K. van Hulst

Botulinum toxin effect on salivary flow rate in children with cerebral palsy

Objective: To investigate the effectiveness of botulinum neurotoxin (BoNT) type A in reducing salivary flow rate in children with cerebral palsy (CP) with severe drooling. Methods: During a controlled clinical trial, single-dose BoNT injections into the submandibular salivary glands were compared with scopolamine treatment. Forty-five school-aged children were included. Salivary flow rates from all major glands were obtained at baseline and compared with measurements during the interventions. Basic statistics consisted of analysis of difference scores. Results: Compared with baseline, the mean decrease in submandibular flow was 25% during scopolamine and 42% following BoNT injections. The difference scores were significant with maximum reductions 2, 4, and 8 weeks following BoNT. Of all children, 95% responded during scopolamine. Response rates for BoNT were significantly lower and varied from 69% at 2 weeks to 49% at 24 weeks after injection (the end of the study). Four patients discontinued scopolamine therapy because of side effects. Only incidentally mild side effects were reported from BoNT. Conclusions: Intraglandular BoNT injections significantly reduce salivary flow rate in the majority of drooling CP children, demonstrating high response rates up to 24 weeks. The procedure is simple to perform, effective, and safe when ultrasound guidance is used. The anticholinergic effect of BoNT exceeds that of scopolamine. As anticholinergic drugs are frequently contraindicated because of side effects, BoNT injections offer an alternative in the treatment of drooling.

The treatment of posterior drooling by botulinum toxin in a child with cerebral palsy.

Drooling is the unintentional loss of saliva from the mouth, known as anterior drooling (1). However, anterior drooling has to be distinguished from posterior drooling which refers to saliva that is spilled over the tongue through the faucial isthmus. Under physiological conditions this initiates the pharyngeal phase of swallowing, during which the larynx closes to protect the airways followed by relaxation of the upper esophageal sphincter. Whenever the trigger to swallow is impaired or missing, pooled saliva may lead to posterior drooling mostly apparent from an alarming congested breathing, coughing, gagging, vomiting, and at times aspiration into the trachea. Unrecognized and silent pneumonia can occur (2). The risk of posterior drooling can be enhanced by the fact that many disabled children are taken care of in a supine position for a substantial part of the day. Many children with cerebral palsy (CP) suffer from gastroesophageal reflux (3). In healthy subjects, exposure of the distal esophagus to acid results in an immediate increase of saliva secretion. The possible function of this is that swallowed saliva plays a role in the defense of esophageal mucosa to acid–induced injuries. Reflux in children with CP causes stimulation of pH-sensitive receptors in the mucosa of the distal esophagus which activates the esophageal-salivary reflex leading to an increase of salivary flow rate (3,4). This may exacerbate anterior and posterior drooling. Botulinum neurotoxin (BoNT) injections in the salivary glands in the treatment of anterior drooling demonstrate promising efficacy (5–8). This case report summarizes the results of repeated bilateral single-dose BoNT injections into the submandibular glands in a patient with CP with severe drooling, aspiration, and recurrent pneumonia. The primary treatment intention was to decrease salivary flow in an effort to reduce anterior as well as posterior drooling.

THE NIJMEGEN HIGH FIELD MAGNET LABORATORY

Abstract The Nijmegen high field facility is configured around a 6-MW electrical power supply and the associated water-cooling system. Five magnet stations are available: three water-cooled magnets, with a maximum field of 20 T, and two hybrid magnet systems; our latest hybrid, Nijmegen-II, generates fields up to 30.4 T in a 32-mm bore.

The Nijmegen high field magnet laboratory and its experimental facilities

Abstract The High Field Magnet Laboratory at the University of Nijmegen is capable of producing continuous magnetic fields up to 30 T. The highest fields are generated using hybrid magnet systems which combine an external superconducting magnet providing the background field with a smaller resistive coil energised from a 6 MW power supply. For effective use of these facilities a broad range of instrumentation has been developed. Of great importance is the capability to maintain millikelvin temperatures, and a plastic dilution refrigerator designed and constructed at Nijmegen has demonstrated a base temperature of well below 30 mK in 30 T.

The Nijmegen laboratory for high magnetic fields

Abstract The 6 MW high field installation at the Faculty of Science of the University of Nijmegen has been operational since 1976. Its main feature is the 25 T hybrid magnet which made its first successful run at Nijmegen in May 1978. Besides the hybrid magnet, two 15 T Bitter magnets have been in use on a routine basis since 1976. A third 15 T Bitter magnet of improved homogeneity will be installed in 1979 and a second hybrid magnet is planned to become operational before 1982.

The Nijmegen High-Field Magnet Laboratory: Experience with the New 30-T Hybrid Magnet System

The Nijmegen high-field facility is configured around a 6-MW electrical power supply and the associated water cooling system. Five magnet stations are available: three water-cooled magnets, with a maximum field of 20 T, and two hybrid magnet systems: the latest hybrid, Nijmegen-II, generates fields up to 30.4 T in a 32-mm bore. The cryogenic characteristics of this 30-T hybrid magnet have been much improved by modifications to the support of the coil tank.

Bilateral submandibular gland excision for drooling: Our experience in twenty-six children and adolescents

Dear Editor, Approximately 40% of children with cerebral palsy (CP) suffer from drooling, and it is considered severe in 15%. Drooling is caused by a combination of several factors such as diminished awareness to swallow, poor posture and dysfunctional oral motor functions. We distinguish between anterior and posterior drooling. Anterior drooling is characterised by saliva spilled from the mouth that is clearly visible. Posterior drooling is defined as the spill of saliva over the tongue through the oropharyngeal isthmus, causing aspiration and associated pneumonias. Morbidity due to drooling has been widely described. Different therapies have been reviewed, but there is no consensus regarding the optimal treatment strategy. Surgical interventions are indicated when conservative measurements have failed, when a more long-term solution is desirable or when conservative measurements are not expected to improve drooling, for example in older patients or patients suffering from a progressive disease. In individuals with combined anterior and posterior drooling, submandibular duct relocation is contraindicated. Bilateral submandibular gland excision may be an effective procedure instead. Previous studies regarding the efficacy of this procedure were based on small and heterogeneous populations. In particular, no validated objective measurements were used. A previous meta-analysis compared different surgical intervention methods, but did not include studies on submandibular gland excision without parotid duct rerouting or ligation. We aim to be the first to provide both objective and subjective results of bilateral submandibular gland excision in young people with neurological disabilities who drool due to severe dysphagia. Materials and methods

The Nijmegen hybrid magnet systems

Abstract The Nijmegen High-Field Magnet Laboratory operates a facility that is configured around a 6 MW electrical power supply and the associated water cooling system. Five magnet stations are available. In three of them, water-cooled magnets with fields up to 20 T. The two hybrid magnet systems constitute our most powerful instruments with maximum field strengths of 25 and over 30 T, respectively.