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Crisafulli S, Ciccimarra F, Khan Z, Maccarrone F, Trifirò G. Understanding Clinical Effectiveness and Safety Implications of Botulinum Toxin in Children: A Narrative Review of the Literature. Toxins (Basel) 2024; 16:306. [PMID: 39057946 PMCID: PMC11281390 DOI: 10.3390/toxins16070306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/20/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024] Open
Abstract
Since its first approval by the Food and Drug Administration in 1989 for strabismus, botulinum toxin indications of use have been widely expanded. Due to its anticholinergic properties, this toxin is currently approved in adult patients for the treatment of a wide range of neuromuscular, otolaryngologic, orthopedic, gastrointestinal, and urologic disorders. Approved pediatric indications of use include the treatment of blepharospasm associated with dystonia, strabismus, lower-limb spasticity, focal spasticity in patients with cerebral palsy, and neurogenic detrusor overactivity. Alongside these approved indications, botulinum toxin is extensively used off-label. Although several clinical studies have shown that botulinum toxin is effective and well-tolerated in children, uncertainties persist regarding its long-term effects on growth and appropriate dosing in this population. As such, further research is needed to better define the botulinum toxin risk-benefit profile and expand approved uses in pediatrics. This narrative review aimed to provide a broad overview of the evidence concerning the clinical effectiveness and safety of BoNT with respect to its principal authorized and non-authorized pediatric therapeutic indications, as well as to describe perspectives on its future use in children.
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Affiliation(s)
| | - Francesco Ciccimarra
- Department of Diagnostics and Public Health, University of Verona, 37124 Verona, Italy; (F.C.); (F.M.)
| | - Zakir Khan
- Department of Pharmacy Practice, Riphah Institute of Pharmaceutical Sciences, Riphah International University, Gulberg Green Campus, Islamabad 44000, Pakistan;
| | - Francesco Maccarrone
- Department of Diagnostics and Public Health, University of Verona, 37124 Verona, Italy; (F.C.); (F.M.)
| | - Gianluca Trifirò
- Department of Diagnostics and Public Health, University of Verona, 37124 Verona, Italy; (F.C.); (F.M.)
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Silva MA, da Silveira MMF, Pedrosa BRV, Dos Santos RTNT, de Farias ZBBM, Sobral APV. A systematic review of the perspectives of botulinum toxin use on the quality of life of neurological patients with drooling. Clin Oral Investig 2024; 28:322. [PMID: 38758415 DOI: 10.1007/s00784-024-05718-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/08/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE To investigate the effectiveness of botulinum toxin in the salivary glands of patients with neurological impairment and drooling and its impact on the quality of life. MATERIALS AND METHODS This systematic review was registered with the International Prospective Register of Systematic Reviews (CRD 42,023,435,242) and conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses. An electronic search was performed in the PubMed/MEDLINE, Embase, Scopus, Cochrane Library, and clinical trial databases until August 2023, no language restriction. Cohort studies and randomized clinical trials of patients diagnosed with drooling and neurological impairment who used botulinum toxin on the salivary gland were included, which evaluated subjective quality of life parameters. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist and Risk of Bias 2 tools. The certainty of the evidence was analyzed using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS Eight studies involving 317 patients were included. All studies, through subjective parameters, suggested the effectiveness of botulinum toxin in reducing drooling, resulting in an improvement in the quality of life. Three studies demonstrated improvements in swallowing and four in cases of respiratory diseases. Two clinical trials had a high risk of bias, whereas one had low risk. The five cohort studies that were evaluated had a high risk of bias. The certainty of the evidence was considered low. CONCLUSIONS Based on the patient/caregivers' perception of improvement in drooling, dysphagia, and respiratory symptoms, it can be inferred that botulinum toxin application reduces subjective drooling in neurologically compromised patients. Its impact contributes to the general well-being and quality of life. CLINICAL RELEVANCE Injection of botulinum toxin into the salivary glands can be considered an alternative technique to surgical or medicinal approaches in reducing drooling. It is effective, less invasive and without significant side effects. It promotes a positive impact on the well-being and quality of life of neurological patients.
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Affiliation(s)
- Michelle Almeida Silva
- Faculdade de Odontologia, Universidade de Pernambuco, Campus Santo Amaro, Pernambuco, Brasil.
