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Botulinum toxin usefulness in the treatment of drooling in childhood

Carmen Marta Perez Cordero, Pedro Agudo Montore, Paola Diaz Borrego*

Sialorrhea is defined as the involuntary excess of saliva in the mouth that exceeds the lip margin. This is not due to excessive saliva production but also to an alteration in the process of oral secretions that occurs mostly in people with neurological damage. Among the pathologies that can be treated with sialorrhea are Parkinson's disease, cerebral palsy, stroke, amyotrophic lateral sclerosis or facial paralysis, among others. It is a disabling symptom which, although sometimes is unnoticed and not always recorded, can lead to significant medical problems. Complications include the appearance of cavities, persistent cough, difficulty in eating, dermatitis, skin infections due to Candida Albicans or Staphylococcus Aureus cause d by persistent humidity, and even recurrent pneumonia and aspiration. Furthermore, it has been proved that it harms the patient social life, causing alterations in speech and diminishing their quality of life, sometimes even leading to social isolation. For the therapeutic management of sialorrhoea, there are currently different treatment alternatives. Oral motor training is postulated as a type of conservative therapy that, although it does not completely stop sialorrhoea, can reduce its clinical severity. Functional management is considered to be beneficial especially when is performed concomitantly with other types of treatment. However, these techniques has limited evidence and requires a capacity for understanding and patient participation that is not possible in all cases Pharmacological treatments, such as anticholinergics (glycopyrrolate or atropine), are the most widely used drugs, due to their mechanism of action: they block the parasympathetic innervation of the salivary glands. However, the reduction of side effects such as tachycardia, confusion, or urinary retention after taking this medication is not negligible. Other invasive techniques include radiotherapy of the salivary glands or surgery to remove the glands, ligation of the duct, or neurotomy of the tympanic nerve. This type of treatment, as it obtains irreversible results, is usually carried out when all other therapies fail. Currently, botulinum toxin is one of the most commonly used therapeutic procedures for the treatment of sialorrhea. Although its aesthetic use has historically been the best known, in recent years its therapeutic use has been consolidated by being introduced in numerous pathologies such as focal spasticity, dystonia or facial paralysis. It is a powerful neurotoxin, produced by the bacterium Clostridium, Botulinum, which reduces sialorrhoea by inhibiting the release of acetylcholine in the cholinergic neurosecretory junction of the salivary glands. The main objective of our study was to evaluate the efficacy of the treatment with botulinum toxin type A infiltrations under ultrasound control in children with sialorrhea treated at our Rehabilitation Unit between 2009 and 2019 and to analyse the factors associated with better results of the technique.