Dayse Manrique

Aplicação de toxina botulínica tipo A para reduzir a saliva em pacientes com esclerose lateral amiotrófica

AIM: To demonstrate the effect of local application of Botox® in patients with amyotrophic lateral sclerosis (ALS), following our 2002 institutional protocol of sialorrhea treatment. STUDY DESIGN: Clinical prospective. MATERIAL AND METHOD: Five patients with ALS assisted at Clinic of Otolaryngology of AACD (Associacao de Assistencia a Crianca Deficiente). They were all submitted to local application of Botox® in salivary glands and followed up for a year. The protocol consisted of clinical questionnaire about the inability of swallowing saliva and its repercussions in quality of life. Patients were submitted to previous odontological treatment, had intolerance to the adverse effects of anti-cholinergic agents and had not used Botox® for at least six months. The application was guided by ultrasound and the doses were 30U in one point for submandibular gland, and 20U in two points for each parotid gland, after topic anesthetic with prilocaine. RESULTS: Five patients with ALS with sialorrhea, aged 45 to 59 years, were submitted to Botox® salivary glands application. We observed that the symptoms of sialorrhea changed dramatically in four patients. Three patients stayed almost four months without complaints with repercussion in quality of life. No patient presented local or systemic effects with local injection of Botox®.

Application of botulinum toxin to reduce the saliva in patients with amyotrophic lateral sclerosis

AIM To demonstrate the effect of local application of Botox(R) in patients with amyotrophic lateral sclerosis (ALS), following our 2002 institutional protocol of sialorrhea treatment. STUDY DESIGN Clinical prospective. MATERIAL AND METHOD Five patients with ALS assisted at Clinic of Otolaryngology of AACD (Associação de Assistência à Criança Deficiente). They were all submitted to local application of Botox in salivary glands and followed up for a year. The protocol consisted of clinical questionnaire about the inability of swallowing saliva and its repercussions in quality of life. Patients were submitted to previous odontological treatment, had intolerance to the adverse effects of anti-cholinergic agents and had not used Botox for at least six months. The application was guided by ultrasound and the doses were 30U in one point for submandibular gland, and 20U in two points for each parotid gland, after topic anesthetic with prilocaine. RESULTS Five patients with ALS with sialorrhea, aged 45 to 59 years, were submitted to Botox salivary glands application. We observed that the symptoms of sialorrhea changed dramatically in four patients. Three patients stayed almost four months without complaints with repercussion in quality of life. No patient presented local or systemic effects with local injection of Botox.

Drooling: analysis and evaluation of 31 children who underwent bilateral submandibular gland excision and parotid duct ligation.

AIM To evaluate the safety of bilateral submandibular gland excision and parotid duct ligation in order to control drooling in children; to assess its long-term efficacy and complications. STUDY DESIGN longitudinal cohort. MATERIALS AND METHODS Thirty-one children aged 6 to 13 years (7.6 years old in average), with multiple neurological disabilities were submitted to a bilateral submandibular gland excision with parotid duct ligation in order to control ptyalism between December 1999 and December 2005, mean follow up of 36 months. RESULTS According to Wilkies success criteria, 87% of children had excellent or good results and insignificant morbidity was insignificant; with temporary parotid edema as the major complication. CONCLUSION Bilateral submandibular gland excision with parotid duct ligation were safe to be performed in children, with 87% of success in drooling control.

Surgery for aspiration: analysis of laryngotracheal separation in 23 children.

The aim of this study was to analyze the efficacy of laryngotracheal separation (LTS) in eliminating aspiration in children by comparing pre- and postoperative conditions. This prospective study used an internal control group. Children with neurologic impairment and a diagnosis of chronic aspiration were subjected to LTS at the Associação de Assistência à Criança Deficiente (AACD). Twenty-three children had undergone LTS with the modified Lindeman technique. All of them gained complete control of aspiration. Frequency of hospitalization, number of respiratory infections, and level of secretion were statistically reduced. After surgery only 21.7% of the children were capable of oral intake exclusively. LTS is an effective and safe technique that can be used in children resulting in aspiration control in 100% of the patients and without repercussions in the respiratory secretion and pulmonary infections.

