We thank the patients who gave their consent and contributed to the publication.

Here, we technically describe the method used for the treatment of sialorrhea in patients with neurological dysphagia. We will not focus on efficacy results, which have been published previously7. In this paper, in the results section, we present data from 5 consecutive patients with long-term follow-up (3 treatment sessions) treated from 2014 to 2016. These patients are considered representative of the entire population, which consists of the botulinum toxin service of San Luigi Gonzaga Hospital. The protocol was approved and follows the guidelines of the local ethical standards committee on human experimentation.
1. Patients&#39; Recruitment
NOTE: Patients eligible for this approach are adults suffering from moderate to severe sialorrhea secondary to neurological dysphagia with a history of failure or contraindication to pharmacological treatments such as anticholinergic drugs.
<ol>
	<li>Ensure that the patient is evaluated by an experienced neurologist before BoNT injection and that the severity and frequency of sialorrhea is assessed with the Drooling Frequency and Severity Scale (DFSS)14. 
	NOTE: The DFSS score is the sum of the frequency (1 = never, 2 = occasionally/not every day, 3 = frequently/part of the day, 4 = constantly) and severity (1 = never drools, 2 = mild or only lips wet, 3 = moderate or wet on lips and chin, 4 = severe or drool extends to clothes wetting, 5 = profuse or clothing, hands, tray, and objects wet) sub-scores14. A score &#62;2 in both of the sub-scores is used as the eligibility cut-off. 
	NOTE: The neurologist scores the scale on the basis of objective and anamnestic data provided by the patient and/or caregiver. In addition, the Visual Analogue Scale (VAS) must be administered for the evaluation of the patients&#39; subjective sufferance related to the sialorrhea. The VAS is a self-reported scale represented by a 10 centimeter horizontal line with a statement at each end representing one extreme of the patient&#39;s discomfort (from 100 = &#34;no discomfort&#34; to 0 = &#34;extreme discomfort&#34;).</li>
	<li>Collect the number of daily saliva aspirations through a saliva aspirator (when applicable) before BoNT injection, as a useful tool for the evaluation of the therapy efficacy (Figure 1).</li>
	<li>Repeat a neurological evaluation along with the DFSS and a daily saliva aspiration assessment during follow-up, 1, 3 and 6 months after the treatment, or according to the sialorrhea re-occurrence. In particular, retreatment must be taken into account when the number of daily aspirations increases over 50% compared to the 1-month follow-up evaluation.</li>
	<li>Collect procedure adverse events (local pain, local bleeding, and facial palsy) immediately after the injection. Collect therapy adverse events (local pain, facial palsy, chewing weakness, viscous saliva, and dry mouth) during follow-up assessments.</li>
</ol>
2. Procedure
<ol>
	<li>BoNT-A preparation 
	NOTE: The abobotulinumtoxinA is a botulinum toxin type A of the Clostridium botulinum complex-hemagglutinin. It is a powder for solution for intramuscular or subcutaneous injection.
	<ol>
		<li>For the treatment of sialorrhea in adults, reconstitute 500 IU abobotulinumtoxinA with 2 mL&#160;of 0.9% sodium chloride solution for injection in order to obtain a solution containing 250 IU/mL&#160;of abobotulinumtoxinA.</li>
		<li>Administer a total of 250 IU of abobotulinumtoxinA per patient as follows: 50 IU in each submandibular gland and 75 IU in each parotid gland. In this way treat two patients with a single vial to avoid drug wastage.</li>
	</ol>
	</li>
	<li>Patients&#39; preparation
	<ol>
		<li>After an adequate explanation of the procedure and of the potential risks and benefits of the treatment, obtain written informed consent from the patient.</li>
		<li>Place the patient on the ultrasound table in the supine position and possibly with the neck extended. 
		NOTE: Consider that not all neurological conditions leading to sialorrhea allow for the complete extension of the neck.</li>
		<li>Disinfect the skin in the area over the parotid and the submandibular glands with an antiseptic. Anesthetize each skin access site with ethylene chloride spray.</li>
	</ol>
	</li>
	<li>Ultrasound guidance 
