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.

Effect of intradermal needling combined with oral motor therapy for salivation in children with cerebral palsy: a randomized controlled trial / 中国针灸

OBJECTIVE@#To compare the effect of combination of intradermal needling with oral motor therapy and simple oral motor therapy on salivation in children with cerebral palsy.@*METHODS@#A total of 60 children with salivation in cerebral palsy were randomized into an observation group and a control group, 30 cases in each group. The observation group was treated with intradermal needling (kept for 24 hours each time at Jiache [ST 6], Dicang [ST 4], tongue three needles, etc. ) and oral motor therapy, while the control group was only given oral motor therapy. The intradermal needling was performed 3 times a week, and oral motor therapy was performed 5 times a week, 4 weeks as a course, totally 3 courses of treatment were required. The classification of teacher drooling scale (TDS), drooling severity and Kubota water swallow test, dysphagia disorders survey (DDS) score were compared before treatment and after 4, 8 and 12 weeks of treatment in both groups, and the clinical efficacy was evaluated.@*RESULTS@#After 8 weeks of treatment in the observation group and after 12 weeks of treatment in the two groups, the classification of TDS and drooling severity were improved (P<0.05), and the observation group was better than the control group after 12 weeks of treatment (P<0.05). After 8 and 12 weeks of treatment, the DDS scores of oral period in the observation group were lower than those before treatment (P<0.05). The total effective rate in the observation group was 83.3% (25/30), which was higher than 53.3% (16/30) in the control group (P<0.05).@*CONCLUSION@#The combination of intradermal needling with oral motor therapy can improve salivation symptoms and swallowing function in children with cerebral palsy, the effect is better than oral motor therapy alone, and the effect is earlier.

Análise do nível de conhecimento das manifestações orais causadas pelo uso de anticonvulsivantes / Analysis of knowledge level of oral manifestations caused by the use of anticonvulsants

Analisar o nível de conhecimento dos usuários de anticonvulsivantes e dos cirurgiões-dentistas a res peito das manifestações orais ocasionadas pela medicação. Trata-se de um estudo transversal realizado no munícipio de Vitória de Santo Antão, em Pernambuco, no qual participaram 30 Odontólogos e 16 usuários de anticonvulsivantes das unidades de saúde da família do município. Foram aplicados questionários sobre o conhecimento dos profissionais e percepção dos usuários sobre as manifestações orais ocasionadas pela medicação. Para avaliar associação entre duas variáveis categóricas foi utilizado teste Exato de Fisher, quando a condição para utilização do teste Qui-quadrado não foi verificada. A análise dos dados demonstrou que 86,7% dos cirurgiões-dentistas conhecem os anticonvulsivantes e 50,0% dos usuários não receberam orientação do dentista sobre a medicação e os seus efeitos adversos. Há escassez de conhecimentos específicos sobre os efeitos adversos do uso de anticonvulsivantes na cavidade bucal por parte dos usuários e cirurgiões-dentistas... (AU)

To analyze the knowledge level of anticonvulsants users and the dental surgeons concerning the oral manifestations caused by the medication. A cross-sectional study conducted in Vitória de Santo Antão, Pernambuco, Brazil, with participation of 30 dentists and 16 anticonvulsants users from the city's family health units. Questionnaires about the knowledge of professionals and users' perception of manifestations in the oral cavity caused by the medication. Fisher's Exact test was used to assess the association between two categorical variables when the condition for using the chi-square test was not verified. The data analysis showed that 86,7% of dental surgeons know the anticonvulsants and 50,0% of users do not receive orientation from the dentist about the medication and its adverse effects. There is a shortage of specific knowledge about the adverse effects of the use of anticonvulsants in the oral cavity, by users and dental surgeons... (AU)

Differences of Salivary Ph, Feature, And Volume Of Children At Three Kindergartens With Different Socioeconomic Standard / Diferenças do Ph Salivar, Característica e Volume, de Crianças Em Três Jardins De Infância Com Diferentes Padrões Socioeconômicos

