Localization of the Submandibular Glands Using High-Frequency Ultrasound.

BACKGROUND: Injecting botulinum toxin (BTX) into the submandibular glands (SMGs) can treat drooling symptoms in neurological diseases and improve the aesthetics of SMG hypertrophy and ptotic SMGs. OBJECTIVES: This study aimed to define the size and position of the SMGs by high-frequency ultrasound, and to perform statistical analysis to improve the safety and accuracy of BTX injection therapy. METHODS: Neck ultrasonography with high-frequency ultrasound was performed on 214 volunteers. The length, height, and thickness of the SMGs, and the distance between the SMGs and the midline, the anterior border of the sternocleidomastoid, the mandible, and the surface were measured. RESULTS: The SMGs were almond-shaped with a mean [standard deviation] length of 33.7 [4.7] mm, a thickness of 13.3 [2.9] mm, and a height of 27.6 [6.0] mm. The length and height were significantly different between underage and youth groups. The size of the SMGs did not show any notable differences with increasing BMI; however, their depth, and the distance from the mandible, midline, and anterior border of the sternocleidomastoid increased. No significant differences were observed between the affected and healthy sides in patients with microtia, hemifacial microsomia, or cleft lip and palate. CONCLUSIONS: Ultrasound provides more comprehensive information regarding the size and position of the SMGs, which can serve as a reference in BTX therapy and in the diagnosis of SMG diseases involving size alterations.

Drooling disrupts the brain functional connectivity network in Parkinson's disease.

AIMS: This study aimed to investigate the causal interaction between significant sensorimotor network (SMN) regions and other brain regions in Parkinson's disease patients with drooling (droolers). METHODS: Twenty-one droolers, 22 PD patients without drooling (non-droolers), and 22 matched healthy controls underwent 3T-MRI resting-state scans. We performed independent component analysis and Granger causality analysis to determine whether significant SMN regions help predict other brain areas. Pearson's correlation was computed between imaging characteristics and clinical characteristics. ROC curves were plotted to assess the diagnostic performance of effective connectivity (EC). RESULTS: Compared with non-droolers and healthy controls, droolers showed abnormal EC of the right caudate nucleus (CAU.R) and right postcentral gyrus to extensive brain regions. In droolers, increased EC from the CAU.R to the right middle temporal gyrus was positively correlated with MDS-UPDRS, MDS-UPDRS II, NMSS, and HAMD scores; increased EC from the right inferior parietal lobe to CAU.R was positively correlated with MDS-UPDRS score. ROC curve analysis showed that these abnormal ECs are of great significance in diagnosing drooling in PD. CONCLUSION: This study identified that PD patients with drooling have abnormal EC in the cortico-limbic-striatal-cerebellar and cortio-cortical networks, which could be potential biomarkers for drooling in PD.

US-guided percutaneous microwave ablation (MWA) of submandibular gland: A new minimal invasive and effective treatment for refractory sialorrhea and treatment response evaluation with contrast-enhanced imaging techniques.

A 33 years' old male complained of excessive salivation with frequent swallowing and spitting, which resulted in communication disturbance, reduced quality of life, and social embarrassment for 19 years. He had been diagnosed as sialorrhea and submandibular gland hyperfunction by stomatologist, then had unilateral submandibular gland resection 13 years ago, but the symptom relief was not satisfactory. After that, he had been treated with glycopyrrolate for less than a year, which was withdrawn because of the short duration of symptomatic control after each tablet take-in and intolerable side effects. With the wish to receive a new treatment with long term effectiveness, low re-operation risk and normal preserved saliva secretion function, the patient was subject to MWA for the right submandibular gland. After systematic clinical evaluation, US-guided percutaneous MWA was successfully performed with an uneventful post-operative course. The volume of the right submandibular gland and ablated area were measured precisely by an ablation planning software system with automatic volume measurement function based on three-dimensional reconstruction of the pre-operative and post-operative enhanced magnetic resonance imaging (MRI) raw data. Finally, the ablated volume was calculated as 62.2% of the whole right submandibular gland. The patient was discharged 1 day after the operation, with symptoms relieved significantly, the mean value of whole saliva flow rate (SFR) decreased from 11 ml to 7.5 ml per 15 minutes. During the follow up by phone three months after operation, the patient reported that the treatment effect was satisfactory, whereas the SFR value became stable as 7 ml per 15 minutes, drooling frequency and drooling severity (DFDS) score decreased from 6 to 5, drooling impact scale (DIS) score decreased from 43 to 26. US-guided percutaneous MWA of submandibular gland seems to be an alternative, minimal invasive, and effective treatment for refractory sialorrhea.We described a patient with refractory sialorrhea treated successfully with ultrasound (US) guided percutaneous microwave ablation (MWA).