	NOTE: An ultrasound-guided procedure with a linear transducer (5 - 10 MHz) is used for gland localization in order to obtain real-time visualization of muscles, glands, bigger vessels or salivary ducts, and other surrounding structures, as well as of the correct needle position within the glandular tissue.
	<ol>
		<li>Turn on the ultrasound system and press the &#34;Start-end&#34; button to begin the exam.</li>
		<li>Press the &#34;Probe&#34; button to select the high frequency probe (5 - 10 MHz).</li>
		<li>Press the &#34;Patient&#34; button and insert the patient&#39;s name and surname.</li>
		<li>Press the &#34;Protocol&#34; button to select the appropriate protocol and sub-protocol (i.e., protocol: &#34;small tissues&#34;, sub-protocol: &#34;general&#34;).</li>
		<li>Press the &#34;Depth&#34; button and specify the depth of view to 5 cm.</li>
		<li>Press the &#34;Focus&#34; button to select the maximum detail of 2 cm.</li>
		<li>Place the transducer under the mandible, between the anterior and posterior bellies of the digastric muscle, to visualize the submandibular gland, which appears as a hypoechoic area with homogeneous echotexture compared to the surrounding tissues. 
		NOTE: Consider the submandibular gland ideally divided into two quadrants, one cranial and one caudal. Identify the widest gland diameter for the lateral needle access.</li>
		<li>Place the transducer below the external acoustic meatus to visualize the parotid gland, which appears as a hypoechoic area with homogeneous echotexture compared to the surrounding tissues. 
		NOTE: Consider the parotid gland ideally divided into four quadrants, two cranial and two caudal. Identify the two access sites for injection midway between the external auditory canal and the mandible angle, one in the cranial part and one in the caudal part of the gland (Supplemental Figure).</li>
	</ol>
	</li>
	<li>BoNT-A injection 
	NOTE: Use a 22 G needle for injections, with needle penetration at least 0.5 cm from the transducer. The transducer must be oriented longitudinally to the needle so that the needle is visible as a bright echoic line. In this way, the penetration of the needle into the soft tissues can be monitored during the procedure as the needle tip proceeds towards the target, preventing injuries to neurovascular structures.
	<ol>
		<li>Use a lateral short-access approach at the widest gland diameter to access the submandibular gland.</li>
		<li>Inject 25 IU BoNT-A into the upper submandibular quadrant. After the injection, slightly retract the needle and change the direction of the needle tip towards the lower submandibular quadrant, injecting 25 IU BoNT-A for a total of 50 IU to each submandibular gland. 
		NOTE: In this way, two submandibular areas (cranial and caudal) are injected, providing a widespread diffusion of the drug within the glandular tissue.</li>
		<li>Use two access sites for the parotid gland injection. Identify the two accesses midway between the external auditory canal and the mandible angle, one in the cranial part of the gland and one in the caudal part of the gland.</li>
		<li>Using the upper access (in the cranial part of the gland), inject 18 - 19 IU BoNT-A into the medial-cranial quadrant. After the injection, slightly retract the needle, without leaving the site of the cranial part of the gland, and change the direction of the needle tip towards the lateral-cranial quadrant; inject 18 - 19 IU BoNT-A.</li>
		<li>Using the lower access (in the caudal part of the gland), inject 18 - 19 BoNT-A IU into the medial-caudal quadrant. After the injection, slightly retract the needle, without leaving the site of the caudal part of the gland, and change the direction of the needle tip towards the lateral-caudal quadrant; inject 18 - 19 IU BoNT-A. 
		NOTE: In this way, four parotid areas (medial-cranial, lateral-cranial, medial-caudal and lateral-caudal) are injected with a total of 75 IU BoNT-A, providing a widespread diffusion of the drug within the glandular tissue.</li>
		<li>After each injection, dab any bleeding with sterile gauze for 1 - 2 min. Re-evaluate the patient after one hour for any potential adverse events. Administer a nonsteroidal anti-inflammatory drug in case of persisting pain. Schedule a follow-up examination after 1 month.</li>
	</ol>
	</li>
</ol>

