; 30:424-31. [DOI: 10.1007/s00292-009-1202-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
37
|
|
38
|
Pena AH, Cahill AM, Gonzalez L, Baskin KM, Kim H, Towbin RB. Botulinum toxin A injection of salivary glands in children with drooling and chronic aspiration. J Vasc Interv Radiol 2009; 20:368-73. [PMID: 19157908 DOI: 10.1016/j.jvir.2008.11.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Revised: 11/13/2008] [Accepted: 11/20/2008] [Indexed: 11/28/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Andres H Pena
- Department of Radiology of The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | | | | | | | | | | |
Collapse
|
39
|
Alrefai AH, Aburahma SK, Khader YS. Treatment of sialorrhea in children with Cerebral Palsy: A double-blind placebo controlled trial. Clin Neurol Neurosurg 2009; 111:79-82. [DOI: 10.1016/j.clineuro.2008.09.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2007] [Revised: 09/08/2008] [Accepted: 09/12/2008] [Indexed: 10/21/2022]
|
40
|
|
41
|
|
42
|
Thevasagayam MS, Gan K, Eksteen E. Control of salivary secretions in esophageal atresia with laryngeal cleft using Botulinum toxin Type A. Int J Pediatr Otorhinolaryngol 2008; 72:965-9. [PMID: 18479756 DOI: 10.1016/j.ijporl.2008.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Accepted: 03/12/2008] [Indexed: 10/22/2022]
Abstract
A baby born with esophageal atresia and a laryngeal cleft is presented. Retained salivary secretions and aspiration were a constant management problem whilst the baby was waiting for delayed primary repair of the atresia. The use of anticholinergic agents resulted in thickening of secretions which were difficult to suction and ultimately led to increasing respiratory compromise. Intraglandular salivary gland injection of Botulinum toxin type A was performed using ultrasound guidance. The mean daily salivary flow output prior to treatment was 59 ml. On glycopyrrolate the mean daily salivary output on glycopyrrolate was 16 ml. After Botulinum injection the mean daily salivary output was 7 ml in the 3 weeks after injection. Over the next 14 weeks this increased to 34 ml. There were no adverse effects or significant thickening of secretions after BTX injection. This is the first reported use of Botulinum toxin injection in the management of salivary aspiration in esophageal atresia with laryngeal cleft.
Collapse
Affiliation(s)
- M S Thevasagayam
- Department of Ear, Nose & Throat Surgery, The Sheffield Children's Hospital, Western Bank, Sheffield, South Yorkshire, UK.
| | | | | |
Collapse
|
43
|
Bilateral submandibular duct relocation by high-frequency radiosurgery. Eur Arch Otorhinolaryngol 2008; 265:1103-8. [DOI: 10.1007/s00405-008-0604-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2007] [Accepted: 01/24/2008] [Indexed: 12/01/2022]
|
44
|
Truong DD, Bhidayasiri R. Evidence for the effectiveness of botulinum toxin for sialorrhoea. J Neural Transm (Vienna) 2008; 115:631-5. [DOI: 10.1007/s00702-007-0861-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Accepted: 10/16/2007] [Indexed: 10/22/2022]
|
45
|
Abstract
Botulinum toxins are potent neurotoxins used in a variety of neurological disorders. Few pediatric reports have been published to date regarding the potential hazards of therapeutic use of botulinum toxins. We describe the case of a 10-year-old boy who developed systemic weakness following treatment of spasticity with botulinum toxin type B. The patient developed iatrogenic botulism with ptosis, facial diplegia, neck flexor and extensor weakness, and profound hypopharyngeal laxity with respiratory compromise from which he eventually recovered. Clinicians should be mindful of the risk for systemic botulism when using local injections of the neurotoxin.
