Cirugía de desfuncionalización de glándulas salivales mayores en sialorrea masiva / Major salivary gland defunctionalization surgery in massive sialorrhea

Introducción: La sialorrea es la pérdida involuntaria de saliva de la boca, ya sea debido a la producción excesiva de saliva o disminución de la frecuencia de deglución. Se habla de sialorrea patológica cuando persiste más allá de los 4 años de edad. Además de las implicaciones sociales, cambios de ropa frecuentes, puede provocar neumonías por aspiración y deshidratación. El manejo de la sialorrea requiere una evaluación completa con un enfoque de equipo multidisciplinario para el tratamiento, que incluye terapias no farmacológicas, farmacológicas y quirúrgicas. Objetivo: Presentar resultados quirúrgicos y farmacológicos en el tratamiento de sialorrea masiva. Material y Método: Se realizó revisión de historias clínicas de 7 pacientes portadores de sialorrea masiva. Todos los pacientes incluidos fueron refractarios a tratamiento médico. El diagnóstico fue obtenido por un equipo multidisciplinario. Se les realizó desfuncionalización quirúrgica y farmacológica de glándulas salivales. Se les aplicó Escala de Severidad (DSS) y escala de frecuencia (DFS), previo a cirugía y posterior a procedimiento hasta el año. Resultados: Mejoría clínica subjetiva posterior a desfuncionalización quirúrgica con disminución de DSS y DFS. Disminución promedio de baberos a 10/día. Conclusión: Los resultados obtenidos son buenos, si se consideran las escalas DSS, DFS y el número de baberos al día, que son mediciones tanto subjetivas y objetivas respectivamente.

Introduction: Massive Sialorrhea is the involuntary loss of saliva from the mouth, either due to excessive saliva production or decreased swallowing frequency. We speak of pathological sialorrhea when it persists beyond 4 years old. In addition to the social implications and frequent clothing changes. It can cause aspiration pneumonia and dehydration. Treatment for sialorrhea requires a comprehensive evaluation with a multidisciplinary team approach. Including non-pharmacological, pharmacological, and surgical therapies. Aim: Presentation of the results of surgical defunctionalization of the salivary glands plus injection of Botulinum Toxin in the treatment of massive sialorrhea. Material and Method: A review of the clinical records of 7 patients with massive sialorrhea was carried out. All included patients were refractory to medical treatment. The diagnosis was obtained by a multidisciplinary team. Surgical and pharmacological dysfunctionalization of salivary glands was performed. Severity Scale (DSS) and Frequency Scale (DFS) were applied before surgery and after the procedure up to a year. Results: Subjective clinical improvement after surgical defunctionalization with decreased SHD and DFS. Average decrease in bibs to 10/day. Conclusion: The evaluated strategy presented similar benefits with respect to the literature. The SHD and DFS scales and the number of bibs per day are both subjective and objective measurements, respectively, and allow the clinical improvement and quality of life of patients undergoing surgery to be evaluated individually.

Translation and validation of the drooling impact scale questionnaire into Brazilian Portuguese / Tradução e validação do questionário da drooling impact scale para o português do Brasil

Abstract Introduction Inadequate drooling can cause serious clinical, functional and social problems. Validated questionnaires to evaluate drooling impact on quality of life are lacking in Brazilian Portuguese. Objectives To translate and validate the drooling impact scale to Brazilian Portuguese. Methods The drooling impact scale was translated to Brazilian Portuguese and back- translated to English to assess potential conceptual differences. Brazilian Portuguese version of drooling impact scale was applied to a 40 patients' sample of sialorrhea presenting pediatric patients (up to 20 years of age). Chronbach's alpha, exploratory factorial analysis and confirmatory factorial analysis were then proceeded with data collected. Results The mean drooling impact scale value for the whole population was 51.77 (SD = 16.13). The internal consistency obtained with Cronbach's alpha indicated a value of 0.72 for the entire sample. The Bartlett's test of sphericity was significant (p< 0.0001), confirming correlation among variables tested. Kaiser-Meyer-Olkin measure of sampling adequacy revealed a value of 0.72, indicating that the correlation matrix was reasonably suitable for factor analysis. Regarding exploratory factorial analysis, parallel analysis suggested a two-factor solution that was used for confirmatory factorial analysis. The first factor was responsible for 33.78% of the variance with an Eigenvalue of 3.38. The second factor explained 16.1% of the variance with an Eigenvalue of 1.61. At confirmatory factorial analysis, the two-factor model showed consistently better adjustments parameters than the one-factor model. Conclusion The drooling impact scale has been successfully translated to Brazilian Portuguese language, showing adequate internal validity. Validation of this instrument allows physicians and other personnel involved in the care of these patients to perform a better management of patients experiencing drooling. With this tool, we are now able to guide routines and provide guidelines both before and after the different kinds of treatments in order to improve the general well-being of the patient and his family.