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	<li>Kumar, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Swallowing+and+dysphagia+in+neurological+disorders.">Swallowing and dysphagia in neurological disorders.</a> Rev Neurol Dis. 7 (1), 19-27 (2010).</li><li>Lakraj, A. A., Moghimi, N., Jabbari, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sialorrhea:+anatomy,+pathophysiology+and+treatment+with+emphasis+on+the+role+of+botulinum+toxins.">Sialorrhea: anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins.</a> Toxins (Basel). 5 (5), 1010-1031 (2013).</li><li>Reed, J., Mans, C. K., Brietzke, S. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+management+of+drooling:+a+meta-analysis.">Surgical management of drooling: a meta-analysis.</a> Arch Otolaryngol Head Neck Surg. 135 (9), 924-931 (2009).</li><li>Crysdale, W. S., White, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Submandibular+duct+relocation+for+drooling:+a+10-year+experience+with+194+patients.">Submandibular duct relocation for drooling: a 10-year experience with 194 patients.</a> Otolaryngol Head Neck. 101 (1), 87-92 (1989).</li><li>Squires, N., Wills, A., Rowson, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+management+of+drooling+in+adults+with+neurological+conditions.">The management of drooling in adults with neurological conditions.</a> Curr Opin Otolaryngol Head Neck Surg. 20 (3), 171-176 (2012).</li><li>Pickett, A., Perrow, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Formulation+composition+of+botulinum+toxins+in+clinical+use.">Formulation composition of botulinum toxins in clinical use.</a> J Drugs Dermatol. 9 (9), 1085-1091 (2010).</li><li>Barbero, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+follow-up+of+ultrasound-guided+botulinum+toxin-A+injections+for+sialorrhea+in+neurological+dysphagia.">Long-term follow-up of ultrasound-guided botulinum toxin-A injections for sialorrhea in neurological dysphagia.</a> J Neurol. 262 (12), 2662-2667 (2015).</li><li>Guidubaldi, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Botulinum+toxin+A+versus+B+in+sialorrhea:+a+prospective,+randomized,+double-blind,+crossover+pilot+study+in+patients+with+amyotrophic+lateral+sclerosis+or+Parkinson's+disease.">Botulinum toxin A versus B in sialorrhea: a prospective, randomized, double-blind, crossover pilot study in patients with amyotrophic lateral sclerosis or Parkinson's disease.</a> Mov Disord. 26, 313-319 (2011).</li><li>Standring, S., Gray, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Gray's anatomy: The anatomical basis of clinical practice. 41st ed. , 527 (2016).</li><li>Standring, S., Gray, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Gray's anatomy: The anatomical basis of clinical practice. 41st ed. , 504 (2016).</li><li>Standring, S., Gray, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Gray's anatomy: The anatomical basis of clinical practice. 41st ed. , 528 (2016).</li><li>Gomez-Caravaca, M. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+botulinum+toxin+in+the+treatment+of+sialorrhea+in+parkinsonian+disorders.">The use of botulinum toxin in the treatment of sialorrhea in parkinsonian disorders.</a> Neurol Sci. 36 (2), 275-279 (2015).</li><li>Walter, U., Dressler, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound-guided+botulinum+toxininjections+in+neurology:+technique,+indications+and+future+perspectives.">Ultrasound-guided botulinum toxininjections in neurology: technique, indications and future perspectives.</a> Expert Rev Neurother. 14 (8), 923-936 (2014).</li><li>Thomas-Stonell, N., Greenberg, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Three+treatment+approaches+and+clinical+factors+in+the+reduction+of+drooling.">Three treatment approaches and clinical factors in the reduction of drooling.</a> Dysphagia. 3 (2), 73-78 (1988).</li><li>Sriskandan, N., Moody, A., Howlett, D. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound-guided+submandibular+gland+injection+of+botulinum+toxin+for+hypersalivation+in+cerebral+palsy.">Ultrasound-guided submandibular gland injection of botulinum toxin for hypersalivation in cerebral palsy.</a> Br J Oral Maxillofac Surg. 48 (1), 58-60 (2010).</li><li>Contarino, M. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Botulinum+toxin+B+ultrasound-guided+injections+for+sialorrhea+in+amyotrophic+lateral+sclerosis+and+Parkinson's+disease.">Botulinum toxin B ultrasound-guided injections for sialorrhea in amyotrophic lateral sclerosis and Parkinson's disease.</a> Parkinsonism Relat Disord. 13 (5), 299-303 (2007).</li><li>Chinnapongse, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+and+efficacy+of+botulinum+toxin+type+B+for+treatment+of+sialorrhea+in+Parkinson's+disease:+a+prospective+double-blind+trial.+Mov+Disord.">Safety and efficacy of botulinum toxin type B for treatment of sialorrhea in Parkinson's disease: a prospective double-blind trial. Mov Disord.</a> Mov Disord. 27 (2), 219-226 (2012).</li><li>Reid, S. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Secondary+effects+of+botulinum+toxin+injections+into+salivary+glands+for+the+management+of+pediatric+drooling.">Secondary effects of botulinum toxin injections into salivary glands for the management of pediatric drooling.</a> J Craniofac Surg. 24 (1), 28-33 (2013).</li><li>Chan, K. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+safety+and+efficacy+data+on+botulinum+toxin+type+A:+an+injection+for+sialorrhea.">Long-term safety and efficacy data on botulinum toxin type A: an injection for sialorrhea.</a> JAMA Otolaryngol Head Neck Surg. 139 (2), 134-138 (2013).</li><li>Petracca, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Botulinum+Toxin+A+and+B+in+sialorrhea:+Long-term+data+and+literature+overview.">Botulinum Toxin A and B in sialorrhea: Long-term data and literature overview.</a> Toxicon. 1 (107), 129-140 (2015).</li></ol>

