Salivagram after gland injection of botulinum neurotoxin A in patients with cerebral infarction and cerebral palsy.

Pulmonary aspiration in patients with brain lesions may result from dysfunction of theswallowing process or gastroesophageal reflux. Inadequate protection of the airway fromoral secretions such as saliva may also induce aspiration. Chronic pulmonary aspiration ofsaliva can lead to substantial respiratory morbidity, including unexplained lung disease orrecurrent pneumonia, and is an important issue in the rehabilitation unit. In particular,patientswithneurologicdiseasewhoareinalong-termbedriddenstatecanbeatgreaterriskfor development of chronic salivary aspiration and pulmonary complications [1,2].Incontrast to aspiration during the swallowing process, continuous secretion of saliva and itsaspiration are difficult to control, even through modification of food consistency orcessation of oral feeding.Useofaradionuclidesalivagramtodetectpassiveaspirationofsalivawasintroducedby Heyman [3] in 1989. After sublingual instillation of a small amount of radiolabeledcolloid, serial images are evaluated for the presence of radiotracer uptake in thetracheobronchial tree, which is suggestive of aspiration. This test may be useful fordetection of aspiration of saliva and for patients with limitations of oral feeding or poorcooperation. For these reasons, a radionuclide salivagram has been used in infants orchildren with neurologic diseases, for example, cerebral palsy, who have recurrentpulmonary infection [4-6]. A radionuclide salivagram can be performed under morephysiological conditions without the challenge of an oral bolus for swallowing and isless invasive than a videofluoroscopic swallow study or a fiberoptic-endoscopic evalu-ation of swallowing[4].TherehasbeenanincreaseintheuseofbotulinumneurotoxinA(BoNT-A)injectionintosalivary glands for the treatment of drooling in patients with neurologic disease, includingcerebral palsy [7], Parkinson disease [8], and amyotrophic lateral sclerosis [9,10]. Variousobjective or subjective methods have been used to evaluate treatment response to BoNT-Ainjection.However,mostofthemethodsfocusonreductionofsialorrheaordroolingitself.FewstudiesassesspulmonaryaspirationofsalivaaftersalivaryglandinjectionwithBoNT-A[11]. We hypothesized that a positive radionuclide salivagram could be strong evidence ofaspirationofsalivaandhelpfultoassesstheindicationformoreintensivetreatment,suchasglandinjectionwithbotulinumtoxinorsurgicalexcision.Inourexperiencewith2patients,saliva aspiration resolved after administration of BoNT-A into salivary glands, as demon-strated on a follow-up radionuclide salivagram.