Botulinum toxin versus submandibular duct relocation for severe drooling

Abstract

AIM Botulinum neurotoxin type A (BoNT-A) has been described as an effective intervention for drooling and is being increasingly adopted. However, its effectiveness compared with established treatments is still unknown. We undertook a within-participants observational study to examine this.METHOD An historic cohort was formed of 19 children and young adults (10 males, nine females) with severe drooling who underwent BoNT-A injections followed by surgical re-routing of the submandibular duct at least 6 months later. Mean age at time of admission was 11 years 5 months (range 5-17y) and mean age at the time of surgery was 14 years (range 6-23y). Fifteen children were diagnosed with bilateral cerebral palsy (CP), three with unilateral CP, and one with non-progressive developmental delay. Gross Motor Function Classification System levels were the following: level I, n=1; level II, n=2; level III, n=7; level IV, n=6; and level V, n=3). The primary outcome was the drooling quotient, which was assessed before each intervention and 8 and 32 weeks thereafter. A multivariate analysis of variance of repeated measures was performed, with the measurement points as the within-participant variables. RESULTSThe drooling quotient was reduced to a greater extent after surgery than after BoNT-A administration (p=0.001). Compared with a baseline value of 28, the mean drooling quotient 8 weeks after surgery was 10, and 32 weeks after surgery was 4 (p<0.001). Among the group treated with BoNT-A, the drooling quotient showed a significant reduction from a baseline value of 30 to 18 after 8 weeks (p=0.02), and a continued but diminished effect after 32 weeks (drooling quotient 22; p=0.05).INTERPRETATION Both interventions are effective, but surgery provides a larger and longer-lasting effect.Drooling is a significant problem for many people with neurological disorders. In particular, children with cerebral palsy (CP), the most common paediatric physical disability, are frequently affected. Approximately 10 to 37% of children with CP suffer to some degree from drooling, 1 mostly as a result of poor oral sensitivity, spasticity, and infrequent swallowing, coupled with insufficient control of the mechanism for coordinating the activity of the orofacial, palatolingual, and head and neck musculature. This leads to excessive pooling of saliva in the anterior oral cavity and, consequently, to unintentional saliva loss. 2,3 Although the amount of drooling varies depending on the severity of the associated developmental disorder, the lifelong physical and emotional consequences for both children and caregivers have been amply described. These can include stigmatization, impaired self-esteem, and community exclusion, as well as chronic dryness and irritation of the facial skin. Personal hygiene can also be cumbersome, as some children require multiple daily clothing changes as a result of their drooling.A wide range of treatments have been proposed over the years, including correction of situational factors, speech therapy, biofeedback therapy, va...

Drooling quantification: Correlation of different techniques

“…however, the association between subjective and objective responses were not assessed (Scheffer et al, 2010).…”

Saliva management options for difficult-to-wean people with tracheostomy following severe acquired brain injury (ABI): A review of the literature

“…In addition to medical therapy, treatment of sialorrhoea can be accomplished with botulinum toxin (Botox Õ or Dysport Õ ) type A [19,76,[80][81][82][83] or type B [84][85][86] injections into the submandibular [19,76,[80][81][82][83][84][85][86] or parotid glands [19,76,81,82,84,85]. In Australia, Botulinum toxin type A is available, whereas Botulinum toxin type B is not.…”

“…Reported side-effects of botulinum toxin injections have been reported which include pain, swelling and bleeding [64]. Additionally, dysphagia, altered speech and thickened saliva have been found [14,79,83]. Given that dysphagia is a key reason for prolonged tracheostomy in adults with severe ABI, it is important that decisions are made in a multidisciplinary context to assess the appropriateness of botulinum injections for the population group.…”

“…Surgical management of increased saliva includes duct relocation [83,[87][88][89][90], gland excision [83,87,91,92] and duct ligation [90][91][92]. Duct relocation alters salivary location to lessen drooling, whereas gland excision or duct ligation aims to decrease salivary quantity.…”

“…Surgery is effective both independently and when combined with sublingual gland excision [87][88][89]. Submandibular duct relocation is reported to be more effective long-term than botulinum toxin A injections, based on reductions in drooling quotient [83]. The combination of submandibular duct relocation with parotid duct ligation achieved improved control of drooling in those with neurological disability [90].…”