Resumo Introdução A produção inadequada de saliva pode causar sérios problemas clínicos, funcionais e sociais. Questionários validados para avaliar o impacto da salivação na qualidade de vida em português do Brasil são necessários. Objetivos Traduzir e validar a Drooling Impact Scale para o português do Brasil. Método A Drooling Impact Scale foi traduzida para português do Brasil e retrotraduzida para o inglês para avaliar possíveis diferenças conceituais. A versão em português do Brasil da Drooling Impact Scale foi aplicada a uma amostra de 40 pacientes pediátricos que apresentavam sialorreia (até 20 anos). Alfa de Cronbach, análise fatorial exploratória e análise fatorial confirmatória foram então feitos com os dados coletados. Resultados O valor médio da Drooling Impact Scale para toda a população foi de 51,77 (DP = 16,13). A consistência interna obtida com o alfa de Cronbach indicou um valor de 0,72 para toda a amostra. O teste de esfericidade de Bartlett foi significante (p < 0,0001), confirmou a correlação entre as variáveis testadas. A medida de adequação da amostra de Kaiser-Meyer-Olkin revelou um valor de 0,72, indicou que a matriz de correlação era razoavelmente adequada para a análise fatorial. Em relação à análise fatorial exploratória, a análise paralela sugeriu uma solução de dois fatores, que foi usada para a análise fatorial confirmatória. O primeiro fator foi responsável por 33,78% da variância com um autovalor de 3,38. O segundo fator explicou 16,1% da variância com um autovalor de 1,61. Na análise fatorial confirmatória, o modelo de dois fatores mostrou parâmetros de ajustes consistentemente melhores do que o modelo de um fator. Conclusão A Drooling Impact Scale foi traduzida com sucesso para o português do Brasil, apresentou validade interna adequada. A validação desse instrumento permite que médicos e outras pessoas envolvidas no cuidado desses pacientes façam um melhor manejo dos pacientes com sialorreia. Com essa ferramenta, agora somos capazes de orientar rotinas e fornecer orientações antes e depois dos diferentes tipos de tratamentos, a fim de melhorar o bem-estar geral do paciente e de sua família.

Uso da bandagem elástica kinesio taping no controle da sialorréia em uma criança com paralisia cerebral / Use of elastic bandage kinesio taping in control of sialorrhia in a child with cerebral paralysis

Objetivo: verificar a eficiência do kinesio Taping (KT) no controle da deglutição de saliva e sialorréia em crianças com Paralisia Cerebral (PC) e logo avaliar a melhora da qualidade de vida, a motivação, e a autoestima da criança. Método: Trata-se de um relato de caso realizado com uma criança de sete anos do sexo feminino, que faz acompanhamento fisioterapêutico na Clínica Escola de uma Instituição de Ensino Superior (IES), no entorno do Distrito Federal. A responsável pela paciente assinou voluntariamente o Termo de assentimento Livre e Esclarecido (TALE), após o esclarecimento sobre os objetivos do estudo e procedimentos a serem utilizados. A participante apresenta diagnóstico clínico de PC com diplegia espástica e sialorréia crônica. Resultados: Foi mantido o tratamento inicial e associado o método o kT, no controle da sialorréia não foi observado nenhuma reação alérgica referente a bandagem pela criança. A criança se adaptou a colocação da fita adesiva KT, e obteve redução de 40% no volume de salivação e logo a redução no número de toalhas usadas por dia para a higienização bucal. No início a média de pontuação para avaliação de frequência da sialorréia foi de 4 pontos. A partir da 2ª aplicação consecutivamente a escala da pontuação obteve uma média de 3 pontos, a mãe também informou que houve uma redução da sialorréia após o uso da bandagem. Conclusão: O método KT se mostrou eficaz na melhoria do controle de deglutição de saliva e sialorréia em crianças com PC, com redução do número de toalhas utilizadas por dia, e melhorando assim sua autoestima e q

Objective: To verify the efficiency of Kinesio Taping (KT) in the control of saliva and sialorrhea swallowing in children with Cerebral Palsy (CP) and then evaluate the improvement of the child's quality of life, motivation and self-esteem. Method: This is a case report performed with a seven-year-old female child, who was undergoing physical therapy at the School Clinic of a Higher Education Institution (HEI), around the Federal District. The patient responsible voluntarily signed the Informed Consent Term (TALE), after clarifying the study objectives and procedures to be used. The participant presents clinical diagnosis of CP with spastic diplegia and chronic sialorrhea. Results: The initial treatment and the kT method were maintained. In the control of sialorrhea, no allergic reaction related to the bandage was observed for child. She has adapted the placement of the KT tape and achieved a 40% reduction in salivation volume and then a reduction in the number of towels used per day for oral hygiene. In the beginning, the average score for sialorrhea frequency assessment was 4 points. After the second consecutive application, the score scale obtained was 3 points, on average, the mother also reported that there was a reduction in sialorrhea after the use of bandage. Conclusion: The KT method was effective in improving the control of swallowing saliva and sialorrhea in children with CP, reducing the number of towels used per day, thus improving their self-esteem and quality of life. It can be an important therapeutic resource in the area of physical therapy.

The etiology, diagnosis and treatment of sialorrhea / 口腔疾病防治

@#Sialorrhea is a group of symptoms characterized by excessive accumulation of saliva in the mouth and unconscious overflow from the mouth. It can be divided into physiological sialorrhea and pathological sialorrhea. The etiology of sialorrhea is complex. Local oral factors, systemic diseases, drug induction or psycho-physiological factors can lead to excessive saliva secretion or excessive saliva storage in the mouth, which can lead to sialorrhea. Physiological sialorrhea generally does not require treatment, while different treatment strategies are needed in cases of pathological sialorrhea. There are many treatments for sialorrhea, including oral and maxillofacial system training, drugs, botulinum toxin injection, surgical treatment, and less commonly, traditional Chinese medicines, radiotherapy and neuromuscular electrical stimulation therapy. For different patients, different treatment methods should be adopted, and the treatment should be gradual. To correct the abnormalities in the oral and maxillofacial regions, the primary disease should be treated, contact with/the use of substances inducing salivation should be stopped, or psychological treatment should be administered, combined with oral and maxillofacial system training; if the effect is not good, invasive treatment, such as surgery, should be considered. At present, there are no unified, clear diagnostic criteria or simple and effective treatments in the clinic. In this paper, the etiology, diagnosis and treatment of sialorrhea, combined with our group′s many years of experience in the diagnosis and treatment of sialorrhea, are reviewed to provide a useful reference for the clinical diagnosis and treatment of sialorrhea.