Sialorrhea Successfully Treated by the Combined Use of Selective M1 and M3 Muscarinic Acetylcholine Receptor Antagonists.

Sialorrhea is often treated with anticholinergic agents, but they can have undesirable side effects such as drowsiness, sedation, and constipation. Effective medication that acts selectively on the salivary glands is needed. We report the case of a patient with sialorrhea who was successfully treated by the combined use of pirenzepine and solifenacin (M1 and M3 muscarinic receptor antagonists, respectively). The patient was a 51-year-old man with mean unstimulated and stimulated salivary flow rates per 10 min of 6.1 mL and 41.7 mL, respectively (both were measured three times). 99mTcO4- salivary gland scintigraphy revealed characteristic spontaneous saliva secretion without stimulation. He was treated with Scopolia extract, escitalopram, solifenacin succinate, and the combined administration of solifenacin succinate and pirenzepine. A statistically significant decrease was observed from the pre-medication unstimulated and stimulated salivary flow rates only following the combined administration of solifenacin and pirenzepine. The major muscarinic receptor subtype expressed in the salivary glands is M3; however, M1 is also present. A study using knockout mice demonstrated that the presence of either M1 or M3 receptors was sufficient for salivation. Thus, the combined use of selective M1 and M3 antagonists could provide a good treatment option for sialorrhea.

Qualitative and quantitative scintigraphy in sialorrhea before and after botulinum toxin injection.

OBJECTIVES/HYPOTHESIS: Sialorrhea is excessive saliva production and its usual escape of from the oral cavity. The use of botulinum toxin has been preconized, but its effectiveness until now has been unreliably measured. Our objective was to qualitatively and quantitatively determine the effectiveness of botulinum toxin injection in the reduction of saliva production by the parotid gland. STUDY DESIGN: Outcomes research. METHODS: Patients with moderate-to-critical sialorrhea had one of the parotid glands injected with 50 U of botulinum toxin, leaving the other as the control. Fifteen days after the toxin injection, they underwent scintigraphic analyses with intravenous injection of 10 mCi (37 MBq) of Tc-99 m (sodium pertechnetate). After this, the noninjected gland was treated for therapeutic complementation. RESULTS: The glands injected with botulinum toxin showed uptake reduction in 100% of patients. The uptake reduction in counts per second varied from 8% to 36%. The Wilcoxon paired test comparing the control glands with those injected showed a significant difference for the action of botulinum toxin (P = .0039). CONCLUSIONS: The scintigraphic study of parotid glands shows that botulinum toxin is effective in reducing sodium pertechnetate uptake. LEVEL OF EVIDENCE: 2c Laryngoscope, 129:2521-2526, 2019.

Ultrasound-Guided Botulinum Toxin Type A Salivary Gland Injection in Children for Refractory Sialorrhea: 10-Year Experience at a Large Tertiary Children's Hospital.

BACKGROUND: Sialorrhea is problematic for neurologically impaired children, and botulinum toxin A salivary gland injection has been reported as effective in reducing sialorrhea. This article assesses the success and safety of ultrasound-guided weight-based botulinum toxin A injection for the management of sialorrhea in children. METHODS: A total of 111 patients (63 males; 48 females; average age 7 years) with refractory sialorrhea were treated with ultrasound-guided botulinum toxin type A salivary gland injections (144 procedures) from July 1, 2004, to July 1, 2014, using a single weight-based protocol. Patient history, procedural records, and clinical follow-up documents were retrospectively reviewed. Clinical data were compared with reported effectiveness and complications using odds ratios. RESULTS: A total of 144 procedures were performed in 111 patients with refractory sialorrhea. Cerebral palsy was the most common underlying etiology for sialorrhea (29%), whereas others included encephalopathy (5%), anoxic brain injury (4%), and a variety of chromosomal anomalies (5%). There was a 100% technical success rate. Overall treatment effectiveness was 68%. Repeat injections were not associated with increased clinical success. No procedure-related deaths or major complications were identified; the minor complication rate was less than 2%. CONCLUSIONS: The protocol used for ultrasound-guided injection of botulinum toxin A proved to be safe and effective in children suffering from sialorrhea. Image guidance technique may lead to a reduction in rates of adverse events reported in other series. Subsequent procedures do not improve upon initial efficacy.

