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A 34-year-old female who had traumatic brain injury caused by a gunshot 13 year ago was seen for anterior drooling. Previously, she underwent several blind botulinum toxin injections into the parotid and submandibular gland which did not work sufficiently. Drooling severity grade was 5/5, drooling frequency grade was 4/4 as assessed by the Drooling Severity and Frequency Scale (DSFS) and she complained about bad odor and soaking of clothes and using hand towels daily. Ultrasound and electromyography & electrical stimulation-guided 25 IU of onabotulinum toxin A injection (a total of 50 IU) was applied to each parotid gland at two different injection points using a 25-gauge 50¥0.5-mm needle electrode using the in-plane technique. Both written and oral informed consents of the patient were obtained before the injection. Ultrasound was used to differentiate the parotid parenchyma having a brighter and homogenous echogenicity (resembling thyroid gland echogenicity) due to its high fatty content. In addition, color or power mode of ultrasound was used to assess the vascular anatomy of the parotid and injection side carefully. When the needle was placed in the accurate position, the absence of motor unit potential was used to confirm that the needle was placed into the parotid gland and electrical stimulation was done to check the proximity of the main branches of the facial nerve to visualize whether there was a twitch in the mimetic muscles. Once no electromyographic signals and contraction of muscles were seen, injection was applied safely and accurately (Figure 1). The patient reported remarkable improvements after botulinum toxin injections. Drooling severity improved to 3/5 and severity improved to 2/4 on DFSS, and the number of soaked towels decreased to only one.

turkish journal of physical medicine and rehabilitation :

Ultrasound and electromyography &amp; electrical stimulation-guided botulinum toxin injection of salivary glands for drooling: A case report with a description of the technique