The use of botulinum toxin injections to manage drooling in amyotrophic lateral sclerosis/motor neurone disease: a systematic review.

Difficulty in managing oral secretions is commonly experienced by patients with amyotrophic lateral sclerosis (ALS)/motor neurone disease (MND) and associated bulbar weakness including dysphagia. There are no definitive evidence-based treatment guidelines to manage the distressing symptom of drooling. We reviewed the evidence for the effectiveness of botulinum toxin injections to reduce saliva in ALS/MND. The search strategy was conducted in four stages: (1) electronic search of relevant databases, (2) hand searches of all international ALS/MND symposium journals, (3) email request to MND care centres in the UK and Ireland, and (4) hand searching of reference lists. All studies were critically appraised and relevant data extracted. Botulinum toxin type A and type B were analysed separately. Due to heterogeneity, it was not possible to calculate a pooled estimate of effect. Twelve studies met the inclusion criteria (9 for type A and 3 for type B). Only two randomised controlled trials were identified. Study sample sizes were small with a mean of 12.5 subjects. The most frequently reported outcomes were weight of cotton rolls and number of tissues used. All studies claimed the intervention tested was effective, but only seven studies (4 for type A and 3 for type B) reported statistically significant differences. Although there is evidence to suggest that botulinum toxin B can reduce drooling, the evidence base is limited by a lack of randomized controlled trials. Evidence to support the use of botulinum toxin A is weaker. Larger trials will help remove the uncertainty practitioners face in treating this disabling symptom.

The management of drooling in adults with neurological conditions.

PURPOSE OF REVIEW: Drooling is a distressing symptom for adults with neurological conditions and can be challenging for health professionals. This review will consider the physical and psychosocial impact of drooling and will discuss the current management options including behavioural, pharmacological and surgical approaches. RECENT FINDINGS: A number of studies describe the use of botulinum toxin injections and irradiation of the salivary glands but no conclusive guidelines exist to recommend the most efficient dose or technique. The majority of saliva management studies focus on children with physical and/or cognitive disabilities and this evidence cannot be generalized to adults. There are relatively few studies that focus on saliva management in the adult neurological population. SUMMARY: Drooling is distressing for patients and their families. Ideally an individual would have easy access to the most efficient treatment with the fewest side effects. More evidence is now available but a lack of consensus on management approach, treatment dose and administration technique still exists. The symptom of drooling is best managed by a multidisciplinary team, starting with a conservative approach and then leading to more invasive procedures as appropriate.