Botulinum toxin and drooling – how much, how often and where?
Reviewed by Suzanne Jervis

This was an incredibly useful article covering all aspects of the use of botulinum toxin as a treatment modality in sialorrhoea. The article starts by outlining why treating sialorrhoea is important and describes the non-pharmacological and pharmacological options, highlighting that a recent Cochrane review found no one treatment as being superior. There are two types of the toxin (A and B) that are used clinically in one of four different preparations within the USA, albeit off-licence from the FDA. These are BOTOX (aka OBTXA), Xeomin, Dysport (all type A) and botulinum toxin B – Myobloc (type B). However, (and of critical importance) each has an individual potency so a unit of one is not equivalent to another. The anatomy and physiology of saliva production is covered in impressive detail as is the literature review regarding the products and the dosing regimens, which vary wildly. The authors recognise a non-response rate to the treatment in about 10% and also a potential loss of response in the longer term, which may improve upon changing to an alternative toxin. The procedure is described in detail, with the preference of using lidocaine cream (e.g. EMLA) on the skin surface to avoid repeated general anaesthetics. The three approaches are covered – blind injection based on anatomical landmarks, USS guided and EMG guidance. The first two are aided with diagrams, photographs and USS images regarding needle placement. The authors remind the reader that serious complications such as dysphagia, choking and aspiration are likely to result in toxin diffusing into localised muscles, either by excessive doses or volumes. This was a highly useful article to anyone embarking upon this treatment modality in their practice and encourages them to use the USS technique as the method of choice due to its accuracy.

Botulinum toxin injection techniques for pediatric sialorrhea.
Daniel S.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY – HEAD AND NECK SURGERY
2015;26(1):42-9.