The option of sonographic guidance in Botulinum toxin injection for drooling in Parkinson's disease.

Parkinson's disease is a syndrome that frequently includes drooling, i.e., the involuntary spillage of saliva over the lip margin. Such drooling places a severe burden on both the health and the quality of life of Parkinsonian patients. Its origin lies in the impairment of oral motor control and swallowing associated with Parkinson's disease. It can be treated surgically or conservatively by reducing the production of saliva in the salivary glands, to which the parotid and submandibular glands make the greatest contribution. Botulinum neurotoxins A and B, administered to these glands, are in increasing use as treatment for drooling from various causes including Parkinson's disease. Wide knowledge was gathered about preferred drugs, dosages, injection sites and injection-guiding techniques, albeit without providing evidence-based guidance or a clear rationale for the mode of action of the medication or any information about further influential or predictive factors for safety and efficacy. However, it is essential that the relevant glands be targeted accurately; although this can be done by using anatomical landmarks, the use of sonographic guidance seems preferable. In the hands of a trained injector, sonography is a quick and non-invasive imaging technique.

Effect of recurrent onabotulinum toxin A injection into the salivary glands: An ultrasound measurement.

OBJECTIVES/HYPOTHESIS: Onabotulinum toxin A (OBTXA) injection is a well-established therapeutic option for the management of drooling. Many of the children treated undertake repeated injections every 3 to 6 months. We aimed to assess quantitative salivary gland changes via ultrasound imaging after intraglandular injection of OBTXA for sialorrhea treatment in children, as a method that suggests permanent changes in glandular size can cause a decrease in functionality or atrophy. STUDY DESIGN: Case-control study. METHODS: The parotid and submandibular glands of 22 patients with sialorrhea with previous repetitive OBTXA treatments were measured via ultrasound. These were compared with a control group of 38 healthy children. RESULTS: A total of 60 patients were included in the study (38 boys, 22 females). Body mass index, sex, and age were defined as confounders. The mean age was 7 years (standard deviation [SD] ±2.3 years) and 9 years (SD ±3.8 years) for treatment and control groups, respectively. There were no postinjection complications. We found significant decrease in the size dimensions (surface area and depth) of both submandibular glands and one parotid gland in the treatment group (P < .05). Significant smaller anterior-posterior dimension of the submandibular glands (P < .01) was also found. CONCLUSIONS: The chronic use of intraglandular OBTXA reduced the size of the salivary glands measured ultrasonographically. Results were correlated with clinical outcomes. Pathological studies should be done to correlate whether ultrasound changes result in atrophy or apoptosis of the glands. LEVEL OF EVIDENCE: 3b

Dysphagia and sialorrhea: the relationship to Parkinson's disease.

CONTEXT: Dysphagia and sialorrhea in patients with Parkinson's disease are both automatically accepted as dependent on this neurological disease. OBJECTIVE: The aim were to establish if these two complaints are a consequence or associated manifestations of Parkinson's disease. METHOD: Two Parkinson's diseases groups from the same outpatients' population were studied. Patients in the first group, with dysphagia, were studied by videofluoroscopy. The second, with sialorrhea, were studied by the scintigraphic method, RESULTS: Videofluoroscopic examination of the oral, pharyngeal and esophageal phases of swallowing showed that 94% of Parkinson's diseases patients present, structural causes, not related to Parkinson's diseases, able to produce or intensify the observed disphagia. The scintigraphic examination of Parkinson's diseases patients with sialorrhea showed that there is no increase of serous saliva production. Nevertheless, showed a significantly higher velocity of saliva excretion in the Parkinson's diseases patients. CONCLUSIONS: Dysphagia can be due to the muscular rigidity often present in the Parkinson's diseases patient, or more usually by non Parkinson's disease associated causes. In Parkinson's diseases patients, sialorrhea is produced by saliva retention. Nevertheless, sialorrhea can produce discomfort in swallowing, although without a formal complaint of dysphagia. In this case, subclinical dysphagia must be considered. Sialorrhea is indicative of dysphagia or at least of subclinical dysphagia. As final conclusion, Parkinson's diseases can be an isolated cause of dysphagia and/or sialorrhea, but frequently, a factor unrelated to Parkinson's diseases is the main cause of or at least aggravates the dysphagia.