Toxina botulínica para tratamento da sialorreia nos pacientes com doença de Parkinson / Botulinum toxin for treatment of sialorrhea in patients with Parkinson's disease

A sialorreia/ptialismo é um sintoma não motor frequente da doença de Parkinson, que pode causar impacto na saúde e na qualidade de vida dos pacientes. O sintoma decorre da combinação da disfagia com disautonomia e, muitas vezes, também do efeito adverso de drogas frequentemente utilizadas no tratamento de sintomas da doença, como por exemplo, os antipsicóticos atípicos e os inibidores da acetilcolinesterase. Diversas opções terapêuticas são utilizadas na prática clínica para controle da sialorreia, dentre elas, drogas anticolinérgicas ou antagonistas dos receptores adrenérgicos, injeção de toxina botulínica, cirurgia, radioterapia e terapias comportamentais e fonoaudiológicas. Este trabalho faz uma revisão das propostas terapêuticas até o presente momento para controlar a secreção de saliva dos pacientes com doença de Parkinson. A injeção de toxina botulínica nas glândulas salivares guiada por ultrassom é a opção com mais evidência de eficácia e segurança, de acordo com os últimos estudos.

Sialorrhea is a frequent nonmotor symptom in Parkinson´s disease (PD) that influences the patients' health and quality of life. The symptom arises from a combination of difficulty in swallowing saliva, autonomic dysfunction or as a side effect of frequent used drugs to control symptoms of the disease, as for example, atypical antipsychotics and acetylcholinesterase inhibitors. In clinical practice, different therapeutic approaches are used to control sialorrhea, such as anticholinergic or beta adrenergic antagonistic drugs, botulinum toxin injection, surgery, radiotherapy, behavioral psychotherapy and speech therapy. This paper reviews the therapeutic options available until now to control the loss of saliva from PD patient. Botulinum toxin injection in the salivary glands guided by ultrasound shows the best efficacy and security profile, according to the last published data.

Translation, linguistic and cultural adaptation, reliability and validity of the Radboud Oral Motor Inventory for Parkinson's Disease - ROMP questionnaire / Tradução, adaptação linguística e cultural, confiabilidade e validade do questionário "Radboud Inventário Motor Oral para doença de Parkinson - ROMP"

ABSTRACT Objective: To translate and linguistically and culturally adapt to Brazilian Portuguese, and verify the reliability and validity of the Radboud Oral Motor Inventory for Parkinson's Disease (ROMP). Methods: The ROMP was translated and retranslated, and the instrument reliability was verified by analyzing the internal consistency and the reproducibility of the intra-examiner retest. The final version was applied to 27 participants with Parkinson's disease. Results: Internal consistency was 0.99 for the total ROMP and 0.96 to 0.99 for the three domains. Intraclass correlation coefficients for reproducibility were 0.99 for the total ROMP and 0.93 to 0.99 for the subscales. The ROMP and its subscales correlated substantially with the Likert-type scale, as well as with the unified Parkinson's disease rating scale II and III items. Conclusion: The linguistic and cultural equivalence of the ROMP in Brazilian Portuguese is now available, with excellent reliability and validity.

RESUMO Objetivo: Traduzir e adaptar linguística e culturalmente para o português brasileiro, verificar a confiabilidade e a validade do Radboud Inventário Motor Oral para Doença de Parkinson (ROMP). Métodos: O ROMP foi traduzido e retraduzido, e a confiabilidade do instrumento foi verificada através da análise da consistência interna e da reprodutibilidade do reteste intra-examinador, sendo a versão final aplicada em 27 participantes com doença de Parkinson (DP). Resultados: A consistência interna foi de 0,99 para o ROMP total e de 0,96 a 0,99 para os 3 domínios. Os coeficientes de correlação intra-classe para reprodutibilidade foram 0,99 para o ROMP total e 0,93 a 0,99 para as subescalas. O ROMP e suas subescalas correlacionaram-se substancialmente com a escala do tipo Likert, bem como com os itens UPDRS II e III. Conclusão: A equivalência linguística e cultural do ROMP no português brasileiro está agora disponível, com excelente confiabilidade e validade.

Esclerosis lateral amiotrófica. Presentación de un caso / Amyotrophic Lateral Sclerosis. Presentation of a case

La esclerosis lateral amiotrófica es una enfermedad del sistema nervioso central. Se presenta el caso de un paciente masculino, raza blanca, de 50 años; el que acude a consulta en el Hos-pital Provincial General Docente "Mártires del 9 de abril" por presentar debilidad de los miembros inferiores. El examen físico mostró fasciculaciones musculares diseminadas, debi-lidad muscular próximo-distal (-2) en los cuatro miembros, atrofia muscular que afecta mus-culatura distal y proximal de las extremidades, sialorrea, lenguaje disártrico, reflejos osteo-tendinosos exaltados de forma generalizada y Babinski bilateral. Los exámenes complemen-tarios arrojaron patrón neurógeno dependiente de los miotomas de C6-C8 con signos de denervación. Diagnóstico nosológico: esclerosis lateral amiotrófica. El enfermo refiere histo-rial de esa patología por 14 años, lo que solo se observa en aproximadamente el 10% de los casos

Amyotrophic lateral sclerosis is a disease of the central nervous system. The clinical case of a male patient, white race and 50 years old is presented. This one goes to consultation in the Provincial General Hospital "Mártires del 9 de April" for presenting weakness in lower limbs. The physical examination showed disseminated muscle twitching, proximal-distal muscular weakness (-2) in all four limbs, muscular atrophy affecting the distal and proximal muscles of the extremities, sialorrhea, disartic language, generalized extenuated osteotendi-nous reflexes and bilateral Babinski. The complementary tests showed a neurogenic pattern dependent on the C6-C8 myotomes with signs of denervation. Nosological diagnosis: amyo-trophic lateral sclerosis. The patient refers history of that pathology.

