A systematic review of the perspectives of botulinum toxin use on the quality of life of neurological patients with drooling.

OBJECTIVE: To investigate the effectiveness of botulinum toxin in the salivary glands of patients with neurological impairment and drooling and its impact on the quality of life. MATERIALS AND METHODS: This systematic review was registered with the International Prospective Register of Systematic Reviews (CRD 42,023,435,242) and conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses. An electronic search was performed in the PubMed/MEDLINE, Embase, Scopus, Cochrane Library, and clinical trial databases until August 2023, no language restriction. Cohort studies and randomized clinical trials of patients diagnosed with drooling and neurological impairment who used botulinum toxin on the salivary gland were included, which evaluated subjective quality of life parameters. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist and Risk of Bias 2 tools. The certainty of the evidence was analyzed using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS: Eight studies involving 317 patients were included. All studies, through subjective parameters, suggested the effectiveness of botulinum toxin in reducing drooling, resulting in an improvement in the quality of life. Three studies demonstrated improvements in swallowing and four in cases of respiratory diseases. Two clinical trials had a high risk of bias, whereas one had low risk. The five cohort studies that were evaluated had a high risk of bias. The certainty of the evidence was considered low. CONCLUSIONS: Based on the patient/caregivers' perception of improvement in drooling, dysphagia, and respiratory symptoms, it can be inferred that botulinum toxin application reduces subjective drooling in neurologically compromised patients. Its impact contributes to the general well-being and quality of life. CLINICAL RELEVANCE: Injection of botulinum toxin into the salivary glands can be considered an alternative technique to surgical or medicinal approaches in reducing drooling. It is effective, less invasive and without significant side effects. It promotes a positive impact on the well-being and quality of life of neurological patients.

The state of the art in therapeutic administration of botulinum toxin in children with cerebral palsy: an integrative review.

OBJECTIVE: To describe the current state of the art in the therapeutic administration of botulinum toxin with indications, efficacy, and safety profile for children and adolescents with cerebral palsy. DATA SOURCE: An integrative review was conducted. The MEDLINE/PubMed database was searched twice within the last decade using distinct terms, and only studies written in the English language were included. The study population was limited to those aged 0-18 years. Articles that were duplicates or lacked sufficient methodology information were excluded. DATA SYNTHESIS: We found 256 articles, of which 105 were included. Among the included studies, most were conducted in developed countries. Botulinum toxin demonstrated good safety and efficacy in reducing spasticity, particularly when administered by a multidisciplinary rehabilitation team. It is primarily utilized to improve gait and upper limb function, facilitate hygiene care, reduce pain, prevent musculoskeletal deformities, and even decrease sialorrhea in patients without a functional prognosis for walking. CONCLUSIONS: The administration of botulinum toxin is safe and efficacious, especially when combined with a multi-professional rehabilitation team approach, which increases the probability of functional improvement. It can also be beneficial for patients with significant functional impairments to help with daily care tasks, such as hygiene, dressing, and reducing sialorrhea. Pediatricians must be familiar with this treatment and its indications to attend to and refer patients promptly when necessary, and to exploit their neuroplasticity. Further research on this topic is required in developing countries.

Comparative Efficacy and Side Effect Profiles of Interventions for Pediatric Saliva Control: A Cohort Study.

OBJECTIVE: To compare efficacy and side effect profile data on conservative, behavioral, pharmacological, and surgical treatments used for pediatric saliva control. STUDY DESIGN: A cohort study of children (n = 483) referred to a specialty Saliva Control service between May 2014 and November 2019 was performed, using quantitative data from pretreatment and post-treatment questionnaires (the Drooling Impact Scale [DIS], Drooling Rating Scale [DRS]) and recording of side effects. Overall, 483 children were included; treatment choices were based on published international guidelines. RESULTS: The greatest improvement was seen after intraglandular botulinum toxin A (BTX-A) injections (n = 207; 551 courses; mean DIS change, 34.7; 95% CI = 29.2-35.7) or duct transpositional surgery (n = 31; mean change in DIS, 29.0; 95% CI, 22.3-35.7). Oral anticholinergics were associated with good outcomes, with no significant statistical difference between glycopyrronium bromide (n = 150; mean DIS change, 21.5; 95% CI, 19.1-24.0) or trihexyphenidyl (n = 87; mean DIS change, 22.4; 95% CI, 18.9-25.8). Inhaled ipratropium bromide was not as efficacious (n = 80; mean DIS change, 11.1; 95% CI, 8.9-13.3). Oromotor programs were used in a selected group with reliable outcomes (n = 9; mean DIS change, 13.0). Side effects were consistent with previous studies. Overall, in cases of milder severity, enterally administered therapies provided a good first-line option. With more severe problems, BTX-A injections or saliva duct transpositional surgery were more effective and well tolerated. CONCLUSIONS: We describe a large, single-center pediatric saliva control cohort, providing direct comparison of the efficacy and side effect profiles for all available interventions and inform clinical practice for specialists when considering different options. BTX-A injections or saliva duct transpositional surgery seem to be more effective for saliva control that is more severe.