Introduction: Saliva is the most important biological factor to protect against dental caries. When saliva flow is reduced, oral health problems such as dental caries and oral infections can develop. It was suggested that the effect of low salivary pH is more in plaque close to the area of susceptible tooth surface. The presence of saliva in pre-school age children is a significant indicator in oral health assessment oral health. There has been an association between salivary cortisol and socioeconomic variable. Descriptions above have encouraged us to examine the salivary pH, feature, and volume of pre-school-aged community. Thus, this study was aimed to describe the differences in salivary pH, feature, and volume of the children in the three pre-school with different location and socioeconomics aspect. Methods: Descriptive survey, with a population of pre-school students in 3 different kindergartens with different socioeconomic environment. Inclusion criteria were the pre-school-aged community and got permission from parents. Exclusion criteria were a pre-school-aged community under medication treatment causes hyposalivation or hypersalivation and children who did not want to be involved in the study, with total sampling as the sampling technique, resulted in as much a 101 respondents as the study sample. The saliva was collected with unstimulated technique. Data analysis was performed using relative frequency distribution. Results: The salivary pH was slightly higher in male children than female by 0.1. The average pH value was 7.25. The salivary feature was mostly frothy bubbly, followed by thin and watery, and the sticky bubbly feature was found the least. The salivary volume of the pre-school-aged community was mostly in the very less category, followed by the less category, with no normal category was found. the p-values of salivary pH and salivary features were below 0.05 There are no significant differences between the salivary pH and salivary feature of children from the three studied kindergartens. However, there is a significant difference in the salivary volume found in children from kindergartens located in high socioeconomic standard and middle socioeconomic standard areas, which have a higher salivary volume than the children from kindergartens situated in areas with lower socioeconomic standard. Conclusion: since the reduced salivary volume was associated to children with lower socioeconomic standard, this association can justify the higher risk for caries described in the literature (AU)

Introdução: A saliva é o fator biológico mais importante na proteção contra a cárie dentária. Quando o fluxo salivar é reduzido, podem ocorrer problemas na saúde bucal, como cáries e infecções orais. Foi sugerido que o efeito do baixo pH salivar é aumentado na placa, próxima à área de superfície dentária suscetível. A presença de saliva em crianças em idade pré-escolar é um indicador significativo na avaliação da saúde bucal. Houve associação entre cortisol salivar e variáveis socioeconômicas. As descrições acima nos encorajaram a examinar o pH salivar, características e volume da comunidade em idade pré-escolar. Assim, este estudo teve como objetivo descrever as diferenças de pH, característica e volume salivar das crianças de três pré-escolas com localização e aspectos socioeconômicos distintos. Material e Métodos: Pesquisa descritiva, com população de estudantes da pré-escola de três diferentes jardins de infância com diferentes ambientes socioeconômicos. Os critérios de inclusão foram comunidade em idade pré-escolar e permissão dos pais. Os critérios de exclusão foram comunidade em idade pré-escolar sob tratamento medicamentoso que causa hipossalivação ou hipersalivação e também crianças que não quiseram se envolver no estudo, com amostragem total resultando em 101 entrevistados como a amostra do estudo. A saliva foi coletada com a técnica não estimulada. A análise dos dados foi realizada usando distribuição de frequência relativa. Resultados: O pH salivar foi ligeiramente superior nas crianças do sexo masculino do que no feminino em 0,1. O valor médio do pH foi de 7,25. O aspecto salivar era principalmente espumoso com bolhas, seguido de aspecto tênue e aguado, e o aspecto pegajoso e espumante foi o menos encontrado. O volume salivar dos estudantes em idade pré-escolar encontrava-se majoritariamente na categoria inferior a todas, seguida da categoria menos, não sendo encontrada nenhuma categoria normal, onde os valores de p do pH salivar e características salivares estavam abaixo de 0,05. Não há diferenças significativas entre o pH salivar e a característica salivar das crianças dos três diferentes jardins de infância estudados. No entanto, existe uma diferença significativa no volume salivar encontrado em crianças de creches localizadas em áreas de médio e alto padrão socioeconômico, que apresentaram maior volume salivar do que as crianças de creches situadas em áreas de menor padrão socioeconômico. Conclusão: O volume salivar reduzido esteve associado a crianças com menor padrão socioeconômico, logo essa associação pode justificar o maior risco de cárie descrito na literatura. (AU)

Clinical effect of functional chewing training in treatment of oral motor dysfunction in children with cerebral palsy: a prospective randomized controlled clinical trial / 中国当代儿科杂志

