Botulinum Toxin A in the Treatment of Sialorrhea in Children with Cerebral Palsy

INTRODUCTION Sialorrhea is problematic for many neurologically impaired patients. They suffer from excessive salivation because of inadequate oral motor control or swallowing dysfunction [1]. Persistent sialorrhea creates major hygienic and psychosocial problems. Maceration of skin around the mouth and neck may result in secondary bacterial infection. In addition, drooling is not a respectable social behavior and thus contributes to embarrassing and disabling social problems. Children with cerebral palsy are often afflicted with this problem. Lack of control in swallowing coordination may lead to excessive pooling of saliva in the oral cavity. Factors that predispose drooling in children with cerebral palsy include the degree of spasticity, a low swallowing frequency, a diminished intra-oral tactile sensitivity, and constant tongue thrusting [2]. The stigma of drooling further labels them " retarded", which results in both a physical barrier and social isolation [3]. Sialorrhea has been reported to be a significant problem in 10% to 37.5% of patients with cerebral palsy [3]. Salivary glands are controlled by the autonomic nervous system, and are primarily under parasympathetic cholinergic control. There are many treatment options for drooling, including behavioral management [4], oral motor intervention [4], use of oral and intra-oral appliances [5], various medications [3,6] and a range of surgical procedures [7]. However, treatments have limited success [3]. Behavioral modification techniques have limited use in children with intellectual problems [4]. The treatment of drooling with anticholinergic drugs is often ineffective and has side effects including Sialorrhea is commonly associated with many neurological and systemic conditions. For children and young adults with cerebral palsy, sialorrhea may cause embarrassment and social isolation. Current medical management used for sialorrhea is unsatisfactory. Preliminary studies in adults with sialorrhea have demonstrated that botulinum toxin A as an effective treatment; however, no studies have defined the optimal dose and the duration of botulinum toxin A's effects on sialorrhea in patients with cerebral palsy. We present four patients with cerebral palsy who received botulinum toxin A treatment for sialorrhea. Under ultrasound guidance, body weight-related dosage of botulinum toxin A was injected bilaterally into the parotid glands. All four patients reported distinct improvement within the first 2 weeks following toxin injection. Duration of the toxin's effect varied from 16 to 20 weeks. There were no therapeutic side effects. ( Mid Taiwan J Med 2006;11:261-6 )