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Updated: Sep 19, 2025
Ultrasound-guided Botulinum Toxin-A Injections: A Method of Treating Sialorrhea
Published on: November 9, 2016
Accuracy and outcomes of endoscopic ultrasound guided anal botulinum toxin injections for pediatric constipation: A
Brianne Shuler1, Alexandra L Kilgore2, Paul Tran3
1Children's Mercy Kansas City, Department of Pediatric Gastroenterology, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA.
Insights
OnabotulinumtoxinA injections for pediatric constipation accuracy was assessed. Standard technique only placed the needle in the internal anal sphincter 50% of the time, highlighting a need for improved guidance.
Area of Science:
- Pediatric Gastroenterology
- Gastrointestinal Motility Disorders
- Minimally Invasive Procedures
Background:
- OnabotulinumtoxinA (BT) injections into the internal anal sphincter (IAS) are a common treatment for pediatric constipation.
- The standard technique (ST) relies on anatomical landmarks for BT placement.
- The accuracy of ST for precise IAS injection has not been well-established.
Purpose of the Study:
- To compare the accuracy of BT injection placement using standard technique versus endoscopic ultrasound (EUS) guidance.
- To evaluate the impact of EUS-guided injections on clinical outcomes in children with constipation.
Main Methods:
- A pilot study involving children aged 2-18 with chronic functional constipation.
- Intervention arm: BT injections using ST with EUS for needle assessment (n=15).
- Control arm: BT injections using ST without EUS guidance (n=30).
- Constipation severity was assessed using a questionnaire at 2 weeks, 3 months, and 6 months post-procedure.
Main Results:
- EUS assessment revealed that ST accurately placed the needle tip in the IAS in only 50.1% of injections.
- The external anal sphincter was the location in 20.3% of ST injections.
- Both groups reported symptom improvement, with no significant long-term differences in constipation scores between EUS-guided and standard technique injections after the initial 2-week period.
Conclusions:
- Standard technique for OnabotulinumtoxinA injection into the internal anal sphincter for pediatric constipation has suboptimal accuracy.
- Endoscopic ultrasound guidance offers a more precise method for targeting the IAS during BT injections.
- While ST accuracy is limited, both ST and EUS-guided BT injections demonstrate clinical efficacy in improving constipation symptoms over time.
Objectives:
Injection of Onabotulinumtoxina (BT) into the internal anal sphincter (IAS) is commonly used for pediatric constipation. Typically, BT injections are guided by anatomic landmarks (standard technique [ST]). This pilot study assessed the accuracy of BT injection placement with ST versus endoscopic ultrasound (EUS) guidance and compared clinical outcomes.
Methods:
Children aged 2-18 with chronic functional constipation undergoing BT injections without anorectal anatomic or neurologic abnormalities were eligible. Fifteen children were enrolled in the intervention arm with ST placement and needle location assessment using EUS. Subsequently, EUS-guided injection was specifically placed into the IAS. Additionally, 30 children (controls) received BT by ST without EUS-guidance. A constipation severity questionnaire was administered at 2 weeks, 3 months, and 6 months postprocedure.
Results:
The initial needle tip location was the IAS for 30 placements (50.1%, 95% confidence interval [CI]: 38.1%-63.5%) and the external anal sphincter in 15 placements (20.3%, 95% CI: 11.8%-32.8%) of a total 59 injections assessed by EUS. Patients reported improvement at 2 weeks, 3 months, and 6 months in both study groups. Constipation scores obtained only after injections were worse in EUS versus control (22.21 vs. 13.83, p < 0.0001) at 2 weeks, with no significant difference at 3 (15.8 vs. 13.57, p = 0.127) or 6 months (13.10 vs. 13.27, p = 0.9322).
Conclusions:
This study shows the IAS is injected with BT only 50% of the time with standard technique based on anatomical landmarks.
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