Excessive drooling (sialorrhea) is a major issue in children with neurological impairment, such as cerebral palsy. Drooling occurs when saliva is not swallowed and flows out of the mouth. This usually occurs from inefficient or infrequent swallowing. It is unusual for drooling to be caused by making too much saliva. Drooling can irritate the skin of the face, neck and chest. In some extreme cases, drooling can lead to aspiration pneumonia and result in long hospitalizations for the child.
Why is Botox used for drooling?
When botulinum toxin (Botox) is injected into the salivary glands, it blocks the function of the salivary glands. This decreases the amount of saliva produced.
The effects of Botox are temporary, meaning the decreased saliva production will eventually wear off. Salivary Botox injections are done using ultrasound by interventional radiologists.
Risks of Botox
Botox is usually considered to be safe. However, there is a small possibility that unexpected or unusual reactions to Botox will happen. These reactions may even take place in areas of the body that were not injected. Unusual reactions have been known to occur within the first few weeks following treatment. These reactions include:
- fever
- muscle soreness that lasts longer than two days
- redness or swelling at the injection sites
- loss of bladder control
- malaise (generally feeling unwell)
Call your doctor or go to the nearest emergency department if your child is experiencing any of the following symptoms:
- severe weakness
- speech that is becoming more difficult to understand, or voice changes (e.g., hoarse voice)
- difficulty breathing
- drooping eyelids or changes in vision
- allergic reaction (anaphylaxis)
Because Botox has a delayed response, these symptoms potentially mean the Botox was injected outside of the salivary gland.
Visiting the clinic before the procedure
Your child may have to visit the interventional radiologist one to three weeks before receiving the Botox injections. During the visit, you should expect the following:
- A health assessment to make sure your child is healthy and that it is safe to have general anaesthesia.
- An overview of the procedure and a review of the consent form with an interventional radiologist.
Giving consent before the procedure
Before the procedure, the interventional radiologist will go over how and why the procedure is done, as well as the potential benefits and risks. They will also discuss what will be done to reduce these risks, and will help you weigh any benefits against the risks. It is important that you understand all of these potential risks and benefits of the Botox injections and that all of your questions are answered. If you agree to the procedure, you can give consent for treatment by signing the consent form. A parent or legal guardian must sign the consent form for young children. The procedure will not be done unless you give your consent.
How to prepare your child for the procedure
Before any treatment, it is important to talk to your child about what will happen. When talking to your child, use words they can understand. Let your child know that medicines will be given to make them feel comfortable during the procedure.
Children feel less anxious and scared when they know what to expect. Children also feel less worried when they see their parents are calm and supportive.
If your child becomes ill within two days before the procedure
It is important that your child is healthy on the day of their procedure. If your child starts to feel unwell or has a fever within two days before the salivary Botox injections, let your doctor know. Your child’s procedure may need to be rebooked.
Food, drink and medicines before the procedure
- Your child’s stomach must be empty before receiving general anesthesia.
- If your child has special needs during fasting, talk to your doctor to make a plan.
- Your child can take their regular morning medicine with a sip of water two hours before the procedure.
- Medicines such as acetylsalicylic acid (ASA), naproxen or ibuprofen, warfarin or enoxaparin may increase the risk of bleeding. Do not give these to your child before the procedure. If your child is taking any of these medicines, please discuss this with your doctor and the interventional radiologist.
On the day of the salivary Botox injections
Arrive at the hospital two hours before the planned time of your child’s procedure. Once you are checked in, your child will be dressed in a hospital gown, weighed and assessed by a nurse. You will also be able to speak to the interventional radiologist who will be doing the salivary Botox injections, and the anaesthetist who will be giving your child medication to make them more comfortable during the procedure.
During the procedure, you will be asked to wait in the surgical waiting area.
Your child will have medicine for pain
Children are given medicine for treatments that may be frightening, uncomfortable or painful. For salivary Botox injections, most children are given general anaesthesia.
How are Botox injections done?
The interventional radiologist uses an ultrasound machine to find the glands in the face that produce saliva. Using the ultrasound image as a guide, a tiny needle is then inserted through the skin into the glands. Once the needle is in place, the radiologist will inject a small amount of Botox into the space. Typically, four salivary glands (two submandibular glands and two parotid glands) are injected.
Salivary Botox injections take one hour to be completed.
After the salivary Botox injections
Once the injections are complete, your child will be moved to the recovery area. The interventional radiologist will come and talk to you about the details of the procedure. As soon as your child starts to wake up, a nurse will come and get you.
Going home
Most children will go home within a few hours of receiving the salivary Botox injections. If your child has any medical conditions such as sleep apnea, you may be asked to spend the night in hospital for observation purposes.
For more details on how to care for your child after Botox injections, please see Botox injections into salivary glands: Caring for your child at home after the procedure.
What to expect after Botox injections
Salivary Botox injections start to work a few weeks after the treatment. Your child may experience slight soreness or bruising at the injection sites. However, they should not experience any severe pain.
At SickKids
At SickKids, the interventional radiologists work in the Department of Image Guided Therapy (IGT). You can call the IGT clinic at (416) 813-6054 and speak to the clinic nurse during working hours (8:00 to 15:00) or leave a message with the IGT clinic nurse.
For more information on fasting see Eating and drinking before surgery.
For more information on preparing your child for their procedure see Coming for surgery.
A nurse from IGT will phone you at home the day after the biopsy to make sure your child is okay, and to answer any questions you may have.