1、Treatment of Drooling 治疗流口水,Because it is Not Cool to Drool（因为流涎并不雅观）,Robert Cooper, MD, FAAPMR （罗伯特. 库帕） China Partners Network中国合作联盟 November 2013（2013年11月）,The Salivary Glands （唾液腺）,-Parotid glands secrete a serous- or watery- secretion Submandibular glands secrete a thicker, mucinous secretion （
2、腮腺分泌的是一种浆液性或水样的分泌物；下颌下腺分泌的是一种粘稠粘液性的分泌物。） -Control of the salivary glands is via the autonomic nervous system（唾液腺是受自主神经系统支配）,Salivary Gland Innervation（与唾液腺有关的神经支配）,Parasympathetic (cholinergic) Cranial and Sacral（脑部和骶部的类胆碱能的副交感神经 ） CN 7 to Submandibular gland via （第7对脑神经面神经的Chorda Tympanae分支配下颌下腺） C
3、N 9 to Parotid（第9对脑神经舌咽神经支配腮腺）,Purpose of Salivation（唾液分泌的目的）,Lubrication and binding of food- making a slippery bolus that slides easily through the esophagus （润滑固定食物，并将其变为小团块以利于经过食道） Makes dry food soluble, so that it can be tasted（溶解干燥的食物，以利于引起味觉） Initiates digestion of starches using amylase（启动唾
4、液淀粉酶对淀粉进行消化）,Saliva Quantity（唾液量）,1.5 Liters per Day（每日1.5升)Swallowing versus Production Problem?（唾液吞咽与产生的相对问题）,Pathologic Drooling (Sialorrhea)（病理性流口水-多涎症）,Pathologic drooling often occurs in patients with cerebral palsy or other neurologic conditions（病理性流口水常常发生在罹患有脑性瘫痪或者其它一些神经系统疾病的病人身上） Often defi
5、ned as severe drooling in a patient older than four years（经常被定义为，4岁以上的病人有严重的流涎情况） Usually dissipates by 18 months（正常人通常到18个月时会消失） Incidence has been reported from 10% - 37% of children with cerebral palsy.（据报道，脑瘫患儿多涎症发病率为10% - 37%。） (PH Jongerius et al, Pediatrics 2004)（文献出自PH Jongerius等人发表在2004年的儿科
6、学杂志上）,Why Treat it?（治疗原因）,Detracts from physical appearance （有损于外貌形象） Affects hygiene（影响卫生） Keeps other children from initiating contact（开始影响和其他孩子的交流） Swallowing is further impaired（ 吞咽进一步受损） May result in more respiratory infections（可使呼吸道感染增加） Wan der Burg, Jan JW et al, Drooling in children with c
7、erebral palsy: effect of salivary flow reduction on daily life and care. DMCN 2006, 48, 103-107（文献出处；口水减少对于脑瘫患儿日常生活护理的影响）,Conservative Approaches（保守治疗方法）,Behavioral Modification行为改善疗法 Most helpful in children with normal cognition（对于认知正常的患儿效果最佳）Dental Appliances（佩戴牙科器具）Acupuncture（针灸疗法）,Oral Motor T
8、raining（口腔功能训练）,In CP there is often a decreased muscle tone in head and neck（通常可使脑瘫患儿头颈部的肌张力下降） Exercises aim to normalize tone, stabilize head position, promote jaw stability and lip closure（训练的目的：使肌张力正常化，稳定头的位置，促进下颌稳定性和嘴唇的闭合） Administered by speech therapy or occupational therapy（在言语疗法或者作业疗法中实施）
9、Requires sufficient cognition and motivation of patient and caregiver（需要病人和护理者有足够的认识和积极性）,Anticholinergics /抗胆碱,Glycopyrolate 胃长宁 Atropine 阿托品 Scopolamine 东莨菪碱,Glycopyrrolate (Robinultm) 胃长宁（商品名）,胃长宁 Dose 0.04-0.1mg/kg orally q 4-8 hours（剂量） Forms（制剂类型） Liquid 0.2mg/ml（注射剂） Tablets 1mg, 2mg（片剂） Maxi
10、mum Dose: 1- 2mg/dose; 8mg per day (最大剂量：每次服用1-2mg；每日8mg) May have less side effects on cognition than other anticholinergic medications（可能比其他抗胆碱药物副作用更少） Blasco PA, Stansbury JC. Arch Pediatr Adolesc Med. 1996 Sep;150(9):932-5（文献出处）,Atropine 阿托品,Use 1% ophthalmic solution（使用1%的滴眼液） 1-2 drops three t