Cirugía de desfuncionalización de glándulas salivales mayores en sialorrea masiva / Major salivary gland defunctionalization surgery in massive sialorrhea

Introducción: La sialorrea es la pérdida involuntaria de saliva de la boca, ya sea debido a la producción excesiva de saliva o disminución de la frecuencia de deglución. Se habla de sialorrea patológica cuando persiste más allá de los 4 años de edad. Además de las implicaciones sociales, cambios de ropa frecuentes, puede provocar neumonías por aspiración y deshidratación. El manejo de la sialorrea requiere una evaluación completa con un enfoque de equipo multidisciplinario para el tratamiento, que incluye terapias no farmacológicas, farmacológicas y quirúrgicas. Objetivo: Presentar resultados quirúrgicos y farmacológicos en el tratamiento de sialorrea masiva. Material y Método: Se realizó revisión de historias clínicas de 7 pacientes portadores de sialorrea masiva. Todos los pacientes incluidos fueron refractarios a tratamiento médico. El diagnóstico fue obtenido por un equipo multidisciplinario. Se les realizó desfuncionalización quirúrgica y farmacológica de glándulas salivales. Se les aplicó Escala de Severidad (DSS) y escala de frecuencia (DFS), previo a cirugía y posterior a procedimiento hasta el año. Resultados: Mejoría clínica subjetiva posterior a desfuncionalización quirúrgica con disminución de DSS y DFS. Disminución promedio de baberos a 10/día. Conclusión: Los resultados obtenidos son buenos, si se consideran las escalas DSS, DFS y el número de baberos al día, que son mediciones tanto subjetivas y objetivas respectivamente.

Introduction: Massive Sialorrhea is the involuntary loss of saliva from the mouth, either due to excessive saliva production or decreased swallowing frequency. We speak of pathological sialorrhea when it persists beyond 4 years old. In addition to the social implications and frequent clothing changes. It can cause aspiration pneumonia and dehydration. Treatment for sialorrhea requires a comprehensive evaluation with a multidisciplinary team approach. Including non-pharmacological, pharmacological, and surgical therapies. Aim: Presentation of the results of surgical defunctionalization of the salivary glands plus injection of Botulinum Toxin in the treatment of massive sialorrhea. Material and Method: A review of the clinical records of 7 patients with massive sialorrhea was carried out. All included patients were refractory to medical treatment. The diagnosis was obtained by a multidisciplinary team. Surgical and pharmacological dysfunctionalization of salivary glands was performed. Severity Scale (DSS) and Frequency Scale (DFS) were applied before surgery and after the procedure up to a year. Results: Subjective clinical improvement after surgical defunctionalization with decreased SHD and DFS. Average decrease in bibs to 10/day. Conclusion: The evaluated strategy presented similar benefits with respect to the literature. The SHD and DFS scales and the number of bibs per day are both subjective and objective measurements, respectively, and allow the clinical improvement and quality of life of patients undergoing surgery to be evaluated individually.

Effectiveness of the pharmacological treatments for sialorrhea in patients with Parkinson's disease: a systematic review and network meta-analysis.