The authors have nothing to disclose.

This protocol describes US-guided BoNT-A injection in the parotid and submandibular glands for the treatment of moderate to severe sialorrhea. Sialorrhea secondary to dysphagia is a frequent complication of the advanced stages of different neurological diseases, and when pharmacological therapy with anticholinergic agents demonstrates scarce efficacy or tolerability, salivary gland BoNT injection represents a useful therapeutic option2,7. However, salivary gland BoNT injection guided by anatomical landmarks ma...

Sialorrhea is an excessive flow of saliva representing a common and disabling complication of several neurological disorders, including stroke, cerebral palsy, multiple sclerosis, and neurodegenerative diseases1. Patients suffering from moderate to severe sialorrhea have an impaired quality of life, often worsened by correlated complications, such as aspiration pneumonia, oral infections, dental caries, and maceration of the skin2. Various therapeutic options are available for the treatment of sialorrhea, ranging from surgery to pharmacological therapy, with the aim of reducing saliva production.
Surgical options include denervation, excision of the salivary glands, and transposition or ligation of the salivary ducts3,4. However, despite its efficacy, surgery is by definition an invasive procedure with potentially serious adverse events, such as salivary fistula and cyst formation, infections, loss of taste, loss of hearing, dysarthria, and irreversible effects on salivary gland production3. In addition, it has been observed that surgical approaches may have only temporary efficacy due to reinnervation of the salivary glands two or more years after the procedure2,5. A more common and less invasive treatment for severe sialorrhea is the use of systemic drugs with anticholinergic properties. However, the chronic use of anticholinergic agents is often associated with systemic side effects such as confusion, memory problems, drowsiness, urinary retention, and paralytic ileus2,5.
Botulinum toxin (BoNT) salivary injection is an emerging treatment option for sialorrhea. BoNT are proteases (seven, from A to G), produced by the bacterium Clostridium botulinum, that are able to halt acetylcholine release from the presynaptic nerve terminals of the neuromuscular junction, blocking muscle contraction and gland activity at the orthosympathetic and parasympathetic postganglionic synapses. BoNT type A (BoNT-A) and type B (BoNT-B) are commonly used for therapeutic management of dystonia and spasticity6. Recently, BoNT injection within the major salivary glands proved to be a useful therapeutic option in moderate to severe sialorrhea with suboptimal response to other medical therapies due to a lack of efficacy or the presence of significant side effects2,7,8.
Human salivary glands are classified into two groups: major and minor. Major salivary glands include a pair of parotid glands, a pair of submandibular glands, and a pair of sublingual glands; the minor salivary glands consist of about 1,000 small glands spread within the sub-mucosa of the oral cavity9. Approximately 0.5 liters of saliva are secreted per day. The three pairs of major salivary glands are responsible for more than 90% of the saliva production, approximately divided as follows: 20% for the parotid glands, 65% for the submandibular glands and 5%, for the sublingual glands9. The parotid gland is the largest one and is located below the external acoustic meatus, between the mandible and the sternocleidomastoid muscle; it projects forward on the surface of the masseter muscle10. Important structures pass through the gland, such as the facial nerve, external carotid artery, and retromandibular vein, and several other important neurovascular structures are close to the gland. The submandibular gland is a seromucous gland situated behind and below the ramus of the mandible, in the region of the submandibular triangle, between the anterior and posterior bellies of the digastric muscle and around the posterior border of the mylohyoid muscle11.
BoNT salivary gland injection is a local treatment with the potential to avoid discomfort and/or systemic side effects correlated with the other therapies, such as oral, transdermal, and surgical options. Here, we show a reliable and easily reproducible method to treat sialorrhea with BoNT-A injections in the parotid and submandibular glands under ultrasound (US) guidance in order to obtain a satisfying and long-lasting reduction of drooling while strongly limiting the occurrence of serious adverse events. Data on BoNT-A injection efficacy in sialorrhea in the absence of US guidance are reported in the literature12; however, the US-guided identification of glands and their surrounding tissues, along with real-time visualization of the needle position, allows for a reduction in adverse events and a more accurate injection, leading to increased efficacy and outcome reproducibility7,13.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>abobotulinumtoxinA (Dysport)&#160;</td>
			<td>&#160;IpsenBiopharm, Wrexham, UK</td>
			<td></td>
			<td>Delivered drug</td>
		</tr>
		<tr>
			<td>MyLab &#160;Twice&#160;</td>
			<td>Esaote</td>
			<td></td>
			<td>Ultraonograph</td>
		</tr>
		<tr>
			<td>LA523 5&#8211;10 MHz&#160;</td>
			<td>Esaote</td>
			<td></td>
			<td>Linear transducer</td>
		</tr>
	</tbody>
</table>