11、imes daily（每日三次每次1-2滴）,Scopolamine 东莨菪碱,Patch delivers 1 mg Scopolamine over 3 days（贴剂能释放1mg东莨菪碱，时效超过3天） Do not cut patch（贴剂不可剪，要保持其完整性）,Side Effects（副作用）,Common (80% in one trial) 常见的有（在一项实验中发现超过 80% 的患者会出现）：Constipation(便秘） Blurred vision（视力模糊） Confusion（意识恍惚） Fatigue（疲乏） Urinary Retention （尿潴留）,S
12、urgery: Salivary Gland Excision（手术：唾液腺切除术）,Salivary Gland Ligation（唾液腺结扎术）,Ductal relocation is becoming more prevalent than gland excision（腺导管重置术比腺体切除术更为常见） Relocate papillae of submandibular ducts from the anterior oral cavity to the base of the tongue（将下颌下腺导管的乳头部从口腔前部移位到舌基底部）May Result in Excessi
13、ve Dryness Or Dental Carries（可致过度口干或牙渍残留）,How do we quantify Drooling?如何对流涎进行量化？,Drooling Severity Scale（流涎严重程度量表） (McMillan Center, Toronto)（多伦多，麦克米兰中心）,Mild - Saliva spills onto lips but not beyond 轻度：口水流到嘴唇但未超出嘴唇范围 Moderate - Reaches chin but not beyond 中度：口水流到下巴但未超出下巴 Severe - Saliva drips onto
14、clothing 重度：口水滴到衣物上 Profuse - books, equipment, everything near face gets wet with saliva. 极重度：口水遍及身边的书本，物品等等,The Drooling Quotient（流涎商数）,2 periods of 10 minutes with 60 minute break in between（分为2期，每期10分钟，中间有60分钟的休息） Episode of drooling= new saliva on lips or chin（流涎片数即新的涎液出现在嘴唇上还是下巴上） Every 15 sec
15、onds, presence or absence of drooling recorded (40 observations in 10 min)（每隔15秒钟要（用“有”或“无”）记录一次流涎情况；规定10分钟之内要进行40次观察记录。） 1 hour after meal, sitting up and alert还规定，在饭后1小时，取坐位，清醒的状态下进行。 DQ(%)= 100 x # drooling episodes/40(流涎商数=100#流涎总片数/40）,Cooper Drool Scale（库帕流涎量表）,Number of bib changes daily +（每日
16、围涎布更换的次数+） Number of shirts changed daily +（每日衬衣更换的次数+） Frequency that suctioning is required per hour（频率是指每个小时需要抽吸涎液的次数）,Botulinum(肉毒杆菌）,Adult Literature（成人 文献） OSullivan JD, Bastia KP, Lees AJ. Botulinum Toxin as treatment for drooling saliva in PD. Neurology 2000,55; 606-607（肉毒素可用来治疗帕金森病人流涎症） Ped
17、iatric Literature(小儿 文献） Suskind D and Tilton A, Clinical study of Btx-A in the treatment of Sialorrhea in Children with Cerebral Palsy, Laryngoscop 112: Jan 2002, 73-81（临床上应用肉毒毒素A治疗脑瘫患儿多涎症）,Adverse Effects（不良反应）,In a controlled clinical trial minor adverse effects were reported in 82% of patients t
18、reated with scopolamine. 在临床对照试验中，发现有82%的患者经过东莨菪碱治疗后不良反应较小. Versus 6% with botox（相比之下，经肉毒素治疗不良反应较小的患者仅占6%） Jongerius, Pediatrics, 2004（文献出处）,Risks（危害）,Bleeding（出血） Nerve Damage（神经损害） Dysphagia（吞咽困难） Infection（感染）,What about Botox?(何为肉毒素）,Reconstituted in preservative free sterile saline (合成于不含防腐剂的无菌
19、生理盐水中） Usually 1 ml per 100 unit vial（通常每100单位的小瓶配有1ml） Typical dosage 10-25 units per gland per side一侧腺体标准剂量为10-25个单位）,Patient Selection（适宜人群）,Should have profuse drooling which is affecting function, hygiene, or respiratory health. （患者极重度型流涎，即影响活动，卫生或呼吸道健康） Greater than 1 year old.（1岁以上） Should ha
20、ve been tried on, and failed treatment with anti-cholinergic medication.（曾屡次尝试服用抗胆碱能药物效果不佳者）,Risks（危害）,Dysphagia （吞咽困难） Can be a potential complication- presumably due to diffusion of the botulinum outside the gland（这是一种潜在性的并发症，原因可能是腺体外侧的肉毒素扩散所致） Not an absolute contra-indication.（这也不单单是作为一种禁忌症） If