OBJECTIVES: The present systematic review and network meta-analysis of randomized control trials (RCTs) aimed to establish whether there are evidence-based differences in the pharmacological agents used to manage sialorrhea in patients with Parkinson's disease (PD). MATERIAL AND METHODS: The authors searched the databases: MEDLINE via PubMed, EMBASE, Scopus, Web of Science, and Cochrane Library for clinical trials. Unpublished trials were searched on clinicaltrials.gov and the Brazilian Clinical Trials Registry. Means and standard deviations of changes in the salivary flow or drooling reported by participants due to the interventions were recorded. RESULTS: The authors analyzed 13 RCTs. Compared to the placebo, types A and B of the botulinum toxin effectively reduced the salivary flow and the severity or frequency of drooling. However, the network meta-analysis did not differentiate between the botulinum toxin types. Ipratropium bromide and glycopyrrolate did not differ from the placebo. Indirect evidence showed that ipratropium had similar results to those obtained with both types of botulinum toxin. The CINeMA approach estimated the quality of the evidence as very low for all comparisons. CONCLUSION: The best treatment for sialorrhea in patients with PD is not fully elucidated yet. Therefore, more well-conducted randomized clinical trials are required to increase the level of evidence. CLINICAL RELEVANCE: There needs to be more evidence defining the best intervention to treat sialorrhea in patients with PD. However, botulinum toxin types A and B seem to reduce sialorrhea in patients effectively.

Effectiveness and safety of botulinum toxin in comparison with surgery for drooling in paediatric patients with neurological disorders: a systematic review.

Different therapeutic methods for chronic drooling in paediatric patients with neurological problems have been described in the scientific literature. However, there is no consensus on the ideal strategy of treatment. The aim of this study was to compare botulinum toxin injection therapy and surgical modalities to control drooling in paediatric patients with neurological disorders. A systematic literature search was conducted on nine electronic databases for publications until April 2020. Six articles were included with a total sample of 209 patients, 67.4% (n = 141) of whom had cerebral palsy. All studies used injections of botulinum toxin type A with application to the submandibular and/or parotid salivary glands. The surgical treatments were duct ligation in the parotid and/or submandibular salivary glands, duct relocation in the submandibular salivary glands, and glandular excision of the submandibular and sublingual salivary glands. There were complications in only 16.1% (n = 27) of the sample (11 cases due to botulinum toxin application and 16 due to surgery). Drooling control was assessed by objective and subjective measures. Although surgical procedures presented a higher risk of adverse effects than botulinum toxin type A in all the studies and measurements performed, they presented larger and longer-lasting positive effects on drooling. We suggest bilateral submandibular duct relocation with bilateral sublingual gland excision or isolated bilateral submandibular duct ligation, which were the surgical techniques with the largest samples in this review. Nevertheless, further studies are necessary to compare samples with botulinum toxin type A and surgical treatment.

Translation and validation of the drooling impact scale questionnaire into Brazilian Portuguese.

INTRODUCTION: Inadequate drooling can cause serious clinical, functional and social problems. Validated questionnaires to evaluate drooling impact on quality of life are lacking in Brazilian Portuguese. OBJECTIVES: To translate and validate the drooling impact scale to Brazilian Portuguese. METHODS: The drooling impact scale was translated to Brazilian Portuguese and back- translated to English to assess potential conceptual differences. Brazilian Portuguese version of drooling impact scale was applied to a 40 patients' sample of sialorrhea presenting pediatric patients (up to 20 years of age). Chronbach's alpha, exploratory factorial analysis and confirmatory factorial analysis were then proceeded with data collected. RESULTS: The mean drooling impact scale value for the whole population was 51.77 (SD = 16.13). The internal consistency obtained with Cronbach's alpha indicated a value of 0.72 for the entire sample. The Bartlett's test of sphericity was significant (p <  0.0001), confirming correlation among variables tested. Kaiser-Meyer-Olkin measure of sampling adequacy revealed a value of 0.72, indicating that the correlation matrix was reasonably suitable for factor analysis. Regarding exploratory factorial analysis, parallel analysis suggested a two-factor solution that was used for confirmatory factorial analysis. The first factor was responsible for 33.78% of the variance with an Eigenvalue of 3.38. The second factor explained 16.1% of the variance with an Eigenvalue of 1.61. At confirmatory factorial analysis, the two-factor model showed consistently better adjustments parameters than the one-factor model. CONCLUSION: The drooling impact scale has been successfully translated to Brazilian Portuguese language, showing adequate internal validity. Validation of this instrument allows physicians and other personnel involved in the care of these patients to perform a better management of patients experiencing drooling. With this tool, we are now able to guide routines and provide guidelines both before and after the different kinds of treatments in order to improve the general well-being of the patient and his family.