OBJECTIVE@#To study the effect of functional chewing training (FuCT) on masticatory function, the severity of tongue thrust, and the severity and frequency of drooling in children with cerebral palsy.@*METHODS@#A prospective study was performed for 48 children who were diagnosed with oral motor dysfunction from January 2019 to January 2020, and they were randomly divided into an FuCT group and an oral motor training group, with 24 children in each group. Both groups received FuCT or oral motor training for 12 weeks, and then they were evaluated in terms of the changes in the masticatory function, the severity of tongue thrust, and the severity and frequency of drooling.@*RESULTS@#There were no significant differences between the two groups in the masticatory function, the severity of tongue thrust, and the severity and frequency of drooling before treatment (P>0.05). After the 12-week training, the FuCT group showed significant improvements in the masticatory function and the severity of tongue thrust and drooling (P0.05), while the oral motor training group had no improvements in the masticatory function, the severity of tongue thrust, and the severity and frequency of drooling (P>0.05). After the 12-week training, the FuCT group had more significantly improvements in the severity of tongue thrust and the severity and frequency of drooling than the oral motor training group (P<0.05).@*CONCLUSIONS@#FuCT can effectively improve the masticatory function, the severity of tongue thrust, and the severity and frequency of drooling in children with cerebral palsy.

Absceso periamigdalino bilateral en pediatría: reporte de un caso / Bilateral peritonsillar abscess in children: case report

El absceso periamigdalino es la complicación más frecuente de la amigdalitis aguda bacteriana, definido como la presencia de pus entre la cápsula periamigdalina y el músculo constrictor superior de la faringe. Habitualmente, su presentación es unilateral; es rara su afectación bilateral. Es más frecuente en adultos y poco común en niños. Cuando es bilateral, el paciente presenta odinofagia, trismus, sialorrea, fiebre y voz gutural, síntomas que comparte con el absceso unilateral, pero, en el examen físico, se evidencia abombamiento de ambos pilares anteriores, edema de úvula y paladar blando, sin asimetrías de las estructuras faríngeas. Se requiere un alto nivel de sospecha clínica para lograr el diagnóstico temprano. El manejo de la vía aérea, que podría ser dificultoso, es un aspecto importante en el tratamiento. Se presenta el caso clínico de un niño con absceso periamigdalino bilateral; se describe el proceso diagnóstico y terapéutico.

Peritonsillar abscess is the most common complication of acute bacterial tonsillitis, defined as the presence of purulent exudate between the peritonsillar capsule and the superior constrictor muscle of the pharynx. Usually, its presentation is unilateral; its bilateral involvement is rare. It is more common in adults, being uncommon in children. Clinically, it presents odynophagia, trismus, sialorrhea, fever, guttural voice, symptoms that it shares with the unilateral abscess, evidencing in the physical examination bulging of both anterior pillars, edema of the uvula and soft palate, but without asymmetries of pharyngeal structures. A high level of clinical suspicion is required to achieve early diagnosis. The management of the airway, which could be difficult, is an important aspect in the treatment. It is reported the clinical case of a child with bilateral peritonsillar abscess, the diagnostic and therapeutic process.

Pharyngeal Dystonia Misdiagnosed as Cricopharyngeal Dysphagia Successfully Treated by Pharmacotherapy

A 43-year-old woman suffered from drooling and dysphagia after a stroke in the left posterior inferior cerebellar artery territory. Videofluoroscopic swallowing study showed compatible findings of cricopharyngeal dysphagia. Despite the injection of botulinum neurotoxin, no symptom improvement was achieved and pharyngeal dystonia was considered as the cause. Medications for dystonia dramatically helped with saliva control and resulted in a small improvement in the progression of food from the pharyngeal to esophageal phase. After adjusting the drug dose, the patient was able to perform social activities without drooling. Moreover, she could consume food orally; however, this was limited to small amounts of liquid, and the main method of nutrition support was via an orogastric tube. Therefore, we suggest that physicians should make a differential diagnosis of combined dystonia in patients complaining of dysphagia by esophageal manometry and electromyography.

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.

