Salivary gland Botulinum Toxin injections for drooling

What is drooling (sialorrhea)?

Drooling is the unintentional loss of saliva from the mouth. It is a common occurrence in healthy children. However, it can become a significant issue, particularly for children with underlying neuromuscular conditions like cerebral palsy.

Too much saliva being produced is rarely the cause of drooling. Instead, it often happens due to inefficient, uncoordinated, or infrequent swallowing. This excess saliva can irritate the skin on the face, neck, and chest, leading to social stigma. In severe cases, it may even result in aspiration pneumonia and hospital admissions for the child.

What is Botulinum Toxin Type A (‘Botox’)?

Botulinum toxin Type A, is commonly known as ‘Botox’. It is a natural substance that when used in precise doses, it can effectively relax excessive muscle contraction.

How does Botulinum Toxin help with drooling?

Saliva production by our salivary glands is controlled by nerve endings. These nerve endings release a chemical messenger called Acetylcholine where they meet the salivary gland tissue. Botulinum Toxin acts on the nerve endings to prevent release of this chemical. By doing this, it reduces the production of saliva.

What is the role of Botulinum Toxin in managing my child’s drooling?

Every child is unique. Your consultant will discuss an individualised treatment plan that best suits your child’s needs.

While salivary gland injections are an option, there are still other options. These may include simply using bibs and dabbing their mouth, and using exercises that work on swallowing coordination.

Medicines (such as hyoscine patches or glycopyrrolium bromide) can also be used to reduce saliva production. Usually we will try these treatments before Botulinum toxin treatment. However, finding the right balance between reducing saliva and providing an adequate dose can be challenging. There are side effects which include constipation, bladder issues and skin reactions for the patches.

Another alternative is surgery to either clip or reposition the salivary gland ducts.

What happens during the procedure?

Your consultant will tailor the treatment plan based on your child’s specific needs. They will discuss the location and number of injections, as well as whether it will be performed under local or general anaesthesia. Typically, salivary gland injections will be a day case procedure.

During the procedure, your consultant uses ultrasound to precisely find your child’s salivary glands, which are along the jawline. They then guide a small needle through the skin using ultrasound, and inject the Botulinum Toxin in and around the gland. After injecting the Botulinum Toxin, they remove the needle.

Since they make only a tiny puncture in the skin, there is no need for dressing.

What are the risks?

Every general anaesthesia carries a small risk, though it is extremely low. Please refer to our resource about risks of anaesthesia for more information.

The risk of infection is minimal in this procedure as no cuts are made in the skin.

In some cases, the Botulinum Toxin may temporarily affect the jaw muscles, making chewing more difficult.

There is a very slight possibility that the nerves around the salivary glands could be affected, leading to swallowing difficulties and the risk of food and drink entering the lungs. The use of ultrasound to locate the glands significantly reduces this chance.

It is important to note that salivary gland injections with Botulinum Toxin are not a permanent solution, and their effectiveness varies among children. If the injections are effective, you should notice a reduction in dribbling and drooling between 3 and 8 days after the procedure. Positive effects may take longer in some children, sometimes up to 6 weeks, and partial effects are possible. The effect of the injections generally last between 3 and 6 months, so repeat procedures may be needed in the future.

What should I expect after the procedure?

If your child does not need further treatment in the hospital, you can return home once they have recovered from the anaesthesia.

Your child may experience pain or discomfort around the injection site, which should only last for a couple of days. Simple pain relief with paracetamol is usually enough to make them feel more comfortable.

In the days following the injections, some children may have mild flu-like symptoms. If necessary, you can use paracetamol to treat these symptoms. Usually, children should feel well enough to return to school the day after the injections.

What should I watch out for?

Contact the hospital if:

• the injection site appears red, swollen, or feels hotter than the surrounding skin
• the injection site is oozing
• your child experiences difficulty swallowing or chewing
• your child is in significant pain that does not improve with pain relief
• your child has a temperature of 38 degrees Celsius or higher

What happens when the Botulinum Toxin wears off?

Depending on your child’s response to therapy, they may be a able to have more injections.

Your consultant will discuss more definitive surgical options, such as clipping or repositioning the salivary gland ducts or gland excision.

During your follow-up appointment, you and your child’s consultant will help to create an individualised treatment plan.

If you have any further questions or concerns, please do not hesitate to contact us.