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Aim  To assess: (1) the effect on drooling of bilateral submandibular duct ligation as surgical therapy after the administration of submandibular botulinum neurotoxin A (BoNT‐A) for excessive drooling and (2) the predictive value of treatment success with BoNT‐A on treatment success after bilateral submandibular duct ligation.    Method  This was a within‐participant retrospective observational study in which 29 children with severe drooling (15 males, 14 females) received BoNT‐A treatment at a mean age of 9 years 6 months (SD 2y 5mo), followed by bilateral submandibular duct ligation at a mean age of 10 years 11 months (SD 2y 4mo). Fifteen children were diagnosed with cerebral palsy (CP), with 12 children classified in Gross Motor Function Classification System levels IV and V. The 14 children without CP had non‐progressive developmental disorders. The primary drooling severity outcomes were the Visual Analogue Scale (VAS; subjective assessment) and drooling quotient (objective assessment). Measurements were taken before each intervention and again at 8 and 32 weeks.    Results  The VAS was significantly lower after bilateral submandibular duct ligation at follow‐up compared to BoNT‐A treatment (mean difference −33,  p ≤0.001; 95% confidence interval [CI]=−43.3 to −22.9). The mean drooling quotient did not significantly differ between BoNT‐A treatment and bilateral submandibular duct ligation at follow‐up (3.3,  p =0.457; 95% CI=−4.35 to 9.62) or between 8 and 32 weeks (4.7,  p =0.188; 95% CI=−2.31 to 11.65).    Interpretation  BoNT‐A treatment and bilateral submandibular duct ligation are both effective treatment modalities for drooling. At 32‐week follow‐up, subjective drooling severity after bilateral submandibular duct ligation was significantly lower compared to previous BoNT‐A injections in participants. However, treatment success with BoNT‐A is no precursor to achieving success with bilateral submandibular duct ligation.    What this paper adds    Bilateral submandibular duct ligation is an effective therapy for drooling after treatment with botulinum neurotoxin A (BoNT‐A).  Treatment success with BoNT‐A is not a predictor of successful therapy with bilateral submandibular duct ligation.

Submandibular duct ligation after botulinum neurotoxin A treatment of drooling in children with cerebral palsy