ultrasound-guided botulinum toxin-a injections: a method of treating sialorrhea

Neurological diseases can be complicated by sialorrhea, an excessive flow of saliva. Patients suffering from moderate to severe sialorrhea have an impaired quality of life, often worsened by correlated complications such as aspiration pneumonia, oral infections, dental caries, and maceration of the skin. Diverse therapeutic approaches have been proposed for the treatment of sialorrhea, including surgery and the use of anticholinergic agents, with limited results and the possible occurrence of serious adverse events. Recently, botulinum toxin (BoNT) injection within the major salivary glands has been proposed in patients refractory to anticholinergic therapy, with the aim of inhibiting local acetylcholine release and gland activity. 
In order to obtain a better outcome in terms of reduction of saliva production, efficacy, duration, and avoidance of major adverse events, we developed an ultrasound-guided BoNT-type A injection technique accurately described in the text. Here we present a method of treating sialorrhea with bilateral parotid and submandibular gland BoNT-type A injections under ultrasound guidance. Four quadrants of the parotid gland and two quadrants of the submandibular gland are visualized and injected using two accesses and one access, respectively. 
The ultrasound-guided procedure provides a simple, non-invasive, real-time visualization of the muscular and glandular tissues and their surrounding structures, optimizing treatment efficacy and safety.

The US-guided injection is an effective technique to obtain real-time and precise needle visualization for BoNT administration in the salivary glands. This approach provides a reliable sialorrhea treatment, with prolonged efficacy and the absence of serious adverse events. Indeed, the visualization of the glands and of the needle penetration provided by the US-guided approach proposed here allows a widespread administration of BoNT-A within the major salivary glands with significant and l...

Watch this Scientific Journal Video about Ultrasound-guided Botulinum Toxin-A Injections: A Method of Treating Sialorrhea at JoVE.com

Ultrasound-guided Botulinum Toxin-A Injections: A Method of Treating Sialorrhea

Botulinum toxin is injected into the salivary glands for the treatment of sialorrhea. The ultrasound-guided botulinum toxin injection in both the parotid and submandibular glands demonstrates a sustained efficacy and the absence of serious side effects.

Neurological diseases can be complicated by sialorrhea, an excessive flow of saliva. Patients suffering from moderate to severe sialorrhea have an ...

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22.6K Views.  University of Torino, San Luigi Gonzaga Hospital. Botulinum toxin is injected into the salivary glands for the treatment of sialorrhea. The ultrasound-guided botulinum toxin injection in both the parotid and submandibular glands demonstrates a sustained efficacy and the absence of serious side effects.

Video: Ultrasound-guided Botulinum Toxin-A Injections: A Method of Treating Sialorrhea

Ultrasound-guided Transthoracic Intramyocardial Injection in Mice

Murine models of cardiovascular disease are important for investigating pathophysiological mechanisms and exploring potential regenerative therapies. Experiments involving myocardial injection are currently performed by direct surgical access through a thoracotomy. While convenient when performed at the time of another experimental manipulation such as coronary artery ligation, the need for an invasive procedure for intramyocardial delivery limits potential experimental designs. With ever improving ultrasound resolution and advanced noninvasive imaging modalities, it is now feasible to routinely perform ultrasound-guided, percutaneous intramyocardial injection. This modality efficiently and reliably delivers agents to a targeted region of myocardium. Advantages of this technique include the avoidance of surgical morbidity, the facility to target regions of myocardium selectively under ultrasound guidance, and the opportunity to deliver injectate to the myocardium at multiple, predetermined time intervals. With practiced technique, complications from intramyocardial injection are rare, and mice quickly return to normal activity on recovery from anesthetic. Following the steps outlined in this protocol, the operator with basic echocardiography experience can quickly become competent in this versatile, minimally invasive technique.

