How is sialorrhea (drooling) treated in amyotrophic lateral sclerosis (ALS)?

Updated: Jan 02, 2020
  • Author: Divakara Kedlaya, MBBS; Chief Editor: Ryan O Stephenson, DO  more...
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Answer

Answer

The treatment of sialorrhea is largely a matter of trial and error, using a variety of drug treatments, natural remedies, upright positioning, intermittent oral suction, and more invasive approaches, such as injection of botulinum toxin into salivary glands, radiotherapy to salivary glands, or ligation of salivary gland ducts. Acetylcholine is the active neurotransmitter, binding at muscarinic receptors in the salivary glands. [32] Thus, direct cholinergic muscarinic receptor antagonists such as atropine, scopolamine, glycopyrronium bromide, and tricyclic antidepressants can be used to treat sialorrhea in motor neuron disease. [33] Beta-blockers have been shown to produce relief from thick secretions in 12 of 16 people with bulbar motor neuron disease. [31]

Use of botulinum toxin to reduce salivary flow in motor neuron disease was first hypothesized by Bushara in 1997. [34] Botulinum toxin injections reduce sialorrhea by blocking the release of acetylcholine at the cholinergic neurosecretory junction of salivary glands. There are several studies reported in the literature, utilizing different preparations of botulinum toxin (botulinum toxin type A and botulinum toxin type B) and treatment regimens, administered by direct injection or a transductal approach, with varying outcome measures. [35, 36, 37, 38, 39, 40, 41] A Cochrane review on treatment of sialorrhea in ALS patients concluded that there is some evidence for use of botulinum toxin injections to salivary glands for the treatment of sialorrhea in motor neuron disease. [42]

Radiotherapy to the salivary glands, either once or in divided fractions, has been used effectively to manage sialorrhea in ALS patients. [43, 44, 45, 46]


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