Análise do nível de conhecimento das manifestações orais causadas pelo uso de anticonvulsivantes / Analysis of knowledge level of oral manifestations caused by the use of anticonvulsants

Analisar o nível de conhecimento dos usuários de anticonvulsivantes e dos cirurgiões-dentistas a res peito das manifestações orais ocasionadas pela medicação. Trata-se de um estudo transversal realizado no munícipio de Vitória de Santo Antão, em Pernambuco, no qual participaram 30 Odontólogos e 16 usuários de anticonvulsivantes das unidades de saúde da família do município. Foram aplicados questionários sobre o conhecimento dos profissionais e percepção dos usuários sobre as manifestações orais ocasionadas pela medicação. Para avaliar associação entre duas variáveis categóricas foi utilizado teste Exato de Fisher, quando a condição para utilização do teste Qui-quadrado não foi verificada. A análise dos dados demonstrou que 86,7% dos cirurgiões-dentistas conhecem os anticonvulsivantes e 50,0% dos usuários não receberam orientação do dentista sobre a medicação e os seus efeitos adversos. Há escassez de conhecimentos específicos sobre os efeitos adversos do uso de anticonvulsivantes na cavidade bucal por parte dos usuários e cirurgiões-dentistas... (AU)

To analyze the knowledge level of anticonvulsants users and the dental surgeons concerning the oral manifestations caused by the medication. A cross-sectional study conducted in Vitória de Santo Antão, Pernambuco, Brazil, with participation of 30 dentists and 16 anticonvulsants users from the city's family health units. Questionnaires about the knowledge of professionals and users' perception of manifestations in the oral cavity caused by the medication. Fisher's Exact test was used to assess the association between two categorical variables when the condition for using the chi-square test was not verified. The data analysis showed that 86,7% of dental surgeons know the anticonvulsants and 50,0% of users do not receive orientation from the dentist about the medication and its adverse effects. There is a shortage of specific knowledge about the adverse effects of the use of anticonvulsants in the oral cavity, by users and dental surgeons... (AU)

The impact of botulinum toxin type A in the treatment of drooling in children with cerebral palsy secondary to Congenital Zika Syndrome: an observational study.

OBJECTIVE: The main aim of this study was to determine the impact of botulinum toxin A (BTX-A) on severity and frequency of drooling in children with Cerebral Palsy (CP) secondary to Congenital Zika Syndrome (CZS). METHODS: This is a prospective longitudinal observational study including 23 children who received bilateral injections of BTX in the parotid and submandibular glands. The Thomas-Stonell & Greenberg Drooling Severity and Frequency Scale was applied by a multidisciplinary team including Speech, Language and Hearing professionals. The Global Impression of Improvement (GII) Scale was also applied to assess parents' subjective perceptions of therapeutic response. Swallowing was assessed using Doppler ultrasonography. Univariate logistic regression was used to analyse differences between responders and non-responders. RESULTS: Participant age varied from 27 to 38 months (mean 31.78, SD = 2.61) all presented with Gross Motor Function Classification System (GMFCS) V. Drooling Severity and Frequency Scale scores ranged from 7 to 9 points (median = 9) prior to BTX administration and from 4 to 6 (median = 6) after. Pre- and post-treatment reduction in drooling severity occurred (Z = -3.746; p < 0.001). No cases of drooling worsening were reported. Only two subjects presented adverse effects attributed to BTX administration. Correlation was only confirmed with GII. DISCUSSION: This article presents the safe and positive impact of BTX-A administration guided by anatomical references described in the literature, even on children with microcephaly. Further studies are needed to facilitate the use of Doppler ultrasonography as a tool to characterize changes in sensory processing and motor response following intraoral input in children with CP.

Self-limited epilepsy with centro-temporal spikes: A study of 46 patients with unusual clinical manifestations.