Histological and immunohistochemical findings of the action of botulinum toxin in salivary gland: systematic review / Achados histológicos e imunohistoquímicos da ação da toxina botulínica em glândula salivar: revisão sistemática

Abstract The treatment of sialorrhea is necessary for the constant risks posed by hypersalivation. A new therapeutic option comes up with the application of botulinum toxin in salivary glands. However, little is known about its mechanism of action in glandular tissue. Based on the above, this work had the objective to systematically review the literature about the action of botulinum toxin on submandibular and parotid salivary glands tissues. Electronic search was performed in databases of great relevance for this study (PubMed, SciELO, HighWire, Crossref, Scopus, Science Direct, MEDLINE, OLDMEDLINE, Serials Database, NLM Catalog, LILACS and IBECS). Inclusion and exclusion criteria for articles were established, and a total number of 14 articles were selected and used. There are few publications that clarify how the salivary gland acini behave with application of botulinum toxin. Although, the immunohistochemical findings were consistent among authors, showing weak immunoreactivity in glands treated with botulinum toxin. Histometric data are divergent, requiring more detailed studies to answer the questions about the efficacy and safety of botulinum toxin in salivary glands.

Resumo O tratamento da sialorreia se faz necessário pelos constantes riscos trazidos por este estado de hipersalivação. Uma nova opção terapêutica surge com a aplicação da toxina botulínica em glândulas salivares. Entretanto, pouco se sabe sobre o seu mecanismo de ação no tecido glandular. Com base no exposto, este trabalho teve o objetivo de revisar sistematicamente na literatura a ação da toxina botulínica sobre o tecido das glândulas salivares submandibular e parótida. Foi realizada uma busca eletrônica em bases de dados de grande relevância para este estudo (PubMed, SciELO, HighWire, Crossref, Scopus, Science Direct, MEDLINE, OLDMEDLINE, Serials Database, NLM Catalog, LILACS e IBECS). Foram estabelecidos critérios de inclusão e exclusão para os artigos, e um "n" de 14 trabalhos foram selecionados e utilizados. São poucas as publicações que esclarecem como os ácinos das glândulas salivares se comportam mediante aplicação da toxina botulínica. Apesar de os achados imunohistoquímicos entre os autores serem concordantes, com imunorreatividade mais fracas nas glândulas tratadas com a toxina botulínica, os dados histométricos são divergentes e há questionamentos metodológicos, necessitando de mais estudos pormenorizados para responder as questões sobre a eficácia e segurança da toxina botulínica nas glândulas salivares.

Treatment of drooling with sublingual atropine sulfate in children and adolescents with cerebral palsy / Tratamento da sialorreia com sulfato de atropina via sublingual em crianças e adolescentes com paralisia cerebral

ABSTRACT Atropine sulfate blocks the muscarinic receptors in the salivary glands and leads to reduced saliva production. There are no published studies about its use in children with cerebral palsy. Objective To report the effect of sublingual atropine sulfate to treat drooling in children with cerebral palsy by comparing the results of the Drooling Impact Scale in a non-controlled open clinical trial. Results Twenty-five children were assessed. The difference in the mean scores of the pre- and post-treatment scales reached statistical significance. There was a low frequency of side effects compared to studies with other anticholinergics. Conclusion The use of sublingual atropine sulfate seems to be safe and there is a reduction in the Drooling Impact Scale score, which suggests efficacy in the treatment of drooling in children and adolescents with cerebral palsy. Our results should be replicated in randomized, placebo-controlled studies with larger numbers of participants.

RESUMO O sulfato de atropina bloqueia os receptores muscarínicos nas glândulas salivares reduzindo a produção de saliva. Não há estudos publicados relativos ao seu uso para tratamento da sialorreia em crianças com paralisia cerebral. Objetivo Relatar o efeito do sulfato de atropina sublingual no tratamento da sialorreia em crianças com paralisia cerebral a partir da comparação dos resultados da Drooling Impact Scale em ensaio clínico aberto não controlado. Resultados Vinte e cinco crianças foram avaliadas. A diferença das pontuações médias nas escalas pré-tratamento e pós-tratamento atingiu significância estatística. Houve baixa frequência de efeitos colaterais em relação a outros anticolinérgicos. Conclusão O uso de sulfato de atropina sublingual parece ser seguro e está relacionado a uma redução na pontuação da Drooling Impact Scale, o que sugere eficácia no tratamento da sialorreia em crianças com paralisia cerebral. Nossos resultados devem ser replicados em estudos randomizados, placebo controlados, com maior número de participantes.

