Medication Summary

Anticholinergic agents inhibit activation at muscarinic receptors, and at best, decrease the volume of drooling. At tolerable anticholinergic doses, drooling is unlikely to completely cease.

Botulinum toxin leads to partial or complete muscle paralysis by inhibiting acetylcholine release at the neuromuscular synaptic end plate. It also blocks the release of acetylcholine at the cholinergic synapses of the autonomic nervous system; thus, this toxin can block cholinergic parasympathetic secretomotor fibers of the salivary gland. IncobotulinumtoxinA has received FDA approval for the treatment of chronic sialorrhea.

Class Summary

Injection of incobotulinumtoxinA or rimabotulinumtoxinB into the parotid and submandibular glands has been approved by the FDA for adults with chronic sialorrhea owing to various neurologic disorders, including Parkinson disease, amyotrophic lateral sclerosis, cerebral palsy, and stroke.

IncobotulinumtoxinA (Xeomin)

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Through inhibition of acetylcholine release from peripheral cholinergic nerve endings, incobotulinumtoxinA deters cholinergic transmission at the neuromuscular junction. It is indicated for adults with chronic sialorrhea.

RimabotulinumtoxinB (Myobloc)

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Through inhibition of acetylcholine release from peripheral cholinergic nerve terminals, rimabolutinumtoxinB deters cholinergic transmission at the neuromuscular and salivary neuroglandular junction. It is indicated for treatment of chronic sialorrhea in adults.