Echocardiography-guided percutaneous intramyocardial injection represents an efficient, reliable, and targetable modality for the delivery of gene transfer agents or cells into the murine heart. Following the steps outlined in this protocol, the operator can quickly become competent in this versatile, minimally invasive technique.

Murine models of cardiovascular disease are important for investigating pathophysiological mechanisms and exploring potential regenerative therapies. ...

Substernal Thyroid Biopsy Using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the lack of a standardized definition for STG. Biopsy is often required to differentiate benign from malignant lesions. Unlike cervical thyroid, the overlying sternum precludes ultrasound-guided percutaneous fine needle aspiration of STG. Consequently, surgical mediastinoscopy is performed in the majority of cases, causing significant procedure related morbidity and cost to healthcare. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) is a frequently used procedure for diagnosis and staging of non-small cell lung cancer (NSCLC). Minimally invasive needle biopsy for lesions adjacent to the airways can be performed under real-time ultrasound guidance using EBUS. Its safety and efficacy is well established with over 90% sensitivity and specificity. The ability to perform EBUS as an outpatient procedure with same-day discharges offers distinct morbidity and financial advantages over surgery. As physicians performing EBUS gained procedural expertise, they have attempted to diversify its role in the diagnosis of non-lymph node thoracic pathologies. We propose here a role for EBUS-TBNA in the diagnosis of substernal thyroid lesions, along with a step-by-step protocol for the procedure.

Substernal thyroid lesions are common, and need to be differentiated from malignancy. Obtaining percutaneous fine needle biopsy is not possible due to its retrosternal location. This article proposes a protocol for biopsy of substernal thyroid lesions using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA).

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the ...

Performing Subretinal Injections in Rodents to Deliver Retinal Pigment Epithelium Cells in Suspension

The conversion of light into electrical impulses occurs in the outer retina and is accomplished largely by rod and cone photoreceptors and retinal pigment epithelium (RPE) cells. RPE provide critical support for photoreceptors and death or dysfunction of RPE cells is characteristic of age-related macular degeneration (AMD), the leading cause of permanent vision loss in people age 55 and older. While no cure for AMD has been identified, implantation of healthy RPE in diseased eyes may prove to be an effective treatment, and large numbers of RPE cells can be readily generated from pluripotent stem cells. Several interesting questions regarding the safety and efficacy of RPE cell delivery can still be examined in animal models, and well-accepted protocols used to inject RPE have been developed. The technique described here has been used by multiple groups in various studies and involves first creating a hole in the eye with a sharp needle. Then a syringe with a blunt needle loaded with cells is inserted through the hole and passed through the vitreous until it gently touches the RPE. Using this injection method, which is relatively simple and requires minimal equipment, we achieve consistent and efficient integration of stem cell-derived RPE cells in between the host RPE that prevents significant amount of photoreceptor degeneration in animal models. While not part of the actual protocol, we also describe how to determine the extent of the trauma induced by the injection, and how to verify that the cells were injected into the subretinal space using in vivo imaging modalities. Finally, the use of this protocol is not limited to RPE cells; it may be used to inject any compound or cell into the subretinal space.

Here we present a community accepted protocol in multimedia format for subretinally injecting a bolus of RPE cells in rats and mice. This approach can be used for determining rescue potentials, safety profiles, and survival capacities of grafted RPE cells upon implantation in animal models of retinal degeneration.

The conversion of light into electrical impulses occurs in the outer retina and is accomplished largely by rod and cone photoreceptors and retinal pigment ...