PURPOSE: We retrospectively analyzed the seizure characteristics, EEG pattern, treatment, and outcome in a series of patients with self-limited epilepsy with centrotemporal spikes (SLECTS) who presented with unusual clinical manifestations. METHOD: A retrospective, descriptive, multicenter study was conducted evaluating 46 patients with SLECTS who had seizures with an unusual semiology. We collected data from patients with SLECTS seen at eight Argentine centers between April 1998 and April 2018. RESULTS: Thirteen patients (28.2 %) had seizures with affective symptoms characterized by sudden fright and autonomic disturbances and mild impairment of consciousness. Eleven patients (24.8 %) had frequent seizures characterized by unilateral facial sensorimotor symptoms, oropharyngolaryngeal manifestations, and speech arrest with sialorrhea only when awake. Seven patients (15.3 %) started with opercular epileptic status with unilateral or bilateral clonic seizures of the mouth with speech arrest and sialorrhea when awake and during sleep. Seven patients (15.3 %) had postictal Todd's paralysis after unilateral clonic seizures with facial and limb movements lasting between 60 min and 130 min. Six patients (13 %) had negative myoclonus, two in a unilateral upper limb, two in a unilateral lower limb, and the remaining two patients had frequent falls. One patient (2.1 %) had focal sensorimotor seizures characterized by unilateral numbness in the cheeks and one upper limb, additional to unilateral facial clonic seizures, speech arrest, and sialorrhea. The remaining patient (2.1 %) had sporadic focal tonic-dystonic seizures in the left upper limb only during sleep. CONCLUSION: In our study, we found evidence of the existence of unusual clinical cases of SLECTS with typical EEG patterns and an excellent prognosis.

Differences of Salivary Ph, Feature, And Volume Of Children At Three Kindergartens With Different Socioeconomic Standard / Diferenças do Ph Salivar, Característica e Volume, de Crianças Em Três Jardins De Infância Com Diferentes Padrões Socioeconômicos

Introduction: Saliva is the most important biological factor to protect against dental caries. When saliva flow is reduced, oral health problems such as dental caries and oral infections can develop. It was suggested that the effect of low salivary pH is more in plaque close to the area of susceptible tooth surface. The presence of saliva in pre-school age children is a significant indicator in oral health assessment oral health. There has been an association between salivary cortisol and socioeconomic variable. Descriptions above have encouraged us to examine the salivary pH, feature, and volume of pre-school-aged community. Thus, this study was aimed to describe the differences in salivary pH, feature, and volume of the children in the three pre-school with different location and socioeconomics aspect. Methods: Descriptive survey, with a population of pre-school students in 3 different kindergartens with different socioeconomic environment. Inclusion criteria were the pre-school-aged community and got permission from parents. Exclusion criteria were a pre-school-aged community under medication treatment causes hyposalivation or hypersalivation and children who did not want to be involved in the study, with total sampling as the sampling technique, resulted in as much a 101 respondents as the study sample. The saliva was collected with unstimulated technique. Data analysis was performed using relative frequency distribution. Results: The salivary pH was slightly higher in male children than female by 0.1. The average pH value was 7.25. The salivary feature was mostly frothy bubbly, followed by thin and watery, and the sticky bubbly feature was found the least. The salivary volume of the pre-school-aged community was mostly in the very less category, followed by the less category, with no normal category was found. the p-values of salivary pH and salivary features were below 0.05 There are no significant differences between the salivary pH and salivary feature of children from the three studied kindergartens. However, there is a significant difference in the salivary volume found in children from kindergartens located in high socioeconomic standard and middle socioeconomic standard areas, which have a higher salivary volume than the children from kindergartens situated in areas with lower socioeconomic standard. Conclusion: since the reduced salivary volume was associated to children with lower socioeconomic standard, this association can justify the higher risk for caries described in the literature (AU)

