Botulinum Toxin Injections for ADSD and Chronic Salivary Aspiration

Ultrasound-guided BTX injections into the bilateral submandibular and parotid glands block the parasympathetic innervation of salivary glands, resulting in a temporary decrease in saliva production and improved quality of life.

This is a technically simple procedure with no reported side effects, which can be done under minimal sedation or local anesthetic at the bedside, resulting in little to no postoperative pain or recovery period, added Dr. Raval. The main disadvantage is that the effects last from only 8 to 12 weeks and must be repeated at this interval to maintain optimal efficacy. This is a very important point to stress to the patient and family.

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. 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.

-Tejas H. Raval, MD

As few reports exist regarding the efficacy of this treatment in the prevention of recurrent aspiration pneumonia, Dr. Raval performed a retrospective chart review of 12 patients (7 months to 37 years of age) treated with BTX injections at a single tertiary care institution, as well as a caregiver telephone questionnaire. The number of pulmonary infections and hospitalizations before and after the initiation of treatment were compared.

Nine of the 12 patients experienced improvement in both the number of diagnoses of aspiration pneumonia and of hospital admissions before and after BTX therapy. Of the nine patients showing improvement, the average yearly episodes of pneumonia or lower respiratory tract infection improved from 4.2 (± 3.2) to 1.0 (±0.7). The same group showed an improvement in hospital admissions for aspiration pneumonia from 1.8 (±1.7) to 0.3 (±0.7). Improvements in anticholinergic medication use and pulmonary toilet requirements were also noted and there were no complications of treatment.10

Based on his research, Dr. Raval concluded that BTX injection into the major salivary glands could be a viable option for many neurologically impaired patients for the treatment of chronic salivary aspiration and recurrent aspiration pneumonia. It may allow for a reduction in anticholinergic medications and obviate the need for surgery. For patients who respond well to BTX treatment, there is the potential to improve pulmonary health, as well as both patient and caregiver quality of life, through regularly repeated injections.