Ultrasound-guided Intracardiac Injection of Human Mesenchymal Stem Cells to Increase Homing to the Intestine for Use in Murine Models of Experimental Inflammatory Bowel Diseases

Crohn&#39;s disease (CD) is a common chronic inflammatory disease of the small and large intestines. Murine and human mesenchymal stem cells (MSCs) have immunosuppressive potential and have been shown to suppress inflammation in mouse models of intestinal inflammation, even though the route of administration can limit their homing and effectiveness 1,3,4,5. Local application of MSCs to colonic injury models has shown greater efficacy at ameliorating inflammation in the colon. However, there is paucity of data on techniques to enhance the localization of human bone marrow-derived MSCs (hMSCs) to the small intestine, the site of inflammation in the SAMP-1/YitFc (SAMP) model of experimental Crohn&#39;s disease. This work describes a novel technique for the ultrasound-guided intracardiac injection of hMSCs in SAMP mice, a well-characterized spontaneous model of chronic intestinal inflammation. Sex- and age-matched, inflammation-free AKR/J (AKR) mice were used as controls. To analyze the biodistribution and the localization, hMSCs were transduced with a lentivirus containing a triple reporter. The triple reporter consisted of firefly luciferase (fl), for bioluminescent imaging; monomeric red fluorescent protein (mrfp), for cell sorting; and truncated herpes simplex virus thymidine kinase (ttk), for positron emission tomography (PET) imaging. The results of this study show that 24 h after the intracardiac administration, hMSCs localize in the small intestine of SAMP mice as opposed to inflammation-free AKR mice. This novel, ultrasound-guided injection of hMSCs in the left ventricle of SAMP mice ensures a high success rate of cell delivery, allowing for the rapid recovery of mice with minimal morbidity and mortality. This technique could be a useful method for the enhanced localization of MSCs in other models of small-intestinal inflammation, such as TNF&#916;RE6. Future studies will determine if the increased localization of hMSCs by intra-arterial delivery can lead to increased therapeutic efficacy.

Murine studies in models of colonic inflammation have demonstrated that a small percentage (1 - 5%) of mesenchymal stem cells (MSC) injected intravenously or intraperitoneally home to the inflamed colon1,2. This study shows that ultrasound-guided intracardiac injections of MSCs result in increased localization to the intestine.

Crohn&#39;s disease (CD) is a common chronic inflammatory disease of the small and large intestines. Murine and human mesenchymal stem cells (MSCs) have ...

Mechanical and Controlled PRP Injections in Patients Affected by Androgenetic Alopecia

23 patients (18 male and 5 female) aged 21-70 years who displayed male pattern hair loss (MPHL) in Stage 1 to Stage 5 as determined by the Norwood-Hamilton classification scale, and female pattern hair loss (FPHL) in Stage 1 to Stage 2 as determined by the Ludwig classification scale, were treated with non-activated autologous platelet-rich plasma (A-PRP). Autologous blood (55 mL) was harvested using sodium citrate as an anticoagulant. A-PRP (23 mL) was produced for all cases using a closed system according to the transfusion service protocol. Following centrifugation (260 x g for 10 min) the A-PRP was inserted in a laser light selector device, and after the centrifugation, 9 mL of A-PRP was collected.
The scalp of the patients affected by androgenetic alopecia (AGA) was divided into four areas (frontal, parietal, vertex, and occipital); local anesthesia was not performed. Interfollicular A-PRP injections (0.2 mL x cm2) were performed by controlled and mechanical injections scheduled at a depth of 5 mm using a medical injector gun. Treatment sessions were performed with a 30-day interval. For each patient, three treatment sessions were performed.
PRP was injected in the androgen-related areas of scalp affected by hair loss. Placebo (normal saline solution) was loaded in another syringe (10 mL) and injected on the adjacent side in a similar fashion.

This paper aims to describe the interfollicular autologous platelet-rich plasma injections (0.20 mL x cm2) in the scalp of 23 patients affected by androgenetic alopecia at a depth of 5 mm using a medical injector gun equipped with a 30 gauge needle, in three sessions.

23 patients (18 male and 5 female) aged 21-70 years who displayed male pattern hair loss (MPHL) in Stage 1 to Stage 5 as determined by the ...

A New Best Practice for Validating Tail Vein Injections in Rat with Near-infrared-Labeled Agents

Intravenous (IV) administration of agents into the tail vein of rats can be both difficult and inconsistent. Optimizing tail vein injections is a key part of many experimental procedures where reagents need to be introduced directly into the bloodstream. Unwittingly, the injection can be subcutaneous, possibly altering the scientific outcomes. Utilizing a nanoemulsion-based biological probe with an incorporated near-infrared fluorescent (NIRF) dye, this method offers the capability of imaging a successful tail vein injection in vivo. With the use of a NIRF imager, images are taken before and after the injection of the agent. An acceptable IV injection is then qualitatively or quantitatively determined based on the intensity of the NIRF signal at the site of injection.