Introdução: A saliva é o fator biológico mais importante na proteção contra a cárie dentária. Quando o fluxo salivar é reduzido, podem ocorrer problemas na saúde bucal, como cáries e infecções orais. Foi sugerido que o efeito do baixo pH salivar é aumentado na placa, próxima à área de superfície dentária suscetível. A presença de saliva em crianças em idade pré-escolar é um indicador significativo na avaliação da saúde bucal. Houve associação entre cortisol salivar e variáveis socioeconômicas. As descrições acima nos encorajaram a examinar o pH salivar, características e volume da comunidade em idade pré-escolar. Assim, este estudo teve como objetivo descrever as diferenças de pH, característica e volume salivar das crianças de três pré-escolas com localização e aspectos socioeconômicos distintos. Material e Métodos: Pesquisa descritiva, com população de estudantes da pré-escola de três diferentes jardins de infância com diferentes ambientes socioeconômicos. Os critérios de inclusão foram comunidade em idade pré-escolar e permissão dos pais. Os critérios de exclusão foram comunidade em idade pré-escolar sob tratamento medicamentoso que causa hipossalivação ou hipersalivação e também crianças que não quiseram se envolver no estudo, com amostragem total resultando em 101 entrevistados como a amostra do estudo. A saliva foi coletada com a técnica não estimulada. A análise dos dados foi realizada usando distribuição de frequência relativa. Resultados: O pH salivar foi ligeiramente superior nas crianças do sexo masculino do que no feminino em 0,1. O valor médio do pH foi de 7,25. O aspecto salivar era principalmente espumoso com bolhas, seguido de aspecto tênue e aguado, e o aspecto pegajoso e espumante foi o menos encontrado. O volume salivar dos estudantes em idade pré-escolar encontrava-se majoritariamente na categoria inferior a todas, seguida da categoria menos, não sendo encontrada nenhuma categoria normal, onde os valores de p do pH salivar e características salivares estavam abaixo de 0,05. Não há diferenças significativas entre o pH salivar e a característica salivar das crianças dos três diferentes jardins de infância estudados. No entanto, existe uma diferença significativa no volume salivar encontrado em crianças de creches localizadas em áreas de médio e alto padrão socioeconômico, que apresentaram maior volume salivar do que as crianças de creches situadas em áreas de menor padrão socioeconômico. Conclusão: O volume salivar reduzido esteve associado a crianças com menor padrão socioeconômico, logo essa associação pode justificar o maior risco de cárie descrito na literatura. (AU)

State-of-the-art pharmacotherapy for autonomic dysfunction in Parkinson's disease.

Introduction: Autonomic dysfunction is one of the most frequent and disabling non-motor symptoms of Parkinson's disease (PD). It includes, among others, orthostatic hypotension (OH), sialorrhea, constipation, erectile dysfunction (ED), urinary dysfunction, and diaphoresis. They are usually under-recognized and suboptimally managed.Areas covered: Recommended treatments for dysautonomias are summarized with a description of the mechanism of action and observed results. The pathophysiology of each disorder is reviewed to pinpoint possible therapeutic targets. Drugs approved for treating dysautonomia in the general population along with those under development for PD-related dysautonomia are also reviewed. Finally, the key elements of each symptom that should be addressed in clinical trials' design are considered.Expert opinion: Midodrine, droxidopa, fludrocortisone, and domperidone may be used for OH treatment. Sialorrhea can be managed with botulin toxin injections and oral glycopyrrolate. Erectile dysfunction can benefit from sildenafil treatment, as urinary dysfunction can from solifenacin. Macrogol, lubiprostone, and probiotics might be effective in treating constipation. Further research is needed to determine adequate treatment for diaphoresis in PD patients. Multidisciplinary management of motor and non-motor symptoms in PD is the best approach for dysautonomias in PD.

[Nemaline rod myopathy treated with L-tyrosine to relieve symptoms in a neonate]. / Miopatía nemalínica tratada con L-tirosina para aliviar los síntomas en un recién nacido.

Nemaline myopathy (NM) is a heterogeneous disorder defined by the presence of rod-shaped structures known as nemaline bodies or rods. The diagnosis is based on muscle weakness, combined with visualization of nemaline bodies on muscle biopsy. There is no curative treatment for nemaline myopathy. Therapeutic strategies for this condition are symptomatic and empirical. Herein, we present a newborn with severe respiratory failure and generalized muscle weakness, who was diagnosed as NM by muscle biopsy. The patient experienced remarkable decrease in sialorrhea and improvement of spontaneous movements after L-tyrosine treatment. This case is presented to emphasize the importance of muscle biopsy in the differential diagnosis of severe hypotonia during neonatal period and a possible benefit of L-tyrosine supplementation for decreasing sialorrhea and restoring muscle strength.

La miopatía nemalínica es un trastorno heterogéneo definido por la presencia de estructuras con forma de bastones, conocidas como cuerpos nemalínicos (o bastones de nemalina). El diagnóstico se funda en la debilidad muscular, además de la visualización de cuerpos nemalínicos en la biopsia muscular. La miopatía nemalínica no tiene cura. Las estrategias terapéuticas para este trastorno son sintomáticas y empíricas. En este artículo, presentamos el caso de una recién nacida con insuficiencia respiratoria grave y debilidad muscular generalizada, a la que se le diagnosticó miopatía nemalínica a través de la biopsia muscular. La paciente tuvo una notable disminución de la sialorrea y una mejora de los movimientos espontáneos después del tratamiento con L-tirosina. Este caso se presenta para destacar la importancia de la biopsia muscular en el diagnóstico diferencial de la hipotonía grave durante el período neonatal y el posible beneficio del aporte suplementario de L-tirosina para disminuir la sialorrea y restaurar la fuerza muscular.

