Safety of Ultrasound‐Guided Botulinum Toxin Injections for Sialorrhea as Performed by Pediatric Otolaryngologists

Abstract

Objective. To evaluate incidence of complications and hospital readmission as a result of ultrasound-guided botulinum toxin injections to manage sialorrhea.Study Design. Case series with chart review.Setting. Children's Hospital of Wisconsin.Subjects and Methods. A case series with chart review was performed of all cases of ultrasound-guided injection of botulinum toxin by pediatric otolaryngologists from March 5, 2010, to September 26, 2014,. Primary outcomes included complications such as dysphagia, aspiration pneumonia, and motor paralysis. Secondary outcomes included hospitalization, intubation, and nasogastric tube placement.Results. There were 48 patients, 111 interventions, and 306 intraglandular injections identified. Botulinum toxin type A and type B were utilized in 4 and 107 operative interventions, respectively. Type A was injected into 4 parotid and 4 submandibular glands, utilizing doses of 20 U per parotid and 30 U per submandibular gland. Type B was injected into 98 parotid and 200 submandibular glands, with average dosing of 923 U per parotid and 1170 U per submandibular gland, respectively. There were 2 instances of subjectively worsening of baseline dysphagia that self-resolved. No cases were complicated by aspiration pneumonia or motor paralysis. No patients required hospital readmission, intubation, or nasogastric tube placement.Conclusion. Prior published data indicated 16% complication incidence with ultrasound-guided injection of botulinum toxin. Our study found a low complication rate (0.6%) with ultrasound-guided injections of botulinum toxin to manage sialorrhea, without cases of aspiration pneumonia or motor paralysis. Of 306 intraglandular injections, there were 2 cases of worsening baseline subjective dysphagia that self-resolved.

A 10-year Retrospective Review of Botulinum Toxin Injections and Surgical Management of Sialorrhea

“…This 15% complication rate is comparable to the wide range published in the literation, 0.6%-24%. The degree of improvement noted within our population is also similar to the 42%-68% range that has been cited [5,6,9]. Forty-three percent of the patients in our sample underwent additional botulinum toxin injections, which is equivalent to Formeister's study [8].…”

A consensus statement on the use of botulinum toxin in pediatric patients

“…Basciani et al compared different dosing amounts of RimB in 27 children with CP, concluding that a total of 3000 units of RimB into the salivary glands significantly improved the frequency and severity of sialorrhea 189 . In a study by Shariat‐Madar et al of 48 pediatric patients who underwent 111 injections, primarily with RimB, they used on average of 923 units per parotid and 1170 units per submandibular gland, with medication volumes ranging from 0.2 to 0.3 mL per gland 190 . They reported a complication rate of only 0.6% consisting of increased dysphagia.…”

“…However, success rates of the injections were not reported. 190 The literature on the use of AboA for treatment of pediatric sialorrhea is scarce. Alrefai et al performed a placebo-controlled trial using placebo versus 100 units and 140 units AboA into the parotid glands of 24 pediatric patients with CP between the ages of 21 months and 7 years.…”

“…They reported a complication rate of only 0.6% consisting of increased dysphagia. However, success rates of the injections were not reported 190 …”

Respiratory Care in Neuromuscular Diseases

“…6 The use of ultrasound guidance to assist with localization of the injection may improve the precision of this procedure. 7 External beam radiation with photon-or electron-based therapy can be used in refractory cases of sialorrhea with lasting benefits. 8,9 Electron-based therapy is preferred due to its precision in targeting the superficial parotid tissue compared to photon-based therapy.…”