- Programa de Pós-Graduação em Odontologia, Universidade de Pernambuco, Pernambuco Recife (PE), Brasil.
- , Rua Coronel Barata 52, João Pessoa, 58025-300, Paraíba, Brasil.
| | - Márcia Maria Fonseca da Silveira
- Faculdade de Odontologia, Universidade de Pernambuco, Campus Santo Amaro, Pernambuco, Brasil
- Programa de Pós-Graduação em Odontologia, Universidade de Pernambuco, Pernambuco Recife (PE), Brasil
| | - Bruna Rafaele Vieira Pedrosa
- Faculdade de Odontologia, Universidade de Pernambuco, Campus Santo Amaro, Pernambuco, Brasil
- Programa de Pós-Graduação em Odontologia, Universidade de Pernambuco, Pernambuco Recife (PE), Brasil
| | - Rebeka Thiara Nascimento Thiara Dos Santos
- Faculdade de Odontologia, Universidade de Pernambuco, Campus Santo Amaro, Pernambuco, Brasil
- Programa de Pós-Graduação em Odontologia, Universidade de Pernambuco, Pernambuco Recife (PE), Brasil
| | - Zilda Betânia Barbosa Medeiros de Farias
- Faculdade de Odontologia, Universidade de Pernambuco, Campus Santo Amaro, Pernambuco, Brasil
- Programa de Pós-Graduação em Odontologia, Universidade de Pernambuco, Pernambuco Recife (PE), Brasil
| | - Ana Paula Veras Sobral
- Faculdade de Odontologia, Universidade de Pernambuco, Campus Santo Amaro, Pernambuco, Brasil
- Programa de Pós-Graduação em Odontologia, Universidade de Pernambuco, Pernambuco Recife (PE), Brasil
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Bradford CV, Parman AM, Johnson PN, Miller JL. Pharmacologic Management of Sialorrhea in Neonatal and Pediatric Patients. J Pediatr Pharmacol Ther 2024; 29:6-21. [PMID: 38332959 PMCID: PMC10849690 DOI: 10.5863/1551-6776-29.1.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/10/2023] [Indexed: 02/10/2024]
Abstract
Sialorrhea, defined as an excess flow of saliva or excessive secretions, is common in patients with cerebral palsy and other neurologic disorders and is associated with clinical complications such as increased risk of local skin reactions, infections, aspiration, pneumonia, and dehydration. Upon failure of non-pharmacologic measures, clinicians have several noninvasive pharmacologic options available to manage sialorrhea. This review of the literature provides detailed descriptions of medications used, efficacy, safety, and practical considerations for use of non-injectable pharmacologic agents. The literature search included published -human studies in the English language in PubMed and Google Scholar from 1997 to 2022. Relevant citations within articles were also screened. A total of 15 studies representing 719 pediatric patients were included. Glycopyrrolate, atropine, scopolamine, and trihexyphenidyl all have a potential role for sialorrhea management in children; however, glycopyrrolate remains the most studied option with 374 (n = 52.0%) of the 719 patients included in the systematic review receiving this medication. Overall, glycopyrrolate showed similar efficacy but higher tolerability than its comparators in 2 comparative studies and is often considered the first-line agent. Patient-specific (age, route of administration) and medication-specific (dosage formulation, medication strength) considerations must be weighed when initiating a new therapy or switching to another medication upon treatment failure. Owing to the high propensity of adverse events with all agents, clinicians should consider initiating doses at the lower end of the dosage range, as previous studies have noted a dose-dependent relationship.
