Sialorrhoea (hypersalivation) is a common adverse effect of clozapine. If severe, it can affect patients' quality of life and adherence to the treatment. Clinicians therefore need to proactively manage this effect. At present, no drugs are licensed to manage clozapine-induced sialorrhoea, although there are many off-label treatment options, with variable effectiveness. Anticholinergic medications are commonly prescribed for it, but they have limited effect and can worsen constipation. This article gives a brief overview of other practical and pharmacological management options.

Dysautonomia symptoms of nutritional interest may often occur in Parkinson's disease (PD), but the role played in affecting the risk of malnutrition still needs to be clarified. A total of 208 consecutive PD outpatients hospitalised on a scheduled basis were assessed for nutritional risk by the Malnutrition Universal Screening Tool. Presence of dysautonomia symptoms (dysphagia, sialorrhoea and constipation) was investigated using clinical rating scales. In our population, prevalence of nutritional risk was 17·2 (95 % CI 12·1, 24·0) % and relied mainly on unintentional weight loss. Sialorrhoea, dysphagia, dysphagia to liquids and constipation were observed in 10·6, 11·0, 14·4 and 59·6 % of the patients, respectively. Nutritional risk was independently associated with the number of dysautonomia symptoms (OR 1·39 (95 % CI 1·00, 1·96); P= 0·048) but not with single symptoms. An independent association was also found with the severity of motor symptoms (Hoehn–Yahr stage, OR 1·48 (95 % CI 1·00, 2·55); P= 0·049) and levodopa dose (OR 1·16 (95 % CI 1·04, 1·31) mg/kg per d; P= 0·009). Nutritional risk in PD outpatients appears to depend mainly on dysautonomic syndrome, disease severity and levodopa dosage. Implications for outcome deserve further investigation. The assessment of nutritional status and of gastrointestinal dysautonomia symptoms should be part of the routine work-up of a PD patient.

Dribbling (sialorrhoea) affects about 10 per cent of patients with chronic neurological disease. The variety of treatments currently available is unsatisfactory. This study was a clinical trial of the efficacy of ultrasound-guided, intraglandular injection of botulinum toxin A for dribbling, performed within the otorhinolaryngology department of the National University of Malaysia. Both pairs of parotid and submandibular glands received 25 U each of botulinum toxin A.

Twenty patients were enrolled in the study. The median age was 15 years. All 20 patients (or their carers) reported a distinct improvement in symptoms after injection. Using the Wilcoxon signed rank test, there were significant reductions in dribbling rating score, dribbling frequency score, dribbling severity score, dribbling visual analogue score and towel changes score, comparing pre- and post-injection states (p<0.001). There were no complications or adverse effects during or after the injection procedure.

Intraglandular, major salivary gland injection of botulinum toxin A is an effective treatment to reduce dribbling. Ultrasound guidance enhances the accuracy of this procedure and minimises the risk of complication.

Background: The aim of this study was to describe the authors' minimally invasive procedure developed to significantly decrease excessive salivation in children suffering from chronic neurological diseases, using botulinum toxin A.

Objective: Ultrasound-guided, intraglandular injection of botulinum toxin blocks the parasympathetic innervation of salivary glands, resulting in a temporary decrease in saliva production and improved quality of life, lasting about three to four months.

Materials and methods: Prior to introducing the method into clinical practice, animal experiments were conducted in order to verify the lack of histological changes three months following botulinum toxin administration. Twenty-one children were included in the clinical study, with ages ranging from two and a half to 14 years.

Results: The animal studies did not reveal any histological changes three months after botulinum toxin administration. Although botulinum toxin A proved to be ineffective in a single case, the majority of the other 20 patients responded well, with a highly significant reduction of their symptoms. The parents of 18 responder children requested repeated treatment with botulinum toxin A. However, two families refused to be further involved in the study, despite good results. The protein content of saliva, regulated by sympathetic innervation, was not affected by the treatment.

Conclusion: This minimally invasive method, applied repeatedly three to four times a year, may be a viable alternative to surgical procedures such as submandibular duct relocation, duct ligature or nervus tympanicus neurectomy.

Drooling is common in patients with neurological disability and a major factor affecting quality of life. Management of this problem is best carried out by a team approach using surgical and non-surgical methods. Submandibular duct relocation is a commonly performed procedure with low complication rate. This procedure has been carried out in 56 patients over the last 14 years at the Belfast City Hospital by the senior author. All the patients underwent physiotherapy for six months before they were selected for surgery. All the patients were over five years of age and most had severe neurological impairment. For the purposes of this study, all the patients were followed by a questionnaire regarding symptomatic improvement, parent satisfaction and complication rate. All case notes were also reviewed retrospectively.

Parental satisfaction was high and drooling was significantly reduced in 49 cases. The main complication was ranula formation seen in five cases. The most significant area of parental concern was post-operative pain. It is important to counsel the parents regarding the post-operative pain relief as well as failure rate of the procedure. It can be concluded that this procedure is a safe and highly successful procedure, which significantly improves the quality of life.

This study examines the long-term results and morbidity of submandibular duct transposition in drooling children. Twenty-two patients, aged 3 to 18 years, with neurological dysfunction and excessive drooling underwent submandibular duct transposition between 1984 and 1987. In January 1990, 20 patients were reviewed. Their degree of drooling pre-operatively, immediately post-operatively and currently was assessed. The rate of improvement and the occurrence of complications were noted. Drooling was ‘much better’ in the early post-operative period in 17 of the 20 patients, and this improvement was invariably noted within three weeks. In the three other patients drooling was ‘better’. Deterioration occurred in only three patients over the entire follow-up period. Complications all occurred in the first 18 months following surgery; they consisted of salivary retention cysts in four and transient submandibular gland swelling in a fifth patient.