Botulinum Toxin Earns a Place in Pediatric Otolaryngology

Cosmetic ‘toxin turned treatment’ now used to treat children

By Brandon Hopkins, MD

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Botulinum toxin (BTX) injections may have gained fame as a tool to slow the wheels of time, but their use has expanded to include the treatment of many head and neck disorders outside the cosmetic arena. We at Cleveland Clinic are pleased to offer this minimally invasive treatment to our pediatric head and neck patients.

Proliferating clinical applications in pediatrics

The safety profile of this medication has opened doors for its use in pediatrics beyond strabismus, which was its first medical use. Spasmodic dysphonia and essential voice tremor are well-known laryngeal indications, but in pediatric head and neck patients, BTX has been used to treat airway obstruction due to bilateral vocal cord paralysis and laryngeal dystonia.

Beyond laryngeal indications, there is strong evidence for BTX use in chronic daily headaches, cervical dystonia, masticatory myalgia, sialorrhea, temporomandibular joint disorders, bruxism, blepharospasm, hemifacial spasm and nasal rhinitis. Its use has also been reported for facial paresis, palatal and stapedial myoclonus, trigeminal neuralgia, first-bite syndrome and Frey syndrome. Four brands of BTX have been approved by the FDA: Botox®, Dysport®, Myobloc® and Xeomin®.

At Cleveland Clinic’s Head & Neck Institute, we have found BTX to be effective for three pediatric indications in particular: congenital muscular torticollis, sialorrhea and facial nerve dysfunction.

Torticollis: Avoiding a surgery

Torticollis is a relatively common condition in newborns, with an incidence as high as 1:250. The most common type is congenital muscular torticollis (CMT). CMT is caused by a unilateral shortening of the sternocleidomastoid muscle (SCM), which leads to an ipsilateral head tilt and contralateral head rotation. This twisted position often leads to positional plagiocephaly. CMT can present as:

  • A palpable SCM tumor
  • Tightness or fibrosis of the SCM with no mass
  • Torticollis without SCM tightness

At Cleveland Clinic, pediatric otolaryngologists work with our physical medicine and rehabilitation team, physical therapists, primary care teams and others to care for children with CMT. Our approach is to identify patients early, rule out other causes of torticollis and implement therapy early in life.

Standard treatment for CMT involves physiotherapy, stretching exercises, molding helmets and neck braces. These conservative treatments are most successful when started early in life. However, some children — especially those with an SCM tumor or fibrosis and those resistant to physical therapy and conservative interventions — are recommended for surgery. Since surgery can leave patients with functional and cosmetic limitations, families welcome the nonsurgical alternative offered by BTX injections. Studies have shown that BTX injections have a high rate of success when they are used early, often before 12 months of age.

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With the child under light anesthesia, we turn the head to the contralateral side to isolate and grasp the SCM. Under sterile conditions, the syringe is placed and then pulled back to ensure that it is not being placed within a blood vessel. (Ultrasound guidance can be helpful but is not usually necessary.) The BTX is then injected under direct vision.

It is common to find that trapezius tightness also limits head rotation; if so, this muscle can also be treated. Typically 25 to 50 units of BTX (10 units/0.1 mL) are injected into each muscle, depending on its size and bulk. We take care to avoid injection and diffusion into surrounding muscles to avoid the possibility of dysphagia.

These outpatient injections are typically well tolerated by infants and children, which allows them to quickly return to physical therapy. Repeat injections are occasionally helpful.

Excessive drooling: Stemming the flow

Sialorrhea, which occurs in as many as one-third of children with cerebral palsy, is a common indication for BTX use at Cleveland Clinic. The clinical consequences of excessive drooling include skin breakdown and an increased risk of aspiration. Its quality-of-life implications can include constant bib changes, social isolation and compromised school performance.

In addition to BTX, medical treatment options include optimizing body position to lessen salivary egress from the oral cavity, intraoral appliances and anticholinergic medications to decrease salivary flow. Traditional surgical options have included transtympanic neurectomy to decrease the neural input triggering salivation, submandibular gland excision, duct ligation, duct rerouting and other procedures.

BTX has been shown both subjectively and objectively to decrease salivation for up to four or five months. We inject bilateral parotid and submandibular glands with 70 to 100 units spread between the glands. Minimizing the volume of injection is important to prevent diffusion of BTX into the facial musculature, which can lead to facial weakness.

For selected compliant patients, the minimally invasive nature of these injections allows us to perform them with ultrasound guidance, minimal sedation and topical anesthesia in an outpatient setting. Other patients are treated in the operating room.

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Our experience has been consistent with studies showing an improved quality of life with these injections, and families often wish to repeat the treatments. BTX injections can also serve as a trial to gauge improvement and help patients feel more comfortable proceeding to a more permanent surgical approach.

Facial paralysis: Restoring the smile

Marginal mandibular nerve paralysis is a relatively common condition that results in an asymmetric smile and even asymmetry at rest, which can be socially and emotionally distressing. Its causes include congenital anomalies, viral insults, trauma, iatrogenic surgery and many other etiologies.

Interventions can be directed to either the paralyzed side or the normal side. Procedures on the former include partial lip resection, hypoglossal nerve transfer, local muscle transfers and free tissue transfers. These approaches have their drawbacks, however, including scarring, the need for secondary incisions and often a lack of functional restoration. Procedures on the nonparalyzed side attempt to create facial symmetry, ideally at rest and with movement. Surgical options include severing the remaining marginal mandibular nerve and myectomy of the lower lip depressor muscles.

BTX injections are a form of chemical myectomy. Many children can be treated in the outpatient setting with topical anesthesia. The injection can be repeated as needed every four or five months, with dosage adjustments to achieve the desired effect. Again, BTX can be used as a trial before proceeding to a more permanent surgical approach, such as myectomy. This offers families the opportunity to “try before they buy” a procedure that has lifelong cosmetic implications.

Further exploration ahead

In a multidisciplinary effort, we work with our colleagues in the Head & Neck Institute to select appropriate pediatric candidates for treatment with BTX. We look forward to further exploring the varied uses of this “toxin turned treatment.”

A bibliography is available from the author at Dr. Hopkins is a member of the Section of Pediatric Otolaryngology and the Department of Otology. He can be reached at 216.444.0322 or