Fiberoptic endoscopic swallowing disorders in chronic encephalopathy

OBJECTIVE: To evaluate the results of fiberoptic endoscopic examination of swallowing safety in children with cerebral encephalopathy in order to identify patients with oropharyngeal dysphagia. METHODS: 68 children from the Association for the Care of Disabled Children (Associação de Assistência à Criança Deficiente -AACD), São Paulo, were submitted to fiberoptic endoscopic examination of swallowing safety from March 1999 to March 2000. RESULTS: We observed premature spillage (53%), penetration in a pureed consistency (5.9%), penetration in a liquid consistency (4.4%), tracheal aspiration in a pureed consistency (14.7%), tracheal aspiration in a liquid consistency (32.3%), residue (7.4%), cough effectiveness (44.1%). CONCLUSIONS: Children showed a high incidence of pharyngeal swallowing disorders. Tracheal aspiration was the most important disorder because it is related with high morbidity in children with cerebral encephalopathy. The texture and consistency of the patientacute;s diet may be modified to decrease the risk of aspiration and improve swallowing examination.

Avaliação nasofibrolaringoscópica da deglutição em crianças

Introduction: Very little has been published about the disorders of deglutition in children with neurological impairment. The swallowing difficutties found by children with cerebral palsy are debilitating, particularly by the chronic pulmonary diseases and malnutrition. Study design: Prospective clinical no randomized. Objective: The purposes of this study were to (1) asses the use of nasoendoscopic examination of swallowing in chlidren and (2) describe the swallowing pharyngeal abnormalities. Material and method: The data reported here were extracted from a database on 134 pediatric swallow studies. All children had primary diagnosis of cerebral palsy, with swallowing abnormalities. The ages ranged from four months to 14 years. Results: The prevalence of each type of abnormality in the study group was: premature spillage (53,7%), tracheal aspiration in a liquid consistence (33,6%), tracheal aspiration in a pureed consistence (14,9%). There was regular agreement between the finds of premature spillage and tracheal aspiration. None of the children had complications during the exam. Conclusion: It was concluded that the nasoendoscopic evaluation of swallowing is a valid and valuable tool for evaluating pharyngeal dysphagia in children.

Salivary gland surgery for control of chronic pulmonary aspiration in children with cerebral palsy

OBJECTIVE To evaluate the outcome of surgical saliva reduction to decrease pulmonary aspiration in children with cerebral palsy and its repercussions in respiratory infection control. METHODS Twenty-nine children with neurological impairment and diagnosis of chronic pulmonary aspiration were submitted to bilateral submandibular gland excision and bilateral parotid duct ligation at the Association for the Welfare of Physically Handicapped Children, from December 2001 to December 2004. Postoperative frequency of lower respiratory tract infection, hospitalization rate due to pulmonary infection and airway secretion level after the surgery were compared to preoperative period. RESULTS Twenty-nine children with cerebral palsy aged 18 months to 9 years were submitted to submandibular glands excision and parotid ducts ligation. All children had gastrostomy and no oral intake. There were no major complications; two children had reopening of one parotid duct. Frequency of lower respiratory tract infections, rate of hospitalization for treatment of pulmonary infections and level of airway secretion were statistically reduced. Preoperative mean rate of lower respiratory tract infection was 6.9/year; in postoperative period, rate was 2.4/year (p<0.001). Pneumonia hospitalization mean rate was 63.4 days/year preoperatively and 17.5 days/year postoperatively (p<0.001). There was also a significant improvement in the need for suctioning of upper airway secretion (mean 11 times/day in preoperative period and 3.1 times/day in the postoperative period; p<0.001). CONCLUSION In children with cerebral palsy, surgical saliva reduction by submandibular glands excision and parotid ducts ligation is an effective and safe technique for frequency reduction of lower respiratory tract infection and level of airway secretion.