Accuracy of Ultrasound-Guided and Non-ultrasound-Guided Botulinum Toxin Injection Into Cadaver Salivary Glands

OBJECTIVE: To compare the accuracy of ultrasound (US)-guided and non-US-guided botulinum toxin (BTX) injection into the salivary glands (parotid and submandibular glands) of cadavers. METHODS: Two rehabilitation physician injected dye into three sites in the salivary glands (two sites in the parotid gland and one site in the submandibular gland) on one side of each cadaver (one was injected on the right side, while the other was injected on the left side), using either a non-US-guided injection procedure based on superficial landmarks or a US-guided procedure. Orange dye was used for the US-guided procedure, and green dye was used for the blind procedure. Two physicians uninvolved with the injection procedures and who were blinded to the method of injection dissected the cadavers to identify whether the dye was accurately injected into each target site. RESULTS: The accuracies of the blind and US-guided injections into the parotid gland were 79.17% and 95.83%, respectively. In the submandibular gland, the accuracies of the blind and US-guided injections were 50.00% and 91.67%, respectively. The difference in accuracy between the two procedures was statistically significant only in the submandibular gland (p=0.025). There were no significant differences in the accuracy of US-guided and non-US-guided injections between the two physicians for the two sites in the parotid gland (p=0.278 and p=0.146, respectively). CONCLUSION: US-guided BTX injection into the submandibular gland offers significantly greater accuracy over blind injection. For the treatment of drooling by injecting BTX into the submandibular gland, clinicians should consider using US guidance for improved accuracy.

The Correlation Between Clinical Characteristics and Radionuclide Salivagram Findings in Patients With Brain Lesions: A Preliminary Study

OBJECTIVE: To evaluate the correlation between radionuclide salivagram findings and clinical characteristics in dysphagic patients with brain lesions. METHODS: The medical records of 35 dysphagic patients with brain lesions who simultaneously underwent both a videofluoroscopic swallowing study (VFSS) and radionuclide salivagram were analyzed retrospectively. The subjects were divided into two groups according to the presence of aspiration on a salivagram (group A, patients with aspiration on the salivagram; group B, patients with no aspiration on the salivagram). The differences between clinical characteristics and VFSS findings (penetration-aspiration scale [PAS]) between the two groups were analyzed. RESULTS: Eleven out of 35 patients displayed salivary aspiration on the radionuclide salivagram. There were no significant differences between the two groups according to age, sex, disease duration, PAS on VFSS and feeding methods (p≥0.05). The incidence of aspiration pneumonia was significantly higher in group A. In a multivariate logistic regression analysis with forward stepwise method, the Mini-Mental State Examination (MMSE) score was the only significant parameter in predicting positive findings in salivagrams (odds ratio=0.760; 95% confidence interval [CI], 0.625–0.923; p=0.006). The area under the receiver operating characteristic curve (AUC) of the MMSE score for positive detection in salivagrams was 0.855 (95% CI, 0.689–0.953; p < 0.0001). The optimal cut-off value was 7 for the MMSE score (sensitivity 72.73%, specificity 100%). CONCLUSION: In patients with brain lesions who complain of dysphagia, the MMSE score was correlated with salivary aspiration. If patients present with a score of 7 or less on the MMSE, performing a radionuclide salivagram may helpful for early detection of patients at high risk of aspiration pneumonia induced from salivary aspiration.

The Correlation Between Clinical Characteristics and Radionuclide Salivagram Findings in Patients With Brain Lesions: A Preliminary Study

OBJECTIVE: To evaluate the correlation between radionuclide salivagram findings and clinical characteristics in dysphagic patients with brain lesions. METHODS: The medical records of 35 dysphagic patients with brain lesions who simultaneously underwent both a videofluoroscopic swallowing study (VFSS) and radionuclide salivagram were analyzed retrospectively. The subjects were divided into two groups according to the presence of aspiration on a salivagram (group A, patients with aspiration on the salivagram; group B, patients with no aspiration on the salivagram). The differences between clinical characteristics and VFSS findings (penetration-aspiration scale [PAS]) between the two groups were analyzed. RESULTS: Eleven out of 35 patients displayed salivary aspiration on the radionuclide salivagram. There were no significant differences between the two groups according to age, sex, disease duration, PAS on VFSS and feeding methods (p≥0.05). The incidence of aspiration pneumonia was significantly higher in group A. In a multivariate logistic regression analysis with forward stepwise method, the Mini-Mental State Examination (MMSE) score was the only significant parameter in predicting positive findings in salivagrams (odds ratio=0.760; 95% confidence interval [CI], 0.625–0.923; p=0.006). The area under the receiver operating characteristic curve (AUC) of the MMSE score for positive detection in salivagrams was 0.855 (95% CI, 0.689–0.953; p < 0.0001). The optimal cut-off value was 7 for the MMSE score (sensitivity 72.73%, specificity 100%). CONCLUSION: In patients with brain lesions who complain of dysphagia, the MMSE score was correlated with salivary aspiration. If patients present with a score of 7 or less on the MMSE, performing a radionuclide salivagram may helpful for early detection of patients at high risk of aspiration pneumonia induced from salivary aspiration.

Sialorrhea in children with cerebral palsy / Sialorreia em crianças com paralisia cerebral

Abstract Objective: To review the literature on sialorrhea in children with cerebral palsy. Source of data: Non-systematic review using the keywords "sialorrhea" and "child" carried out in the PubMed®, LILACS®, and SciELO® databases during July 2015. A total of 458 articles were obtained, of which 158 were analyzed as they were associated with sialorrhea in children; 70 had content related to sialorrhea in cerebral palsy or the assessment and treatment of sialorrhea in other neurological disorders, which were also assessed. Data synthesis: The prevalence of sialorrhea is between 10% and 58% in cerebral palsy and has clinical and social consequences. It is caused by oral motor dysfunction, dysphagia, and intraoral sensitivity disorder. The severity and impact of sialorrhea are assessed through objective or subjective methods. Several types of therapeutic management are described: training of sensory awareness and oral motor skills, drug therapy, botulinum toxin injection, and surgical treatment. Conclusions: The most effective treatment that addresses the cause of sialorrhea in children with cerebral palsy is training of sensory awareness and oral motor skills, performed by a speech therapist. Botulinum toxin injection and the use of anticholinergics have a transient effect and are adjuvant to speech therapy; they should be considered in cases of moderate to severe sialorrhea or respiratory complications. Atropine sulfate is inexpensive and appears to have good clinical response combined with good safety profile. The use of trihexyphenidyl for the treatment of sialorrhea can be considered in dyskinetic forms of cerebral palsy or in selected cases.