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Affiliation(s)
- Caitlyn V. Bradford
- Department of Pharmacy Practice (CVB), Philadelphia College of Pharmacy at Saint Joseph’s University, Philadelphia, PA
| | - Avery M. Parman
- Department of Pharmacy, Clinical and Administrative Sciences (AMP, JLM, PNJ), University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Peter N. Johnson
- Department of Pharmacy, Clinical and Administrative Sciences (AMP, JLM, PNJ), University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Jamie L. Miller
- Department of Pharmacy, Clinical and Administrative Sciences (AMP, JLM, PNJ), University of Oklahoma College of Pharmacy, Oklahoma City, OK
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Chen CR, Su YC, Chen HC, Lin YC. Botulinum Toxin for Drooling in Adults with Diseases of the Central Nervous System: A Meta-Analysis. Healthcare (Basel) 2023; 11:1956. [PMID: 37444790 DOI: 10.3390/healthcare11131956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
(1) Background: The purpose of this study was to determine whether the drooling of adult patients with diverse central nervous system diseases can be treated with botulinum toxin type A. (2) Methods: The Cochrane Library, MEDLINE, and Embase were all searched for studies that fit the inclusion criteria. The patients in the studies had to be adults (>18 years old), and the studies had to be randomized placebo-controlled trials, controlled trials, or prospective studies. Each study had to have enough quantifiable data available for meta-analysis. The primary outcome measure was the Drooling Severity and Frequency Scale (DSFS). (3) Results: The meta-analysis comprised three studies. A statistically significant difference in DSFS score between the treatment and control groups was observed in the meta-analysis, with an overall standardized mean difference of -0.9377 (95% CI, -1.2919 to -0.5836; p < 0.0001). A total of seven studies were ineligible for inclusion in the meta-analysis and were only assessed as qualitative data. All qualitative studies showed a significant reduction in DSFS score a few weeks or months after the injection of botulinum toxin. (4) Conclusions: Botulinum toxin type A is safe and effective as a treatment for drooling in adult patients with central nervous system diseases.
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Affiliation(s)
- Chih-Rung Chen
- School of Medicine, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan
| | - Yu-Chi Su
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan
| | - Hui-Chuan Chen
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan
| | - Yu-Ching Lin
- Department of Physical Medicine and Rehabilitation, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan
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Santos Junior LC, Santos JR, Reis A, Faria-E-Silva AL, Leal PC. Effectiveness of the pharmacological treatments for sialorrhea in patients with Parkinson's disease: a systematic review and network meta-analysis. Clin Oral Investig 2023:10.1007/s00784-023-04981-9. [PMID: 37036514 DOI: 10.1007/s00784-023-04981-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 03/28/2023] [Indexed: 04/11/2023]
Abstract
OBJECTIVES The present systematic review and network meta-analysis of randomized control trials (RCTs) aimed to establish whether there are evidence-based differences in the pharmacological agents used to manage sialorrhea in patients with Parkinson's disease (PD). MATERIAL AND METHODS The authors searched the databases: MEDLINE via PubMed, EMBASE, Scopus, Web of Science, and Cochrane Library for clinical trials. Unpublished trials were searched on clinicaltrials.gov and the Brazilian Clinical Trials Registry. Means and standard deviations of changes in the salivary flow or drooling reported by participants due to the interventions were recorded. RESULTS The authors analyzed 13 RCTs. Compared to the placebo, types A and B of the botulinum toxin effectively reduced the salivary flow and the severity or frequency of drooling. However, the network meta-analysis did not differentiate between the botulinum toxin types. Ipratropium bromide and glycopyrrolate did not differ from the placebo. Indirect evidence showed that ipratropium had similar results to those obtained with both types of botulinum toxin. The CINeMA approach estimated the quality of the evidence as very low for all comparisons. CONCLUSION The best treatment for sialorrhea in patients with PD is not fully elucidated yet. Therefore, more well-conducted randomized clinical trials are required to increase the level of evidence. CLINICAL RELEVANCE There needs to be more evidence defining the best intervention to treat sialorrhea in patients with PD. However, botulinum toxin types A and B seem to reduce sialorrhea in patients effectively.
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Affiliation(s)
- Luiz Carlos Santos Junior
- Graduate Program in Dentistry, Federal University of Sergipe, Rua Cláudio Batista, S/N, Sanatório, Aracaju, SE, 49.060-108, Brazil
| | - José Ronaldo Santos
- Behavioral and Evolutionary Neurobiology Laboratory, Department of Biosciences, Federal University of Sergipe, Av. Vereador Olímpio Grande, S/N, Itabaiana, SE, 49506-036, Brazil
| | - Alessandra Reis
- Department of Restorative Dentistry, State University of Ponta Grossa, Avenida Carlos Cavalcanti, 4748, Bloco M, Sala 04, Ponta Grossa, PR, 84030-900, Brazil
| | - André Luís Faria-E-Silva
- Graduate Program in Dentistry, Federal University of Sergipe, Rua Cláudio Batista, S/N, Sanatório, Aracaju, SE, 49.060-108, Brazil
| | - Pollyana Caldeira Leal
- Graduate Program in Dentistry, Federal University of Sergipe, Rua Cláudio Batista, S/N, Sanatório, Aracaju, SE, 49.060-108, Brazil.