Dysphagia and sialorrhea

ContextDysphagia and sialorrhea in patients with Parkinson's disease are both automatically accepted as dependent on this neurological disease.ObjectiveThe aim were to establish if these two complaints are a consequence or associated manifestations of Parkinson's disease.MethodTwo Parkinson's diseases groups from the same outpatients' population were studied. Patients in the first group, with dysphagia, were studied by videofluoroscopy. The second, with sialorrhea, were studied by the scintigraphic method,ResultsVideofluoroscopic examination of the oral, pharyngeal and esophageal phases of swallowing showed that 94% of Parkinson's diseases patients present, structural causes, not related to Parkinson's diseases, able to produce or intensify the observed disphagia. The scintigraphic examination of Parkinson's diseases patients with sialorrhea showed that there is no increase of serous saliva production. Nevertheless, showed a significantly higher velocity of saliva excretion in the Parkinson's diseases patients.ConclusionsDysphagia can be due to the muscular rigidity often present in the Parkinson's diseases patient, or more usually by non Parkinson's disease associated causes. In Parkinson's diseases patients, sialorrhea is produced by saliva retention. Nevertheless, sialorrhea can produce discomfort in swallowing, although without a formal complaint of dysphagia. In this case, subclinical dysphagia must be considered. Sialorrhea is indicative of dysphagia or at least of subclinical dysphagia. As final conclusion, Parkinson's diseases can be an isolated cause of dysphagia and/or sialorrhea, but frequently, a factor unrelated to Parkinson's diseases is the main cause of or at least aggravates the dysphagia.

ContextoDisfagia e sialorreia em pacientes com doença de Parkinson são automaticamente entendidos como decorrentes do comprometimento neurológico produzido pela doença de Parkinson.ObjetivoEstabelecer se estas duas queixas são consequências ou manifestações associadas à doença de Parkinson.MétodoDois grupos de pacientes com doença de Parkinson provenientes da mesma população ambulatorial foram estudados. O primeiro grupo com queixa de disfagia foi estudado pelo método videofluoroscópico. Um segundo grupo com sialorreia foi estudado pelo método cintigráfico.ResultadosO exame videofluoroscópico das fases oral, faríngea e esofágica da deglutição mostrou que 94% das disfagias nos pacientes com doença de Parkinson eram devidas a causas estruturais não relacionadas com a doença de Parkinson e capazes de produzir ou intensificar a disfagia observada. Os exames cintigráficos dos pacientes com doença de Parkinson e sialorreia mostraram que não ocorre aumento da produção de saliva. No entanto mostrou significante aumento na velocidade de excreção da saliva nesses pacientes.ConclusõesA disfagia pode ser devido à rigidez muscular frequentemente presente nos pacientes com doença de Parkinson ou mais frequentemente por causas associadas que independem desta. Nos pacientes com doença de Parkinson a sialorreia é produzida pela retenção oral da saliva. Contudo é possível observar queixa de sialorreia sem formal queixa associada de disfagia. Nesses casos, disfagia sub-clínica deve ser considerada. Sialorreia é um indicativo de disfagia ou pelo menos de disfagia sub-clínica. Como conclusão final, a doença de Parkinson pode ser causa isolada de disfagia e ou sialorreia, mas frequentemente um fator não relacionado com a doença de Parkinson pode cursar como a principal causa ou pelo menos como causa agravante da disfagia.