Resumo Objetivo: Revisar a literatura referente à sialorreia em crianças com paralisia cerebral. Fonte de dados: Revisão não sistemática com as palavras-chave "sialorreia"; e "criança" feita nas bases de dados Pubmed®, Lilacs® e Scielo® em julho de 2015. Foram recuperados 458 artigos, 158 foram analisados por terem relação com sialorreia em crianças, foram aproveitados 70 com conteúdo relativo à sialorreia na paralisia cerebral ou à avaliação e ao tratamento da sialorreia em outros distúrbios neurológicos. Síntese dos dados: A sialorreia tem prevalência entre 10% e 58% na paralisia cerebral e implica consequências clínicas e sociais. É causada por disfunção motora oral, disfagia e distúrbio da sensibilidade intraoral. A gravidade e o impacto da sialorreia são avaliados por meio de métodos objetivos ou subjetivos. Estão descritas diversas formas de manejo terapêutico: treino para consciência sensorial e habilidades motoras orais, terapia farmacológica, injeção de toxina botulínica e tratamento cirúrgico. Conclusões: O tratamento mais eficaz e que aborda a causa da sialorreia nas crianças com paralisia cerebral é o treino para consciência sensorial e habilidades motoras orais, feito por um fonoaudiólogo. Injeção de toxina botulínica e o uso de anticolinérgicos têm efeito transitório e são auxiliares ao tratamento fonoaudiológico ou devem ser considerados nos casos de sialorreia moderada a grave ou com complicações respiratórias. O sulfato de atropina tem baixo custo e parece ter boa resposta clínica com bom perfil de segurança. O uso de triexifenidil para o tratamento da sialorreia pode ser considerado nas formas discinéticas de paralisia cerebral ou em casos selecionados.

Application of botulinum toxin to treat sialorrhea in amyotrophic lateral sclerosis patients: a literature review / Aplicação da toxina botulínica no tratamento da sialorreia em pacientes com esclerose lateral amiotrófica: revisão da literatura

ABSTRACT Amyotrophic lateral sclerosis is a progressive and fatal neurodegenerative disease characterized by the degeneration of motor neurons, which are the central nervous system cells that control voluntary muscle movements. The excessive salivation (sialorrhea) is present in approximately 50% of amyotrophic lateral sclerosis cases. Thus, some alternative therapeutic methods are sought, such as anticholinergic drugs and surgery. Recently the use of botulinum toxin applied at a midpoint of the salivary glands, often guided by ultrasound, have demonstrated positive results. The objective was to review the literature to demonstrate an alternative method to treatments of sialorrhea in patients with amyotrophic lateral sclerosis. In recent studies, the efficacy of botulinum toxin is confirmed, although new applications are required. Since the side effects are negligible, this is an alternative to treat amyotrophic lateral sclerosis, and other patients with diseases that present sialorrhea.

RESUMO Esclerose lateral amiotrófica é uma doença neurodegenerativa progressiva e fatal, caracterizada pela degeneração dos neurônios motores, as células do sistema nervoso central que controlam os movimentos voluntários dos músculos. A salivação excessiva (sialorreia) está presente em cerca de 50% dos casos de esclerose lateral amiotrófica. Dessa forma, surgem medidas terapêuticas alternativas como drogas anticolinérgicas e cirurgia, e recentemente, o uso da toxina botulínica, aplicada em um ponto central das glândulas salivares, muitas vezes guiado por ultrassonografia, demostrou resultados positivos. Objetivou-se revisar a literatura no intuito de demonstrar um método alternativo aos tratamentos de sialorreia em pacientes com esclerose lateral amiotrófica. Em estudos recentes, a eficácia do tratamento com toxina botulínica foi confirmada e, mesmo requerendo novas aplicações, os efeitos colaterais são ínfimos. Ela surge então como alternativa não só ao tratamento de esclerose lateral amiotrófica, mas também para outros pacientes com doenças que apresentem a sialorreia.

Infiltración de onabotulinumtoxin a para el tratamiento de la sialorrea en niños con diagnóstico de parálisis cerebral: estudio de casos / Onabotulinumtoxin a injection for the treatment of sialorrheain children with cerebral palsy: case series

Sialorrhea is a common oral motor impairment related to various neurological disorders such as cerebral palsy (CP), generating both physical and psychological complications that affect the quality of life of patients and their caregivers. Objective: To determine the clinical reduction of sialorrhea after injection with onabotulinumtoxin A (BTXA) in children diagnosed with CP. Methods: In 8 children 4-15 years of age, with GMFCS between II and V, injection with BTXA was performed in parotid and submandibular glands under ultrasound guidance. Measurement of salivation was made at baseline and 2, 4, 16, and 24 weeks post-infiltration through the Drooling Impact Scale (DIE), the Drooling Quotient (DQ) and the Drooling Severity and Frequency Scale (DSFS). Results: All children showed a significant reduction in salivation measured with the DQ (p < 0.002), the DIE (p < 0.002). Similarly, all children showed a 1 point reduction in the frequency subcomponent of the DSFS at 4 weeks post-injection. The severity subcomponent of DSFS showed a 1 point reduction only in the group of children with GMFCS II and IV. Conclusion: The use of BTXA in parotid and submandibular glands under ultrasound guidance is an effective intervention to reduce salivation, the severity and frequency of drooling, as well as the impact that sialorrhea has on patients and caregivers.