Pediatric food impaction detected through point-of-care ultrasonography

A previously healthy 1-year-old boy suddenly began coughing while eating a dried sweet potato. Because he continued gagging after vomiting a piece of the dried sweet potato, his mother brought him to our emergency room. Upon arrival, despite normal pulmonary findings, he was drooling and gagging. Ultrasonography was performed because food impaction at the upper esophagus was suspected based on his medical history and physical examination, and results showed that a linear hyperechoic lesion was obstructing the posterior esophageal wall. Computed tomography was also considered for a detailed examination of the foreign body. However, the patient vomited the dried sweet potato before the test was performed. After vomiting the foreign body, the patient stopped gagging, and his ultrasonographic findings were normal. Therefore, the patient was discharged without any complications.

Staged lower lip reconstruction following gangrenous stomatitis in an immunosuppressed patient

A 70-year-old male with a history of diabetes mellitus, hypertension, and coronary stent insertion visited our hospital 7 days after biting his lower lip. Swelling and inflammation had worsened despite debridement and antibiotic treatment. On the 8th hospital day, fungal infection with Candida albicans and superimposed bacterial infection with Klebsiella pneumoniae were found on tissue culture. Extensive necrosis resulted in a defect of approximately 3/4 of the entire lower lip and a full-layer skin defect from the vermilion to the gingivobuccal sulcus at the right corner of the mouth. To correct drooling, incomplete lip sealing, and trismus, staged reconstruction was performed with consideration of cosmetic and functional features. The treatment process using staged reconstruction and antifungal treatment for an extensive lower lip defect caused by fungal stomatitis is described.

A bandagem elástica como recurso terapêutico para o controle da sialorreia: análise de sua eficácia / Elastic bandage as a therapeutic resource for the control of sialorrhea: an analysis of its efficacy / El vendaje elástico como recurso terapéutico para la gestión de babeo: análisis de su eficacia

Objetivo: Verificar a eficácia da aplicação da bandagem elástica na musculatura supra-hióidea de pacientes com paralisia cerebral. Método: Estudo clínico prospectivo com análise da técnica de aplicações padronizadas de bandagem elástica em musculatura suprahioídea, realizada por oito semanas, consistindo na sua troca por três vezes por semana. Para analisar a eficácia do procedimento, questionários foram aplicados (qualidade de vida, controle de deglutição da saliva, de frequência e gravidade da sialorreia) e foi realizada avaliação do estadiamento da sialorreia em períodos pré e pós-terapias. Foram comparados dois grupos de pacientes, um denominado por espera assistida e outro, experimental, ambos com quatro sujeitos no grupo, divididos igualitariamente entre os sexos, com idades entre quatro e doze anos (9 anos ± 3,55) para o grupo experimental e entre três e sete anos (4,25 ± 1,89) o de espera assistida. A bandagem elástica foi considerada eficaz quando o total de pontos obtidos após o procedimento foi igual ou superior a três pontos. Resultados: Houve diminuição da sialorreia em todos os sujeitos do grupo experimental por meio da aplicação da bandagem elástica e melhora na qualidade de vida, de acordo com seus responsáveis. No entanto, no grupo de espera assistida não foi observado progresso. Conclusão: A eficácia da aplicação da bandagem elástica para o controle da sialorreia foi comprovada no grupo experimental, contribuindo para o conhecimento na área da motricidade orofacial, além de enfatizar a reflexão acerca de procedimentos fonoterapêuticos não invasivos.

Objective: To verify the efficacy of elastic bandaging in supra-hyoid muscles in patients with cerebral palsy. Method: Prospective clinical study with the technique of standardized applications of elastic bandage in suprahyoid muscles, performed for 8 weeks, consisting of three times a week. In order to analyze the efficacy of the procedure, questionnaires were applied (quality of life, control of saliva swallowing, frequency and severity of sialorrhea) and evaluation of sialorrhea staging in pre and post-therapy periods. There were compared two groups of patients, one called as assisted waiting and the other experimental , were compared with four subjects in the group, equally divided between sexes, aged between four and twelve years (9 years ± 3.55) for the experimental group and between three and seven years (4.25 ± 1.89) the assisted waiting period. Elastic bandage was considered effective when the total score obtained after the procedure was equal to, or greater than three points. Results: According to the responsible persons there was a decrease in sialorrhea in all subjects of the experimental group by the use of elastic bandage, and improvement in quality of life. However, no progress was observed in the assisted waiting group. Conclusion: The efficacy of elastic bandaging for the control of sialorrhea was confirmed in the experimental group, contributing to the knowledge in the area of orofacial motricity, besides emphasizing the reflection about noninvasive speech therapy procedures.

