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J Pediatr Rehabil Med. 2019 Jun 10. doi: 10.3233/PRM-180552. [Epub ahead of print]

Safety of combined salivary gland and multilevel intramuscular onabotulinumtoxinA injections with and without ethanol in pediatric patients with cerebral palsy: A retrospective study.

Shoval H1, Levin J2,3, Friel K4,5,6, Kim H2,3.

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Pediatric Physical Medicine and Rehabilitation, Children's Specialized Hospital, Clifton, NJ, USA.
Pediatric Physical Medicine and Rehabilitation, Columbia University Medical Center and Weill Cornell Medical College New York Presbyterian Hospital, New York, NY, USA.
Physiatry, Blythedale Children's Hospital, Valhalla, NY, USA.
Burke Neurological Institute, White Plains, NY, USA.
Brain-Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.
Blythedale Children's Hospital, Valhalla, NY, USA.



To evaluate the safety of combining salivary gland onabotulinumtoxinA (BTX-A) injections for sialorrhea with intramuscular BTX-A injections for spasticity in the same procedure.


A retrospective cohort study in a tertiary hospital center. Patients selected were younger than 20 years, diagnosed with cerebral palsy, and received their first salivary gland BTX-A injection between March 2011 and July 2015. Chart reviews and telephone interviews were performed. The primary outcome measure was the rate of adverse events after combined BTX-A injections into salivary glands and muscles. The secondary outcome measure was the efficacy of injections, as reported by patients.


Twenty-five of the 52 selected patients received salivary gland BTX-A injections only, and 27 received concurrent salivary gland and multi-level intramuscular chemodenervation with BTX-A injections. The rate of adverse events was < 10% in both groups: 4% in "salivary only" group and 7% in the group with salivary + multi-level intramuscular chemodenervation with BTX-A (with or without alcohol). Both approaches were equally effective in meeting their goals of salivary injections (> 50% improvement for at least two months). In the "salivary only" and in the "salivary + multi-level intramuscular" group, 76 and 85% of the patients reached their goals respectively.


Combining BTX-A injections for sialorrhea with multilevel intramuscular BTX-A injections (with or without alcohol) appears to be safe and effective and allows treatment of patients for both conditions simultaneously.


OnabotulinumtoxinA injection; cerebral palsy; diffuse spasticity; sialorrhea


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