21、the patient has a feeding tube, prior to the procedure, then there is a means of feeding should swallow function worsen.（如果之前病人插有饲管，这可能会导致吞咽功能恶化）,Botulinum Toxin（肉毒毒素）,Heavy Chain binds neuron (100k daltons)（重链（100k道尔顿）：结合神经元） Light Chain (50k daltons) A protease acts on fusion protein responsible f
22、or exocytosis of acetycholine（轻链（50k道尔顿）：是一种蛋白酶，主要作用于乙酰胆碱的胞外分泌）,Normal Acetylcholine Release（正常情况下乙酰胆碱的释放过程）,SNARE: Soluble Attachment protein REceptor complex（SNARE：是一种可溶性蛋白受体复合物）,Blockade with Botulinum（肉毒素的阻滞作用）,Procedure,Botox (botulinum Type A) is injected into the salivary glands using ultraso
23、und guidance（将肉毒毒素A借着超声影像引导注射到唾液腺中） The parotid glands, the submandibular glands, or both sets may be injected（两侧腮腺，下颌下腺或二者均可注射肉毒毒素） Parotid glands are sufficiently superficial that these can be done without ultrasound（由于腮腺位置表浅，故可以不用超声引导） Use of sedation essential（镇静剂的使用也必不可少）,Salivary Gland Contrib
24、ution（唾液腺分布状况）,Submandibular Gland（下颌下腺）,Parotid Gland(腮腺）,More superficial（注射位置较为表浅） Can be injected without ultrasound（注射时无需超声引导） Extends beyond ear（注射范围超过耳部） “the tail of the parotid”（“腮腺的尾端“也要注射）,Clinical Effect（临床疗效）,In Jongerius study, effect of botox injection was reduction of DQ by 50% until
25、 24 weeks after botox injections 在乔恩基利斯的研究中，发现使用肉毒毒素24周后流涎商数（DQ)降低了50%。,Botox versus Surgery肉毒毒素与手术疗法的比较,Drooling Quotient was reduced to a greater extent after surgery than after Botox A. （在很大程度上讲，在降低流涎商数的疗法中，手术治疗优于注射肉毒毒素治疗） Both effective but surgery provides a larger and longer lasting effect（虽然二
26、者对治疗流涎症皆有效，但手术效果更持久有力。） Sheffer AF et al, Botulinum toxin versus submandibular duct relocation for severe drooling. DMCN 2010 Nov;52(11):984.（文献出处；比较肉毒毒素治疗和下颌下腺导管重置术，哪种疗法对严重流涎有效）,Thank You.,robert.coopermulticare.org 403-4437 877-513-7137,REFERENCES:（参考文献）,Baneree JK, Glasson C, OFlaherty SJ. Paroti
27、d and submandibular botulinum toxin A injections for sialorrhoea in children with cerebral palsy, Dev Med Child Neurol 2006 48(11):883-7. Blasco PA, Stansbury JC. Arch Pediatr Adolesc Med. 1996 Sep;150(9):932-5 Bothwell JE, et al, Botulinum Toxin A as a Treatment for Excessive Drooling in Children,
28、Pediatr Neurol 2002; 27:18-22. Ellies M, et al, Successful Management of Drooling with Botulinum Toxin A in Neurologically Disabled Children, Neuropediatrics 2002; 33: 327-330. Jongerius PH, et al, Effects of Botulism Toxin in the Treatment of Drooling: A Controlled Clinical Trial, Pediatrics 2004;1
29、14;620-27 Scheffer, Arthur RT et al, Botulinum toxin vs submandibular duct relocation for severe drooling, DMCN 2010; 52: 038-42. Suskind DL, Tilton A, Clinical Study of botulinum-A toxin the the treatment of sialorrhea in children with cerebral palsy. Laryngoscope 2002; 112(1): 73-81. Wan der Burg, Jan JW et al, Drooling in children with cerebral palsy: effect of salivary flow reduction on daily life and care. DMCN 2006, 48, 103-107 Wong, Virginia, JG Sun, W Wong, Traditional Chinese Medicine (Tounge Acupuncture) in Children with Dooling Problems, Pediatr Neurol 2001; 25(1): 47-54.,