La sialorrea es consecuencia de una alteración motora oral frecuente en diversos trastornos neurológicos, como la parálisis cerebral (PC), generando complicaciones tanto físicas como psicosociales que impactan en la calidad de vida de los pacientes y sus cuidadores. Objetivo: Determinar la reducción clínica de sialorrea después de la infiltración de Onabotulinumtoxin A (BTXA) en niños con diagnóstico de PC. Pacientes y Métodos: En 8 niños de 4 a 15 años de edad, con GMFCS entre II y V, se realizó una infiltración con BTXA en glándulas parótida y submandibular bajo guía ecográfica. Se efectuó una medición basal de la salivación y en diferentes semanas post infiltración (2ª, 4ª, 8ª, 16ª y 24ª), a través de la Escala de Impacto de la Sialorrea (EIS), el Cociente de Salivación (DQ) y la Escala de Severidad y Frecuencia de la Sialorrea (DSFS). Resultados: Todos los niños presentaron una reducción significativa de la salivación en la evaluación con el DQ (p < 0,002) y la EIS (p < 0,002). En la DSFS en el subcomponente de frecuencia baja 1 punto posterior a la 4ª semana de infiltración en el total de los niños. En cambio, en el subcomponente de severidad baja 1 punto sólo en el grupo de GMFCS II y IV. Conclusión: El uso de BTXA en glándulas parótidas y submandibulares bajo guía ecográfica es un método de intervención efectivo para disminuir la salivación, la severidad y frecuencia de la sialorrea, así como el impacto que causa esta patología en los pacientes y cuidadores.

Therapeutic Observation of Hypersalivation in Cerebral Palsy Predominantly Treated with Acupuncture at Three Tongue Points plus Tuina / 上海针灸杂志

Objective To observe the clinical efficacy of acupuncture at the three tongue points plus tuina in treating hypersalivation in cerebral palsy.Method Sixty patients with hypersalivation due to cerebral palsy were randomized into a treatment group and a control group, 30 cases in each group. The treatment group was intervened predominantly by acupuncture at the three tongue points plus tuina, while the control group was by tuina alone. The clinical efficacies were compared between the two groups.Result The total effective rate was 96.7% in the treatment group versus 83.3% in the control group, and the difference was statistically significant (P<0.05).Conclusion Acupuncture at the three tongue points plus tuina is an effective approach in treating hypersalivation in cerebral palsy.

Relationship between sialorrhea and dysphagia in Chinese patients with Parkinson′s disease / 中华神经科杂志

Objective To explore the prevalence of sialorrhea and its clinical correlation with dysphagia in Chinese patients with Parkinson′s disease ( PD ).Methods One hundred and sixteen consecutive patients with a clinical diagnosis of PD were selected.Demographic data included sex , age, years of education, age at onset of PD, clinical genotype, disease duration, treatment, Hoehn and Yahr (H&Y) stage.Sialorrhea was assessed using the Unified Parkinson′s Disease Rating Scale (UPDRS) Ⅱitem number 6.All patients were studied with videofluoroscopic study of swallowing ( VFSS).Results The prevalence rate of sialorrhea in PD was 59.5% (69/116, 95% CI 50.6%-68.4%).Males were more likely to develop sialorrhea than females (47/70 vs 22/46,χ2 =4.298, P=0.038).PD patients′sialorrhea correlated with oral dysphagia:with food leaking from the mouth ( liquid r=0.229, P=0.014; juice r=0.197, P=0.034;pudding viscosities r=0.231, P=0.013;solid food r=0.255, P=0.006), with more than 1 ml of oral food residues (liquid r=0.319, P<0.01;solid food r=0.185, P=0.047), with delay in food transfer to the root of the tongue (liquid r=0.279, P=0.002; juice r=0.209, P=0.024), and delayed swallow transfer ( pudding viscosities r=0.257, P=0.005).Sialorrhea score was not related to H&Y stage, clinical course and levodopa equivalent doses (LED).The prevalence rate of dysphagia in PD was 87.1%(95% CI 81.0% -93.2%).Liquid was more likely to cause pharyngeal dysphagia ( P=0.03).With the increase in H&Y stage , so did the oral and pharyngeal stages of dysphagia.Late and mid-course was more likely to develop oral and pharyngeal dysphagia than those with early clinical course .Conclusions Sialorrhea and dysphagia are common non-motor symptoms in PD patients.Sialorrhea is more prevalent in males and correlates with oral phase of dysphagia.Liquid is more likely to cause pharyngeal dysphagia.With increase in H&Y stage , so did oral and pharyngeal dysphagia.Even though late clinical course is more likely to develop oral and pharyngeal dysphagia than early clinical course , the comparison between late and intermediate clinical courses does not reach statistical significance .

Effect of Scopolamine Butylbromide on Clozapine-induced Hypersalivation in Schizophrenic Patients: A Case Series

Clozapine has been demonstrated to be useful for treating refractory schizophrenia. However, hypersalivation occurs in 31.0-97.4% of the patients treated with clozapine. Accordingly, some patients who are disturbed by their hypersalivation refuse to continue with clozapine treatment. This study investigated the efficacy of the anticholinergic agent scopolamine butylbromide against clozapine-induced hypersalivation. Five schizophrenia patients were coadministered scopolamine butylbromide (30-60 mg/day) for 4 weeks. At the baseline and after 4 weeks' treatment, we subjectively evaluated hypersalivation using a visual analog scale and objectively assessed it using the Drooling Severity Scale and Drooling Frequency Scale. As a result, improvements in the patients' Drooling Severity Scale and Drooling Frequency Scale scores, but no improvements in their visual analog scale scores, were observed after scopolamine butylbromide treatment. These results indicate that at least some schizophrenic patients with clozapine-induced hypersalivation would benefit from scopolamine butylbromide treatment. We conclude that clozapine-induced hypersalivation is one factor of stress to patients. Subjective hypersalivation was not improved, but objective hypersalivation was, by scopolamine butylbromide treatment. However, scopolamine butylbromide and clozapine possess anticholinergic effects so clinicians should closely monitor patients who take scopolamine butylbromide.

