Xeomin® treatment for the management of uncontrolled saliva (sialorrhea)

Sialorrhea is a term used to describe uncontrolled saliva. It is common in people living with neurological conditions such as Parkinson’s Disease and motor neurone disease who experience changes to brain, nerves and/or muscles that control their mouth and throat. When the mouth and throat are affected, people struggle to manage their saliva as well as they may have previously done.

If not properly managed, excess saliva pours from the mouth causing drooling. This impacts quality of life, well-being and can lead to loss of confidence or social anxiety. In some cases it can lead to poor oral hygiene, malodour and skin infections. It can also cause chest infections caused by saliva spilling into the airway and onto the lungs.

Saliva is produced by the salivary glands. Botulinum neurotoxin type A (Xeomin®) is a treatment that temporarily stops these glands from working, therefore reducing the flow of salvia in the mouth and throat.

Xeomin® is injected into two sets of salivary glands; the parotid gland (by the ears) and the submandibular glands (underneath the jaw). Because the toxin is injected directly into the gland, the effects of the injection are localised to the salivary glands. Because of this, there are no systemic side effects. The treatment lasts for several weeks, with recommended repeat injections no sooner than every 16 weeks.

The dosage of Xeomin® used in this treatment is small and therefore the risks are small. It is generally a safe and effective treatment method. Nevertheless, side effects can occur and these usually develop in a few days and may last up to two weeks. It is important to note that sometimes it may take a few weeks for side effects to appear. Common side effects related to Xeomin® injection for sialorrhea can include:

• dry mouth
• increased difficulty in swallowing (dysphagia).

Less common are:

• speech alterations
• altered (thickened) saliva and
• taste alterations

Localised pain, tenderness, swelling or infection may occur at the injection site.

Please tell the therapist/doctor treating you if:

• You are allergic to botulinum toxin or any other ingredients of the injection
• You have had an allergic reaction to a botulinum toxin in the past
• You have an infection at the proposed site of the injection
• You have problems swallowing
• You have any history of bronchitis, pneumonia or problems with breathing
• You are pregnant or breast feeding
• You suffer with myasthenia gravis
• You take medication to thin your blood (e.g. Warfarin, Apixaban, Rivaroxaban, Dabigatran or Edoxaban)
• You are taking any antibiotics for an infection (e.g. aminoglycosides such as Gentamicin or Streptomycin)
• You have a fear of needles (needle phobia)
• You have had any problems with injections into your muscles in the past
• You have glaucoma
• You are scheduled to have any surgery in the near future
• You object to blood donor products as botulinum toxin contains human serum albumin.

Alternative treatments are available to treat sialorrhea. These include behavioural approaches such as reminding yourself to swallow, or medications you can take orally or wear as a patch.

Xeomin® is only usually offered when the above treatments are either ineffective or side-effects occur. It is however your choice as to whether you choose to receive Xeomin® injections.

No specific preparation is necessary unless you are taking anti-coagulation (blood thinning) medication. It is helpful to wear clothing that allow access to your neck. The injections will be administered during the clinic appointment and people often find it helpful to have someone accompany them on the day. If you are on medication to thin your blood (e.g., warfarin, rivaroxaban, digabatrin, apixaban, edoxaban, heparin injections), we will need to be aware of this prior to the appointment and we will liaise with you regarding altering the dose if necessary. If you experience severe bleeding or bruising after the injection please seek medical advice.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the risks, benefits and alternatives before they ask you to sign a consent form.

The therapist will give injections into your salivary glands at four locations. The skin will be cleaned with a sterile alcohol wipe. The botulinum toxin will be injected using ultrasound-guidance as close as possible into the middle of each salivary gland. The needle used for injecting is very fine and therefore patients experience very little pain. Most patients report feeling very brief, slight pain due to the sharpness of the needle, which is over immediately.

The initial effects of treatment tend to become apparent within 2 weeks of the injections. At this point we recommend you stop (or reduce) any existing medication prescribed for sialorrhea.

The effect of treatment generally lasts between 12–16 weeks. A member of the clinical team will contact you 2–3 weeks after your injections to evaluate the outcomes of treatment and discuss future treatments.

On rare occasions patients may have an adverse reaction to Xeomin®. Please contact your doctor and seek medical attention immediately if you develop any of the following:

• Breathing, swallowing or speech difficulties.
• Severe allergic reaction, (hives, swelling including swelling of the face, lips, tongue and/or throat, wheezing, feeling faint or shortness of breath)
• Please note that this may even occur a few weeks after the injection.

• The Motor Neurone Disease Association (MNDA) ‘Managing Saliva in Motor Neuron Disease’
• Parkinson’s UK ‘Managing drooling when you have Parkinson’s’ 
• Xeomin® website

UCLH cannot accept responsibility for information provided by other organisations

Speech and Language Therapy Botulinum Toxin Pathway
The National Hospital for Neurology and Neurosurgery
Queen Square
London
WC1N 3BG

Website: www.uclh.nhs.uk

We are currently located in Basil Samuel’s outpatient department of The National Hospital for Neurology and Neurosurgery.