79 Submandibular Duct Ligation After Botulinum Neurotoxin A Treatment of Drooling in Children With Cerebral Palsy 3 study is the 6-month washout period between BoNT-A injection and bilateral submandibular duct ligation. Even though BoNT-A treatment is thought to have a temporary effect lasting a median of 22 weeks on average, 11% of patients treated with intraglandular BoNT-A, as reported by Scheffer et al.,4 noticed an effect beyond 33 weeks and a handful of children experienced continued drooling relief until 1 year after injection.4 This carry-over effect might have negatively influenced the results of bilateral submandibular duct ligation since the mean time between BoNT-A treatment and baseline bilateral submandibular duct ligation was 9.7 months (SD 5.7). This might have led to a significantly lower drooling quotient baseline value before bilateral submandibular duct ligation and a relatively higher 32-week drooling quotient after bilateral submandibular duct ligation, which was not reflected in the subjective (VAS) impression of caregivers. Another explanation for this phenomenon might be a learning effect. Patients learn to better manage their saliva as they grow older; this might be reinforced by the reduced production of saliva after BoNT-A treatment. In conclusion, this study suggests that BoNT-A and bilateral submandibular duct ligation are both effective in reducing drooling severity in the short term, whereas bilateral submandibular duct ligation as surgical therapy provides a greater subjective effect at both 8 (short term) and 32 (medium term) weeks compared to BoNT-A treatment. Nonetheless, BoNT-A treatment is widely used and treatment success in response to BoNT-A does not predict a successful response to subsequent bilateral submandibular duct ligation. However, clinical relevance of bilateral submandibular duct ligation among the current modalities used to treat drooling is cautiously suggested by the results of this study. Bilateral submandibular duct ligation should be considered when children or their parents experience inadequate benefits from conservative treatment modalities, when the burden of BoNT-A outweighs its benefits, or when SMDR and bilateral submandibular gland excision surgeries are rejected.26–31 Bilateral submandibular duct ligation is accompanied by minimal morbidity and offers a potentially definitive solution in contrast to BoNT-A injections. Given the lack of evidence for a long-term effect and particularly in cases of anterior drooling (visible drooling), indication
RkJQdWJsaXNoZXIy MjY0ODMw