Sialorrhea

Q: 66 years old male with metastatic lung cancer has been made comfort care in ICU. Patient is struggling with severe Sialorrhea (excess salivation). There is no response to glycopyrrolate. Botulinum toxin A (Botox) injection in salivary gland should be considered?

A) Yes

B) No

Answer: A

Sialorrhea is a common problem with various centrally acting and neurological diseases such as amyotrophic lateral sclerosis (ALS), cerebral palsy, stroke, and Parkinson's disease. Patients with Alzheimer's disease or myasthenia gravis are usually prescribed drugs with reversible cholinesterase inhibitor activity, and develop excess salivation as a side effect.

This can be distressing to patients as well as to the family. Also, it may lead to aspiration pneumonia. A few drugs which can be helpful are glycopyrrolate and scopolamine. In case of resistant sialorrhea intrasalivary gland injection of botulinum toxin A may be helpful. In extremely severe cases radiation to the parotid and submandibular glands could be considered. 

In the ICU, a portable suction device can be used.

#palliative care

References:

1. Hugel H, Ellershaw J, Gambles M. Respiratory Tract Secretions in the Dying Patient: A Comparison between Glycopyrronium and Hyoscine Hydrobromide. J Palliat Med 2006; 9:279.

2. Bennett M, Lucas V, Brennan M, et al. Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. Palliat Med 2002; 16:369.

3. Hockstein NG, Samadi DS, Gendron K, Handler SD. Sialorrhea: a management challenge. Am Fam Physician 2004; 69:2628.