Objetivo: Verificar la eficacia de la aplicación del vendaje elástico en la musculatura suprahioidea en pacientes con parálisis cerebral. Método: Estudio clínico prospectivo con análisis de la técnica de aplicaciones estandarizadas de vendaje elástico en la musculatura suprahioidea, realizada por 8 semanas, consistiendo en cambio tres veces por semana. Para analizar la eficacia del procedimiento, cuestionarios fueron aplicados (calidad de vida, control de deglución de la saliva, de frecuencia y gravedad de la sialorrea) y se realizó evaluación de la estadificación de la sialorrea en períodos pre y pos-terapias. Se compararon dos grupos de pacientes, uno denominado por espera asistida y otro experimental, ambos con cuatro sujetos en el grupo, divididos igualitariamente entre los sexos, con edades entre cuatro y doce años (9 años ± 3,55) para el grupo experimental y entre tres y siete años (4,25 ± 1,89) el de espera asistida. El vendaje elástico se considera eficaz cuando el total de puntos obtenidos tras el procedimiento fue igual o superior a tres puntos. Resultados: Hubo disminución de la sialorrea en todos los sujetos del grupo experimental por medio de la aplicación del vendaje elástico y mejora en la calidad de vida. No obstante, en el grupo de espera asistida no se observó progreso. Conclusion: La eficacia de la aplicación del vendaje elástico para el control de la sialorrea fue comprobada en el grupo experimental, contribuyendo para el conocimiento en el área de la motricidad orofacial, además de enfatizar la reflexión acerca de procedimientos fonoterapéuticos no invasivos.

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.

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.

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.

Effectiveness and Tolerability of Rufinamide in Korean Children with Lennox-Gastaut Syndrome

PURPOSE: Rufinamide (RFM) is known to be effective for children with Lennox-Gastaut syndrome (LGS). The aim of this study is to evaluate its efficacy and tolerability of Korean children with LGS. METHODS: This is a single center, open label, retrospective study. Patients with LGS who received rufinamide as adjunctive therapy were enrolled in this study. Their baseline clinical characteristics, the percent change in the seizure frequency per 4 weeks, and adverse events were evaluated. RESULTS: Among 32 children, 20 were males and the mean age was 11.3±6.6 years. After 1 month of rufinamide medication, the frequency of seizures was reduced by more than 50% in 31.3% of patients and 6.3% of patients had no seizures. After 6 months of rufinamide administration, patients with a 50% or less decrease in seizure frequency remained in a state of reduced seizure frequency and 3.1% of patients had no seizures. Side effects such as nausea, vomiting, anorexia, less active, somnolence, aggression, drooling were noted in 28.1% of patients. CONCLUSION: This study suggests that rufinamide can be considered as an effective and safe treatment option for intractable epileptic children such as LGS.

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.

Bulbar Myasthenia Gravis Superimposed in a Medullary Infarction Diagnosed by a Fiberoptic Endoscopic Evaluation of Swallowing With Simultaneous Tensilon Application

In the elderly, myasthenia gravis (MG) can present with bulbar symptoms, which can be clinically difficult to diagnose from other neurological comorbid conditions. We describe a case of a 75-year-old man who had been previously diagnosed with dysphagia associated with medullary infarction but exhibited aggravation of the dysphagia later on due to a superimposed development of bulbar MG. After recovering from his initial swallowing difficulties, the patient suddenly developed ptosis, drooling, and generalized weakness with aggravated dysphagia. Two follow-up brain magnetic resonance imaging (MRI) scans displayed no new brain lesions. Antibodies to acetylcholine receptor and muscle-specific kinase were negative. Subsequent electrodiagnosis with repetitive nerve stimulation tests revealed unremarkable findings. A diagnosis of bulbar MG could only be established after fiberoptic endoscopic evaluation of swallowing (FEES) with simultaneous Tensilon application. After application of intravenous pyridostigmine, significant improvement in dysphagia and ptosis were observed both clinically and according to the FEES.

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.