Absceso periamigdalino bilateral en pediatría: reporte de un caso / Bilateral peritonsillar abscess in children: case report

El absceso periamigdalino es la complicación más frecuente de la amigdalitis aguda bacteriana, definido como la presencia de pus entre la cápsula periamigdalina y el músculo constrictor superior de la faringe. Habitualmente, su presentación es unilateral; es rara su afectación bilateral. Es más frecuente en adultos y poco común en niños. Cuando es bilateral, el paciente presenta odinofagia, trismus, sialorrea, fiebre y voz gutural, síntomas que comparte con el absceso unilateral, pero, en el examen físico, se evidencia abombamiento de ambos pilares anteriores, edema de úvula y paladar blando, sin asimetrías de las estructuras faríngeas. Se requiere un alto nivel de sospecha clínica para lograr el diagnóstico temprano. El manejo de la vía aérea, que podría ser dificultoso, es un aspecto importante en el tratamiento. Se presenta el caso clínico de un niño con absceso periamigdalino bilateral; se describe el proceso diagnóstico y terapéutico.

Peritonsillar abscess is the most common complication of acute bacterial tonsillitis, defined as the presence of purulent exudate between the peritonsillar capsule and the superior constrictor muscle of the pharynx. Usually, its presentation is unilateral; its bilateral involvement is rare. It is more common in adults, being uncommon in children. Clinically, it presents odynophagia, trismus, sialorrhea, fever, guttural voice, symptoms that it shares with the unilateral abscess, evidencing in the physical examination bulging of both anterior pillars, edema of the uvula and soft palate, but without asymmetries of pharyngeal structures. A high level of clinical suspicion is required to achieve early diagnosis. The management of the airway, which could be difficult, is an important aspect in the treatment. It is reported the clinical case of a child with bilateral peritonsillar abscess, the diagnostic and therapeutic process.

Effects of chronic treatment with botulinum toxin type A in salivary glands of rats: Histological and immunohistochemical analyses.

BACKGROUND: The intraglandular application of botulinum neurotoxin type A (BoNT-A) is used in patients with neuromotor disorders to control the escape of saliva. The aim of this study was to analyze the impact of repeated treatment with BoNT-A on the submandibular-sublingual complex of rats. METHODS: A total of 35 Wistar rats were divided into three groups: control group (C), in which animals were not treated; group B, treated with 2.5 U intraglandular injections of BoNT-A (Prosigne® ) and group G, that received bovine gelatine (Prosigne stabilizer). Three applications were performed in intervals of 35 days. Twelve and 35 days after ending the treatment, submandibular-sublingual complex was collected for histological analysis. Immunohistochemical reactions for calponin and specific muscle actin were also performed, besides detection of apoptosis by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) assay. RESULTS: A decrease in mucosal and serous acini diameter was observed, with increased interstitial space after 12 days of treatment with BoNT-A, which was observed in a lesser degree on the 35th day. At 12 days, immunohistochemical analysis revealed a decrease in myoepithelial cells of serous acini in group B. TUNEL methods evidenced apoptosis in animals from group B. CONCLUSIONS: BoNT-A caused histological and cellular changes in submandibular-sublingual complex, followed by a tendency toward reversal after 35 days. The reversal characteristic of cellular changes in the submandibular-sublingual complex suggests that this BoNT-A formulation may be safely used for sialorrhea treatment.

Effects of treatments for drooling on caries risk in children and adolescents with cerebral palsy.

