See also:
- Botulinum Toxin Treatment for Sialadenitis
- Botox/Xeomin/Botulinum Toxin Injection to Salivary Glands for Drooling, Sialorrhea, Hypersalivation
- Sialograms and Sialography
Background
Marks et al (2024) evaluated the capacity to place needles into the salivary glands of 117 children under general anesthesia for botulinum toxin injection to treat sialorrhea. Initial needle placement directed by anatomic landmarks was then assessed by ultrasound. Only 32% of the needle placements targetted to the submandibular gland were confirmed to be in the gland by ultrasound. 68% of the parotid needle placements were on target. Subgroup analysis identified no difference in success when analyzed according to the seniority of the practitioner, age of patient or hand dominance.
Our (Hoffman) technique employs ultrasound to place an echogenic needle (25 gauge, 5 cm long Chiba Biopsy Needle)
Via an anterior approach to avoid the prominent vascular supply. The facial artery is most dominant on the posterior and superior aspects of the gland per color doppler ultrasound image below:
Case History
Presentation to Clinic June 2022: Painful swelling left submandibular gland preceding 2 years with intermittent pain "7 / 10" radiating to left ear
Sialogram August 2022: pre-stricture (proximal) ductal dilation
Sialendoscopy under general anesthesia with dilation and steroid insufflation January 2023: at best offered only minor improvement with still ongoing concerns that may have improved slightly but her perception that she is not getting saliva from that gland
In-Clinic Ultrasound guided botulinum (Botox®) injection: persistence of submandibular pain and swelling warranted further treatment with botulinum injection
Follow-Up 3 Months After Botox Injection: "feeling a lot better" following the Botox injection by way of 30 units delivered with ultrasound guidance to the left submandibular gland June 4, 2024. Still sometimes "get achy when she gets too tired" but relates it is relieved the constant and intense pain that she had previously sufficiently to the point that when I identified the potential value for a second injection she felt she was not there yet but should symptoms recur she may contact us.
Modified Operative Note
Procedure: Ultrasound guided Botox injection (30 units and 0.6 cc) to the left submandibular gland
Preop Diagnosis: Left submandibular sialadenitis with high-grade stricture refractory to treatment with sialendoscopy
Postop Diagnosis: Same
Surgeon: XXX
Assistant: XXX
Anesthesia: None
Description of Procedure: Following identification the patient informed consent and a brief timeout a diagnostic ultrasound was done of the left submandibular gland showing it to be intact with a prominent facial artery seen posterior and superior as denoted by color Doppler (see photos).
A 25-gauge Chiba needle primed and connected to a syringe containing Botox 30 units in 0.6 cc (5 units/0.1 cc) was then placed percutaneously through the anterior aspect of the skin overlying the anterior submandibular gland with ultrasound guidance (see photos) allowing for delivery of all 0.6 cc within the capsule of the submandibular gland. Reappraisal with ultrasound after injection showed no hematoma or signs of other extravasation she was observed show and show no neck swelling was discharged home with follow-up as per video telemedicine in 2 to 3 months
References
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