Collapse
Affiliation(s)
- Arthur Partikian
- Pediatric Neurology Division, Childrens Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | | |
Collapse
|
46
|
Teymoortash A, Sommer F, Mandic R, Schulz S, Bette M, Aumüller G, Werner JA. Intraglandular application of botulinum toxin leads to structural and functional changes in rat acinar cells. Br J Pharmacol 2007; 152:161-7. [PMID: 17618309 PMCID: PMC1978275 DOI: 10.1038/sj.bjp.0707375] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- A Teymoortash
- Department of Otolaryngology-Head and Neck Surgery, Philipp University, Deutschhausstrasse 4, Marburg 35037, Germany.
| | | | | | | | | | | | | |
Collapse
|
47
|
Abstract
PURPOSE OF REVIEW Drooling is the involuntary spillage of saliva from the mouth. It is a major morbidity associated with cerebral palsy and other neurodegenerative disorders. The consequences of drooling are not restricted to medical issues but can cause major social handicaps. Severe psycho-social consequences, such as social stigmatization and emotional devastation for the patients and their families, may result. This paper reviews recent developments in the management of drooling. RECENT FINDINGS Recent publications report encouraging results with botulinum toxin A. Several surgeons report on their long-term results. Reviews analyze anticholinergic drugs, surgical options, biofeedback, behavioral and speech therapy, and a multidisciplinary team approach. SUMMARY A team approach is the key to successful rehabilitation. Oromotor therapy is the most useful nonsurgical option. Drugs are unsuitable for long-term use due to adverse effects causing serious medical complications or noncompliance. Botulinum toxin A injection is promising, but no data exists on optimal dosage, duration of action and frequency of repeat injections. Bilateral submandibular duct relocation with bilateral sublingual gland excision has been shown to be effective and safe in long-term follow-up of the largest series of patients. At present, it is the best available surgical option.
Collapse
Affiliation(s)
- Devyani Lal
- Department of Otolaryngology, Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA
| | | |
Collapse
|
48
|
Vaile L, Finlay F. Is injection of botulinum toxin type A effective in the treatment of drooling in children with cerebral palsy? Arch Dis Child 2006; 91:862-3. [PMID: 16990361 PMCID: PMC2066027 DOI: 10.1136/adc.2005.084681] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- L Vaile
- Community Child Health, NHS House, Newbridge Hill, Bath BA1 3QE, UK.
| | | |
Collapse
|
49
|
Abstract
Two patients with spastic cerebral palsy recently treated with modafinil at the Walter Reed Army Medical Center child neurology clinic have stopped drooling. This occurred after starting modafinil for spasticity and without other changes in the patients' treatment programs. The decrease in drooling is to a remarkable degree. Both patients had a chronic problem with drooling. One patient has gone from wearing a bib or bandanna, which was constantly wet from drooling to being essentially dry. After starting modafinil, both patients stopped drooling. The parents initially observed decreased drooling at home. Clinic appointment examinations and evaluations at physical therapy confirmed these observations. Better coordination and speech have been noted in each patient. Modafinil improves drooling in at least some patients with spastic cerebral palsy. The decreased drooling is due to improvements noted in swallowing.
Collapse
Affiliation(s)
- Daniel Hurst
- Department of Neurology, Walter Reed Army Medical Center, Washington, DC 20307, USA.
| | | |
Collapse
|
50
|
Van der Burg JJW, Jongerius PH, Van Hulst K, Van Limbeek J, Rotteveel JJ. Drooling in children with cerebral palsy: effect of salivary flow reduction on daily life and care. Dev Med Child Neurol 2006; 48:103-7. [PMID: 16417664 DOI: 10.1017/s0012162206000235] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2005] [Indexed: 11/06/2022]
Abstract
The purpose of this study was to investigate the effect of salivary flow reduction on daily life and provision of care in children with cerebral palsy (CP). Parents of children with CP were asked to fill in a questionnaire on the impact of drooling on the daily life of their children and their families and the data were then analyzed. Forty-five children with severe drooling (28 males, 17 females; mean age 9y 5mo [SD 3y 7mo]; range 3 to 16y) were monitored before and after receiving medication (scopolamine and botulinum toxin) to reduce salivary flow. Type of CP included hypotonia (n = 1), spastic paresis (n = 27), and mixed motor disorders with spastic and dyskinetic paresis (n = 17). Eight children were independently ambulant and 37 children were wheelchair users. Thirty-four children had learning disability with a developmental age of below 6 years. Six participants dropped out of the study; data on 39 children were analyzed. Results showed that anticholinergic agents effectively reduced salivary flow. Drooling diminished substantially and this was accompanied by a significant reduction in care needs, making daily care less demanding. The amount of reported damage to communication devices and computers decreased. In addition to the evaluation of primary variables, such as the salivary flow rate, investigation of impact of drooling on daily life provides useful information about the outcome of treatment for reduction in drooling.
Collapse
|