Acquired epileptiform opercular syndrome: F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) findings and efficacy of levetiracetam therapy.

We report a five-year-old girl presenting with dysphagia, dysarthria, drooling, and generalized tonic convulsions in whom the final diagnosis was acquired epileptiform opercular syndrome. Levetiracetam monotherapy at a dosage of 40 mg/kg/day improved the clinical findings, and seizures were controlled at the end of the first month of treatment. Six months after the initial diagnosis, she presented with speech deterioration and dysarthria. At this time, although sleep and awake electroencephalography (EEG) were normal, FDG-PET showed hypometabolic and hypermetabolic regions in the anterior/inferior and anterior regions of the right frontal lobe, respectively. By increasing before levetiracetam dosage to 50 mg/kg/day, the clinical findings resolved and the patient is still seizure free. Acquired epileptiform opercular syndrome is a rare epileptic disorder in which the seizures are resistant to conventional antiepileptic drugs. Levetiracetam may be an effective antiepileptic drug in controlling seizures and other clinical findings in acquired opercular epileptiform syndrome. Hypometabolic and hypermetabolic regions in FDG-PET study may be due to ongoing seizure activity or impaired glucose metabolism in this disorder.

What could predict effectiveness of Botulinum Toxin to treat drooling: a search for evidence of discriminatory factors on the level of body functions or structures.

BACKGROUND: The treatment of drooling is important to families that experience the daily impact and research to elucidate clinical factors that play a role in the outcome of drooling treatment should be encouraged. AIM: To define clinical factors that influence therapy outcome of submandibular Botulinum Toxin (BoNT-A) injections for drooling. METHODS: Prospectively collected data of 128 children with cerebral palsy were evaluated; 80 spastic and 48 dyskinetic movement disorder, mostly Gross Motor Function Classification System III and higher; over 70% had an IQ <70. In addition, 23 fully ambulant children with exclusively intellectual disability were treated for drooling by ultrasound-guided injections of BoNT-A into the submandibular glands. Salivary flow rates and drooling quotients were measured at baseline and at 8 weeks after injection. Extensive information about the oral motor performance was gathered. Successful clinical response was defined as a 50% reduction of the baseline Drooling Quotient; 85 children were responsive to BoNT-A and 66 children unresponsive. RESULTS: Five nominated clinical factors that possibly could influence saliva reduction (head position, lip seal, voluntary control over the tongue, control of voluntary movement functions, and mental age) did not influence the responsiveness to BoNT-A. INTERPRETATION: Other variables need to be considered to predict the outcome of BoNT-A treatment. This article describes the first attempt to reveal the contribution of body functions and structures to the outcome of BoNT-A submandibular injections.

Unilateral parotid electron beam radiotherapy as palliative treatment for sialorrhea in amyotrophic lateral sclerosis.

When ALS patients experience oropharyngeal weakness, sialorrhea can become a considerable challenge. Drooling has a profound negative impact in patient's quality of life causing embarrassing social situations. Several therapeutic modalities, including anticholinergic drugs, botulinum toxin injection, and radiotherapy have emerged as treatments for drooling in ALS. This retrospective case series study examined the effect of palliative radiotherapy in controlling problematic oral secretions in 10 ALS patients refractory to medical management. External electron beam radiation was targeted to a single parotid gland unilaterally with a total dose of 1500 cGy in 3 fractions at a depth determined by CT scanning. One patient received additional radiotherapy to the contralateral parotid due to persistent secretions. All patients reported improvement with a reduction in the intensity and amount of drooling. In 5 of 10 patients, anticholinergics were discontinued and were reduced in another two. There were no major side effects of treatment. We conclude that unilateral parotid electron radiotherapy provides satisfactory relief from sialorrhea in ALS patients and should be considered as a therapeutic option for patients who are refractory to medical management.

