The Role of Radiation Therapy and Botulinum Toxin Injections in the Management of Sialorrhea in Patients With Amyotrophic Lateral Sclerosis: A Systematic Review

Abstract

Objectives: Half of patients with amyotrophic lateral sclerosis experience sialorrhea due to facial weakness. Although anticholinergic medications are first-line therapy, they often lead to unacceptable side effects. Radiation therapy and botulinum toxin may be considered when medical management fails. In this systematic review, we investigated the effectiveness of these interventions. Methods: Eligible studies were retrieved from PubMed and Scopus databases up to March 2017 along with hand-searching of references from primary articles. Results: Fourteen studies (N = 138) examined the benefits of botulinum toxin. Studies varied in salivary glands treated, dosages used, and the use of botulinum toxin subtype A or B. A majority of studies showed benefit after treatment. Although most studies reported only mild adverse effects, 2 case studies revealed severe complications including recurrent TMJ dislocations and rapid deterioration in bulbar function. Ten studies (N = 171) examined the benefits of radiation. Most studies reported improvement with only mild adverse events reported. Conclusions: Both radiation and botulinum toxin are effective treatments for sialorrhea in patients with amyotrophic lateral sclerosis and should be considered when medical management fails. Radiation may offer longer duration of symptom improvement with fewer complications.

Non-Surgical Strategies for Assisting Closure of Pharyngocutaneous Fistula after Total Laryngectomy: A Systematic Review of the Literature

“…Botulinum toxin therapy represents one of the many pharmacological strategies to reduce salivary flow, which is a major culprit in PCF formation and persistence [6 bomeli]. This molecule has been extensively used in the treatment of sialorrhea for many neurological syndromes [ 42 , 43 , 44 , 45 ]. Botulinum toxin starts to reduce the salivary secretion from 72 h after the periparotid infiltration and it has a more noticeable effect after 5 to 7 days [ 46 ]; its action is reversible and it lasts about 2–4 months, and with minimal systemic side effects [ 47 ].…”

The Role of Specialty Palliative Care for Amyotrophic Lateral Sclerosis

“…10 Table 2 provides a summary of the interventions, both pharmacologic and nonpharmacologic, for the most common symptoms in ALS. 18,19,26,[29][30][31][32][33][34][35][36][37][38]…”

“…The treatment of muscle cramping (using mexiletine) and sialorrhea (using botulinum toxin or radiotherapy) has some of the best supporting evidence for treatment. 38,61 It is recommended to conduct randomized controlled trials for symptom management in ALS.…”

Using Intensity Modulated Radiation Therapy for the Treatment of Sialorrhea in Amyotrophic Lateral Sclerosis

“…Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder of motor neurons affecting >12,000 patients in the United States, 1 with bulbar-onset ALS presenting with difficulty speaking and/or swallowing. 2 , 3 Sialorrhea (excessive salivation) affects approximately 80% of patients with ALS who exhibit an inability to seal their lips and suffer from a decreased coordination of the palato-lingual and/or oro-facial muscles. These symptoms lead to constant drooling, contributing to the serious risk of aspiration pneumonia and limiting the use of invasive ventilation.…”

“…In patients suffering from sialorrhea, the initial course of treatment has been the use of oral anticholinergic medications. 2 , 3 Unfortunately, many patients do not tolerate the anticholinergic side effects, including constipation, drowsiness, and urinary dysfunction. Additionally, most patients undergo many lines of anticholinergic medications, and ultimately become refractory or intolerant to the side effects.…”