Botulinum toxin injection techniques for pediatric sialorrhea

Sialorrhea or drooling refers to the unintentional spillage of saliva from the oral cavity. Botulinum toxin injection into the salivary glands is a recognized clinically effective therapy for this condition. There are currently 4 botulinum toxin formulations available for clinical (off label) use to improve sialorrhea: onabotulinumtoxinA (BOTOX), incobotulinumtoxinA (Xeomin), abobotulinumtoxinA (Dysport), and rimabotulinum toxin B (Myobloc). These should not be considered interchangeable. Botulinum toxin injection in the salivary glands can be performed under either local or general anesthesia. OnabotulinumtoxinA is currently the most commonly used agent in the treatment of drooling in children. There are 3 different injection techniques consisting of injection using anatomical landmarks with manual palpation of the gland, ultrasound guidance, or electromyography guidance. These are detailed later, and the technical preference varies among centers. Reported complications include dysphagia, xerostomia, and aspiration. Using a guided injection technique provides a safe, effective, and noninvasive option for drooling control.