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Updated: Oct 3, 2025
Ultrasound-guided Botulinum Toxin-A Injections: A Method of Treating Sialorrhea
Published on: November 9, 2016
Botulinum Toxin A in the Management of Pediatric Sialorrhea: A Systematic Review
Tiffany Heikel1, Shivam Patel2, Kasra Ziai1
1Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA, USA.
Insights
Botulinum toxin A injections effectively manage pediatric sialorrhea. Recommended dosages include 50 units for submandibular glands and 60-100 units for four-gland injections, with four-gland treatments appearing superior.
Area of Science:
- Neurology
- Pediatrics
- Pharmacology
Background:
- Sialorrhea, or excessive drooling, is a common challenge in pediatric patients.
- Botulinum toxin type A (BoNT-A) is recognized for its efficacy and safety in treating pediatric sialorrhea.
- Optimal injection protocols, including sites and dosages, remain inconsistently defined.
Approach:
- A systematic review was conducted following PRISMA guidelines.
- Searches of PubMed, EMBASE, and other databases identified 405 studies.
- 31 articles met inclusion criteria for evaluating BoNT-A in pediatric sialorrhea.
Key Points:
- 14 studies used 2-gland injections (primarily submandibular), with dosages ranging from 30-50 units.
- 17 studies used 4-gland injections (submandibular and parotid), with common dosages of 60-100 units.
- OnabotulinumtoxinA (Botox®) was predominantly studied; incobotulinumtoxinA (Xeomin®) was assessed in one study.
- Dysphagia was the most frequent adverse event, typically resolving.
- Two of three comparative studies favored 4-gland over 2-gland injections.
Conclusions:
- 50 units of onabotulinumtoxinA to the submandibular glands is a safe and effective pediatric dosage.
- 60-100 units total for bilateral submandibular and parotid gland injections is a safe and effective pediatric dosage.
- While evidence is limited, 4-gland injections appear more effective than 2-gland injections.
Objective:
Botulinum toxin A is known to be effective and safe in managing sialorrhea in pediatric patients; however, there is no consensus on a protocol for optimal injection sites and appropriate dosing for injection.
Methods:
This review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol. PubMed, EMBASE, and other databases were queried to identify articles that evaluated botulinum toxin type A for the treatment of sialorrhea in the pediatric population. A total of 405 studies were identified. After applying inclusion and exclusion criteria, 31 articles were included for review.
Results:
A total of 14 studies evaluated 2-gland injections, and 17 studies evaluated 4-gland injections. Of the 31 studies included, one study assessed incobotulinumtoxinA (Xeomin®) the remaining all used onabotulinumtoxinA (Botox®). For 2-gland injection studies, a combined total of 899 participants were reviewed, where 602 participants received 50 units into their submandibular glands, while 262 participants received 30 to 50 units. Among 4-gland injection studies, there was a combined total of 388 participants, with the most prevalent dosage utilized being 60 to 100 units in 230 participants, followed by 100 units total in 77 participants. The most common adverse event was dysphagia which resolved in nearly all cases. Three studies aimed to examine 2-gland versus 4-gland injections, with 2 of the studies concluding 4-gland injection was superior.
Conclusions:
The strength of evidence suggests that the dosing of 50 units total of onabotulinumtoxinA to the submandibular glands is safe and effective in the pediatric population. For 4-gland injections, bilateral submandibular and parotid gland injections of 60 to 100 units total is the safe and effective dosage. There is no substantial evidence comparing 4-gland injections to 2-gland injections, but research thus far suggests 4-gland injections to be superior. Future study is needed to evaluate incobotulinumtoxinA and abobotulinumtoxinA dosages in the pediatric population.
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