Staggered botulinum toxin-a injections into parotid and submandibular glands prior to four-duct ligation for pediatric sialorrhea

ObjectivesThis study aimed to assess the effectiveness of four-duct ligation following Botulinum toxin-A injections into the parotid and submandibular glands in pediatric patients with sialorrhea resistant to nonsurgical treatments. Prior research has individually explored either surgical or Botulinum toxin interventions; however, the safety and efficacy of the combined approach to these treatments have yet to be documented.MethodsPatients were assessed before surgery and 6, 12, and 24 months post-operatively. Evaluations involved interviews with parents and caregivers, conducted face-to-face or by telephone, using the Drooling Severity and Frequency Scales. Additionally, metrics such as the daily count of bib changes and the hourly frequency of saliva wiping were recorded. Quality-of-life assessments were performed before and after the surgical procedures. All complications associated with the interventions were carefully recorded.ResultsThe study group consisted of 25 participants, with a median age of 6 years (range 2-17 years). Each participant was diagnosed with a neurological, metabolic, or genetic disorder. Evaluations were conducted periodically, culminating in a final follow-up at 24 months. The treatment demonstrated a 100% success rate at six months post-operation (25/25 patients), which slightly decreased to 96% at the 12-month mark (24/25 patients) and further to 84% by the 24-month follow-up (21/25 patients). Major complications were not observed. However, minor complications were reported in six patients (24%): three exhibited temporary facial swelling (12%), two encountered minor bleeding (8%), and one experienced excessive dryness (4%).ConclusionsThe combination of Botulinum toxin-A injection 3 weeks prior to the four-duct ligation procedure demonstrated high success rates and substantially reduced the incidence of infectious and cosmetic complications. Consequently, this staggered approach to combination treatment is recommended for managing pediatric sialorrhea cases that are resistant to non-surgical interventions.