Tialismo como presentación clínica atípica del divertículo de Zencker: reporte de un caso / Ptyialism as an atypical clinical presentation of Zencker diverculum: a case report

Fundamento: El divertículo de Zencker es relativamente infrecuente, puede presentarse con sintomatologías típicas de la enfermedad o con otras manifestaciones atípicas, como el tialismo o crisis sialorreica. Objetivo: Describir el tialismo o crisis sialorreica como forma de presentación no habitual del divertículo de Zencker. Presentación de caso: Paciente masculino de 60 años de edad que acudió a la consulta de gastroenterología porque desde hacía un año presentaba exceso de salivación o crisis sialorreica, acompañado en ocasiones de regurgitaciones y acidez. Entre los medios diagnósticos utilizados estuvo el esofagograma contrastado mediante el cual se diagnosticó un divertículo de Zencker. Al paciente se le realizó una cervicotomía lateral izquierda con resección del divertículo y ligadura de su base. Conclusiones: El método clínico es la piedra angular para sospechar el diagnóstico del divertículo de Zencker aunque su forma de presentación clínica sea infrecuente o atípica, como lo es el tialismo o la crisis sialorreica.

Background: Zencker diverculum is relatively infrequent, it can be presented with typical symptomatologies of the disease or with other atypical manifestations, as ptyalism or sialorrhea. Objective: to describe ptyalism or crisis of sialorrhea as a non-habitual presentation of Zencker diverculum. Case presentation: a 60 year-old male patient who attended the gastroenterology consultation as he was suffering from excessive salivation or sialorrhea since a year ago, sometimes along regurgitations and acidity. The contrasted oesophagogram was among the diagnostic means used, through which a Zencker diverculum was diagnosed. A left lateral cervicotomy with diverculum resection and ligature of its base was performed. Conclusions: the clinical method is the key to suspect the diagnosis of Zencker diverculum though its clinical presentation is infrequent and atypical as it is ptyalism or sialorrhea.

Uso da bandagem elástica associada ao tratamento fonoaudiológico no controle da sialorréia / Use of elastic bandage associated with speech therapy in the control ofsialorrhea (hypersalivation)

OBJETIVO: verificar a efetividade do uso da bandagem elástica associada ao tratamento fonoaudiológico no controle da sialorréia. MÉTODOS: estudo longitudinal realizado com onze crianças com quadro de sialorréia crônica e alteração neurológica. Foi verificada a percepção do fonoaudiólogo e do responsável acerca da gravidade e o número de toalhas/paninhos de boca utilizados ao dia. Empregou-se também a sialometria. Cada participante recebeu a aplicação da bandagem elástica Kinesio Tape na região da musculatura supra-hióidea por 30 dias. As crianças foram avaliadas sem a bandagem (T0), imediatamente após a retirada da bandagem (T1) e três meses após (T2). O tratamento fonoaudiológico foi realizado pelo o mesmo profissional em duas sessões semanais. Os dados foram analisados estatisticamente. RESULTADOS: no questionário verificou-se redução da queixa de engasgos com saliva em T1 (p=0,024).A média de uso diário de toalhas/paninhos era de quatro (10,2%) em T0, duas (5,1%) em T1 e quatro (10,2%) em T2.De acordo com a sialometria, verificou-se redução da sialorréia de T0 para T1 (p=0,018) e ausência de diferença entre T0 e T2 (p=0,215) e aumento de T1 para T2 (p=0,05).De acordo com a percepção do fonoaudiólogo houve redução da sialorréia 30 dias após o uso da bandagem, entretanto não se observou melhora ao se comparar os resultados 30 dias após o uso e três meses sem a bandagem. CONCLUSÃO: a bandagem elástica se mostrou eficaz no controle da sialorréia durante seu período de uso, não sendo observada permanência dos resultados após interrupção da aplicação. .

PURPOSE: to verify the effectiveness of the use of elastic bandage associated with speech therapy to control sialorrhea. METHODS: a longitudinal study was conducted with eleven children with a condition of chronic hypersalivation and neurological disorders. The perception of the speech therapists and of the responsible as of the graveness and the number of mouth towels utilized per day. Sialometry was also applied. Each participant received an application of the Kinesio Tape elastic bandage in the supra-hiodea musculature for thirty days. The children were evaluated without the bandage (T0), immediately after removal of the bandage (T1) and three months after (T2). The speech therapy treatment was realized by the same professional in two weekly sessions. The data was analyzed statistically. RESULTS: it was verified in the questionnaire there was a reduction of complaints of saliva choking in T1 (p=0.024). The average daily use of towels / cloths was of four (10.2%) in T0, two (5.1%) in T1 and four (10.2%) at T2. According to sialometry, there was a reduction of drooling from T0 to T1 (p=0.018) and no difference between T0 and T2 (p=0.215) and a raise from T1 to T2 (p=0.05). According to the speech therapist perception there was a reduction in drooling after thirty days after the use of the bandage, however no improvement was observed when comparing the results of thirty days without usage and three months without the bandage. CONCLUSION: the taping has shown to be effective in controlling sialorrhea during its use period, not being observed the permanence of the results after interruption of its application. .