Postoperative acute respiratory insufficiency following adenotonsillectomy in children with neuropathy

OBJECTIVE Evaluate the incidence of acute respiratory insufficiency (ARI) in the immediate postoperative period following adenotonsillectomy in children with neurological diseases. METHODS Medical records from all pediatric adenotonsillectomies performed from January 1997 through August 2003 at the Roberto de Abreu Sodré Hospital of the Association for the Welfare of Physically Handicapped Children (AACD) in São Paulo were reviewed. Data were collected for patient age, neurological diagnosis, associated comorbidities, index of respiratory insufficiency in the immediate postoperative period and period of hospitalization. RESULTS One hundred and nine patients charts had sufficient documentation to be included in this study. Of these, 15 (13.7%) developed ARI in the immediate postoperative period. Ages ranged from 1 to 12 years old (average of 5). Of the 15 patients that presented ARI, 10 (67%) were intubated in the first 3h following extubation. The predominant neurological diagnosis was non-progressive chronic encephalopathy, observed in 84 children (77%), and, among that, 14 (17%) presented ARI. Other neurological diagnoses present in this study were Rett syndrome, neuromuscular disease and meningomyelocele. All of the children that developed ARI presented quadriplegia. Among children that did not develop ARI, the predominant motor pattern was: 28 with quadriplegia, 38 diplegia, 10 hemiplegia, 12 with involuntary movement (choeroathethosis) and six without motor involvement. Children presenting ARI needed mechanical ventilation for an average of 37.87 h (1.5 days) in the intensive care unit. ARI increased the period of hospitalization; these children had an average length of stay of 7 days versus 1.5 days for those that did not develop complications. CONCLUSION Children with neurological disorders, especially those with quadriplegic pattern of motor involvement and severe oropharyngeal dysphagia, are at higher risk for respiratory insufficiency in immediate postoperative period of adenotonsillectomy and should be observed in intensive care unit.

First Clinical Consensus and National Recommendations on Tracheostomized Children of the Brazilian Academy of Pediatric Otorhinolaryngology (ABOPe) and Brazilian Society of Pediatrics (SBP)

INTRODUCTION Tracheostomy is a procedure that can be performed in any age group, including children under 1year of age. Unfortunately health professionals in Brazil have great difficulty dealing with this condition due to the lack of standard care orientation. OBJECTIVE This clinical consensus by Academia Brasileira de Otorrinolaringologia Pediátrica (ABOPe) and Sociedade Brasileira de Pediatria (SBP) aims to generate national recommendations on the care concerning tracheostomized children. METHODS A group of experts experienced in pediatric tracheostomy (otorhinolaryngologists, intensive care pediatricians, endoscopists, and pediatric pulmonologists) were selected, taking into account the different regions of Brazil and following inclusion and exclusion criteria. RESULTS The results generated from this document were based on the agreement of the majority of participants regarding the indications, type of cannula, surgical techniques, care, and general guidelines and decannulation. CONCLUSION These guidelines can be used as directives for a wide range of health professionals across the country that deal with tracheostomized children.

Benefícios da aplicação de toxina botulínica associada à fonoterapia em pacientes disfágicos graves

Case report with the aim to characterize the benefits of botulinum toxin injection into salivary glands in association with swallowing therapy in patients with severe dysphagia. The medical records of five neurological patients (four male and one female, aged between 17 and 70 years) who exclusively used alternative feeding were analyzed. Four patients were tracheostomized. Inclusion criterion was to present severe dysphagia associated to clinical manifestations of drooling and/or sialorrhea with significant aspiration of saliva, restricting the improvement in swallowing rehabilitation. Data were collected before and after intervention associated with botulinum toxin injection, regarding the following aspects: mobility and strength of oropharyngeal structures (lips, tongue and cheeks), laryngeal elevation, severity degree of dysphagia, use of alternative tube feeding and tracheostomy. After swallowing therapy, four patients showed improvement in mobility and strength of the lips, tongue, cheeks and larynx. Four patients presented functional swallowing and one of them modified had the severity degree of dysphagia changed. Therefore, most patients were able to receive exclusive oral feeding, and only one remained on mixed feeding, that is, gastrostomy and oral feeding with pasty consistence. All tracheostomized patients had the tracheostomy cannula removed. The study showed that the treatment described contributed to swallowing rehabilitation, reintroduction of oral feeding, and withdrawal of the tracheostomy cannula.