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

PURPOSE: To review outcomes of ultrasound (US)-guided percutaneous submandibular gland injection of botulinum toxin A (BTX-A) in the treatment of drooling and chronic aspiration. MATERIALS AND METHODS: A 3-year retrospective review was performed of 220 US-guided salivary gland injections in 36 patients. There were 21 male patients and 15 female patients with an age range of 1.4 to 19.8 years (mean, 8.6 y) and a weight range of 7.8 to 73 kg (mean, 24.4 kg). The mean pretreatment analysis period was 48 months and the mean follow-up period was 21 months. The study group was divided into groups with anterior (n = 9) and posterior (n = 27) drooling, with those with both (n = 10) included in the posterior group. RESULTS: All procedures were technically successful. Bilateral submandibular injections were performed in 34 procedures and bilateral submandibular and parotid injections were performed in 38 procedures. Of the 27 patients with posterior drooling, improvement occurred in 24 patients (88%), no improvement was seen in two (8%), and one (4%) was lost to follow-up. Of the nine patients with anterior drooling, six (66%) showed improvement, there was no response in two (22%), and one (12%) was lost to follow-up. The total number of hospitalizations for respiratory issues and presumed aspiration pneumonia decreased by 56.4% per year in the patients with posterior drooling. There was one procedure-related complication: an episode of self-limited oral bleeding. CONCLUSION: Salivary gland BTX-A injection for salivary control shows promising results in decreasing saliva production and frequency of respiratory symptoms in children with drooling and chronic aspiration.

[Pharmacological therapy of sialorrhea in patients with motor neuron disease].

A comparative trial of amithryptiline and dysport (botulinic toxin type A) in the treatment of sialorrhea in patients with motor neuron disease (MND) was conducted in 10 MND patients with sialorrhea, of whom 5 were treated with subcutaneous injections of Dysport and 5 with Amithriptiline, and 6 controls without salivary dysfunction. Gravimetry and scintigraphy of salivary glands were used before and after treatment. Compared to controls, saliva production was significantly decreased in MND patients. Both amithryptilin and dysport used in mean therapeutic doses decreased sialorrhea with similar effect. However, 3 patients, receiving amythryptiline in dosage 50 mg/day, experienced side effects (constipation, accommodation disturbances, dry mouth, sleepiness and poor concentration). Reducing of amithryptiline dose, along with prescribing dysport, removed the side-effects in these patients, while sialorrhea did not increase. The authors concluded that due to high efficacy and low cost of amithryptiline therapy of sialorrhea proved to be a golden standard of palliative care in MDN. However, in these terms dysport can not be an alternative to amithryptiline in sialorrhea therapy. Nevertheless, in cases when amithryptiline treatment is accomplished with side-effects, the drug dosage can be reduced and combined with dysport.

Botulinum toxin injections for children with excessive drooling.

The objective of this study was to evaluate the feasibility of ultrasonography-guided injections of botulinum toxin A into the parotid glands of children with severe drooling (sialorrhea). Excessive drooling is common in children with chronic neurologic disorders. Preliminary observations in adults suggest that injections of botulinum toxin A into the parotid glands can decrease drooling, but the optimal dose, sites of injection, and concomitant use of imaging during injections and its use for children have not been established. Ultrasonography was used to guide the injection of botulinum toxin (10-25 IU) into both parotid glands of nine children with excessive drooling. Subjective and objective measures of the severity of drooling were collected before and after botulinum toxin A injections. A booster injection was provided if the initial response was inadequate. Injections were well tolerated, and no adverse reactions were observed. Ultrasonography revealed that the parotid gland showed a variable depth, extent, and vascularization. Eight of nine patients needed a booster injection after 1 month. Objective measures of drooling severity were improved in seven of nine patients. However, subjective improvement was reported in only three of nine patients, and this improvement was functionally significant in only one patient. Although intraparotid injection of botulinum toxin A is safe and causes a reduction in saliva production in children, the doses used in this study did not result in functionally significant improvement. Higher doses of botulinum toxin A in the parotid glands or concomitant injections into the submandibular glands can increase the efficacy of these injections. Variability in size, depth, and vascular supply of the parotid gland suggests the importance of ultrasonography guidance for optimizing injections. These results underscore the need for further studies to establish the efficacy of this treatment in children.

Ultrasound-guided versus 'blind' intraparotid injections of botulinum toxin-A for the treatment of sialorrhoea in patients with Parkinson's disease.