Jongerius PH, van Hulst K, van den Hoogen FJ, et al. The treatment of posterior drooling by botulinum toxin in a child with cerebral palsy. J Pediatr Gastroenterol Nutr. 2005 Sep. 41(3):351-3. [QxMD MEDLINE Link].
Montgomery J, McCusker S, Lang K, et al. Managing children with sialorrhoea (drooling): Experience from the first 301 children in our saliva control clinic. Int J Pediatr Otorhinolaryngol. 2016 Jun. 85:33-9. [QxMD MEDLINE Link].
Walshe M, Smith M, Pennington L. Interventions for drooling in children with cerebral palsy. Cochrane Database Syst Rev. 2012 Nov 14. 11:CD008624. [QxMD MEDLINE Link].
Evatt ML. Oral glycopyrrolate for the treatment of chronic severe drooling caused by neurological disorders in children. Neuropsychiatr Dis Treat. 2011. 7:543-7. [QxMD MEDLINE Link]. [Full Text].
Ondo W, Isaacson S, Lew M, et al. RimabotulinumtoxinB (Myobloc) in the treatment of adult sialorrhea (abstract P48-024). Presented at the Annual Meeting of the American Academy of Neurology. May 8, 2019. Philadelphia, PA. Available at http://indexsmart.mirasmart.com/AAN2019/PDFfiles/AAN2019-001281.pdf.
Myobloc (rimabotulinumtoxinB) [package insert]. Louisville, KY: Solstice Neurosciences, LLC. 2019 Aug. Available at [Full Text].
Blitzer A, Friedman A, Michel O, Flatau-Baque B, Csikos J, Jost W. SIAXI: IncobotulinumtoxinA for sialorrhea in Parkinson’s disease, stroke, and other etiologies-Phase 3 Results (S30.007). Neurology. 2018 Apr. 90 (15 Suppl):S30.007. [Full Text].
Dashtipour K, Bhidayasiri R, Chen JJ, Jabbari B, Lew M, Torres-Russotto D. RimabotulinumtoxinB in sialorrhea: systematic review of clinical trials. J Clin Mov Disord. 2017. 4:9. [QxMD MEDLINE Link]. [Full Text].
von Lindern JJ, Niederhagen B, Appel T, et al. New prospects in the treatment of traumatic and postoperative parotid fistulas with type A botulinum toxin. Plast Reconstr Surg. 2002 Jun. 109(7):2443-5. [QxMD MEDLINE Link].
Yuan M, Shelton J. Acute sialadenitis secondary to submandibular calculi after botulinum neurotoxin injection for sialorrhea in a child with cerebral palsy. Am J Phys Med Rehabil. 2011 Dec. 90(12):1064-7. [QxMD MEDLINE Link].
Hay N, Penn C. Botox(®) to reduce drooling in a paediatric population with neurological impairments: a Phase I study. Int J Lang Commun Disord. 2011 Sep. 46(5):550-63. [QxMD MEDLINE Link].
Squires N, Wills A, Rowson J. The management of drooling in adults with neurological conditions. Curr Opin Otolaryngol Head Neck Surg. 2012 Jun. 20(3):171-6. [QxMD MEDLINE Link].
Laskawi R, Drobik C, Schönebeck C. Up-to-date report of botulinum toxin type A treatment in patients with gustatory sweating (Frey's syndrome). Laryngoscope. 1998 Mar. 108(3):381-4. [QxMD MEDLINE Link].
Lim YC, Choi EC. Treatment of an acute salivary fistula after parotid surgery: botulinum toxin type A injection as primary treatment. Eur Arch Otorhinolaryngol. 2008 Feb. 265(2):243-5. [QxMD MEDLINE Link].
Manrique D. Application of botulinum toxin to reduce the saliva in patients with amyotrophic lateral sclerosis. Braz J Otorhinolaryngol. 2005 Sep-Oct. 71(5):566-9. [QxMD MEDLINE Link].
Costa J, Rocha ML, Ferreira J, et al. Botulinum toxin type-B improves sialorrhea and quality of life in bulbaronset amyotrophic lateral sclerosis. J Neurol. 2008 Apr. 255(4):545-50. [QxMD MEDLINE Link].
Marina MB, Sani A, Hamzaini AH, et al. Ultrasound-guided botulinum toxin A injection: an alternative treatment for dribbling. J Laryngol Otol. 2008 Jun. 122(6):609-14. [QxMD MEDLINE Link].
Barbero P, Busso M, Tinivella M, et al. Long-term follow-up of ultrasound-guided botulinum toxin-A injections for sialorrhea in neurological dysphagia. J Neurol. 2015 Sep 26. [QxMD MEDLINE Link].
Lungren MP, Halula S, Coyne S, Sidell D, Racadio JM, Patel MN. Ultrasound-Guided Botulinum Toxin Type A Salivary Gland Injection in Children for Refractory Sialorrhea: 10-Year Experience at a Large Tertiary Children's Hospital. Pediatr Neurol. 2016 Jan. 54:70-5. [QxMD MEDLINE Link].
Petracca M, Guidubaldi A, Ricciardi L, et al. Botulinum toxin A and B in sialorrhea: long-term data and literature overview. Toxicon. 2015 Aug 30. [QxMD MEDLINE Link].
Hawkey NM, Zaorsky NG, Galloway TJ. The role of radiation therapy in the management of sialorrhea: A systematic review. Laryngoscope. 2015 Jul 7. [QxMD MEDLINE Link].
Neppelberg E, Haugen DF, Thorsen L, et al. Radiotherapy reduces sialorrhea in amyotrophic lateral sclerosis. Eur J Neurol. 2007 Dec. 14(12):1373-7. [QxMD MEDLINE Link].
Postma AG, Heesters M, van Laar T. Radiotherapy to the salivary glands as treatment of sialorrhea in patients with parkinsonism. Mov Disord. 2007 Dec. 22(16):2430-5. [QxMD MEDLINE Link].
Steenbakkers RJHM, van Doornik SP, Vissink A, Kerdijk W, van Laar T. Radiation of parotid or submandibular glands is effective for drooling in patients with parkinsonism; a randomised double-blind placebo-controlled trial. Clin Park Relat Disord. 2022. 6:100138. [QxMD MEDLINE Link]. [Full Text].
Shott SR, Myer CM 3rd, Cotton RT. Surgical management of sialorrhea. Otolaryngol Head Neck Surg. 1989 Jul. 101(1):47-50. [QxMD MEDLINE Link].
Wilkie TF. The problem of drooling in cerebral palsy: a surgical approach. Can J Surg. 1967 Jan. 10(1):60-7. [QxMD MEDLINE Link].
Bekkers S, de Bock S, van Hulst K, Kok SE, Scheffer ART, van den Hoogen FJA. The medium to long-term effects of two-duct ligation for excessive drooling in neurodisabilities, a cross-sectional study. Int J Pediatr Otorhinolaryngol. 2021 Nov. 150:110894. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Rhombus-shaped incision for bilateral submandibular duct transposition. Image courtesy of Dr Neeraj N Mathur.
Dissected submandibular duct with peri-stomal cuff mucosa. Image courtesy of Dr Neeraj N Mathur.
Artery passed through the submucosal tunnel opening just behind the anterior tonsillar pillar. Image courtesy of Dr Neeraj N Mathur.
Sublingual glands seen along submandibular duct and relation of duct to lingual nerve. Image courtesy of Dr Neeraj N Mathur.
Floor of mouth, as seen after bilateral submandibular duct transposition. Image courtesy of Dr Neeraj N Mathur.

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Author

Neeraj N Mathur, MBBS, MS, DNB, MAMS, FAMS Professor and Head, Department of ENT, Amrita Hospital and Amrita Institute of Medical Sciences, Faridabad, India

Neeraj N Mathur, MBBS, MS, DNB, MAMS, FAMS is a member of the following medical societies: Association of Otolaryngologists of India, Cochlear Implant Group of India, Indian Medical Association, National Academy of Medical Sciences (India), Neuro-Otological and Equilibriometric Society of India, Royal Society of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Karen H Calhoun, MD, FACS, FAAOA Professor, Department of Otolaryngology-Head and Neck Surgery, Ohio State University College of Medicine

Karen H Calhoun, MD, FACS, FAAOA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, Association for Research in Otolaryngology, Southern Medical Association, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Rhinologic Society, Society of University Otolaryngologists-Head and Neck Surgeons, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Ryte; Neosoma; MI10<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10.

Additional Contributors

Jennifer P Porter, MD Assistant Professor, Department of Otorhinolaryngology, Division of Communicative Science, Chevy Chase Facial Plastic Surgery

Jennifer P Porter, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, Texas Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Karla R Brown, MD, and Traci L Vaughn, MD, to the development and writing of this article.