Sialorrhea: anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins

Amanda Amrita Lakraj, Narges Moghimi, Bahman Jabbari, Amanda Amrita Lakraj, Narges Moghimi, Bahman Jabbari

Abstract

Sialorrhea or excessive drooling is a major issue in children with cerebral palsy and adults with neurodegenerative disorders. In this review, we describe the clinical features, anatomy and physiology of sialorrhea, as well as a review of the world literature on medical treatment using Yale University's search engine; including but not limited to Medline and Erasmus. Level of drug efficacy is defined according to the guidelines of American Academy of Neurology. Current medical management is unsatisfactory. Topical agents (scopolamine and tropicamide) and oral agents (glyccopyrolate) combined render a level B evidence (probably effective); however, this treatment is associated with troublesome side effects. Double-blind and placebo-controlled studies of botulinum toxin (BoNT) provide a level A evidence for type B (two class I studies; effective and established) and both overall and individual B level of evidence for OnabotulinumtoxinA (A/Ona) and AbobotulinumtoxinA (A/Abo); these are probably effective. For IncobotulinumtoxinA (A/Inco), the level of evidence is U (insufficient) due to lack of blinded studies. Side effects are uncommon; transient and comparable between the two types of toxin. A clinical note at the end of this review comments on fine clinical points. Administration of BoNTs into salivary glands is currently the most effective way of treating sialorrhea.

Figures

Figure 1
Figure 1
Locations for Parotid gland injections. This figure depicts the way in which Lagalla et al. [29] inject into the parotid gland (the black x’s). Many of thestudies have used the same approach, injecting in only 2 sites on the parotid gland. At our institution, we inject into nine different sites and have modified the figure to portray this by the blue dots. Modified with permission from Springer [29].
Figure 2
Figure 2
Facial Nerve location in relation to parotid gland. It is important to note the anatomical location of the facial nerve in relation to the parotid gland in order to avoid injury to this functionally important nerve during injection.

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