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Naeem F, Reid J, Bailey M, Reid A, Smyth C, Taylor‐Rowan M, Newman EJ, Quinn T. Pharmacological Interventions for Sialorrhoea in People with Parkinson's Disease: A Systematic Review and Meta-Analysis. Mov Disord Clin Pract 2023; 10:558-568. [PMID: 37070045 PMCID: PMC10105093 DOI: 10.1002/mdc3.13688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 11/18/2022] [Accepted: 12/21/2022] [Indexed: 02/11/2023] Open
Abstract
Background/objectives Sialorrhoea is a common non motor complication experienced by people with Parkinson's disease (PD). Despite its prevalence there is conflicting evidence on how to effectively treat it. Our aim was to establish the efficacy and safety outcomes of pharmacological interventions used to treat sialorrhoea in people with idiopathic PD. Methods We registered and conducted a systematic review and meta-analysis (PROSPERO: CRD42016042470). We searched seven electronic databases from inception until July 2022. Quantitative synthesis was performed where data allowed using random effects models. Results From 1374 records we included 13 studies (n = 405 participants). Studies were conducted in Europe, North America and China. There was marked heterogeneity in the interventions used, follow up times and outcome measures investigated. The main source of risk of bias identified was reporting bias. Five studies were included in the quantitative synthesis. Summary estimates showed administration of botulinum toxin significantly reduced saliva production, improved patient reported functional outcomes and was associated with an increase in adverse events. Conclusion Sialorrhoea in PD is an important condition, but current data does not allow for strong recommendations on optimal pharmacological treatments. There is significant heterogeneity in outcomes measures used to evaluate the burden of sialorrhoea with lack of consensus on what constitutes clinically meaningful change. More research is required to better understand the underlying mechanism and potential treatments of sialorrhoea in idiopathic PD.
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Affiliation(s)
- Fariha Naeem
- Department of Geriatric MedicineGlasgow Royal InfirmaryGlasgowUK
| | - James Reid
- Department of Geriatric MedicineQueen Elizabeth University HospitalGlasgowUK
| | - Matthew Bailey
- Department of Geriatric MedicineHairmyres HospitalEast KilbrideUK
| | - Amanda Reid
- Department of Geriatric MedicineUniversity Hospital MonklandsAirdrieUK
| | - Clare Smyth
- Department of Geriatric MedicineQueen Elizabeth University HospitalGlasgowUK
| | | | | | - Terry Quinn
- Department of Geriatric MedicineGlasgow Royal InfirmaryGlasgowUK
- School of Cardiovascular and Metabolic HealthUniversity of GlasgowGlasgowUK
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Bakke M. Botulinum Toxin, a Drug with Potential Interest for Dentists—An Introduction. Toxins (Basel) 2022; 14:toxins14100667. [PMID: 36287936 PMCID: PMC9607019 DOI: 10.3390/toxins14100667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/29/2022] Open
Abstract
The review is an introduction to medical, non-cosmetic treatments with botulinum neurotoxin (BoNT) in the orofacial region. It focuses on the current most common, best-documented and safest indications of interest for dentists in terms of dystonia and sialorrhea. These conditions are recommended to start with and suitable to gain better skill and experience with BoNT. The introduction also stresses the importance of correct diagnostics based on interdisciplinary cooperation, precise targeting of the injections, measurements of treatment effect, and control of the oral health with regard to side effects.
