Botulinum Toxin: An Effective Treatment for Sialorrhea

First used for the treatment of strabismus in children in the 1980s, injections with botulinum toxin (BoNT) have found myriad uses. One of these is for sialorrhea, or drooling, a frequent problem for many patients with neurological diseases, including about 70% to 80% of people with Parkinson’s. 

Sialorrhea has medical consequences, including infections, dehydration, and increased risk of pneumonia from inhaling saliva. It is most often caused by problems swallowing, not by excessive production of saliva.

Since the introduction of medical uses of BoNT injections in the 1980s, Seth Pullman, MD, professor of neurology and clinical motor physiologist at VP&S, has been using BoNT-B (rimabotulinumtoxinB or Myobloc) or BoNT-A (onabotulinumtoxinA or Botox) to treat patients for movement disorders, such as blepharospasm (a chronic twitching of the eyelids), torticollis (when the neck muscles contract and hold the head at an angle), and musician’s dystonia (when fingers are pulled into abnormal positions). He also uses the injections to treat children with cerebral palsy. 

The injections block nerve signals from reaching the muscles involved in the disorder, which relaxes the muscles and relieves symptoms.

“When it was noted that BoNT-B had an effect of causing dry mouth, many other neurologists and I considered the possibility of using it for sialorrhea and started to do so in the early 2000s,” Dr. Pullman says. “The relief patients experience can be profound.” The effect of the injections is typically felt within five to 10 days of the first treatment.

Many physicians, even fellow neurologists, are unaware of the treatment, Dr. Pullman notes, but BoNT has advantages compared with anticholinergics, the standard treatment. Systemic or topical anticholinergics don’t always help and have notable potential adverse effects, including confusion, memory loss, hallucinations, drowsiness, urinary retention, constipation, and blurred vision. 

Anticholinergic medications often need to be administered several times per day to be effective, while a BoNT injection lasts about three months.

The injections are made near a patient’s ear and sometimes under the jaw using a very fine needle. The toxin relaxes the muscles in the salivary glands and reduces saliva release.

“The injections may sting or burn for about five seconds, but that is usually the only side effect,” says Dr. Pullman. Very rarely, weakness develops in nearby muscles that can result in trouble swallowing or moving the neck for a short time, “but these are not typical and can be related to the technique and skill of the injector.”

Dr. Pullman says successful management of sialorrhea can alleviate the associated hygienic problems, improve appearance, enhance self-esteem, and significantly reduce caretaking time.

— Jeff Ballinger


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