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Hypersalivation Botulinum Toxin Treatment

Salivary gland injection therapy for refractory drooling and sialorrhea

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our KBB (Kulak Burun Boğaz) department. Book Appointment →

What is Hypersalivation Botulinum Toxin Treatment?

Hypersalivation (sialorrhea) and drooling significantly impair quality of life in neurological conditions including Parkinson disease, amyotrophic lateral sclerosis (ALS), cerebral palsy, intellectual disability, post-stroke dysphagia, and clozapine-induced sialorrhea. Salivary gland botulinum toxin injection (typically onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, or rimabotulinumtoxinB) reduces saliva production through inhibition of acetylcholine release at parasympathetic neuromuscular junctions of glandular tissue.

Standard injection sites are bilateral parotid glands (responsible for stimulated saliva, mainly serous) and bilateral submandibular glands (responsible for resting saliva, both serous and mucous). Doses range from 50-100 units per parotid and 25-50 units per submandibular gland depending on toxin type. Injection is performed under ultrasound guidance for accuracy and to avoid facial nerve injury and significant complications.

Effects begin within 1-2 weeks, peak at 3-4 weeks, and last 3-6 months. Repeat injections every 3-6 months are common. Side effects include transient mouth dryness, thickened saliva, dysphagia (sometimes), and very rarely facial nerve weakness, parotitis, or systemic effects. The procedure is generally safe and effective with multidisciplinary follow-up. RimabotulinumtoxinB has been specifically studied for sialorrhea and is FDA-approved.

Symptoms

Excessive saliva production
Drooling from corners of mouth
Wet clothing, bedding, communication devices
Skin maceration around lips
Aspiration with dysphagia
Aspiration pneumonia recurrence
Social embarrassment, isolation
Difficulty with oral hygiene
Halitosis
Speech difficulty
Choking on saliva
Sleep disturbance from pooling saliva
Caregiver burden in dependent patients
Reduced food intake
Difficulty with dentures
Skin breakdown around chin
Embarrassment in social situations
Severe drooling unresponsive to anticholinergic medications
Anticholinergic side effects intolerable (dry eyes, urinary retention, cognitive impairment, constipation)
Clozapine-induced sialorrhea unresponsive to dose adjustment

Risk Factors

Parkinson disease
Atypical Parkinsonism (PSP, MSA, CBS)
Amyotrophic lateral sclerosis (ALS, motor neuron disease)
Cerebral palsy
Intellectual disability with neurological involvement
Post-stroke dysphagia
Multiple sclerosis (rare)
Bulbar dysfunction from various causes
Brain tumor with bulbar involvement
Brainstem injury
Clozapine therapy
Other antipsychotic-induced sialorrhea
Chronic gastroesophageal reflux disease
Hypertrophy of salivary glands
Drug-induced (pilocarpine, anticholinesterases)
Cranial nerve disorders
Severe oral motor dysfunction
Pediatric neurological disorders
Dementia with bulbar dysfunction
Tracheostomy dependence (less commonly)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Severe drooling impairing quality of life
  • Failed anticholinergic therapy
  • Anticholinergic side effects intolerable
  • Aspiration pneumonia from sialorrhea
  • Skin breakdown around lips
  • Severe psychosocial impact
  • Caregiver burden
  • Clozapine-induced severe sialorrhea
  • Considering botulinum toxin therapy
  • Recurrence after botulinum toxin (repeat injection)
  • Multidisciplinary management need
  • Comprehensive evaluation of underlying disorder

Treatment Methods

01
Comprehensive evaluation by neurology, otolaryngology, or rehabilitation medicine specialist
02
Detailed history of underlying disorder, severity, prior treatments
03
Severity scoring with Drooling Severity and Frequency Scale, Drooling Impact Scale
04
Speech-language pathology evaluation
05
Swallowing assessment if dysphagia present
06
Dental and oral hygiene assessment
07
Trial of conservative measures first: positioning, head control, swallow training, oral motor therapy
08
First-line pharmacotherapy with anticholinergic agents (glycopyrrolate, scopolamine patch, atropine drops, benztropine, trihexyphenidyl) often limited by side effects
09
Consider sublingual atropine drops for short-term effect
10
Botulinum toxin selection: onabotulinumtoxinA (Botox), abobotulinumtoxinA (Dysport), incobotulinumtoxinA (Xeomin), rimabotulinumtoxinB (Myobloc) — only rimabotulinumtoxinB has specific FDA approval for sialorrhea
11
Ultrasound-guided injection of bilateral parotid and submandibular glands (preferred over landmark-based)
12
Typical doses: parotid 25-50 units (Botox/Xeomin) or 75-100 units (Dysport) per gland; submandibular 12.5-25 units (Botox/Xeomin) or 30-50 units (Dysport) per gland; rimabotulinumtoxinB 1500-2500 units total
13
Onset of effect 1-2 weeks, peak 3-4 weeks, duration 3-6 months
14
Repeat injections every 3-6 months as needed
15
Side effect monitoring: thickened saliva, dysphagia, mouth dryness
16
Avoid in patients with dysphagia worsening risk
17
Ultrasound guidance reduces risk of facial nerve injury
18
Surgical alternatives: salivary duct ligation or relocation, gland excision (last resort)
19
Radiotherapy in selected cases (rare)
20
Coordination with neurology for primary disease management
21
Speech and swallowing therapy continuation
22
Patient and caregiver education on aspiration risk
23
Multidisciplinary follow-up
24
Continued monitoring for return of symptoms and need for re-injection

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.