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Affiliation(s)
- Merete Bakke
- Clinical Oral Physiology, Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2200 Copenhagen, Denmark
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Safety Profile and Lack of Immunogenicity of IncobotulinumtoxinA in Pediatric Spasticity and Sialorrhea: A Pooled Analysis. Toxins (Basel) 2022; 14:toxins14090585. [PMID: 36136523 PMCID: PMC9505819 DOI: 10.3390/toxins14090585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/16/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
IncobotulinumtoxinA, a pure botulinumtoxinA formulation, is free of accessory proteins. This analysis provides pooled safety data from phase 3 trials of children/adolescents (2–17 years), investigating incobotulinumtoxinA for the treatment of spasticity associated with cerebral palsy (at doses ≤20 U/kg (max. 500 U) per injection cycle (IC) for ≤6 ICs; three trials) or sialorrhea associated with neurologic disorders (at total doses of 20–75 U per IC for ≤4 ICs; one trial) for ≤96 weeks. Safety endpoints included the incidences of different types of treatment-emergent adverse events (TEAEs) and immunogenicity. IncobotulinumtoxinA dose groups were combined. Of 1159 patients (mean age 7.3 years, 60.4% males) treated with incobotulinumtoxinA, 3.9% experienced treatment-related TEAEs, with the most common being injection site reactions (1.3%) (both indications), muscular weakness (0.7%) (spasticity), and dysphagia (0.2%) (sialorrhea). Two patients (0.2%) experienced a treatment-related treatment-emergent serious adverse event, and 0.3% discontinued the study due to treatment-related TEAEs. No botulinumtoxinA-naïve patients developed neutralizing antibodies (NAbs) after incobotulinumtoxinA. All children/adolescents with known pre-treatment status and testing positive for Nabs at final visit (n = 7) were previously treated with a botulinumtoxinA other than incobotulinumtoxinA. IncobotulinumtoxinA was shown to be safe, with very few treatment-related TEAEs in a large, diverse cohort of children/adolescents with chronic conditions requiring long-term treatment and was without new NAb formation in treatment-naïve patients.
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Point-of-Care Ultrasound of the Head and Neck in Children. CURRENT OTORHINOLARYNGOLOGY REPORTS 2022. [DOI: 10.1007/s40136-022-00419-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Harbottle J, Carlin H, Payne-Doris T, Tedd HMI, de Soyza A, Messer B. Developing an intrasalivary gland botox service for patients receiving long-term non-invasive ventilation at home: a single-centre experience. BMJ Open Respir Res 2022; 9:9/1/e001188. [PMID: 35190461 PMCID: PMC8862502 DOI: 10.1136/bmjresp-2021-001188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 01/31/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Sialorrhoea is a debilitating symptom in neurological disease and there is a growing literature for the use of intrasalivary gland Botulinum Toxin (botox) injections in its management. However, provision of intrasalivary gland botox remains inconsistent and sialorrhoea is often poorly controlled in motor neuron disease (MND). Sialorrhoea in association with bulbar dysfunction can cause intolerance of non-invasive ventilation (NIV) and respiratory infection, so its treatment is critical within a home ventilation service (HVS). This treatment can also be used to enable tracheostomy cuff deflation to facilitate weaning from ventilation. We report on the outcomes of intrasalivary gland botox in our HVS. Methods In 2015, we set up an intrasalivary gland botox service for patients under our HVS. Under ultrasound guidance, we injected submandibular gland (SMG), parotid gland (PG) or both. Results 109 intrasalivary gland botox procedures were performed in 72 patients. Diagnostic groups included MND 32 Cerebral Palsy 8 and Weaning 14. Glands injected were, SMG (6%), PG (47%) and both (47%). The majority (84%) received the Dysport preparation with mean dose 273 units. 94% were ultrasound guided. 81% of injections resulted in a positive treatment effect, with 47% patients requesting repeat injections. Complications were angioedema (0.9%) and worsening dysphagia (3.7% following SMG injection). Mean survival following treatment was 40 months with 53% patients still alive. Conclusions Intrasalivary gland botox appears effective across a range of neurological conditions requiring long-term NIV with few complications. Dysphagia may be an important complication of SMG injection. A randomised controlled trial may help establish the evidence base.
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Affiliation(s)
- Jessica Harbottle
- School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
| | - Hannah Carlin
- Respiratory Medicine, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Thomas Payne-Doris
- North East Assisted Ventilation Service, Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Hilary M I Tedd
- Respiratory Medicine, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Anthony de Soyza
- Population Health Science Institutes, Newcastle University, Newcastle upon Tyne, UK
| | - Ben Messer
- North East Assisted Ventilation Service, Newcastle upon Tyne NHS Hospitals Foundation Trust, Newcastle upon Tyne, UK
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