221 63% after 2-DL and 27% for BoNT-A (p = 0.008). Baseline VAS and DQ were equal for both treatment arms, but for both VAS and DQ, follow-up measurements after 2-DL were lower compared to BoNT-A. The total number of adverse events was 41% after 2-DL and 19% after BoNT-A (p = 0.088). The total days of postoperative complaints were higher (p < 0.001, mean 9.6 vs 3.6 days) after 2-DL than after BoNT-A. Twenty-six percent of patients achieved treatment success 8 weeks after 2-DL but did not achieve treatment success 32 weeks after 2-DL. We conclude that 2-DL is a more effective treatment for drooling than BoNT-A but carries a slightly greater risk of complications and morbidity. Moreover, there is a certain degree of relapse between 8 and 32 weeks after 2-DL. Chapter 3 The aim of chapter 3 was to evaluate the effect and effect association of submandibular duct ligation (2-DL) after previous submandibular botulinum neurotoxin type A (BoNT-A) injections for severe drooling in a within-participants observational design. Twenty-nine severely drooling children (15 males) received BoNT-A at a mean age of 9 years and 6 months (SD 2yr, 5m), followed by 2-DL at a mean age of 10 years and 11 months (SD 2yr, 4m). Primary outcomes included the subjective Visual Analog Scale (VAS) and objective Drooling Quotient (DQ). Data were obtained before each intervention and 8 and 32 weeks after the intervention. VAS was significantly lower at follow-up after 2-DL compared to BoNT-A (-33, p=<0.001; 95% CI -43.3 – -22.9). DQ did not significantly differ between BoNT-A and 2-DL (p=0.46). DQ was not significantly different at baseline compared to follow-up after BoNT-A and 2-DL (p=0.188). BoNT-A and 2-DL are both effective treatment modalities for drooling. At 32 weeks follow-up, there is a significantly lower subjective drooling severity after 2-DL than former BoNT-A injections within participants. Moreover, this study illustrates that the BoNT-A treatment effect is not of predictive value for treatment success of subsequent 2-DL. Chapter 4 Drooling is dependent on various clinical variables. However, while drooling proves refractory to surgery in 40% of patients, predictors for treatment success are
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