BACKGROUND: Neuromuscular impairment makes individuals with cerebral palsy (CP) more prone to drooling. Among the treatment options, there are procedures that interfere with saliva production. It is imperative to evaluate the effect of the different modalities since the reduction in salivary flow rate/production may exacerbate the risk of dental caries. MATERIAL AND METHODS: The aim of this study was to compare the effects of different treatments for drooling on caries risk and salivary parameters in children and adolescents with CP. STUDY DESIGN: A total of 142 children and adolescents with CP, aged 6 to 18 years, were assigned to groups based on the different treatments they had received for drooling: G1-anticholinergic drugs (n = 18), G2-botulinum toxin injection (n = 16), G3-salivary glands surgery (n = 16), G4-no treatment (n = 42), and G5-non-drooling subjects (n = 50). All participants were evaluated on the Simplified Oral Hygiene Index, and for the prevalence of dental caries (decayed, missing, and filled teeth index and white spot lesions). Unstimulated whole saliva was collected, and salivary flow rate and osmolality were measured. Chi-square, ANOVA and Poisson regression were calculated. Prevalence ratios and their respective 95 % confidence intervals were obtained. The significance level was fixed at 5%. RESULTS: No differences were found in the decayed, missing, and filled teeth index (p = 0.128) and Simplified Oral Hygiene Index (p = 0.674) among the different groups. G3 presented significantly higher percentages of WSL (p < 0.001), lower values of salivary flow rate (p < 0.001), and higher values of osmolality (p < 0.001). The white spot lesion prevalence ratio was higher only for G3 (Prevalence ratio = 14.36; IC 95% = 4.64-44.40; p < 0.001). CONCLUSIONS: Children and adolescents with CP who had received surgical treatment for drooling exhibited higher number of white spot lesions because of the reduced salivary flow rate and higher salivary osmolality.

Qualitative and quantitative scintigraphy in sialorrhea before and after botulinum toxin injection.

OBJECTIVES/HYPOTHESIS: Sialorrhea is excessive saliva production and its usual escape of from the oral cavity. The use of botulinum toxin has been preconized, but its effectiveness until now has been unreliably measured. Our objective was to qualitatively and quantitatively determine the effectiveness of botulinum toxin injection in the reduction of saliva production by the parotid gland. STUDY DESIGN: Outcomes research. METHODS: Patients with moderate-to-critical sialorrhea had one of the parotid glands injected with 50 U of botulinum toxin, leaving the other as the control. Fifteen days after the toxin injection, they underwent scintigraphic analyses with intravenous injection of 10 mCi (37 MBq) of Tc-99 m (sodium pertechnetate). After this, the noninjected gland was treated for therapeutic complementation. RESULTS: The glands injected with botulinum toxin showed uptake reduction in 100% of patients. The uptake reduction in counts per second varied from 8% to 36%. The Wilcoxon paired test comparing the control glands with those injected showed a significant difference for the action of botulinum toxin (P = .0039). CONCLUSIONS: The scintigraphic study of parotid glands shows that botulinum toxin is effective in reducing sodium pertechnetate uptake. LEVEL OF EVIDENCE: 2c Laryngoscope, 129:2521-2526, 2019.

Empleo de Kinesiotaping como tratamiento de la sialorrea en pacientes con enfermedad cerebrovascular / Use of Kinesiotaping as a treatment of sialorrhea in patients who suffer from cerebrovascular disease

la sialorrea es la pérdida involuntaria de saliva de la cavidad oral; es un síntoma potencialmente incapacitante en muchos pacientes con enfermedad cerebrovascular. El vendaje neuromuscular puede ser una alternativa terapéutica. El mismo tiene: acción circulatoria-analgésica, muscular, biomecánica estructural(AU)

Addition of Kinesio Taping of the orbicularis oris muscles to speech therapy rapidly improves drooling in children with neurological disorders.

OBJECTIVE: To evaluate the effects of Kinesio Taping (KT) of the orbicularis oris muscles as an adjunct to standard therapy for drooling. METHODS: Fifteen children with neurological disorders and drooling received speech therapy and twice-weekly KT of the orbicularis muscles over a 30-day period. Drooling was assessed by six parameters: impact on the life of the child and caregiver; severity of drooling; frequency of drooling; drooling volume (estimated by number of bibs used); salivary leak; and interlabial gap. Seven markers of oral motor skills were also assessed. RESULTS: KT of the orbicularis oris region reduced the interlabial gap. All oral motor skills and almost all markers of drooling improved after 15 days of treatment. CONCLUSION: In this sample of children with neurological disorders, adding KT of the orbicularis oris muscles to speech therapy caused rapid improvement in oral motor skills and drooling.