OBJECTIVE: To investigate the efficacy and safety of intraparotid botulinum toxin-A (BTX-A) injections into parotid gland using ultrasound-guided versus nonguided techniques for the treatment of sialorrhoea in patients with Parkinson's disease (PD). METHODS: 15 patients with PD and sialorrhoea were included and divided into two groups. Group A patients (n=8) were injected with BTX-A using ultrasound guidance. Group B patients (n=7) were injected with BTX-A without ultrasound guidance. Saliva secretion was assessed quantitatively at baseline and at weeks 1, 4, and 12. Patients and/or caregivers also assessed the saliva secretion using visual analog scale (VAS). RESULTS: All patients except one reported subjective improvement in sialorrhoea at the first week. Group A patients showed significantly higher rate of saliva reduction at the first week, whereas in Group B the reduction was not statistically significant from baseline at the first week (P>0.05). Comparisons of quantitative saliva assessments at each follow-up visit also showed that ultrasound-guided injections were superior to blind injections for saliva reduction. VAS scores showed an improvement in the mean rate of saliva secretion in each group at first week (P<0.05). Two patients suffered from dry mouth in mild severity lasting 1 month. CONCLUSION: Intraparotid BTX-A injections using ultrasound guidance may be an effective, easy, and safe treatment for parkinsonian sialorrhoea.

Up-to-date report of botulinum toxin therapy in patients with drooling caused by different etiologies.

PURPOSE: In this study, we evaluated the clinical data for patients with drooling caused by various diseases, treated by injection of botulinum toxin A. We also present a controlled follow-up study documenting efficiency, possible adverse events, and duration of the effect of treatment. PATIENTS AND METHODS: Thirteen patients with drooling caused by head and neck carcinoma, neurodegenerative diseases, or stroke received injections of 50 to 65 U botulinum toxin A (Botox; Allergan, Irvine, CA) in both submandibular and both parotid glands under sonographic control. We measured whole salivary flow rate and the salivary analytes of total protein, alpha-amylase, acid phosphatase, kallikrein, and immunoglobulin A at various times before and after injection. The patients were examined for severity of symptoms, including sonographic investigation of cephalic salivary glands. RESULTS: All 13 patients reported a distinct improvement of their symptoms within 2 weeks after toxin injection. Three patients noted a return of high salivation rates after 12 weeks. Duration of toxin effect varied widely between individuals. In general, salivary flow rates dropped sharply within 1 week after injection but had risen again after 12 weeks. Conversely, analyte concentrations increased in the first stages of treatment and later decreased, returning to pretherapy levels. Sonography did not reveal any major changes of salivary gland parenchyma, and side effects were absent. CONCLUSIONS: Local injection of botulinum toxin A into the salivary glands proved to be a dependable therapy for drooling caused by various etiologies, as shown in 13 patients. Adverse events were not seen. The effect of toxin application lasted for about 3 months. To further clarify this aspect, long-term studies are under way.

The treatment of drooling by ultrasound-guided intraglandular injections of botulinum toxin type A into the salivary glands.

OBJECTIVE: The aim of the study was to present the background, procedure, and technique of bilateral ultrasound-guided, single-dose injections of botulinum toxin type A (BTX) into the salivary glands in patients with severe drooling. STUDY DESIGN: Clinical trial. METHODS: Initially, an in vitro study was performed to determine the volume of the dilution of BTX required for optimal spreading and to gain insight in the spreading pattern of the fluid in the submandibular gland. Subsequently, patients with severe drooling were included in a clinical study. Salivary flow was measured under standardized conditions, and BTX was injected into the submandibular glands with the patient under general anesthesia and with ultrasound guidance as an outpatient procedure or during a short stay at the daytime care unit. RESULTS: BTX for each gland should be diluted in a volume of 1 to 1.5 mL saline to achieve adequate spreading within the gland and to diminish the risk of diffusion into surrounding structures. With ultrasound guidance, separate structures surrounding the glands and structures within the glandular parenchyma are well recognized and injection errors can be avoided. CONCLUSIONS: With the procedure described, it is possible to accurately inject BTX directly into the glandular parenchyma and to visualize spreading of the fluid in the glandular parenchyma. It is found to be a safe method that guarantees an optimal clinical effect and avoids potentially harmful side effects. We recommend ultrasound guidance if injections of BTX into the salivary glands are considered.