Salivary Gland Botulinum Toxin a Injections for Treating Sialorrhea Among Critically Ill Patients With Neurological Disorders.

Sialorrhea is associated with various neurological conditions. Among critically ill patients with acute neurological injuries (ANI), sialorrhea leads to several adverse consequences, including extubation failure, inability to initiate non-invasive ventilation, aspiration pneumonia and prolonged hospitalization. Botulinum toxin (BoTN) injections can reduce salivary production. Both BoTN-A and BoTN-B are effective in managing sialorrhea among patients with neurogenic dysphagia. BoTN utilization for sialorrhea in critically ill adult ANI patients is not well-studied. The purpose of this study to evaluate the safety and feasibility of using BoTN-A salivary injections to reduce sialorrhea in ANI patients. In this case series, we retrospectively reviewed the off-label use of BoTN-A for sialorrhea in ANI patients at the University of North Carolina Neurosciences Intensive Care Unit. Study Sample: Six patients with ANI who received BoTNA treatment for neurogenic sialorrhea in absence of infection and medications with known side-effect of sialorrhea. For safety evaluation, we reviewed any documented adverse effects of BoTN-A injection. For efficacy, we evaluated the drooling severity, suctioning frequency, oxygen requirements, continued days on the ventilator, and pneumonia diagnoses. All patients had reduction in their documented drooling and suctioning requirements following BoTN-A injection. None had adverse events associated with BoTN-A injections. All patients experienced recurrent ventilator-associated pneumonias prior to BoTN-A injections whereas four patients had no pneumonia events after injections. Also, two patients were successfully weaned of oxygenation prior to discharge. This case series highlights the safety and potential efficacy of salivary gland BoTN-A for reducing refractory sialorrhea among critically ill ANI patients. Future studies are needed to evaluate whether sialorrhea reduction can lead to reduced hospital complications and overall length of hospital stay.