Botulinum Toxin Injections for ADSD and Chronic Salivary Aspiration

Voice-Related Quality of Life

Another scientific session at COSM addressed the variations in voice-related quality of life (VRQOL) experienced by patients with ADSD after receiving BTX injections, based on a prospective, nonrandomized case series. Researchers from the Washington University School of Medicine in St. Louis collected voice recordings and clinical outcomes data from 22 patients by telephone every two weeks throughout one to three injection cycles (average cycle = 25.9 weeks).

On a 100-point scale, the total VRQOL scores peaked at 77.4 at 30% of the cycle, but then gradually declined. The social-emotional (SE) subscale scores were significantly better than the physical subscale scores (p < 0.05). The total VRQOL score exceeded 75 during only 14% of the cycle (52.6% for SE subscores, 0% for physical subscores).8

If the threshold was lowered to 70, the total VRQOL exceeded this level during 54.6% of the cycle (69.6% for SE subscores, 44.1% for physical subscores). For the 11 patients completing three full injection cycles, there were no significant differences between the three cycles, and the mean VRQOL scores were similar to the values above. At the beginning and end of each cycle, the total VRQOL scores averaged 52.8 (56.0 for SE subscale, 50.7 for physical subscale).9

The researchers concluded that although BTX injections provide significant improvement for these patients, the initial breathy phase and the late declining phase add up to a significant proportion of each cycle spent with a reduced quality of life. Since the total VRQOL averages were below 80% at best, the authors believe that a suitable long-term treatment for ADSD is needed to eliminate the cyclical voice results experienced with BTX therapy.

Until this happens, the dose stability, as well as the initial dose, do improve the breathiness and dysphagia aspects of ADSD, said Dr. Holden. The late declining phase can also be improved insofar as the relative consistency of dose interval can make the return of SD symptoms more predictable.

Chronic Salivary Aspiration

BTX therapy is also being used to reduce sialorrhea, which is a common problem in neurologically impaired children and adults that can lead to chronic salivary aspiration, and subsequently, recurrent aspiration pneumonia.

Although glycopyrrolate, an anticholinergic medication, is still the first choice for patients with chronic salivary aspiration who have no contraindications, certain patients will either develop tachyphylaxis or side effects, requiring that the dose be lowered, said Tejas H. Raval, MD, from the Department of Otolaryngology-Head and Neck Surgery at Tufts New England Medical Center in Boston, during his scientific session presentation at COSM. For these patients, BTX offers an excellent option to either replace the glycopyrrolate or allow better control of secretions with a combined modality treatment that minimizes side effects.