Here we present a method to validate tail vein injections in rats by utilizing near-infrared fluorescence imaging data from dyes incorporated into agents or biological probes. The tail is imaged before and after the injection, the fluorescent signal is quantified, and an assessment of the injection quality is made.

Intravenous (IV) administration of agents into the tail vein of rats can be both difficult and inconsistent. Optimizing tail vein injections is a key part ...

International Expert Consensus and Recommendations for Neonatal Pneumothorax Ultrasound Diagnosis and Ultrasound-guided Thoracentesis Procedure

Pneumothorax (PTX) represents accumulation of the air in the pleural space. A large or tension pneumothorax can collapse the lung and cause hemodynamic compromise, a life-threatening disorder. Traditionally, neonatal pneumothorax diagnosis has been based on clinical images, auscultation, transillumination, and chest X-ray findings. This approach may potentially lead to a delay in both diagnosis and treatment. The use of lung US in diagnosis of PTX together with US-guided thoracentesis results in earlier and more precise management. The recommendations presented in this publication are aimed at improving the application of lung US in guiding neonatal PTX diagnosis and management.

Pneumothorax is a common emergency and critical disease in newborn infants that needs rapid, clear diagnosis and timely treatment. Diagnosis and treatment based on chest X-rays are associated with delayed management and radiation damage. Lung ultrasound (US) provides useful guidance for rapid, accurate diagnosis and the precise thoracentesis of pneumothorax.

Pneumothorax (PTX) represents accumulation of the air in the pleural space. A large or tension pneumothorax can collapse the lung and cause hemodynamic ...

Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary biliary drainage method whenever possible. Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method if ERCP fails. Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method where one of the methods is EUS guided Hepaticogastrostomy (EUS-HGS). Here we describe the EUS-HGS technique in a case of unresectable malignant hilar biliary obstruction to achieve biliary drainage.
Presented here is the case of a 71-year-old female with painless jaundice and weight loss for 2 weeks. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor with lymphadenopathy and liver metastasis. EUS fine needle biopsy (FNB) of the lesion was consistent with cholangiocarcinoma. Her bilirubin levels were 212 &#181;mol/L (&lt;15) during presentation.
A linear echoendoscope was used to locate the left dilated intrahepatic ducts (IHD) of the liver. The segment 3 dilated IHD was identified and punctured using a 19 G needle. Contrast was used to opacify the IHDs under fluoroscopic guidance. The IHD was cannulated using a 0.025-inch guidewire. This was followed by the dilation of the fistula tract using a 6 Fr electrocautery dilator along with a 4 mm biliary balloon dilator. A partially covered metallic stent of 10 cm in length was deployed under fluoroscopic guidance. The distal part opens in the IHD and the proximal part was deployed within the working channel of the echoendoscope that subsequently released into the stomach. The patient was discharged three days after the procedure. Follow up performed in the second and fourth weeks showed that the bilirubin levels were 30 &#181;mol/L and 14 &#181;mol/L, respectively. This indicates that EUS-HGS is a safe method for biliary drainage in unresectable malignant biliary obstruction.

Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) is an alternative method of biliary decompression in malignant biliary obstruction. Here we describe the technique of EUS guided-Hepaticogastrostomy (EUS-HGS) in a case of unresectable malignant hilar biliary obstruction.

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde ...

Ultrasound-Guided Induced Pluripotent Stem Cell-Derived Cardiomyocyte Implantation in Myocardial Infarcted Mice

The key objective of cell therapy after myocardial infarction (MI) is to effectively enhance the cell grafted rate, and human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) are a promising cell source for cardiac repair after ischemic damage. However, a low grafted rate is a significant obstacle for effective cardiac tissue regeneration after transplantation. This protocol shows that multiple hiPSC-CM ultrasound-guided percutaneous injections into an MI area effectively increase cell transplantation rates. The study also describes the entire hiPSC-CM culture process, pretreatment, and ultrasound-guided percutaneous delivery methods. In addition, the use of human mitochondrial DNA help detect the absence of hiPSC-CMs in other mouse organs. Lastly, this paper describes the changes in cardiac function, angiogenesis, cell size, and apoptosis at the infarcted border zone in mice 4 weeks after cell delivery. It can be concluded that echocardiography-guided percutaneous injection of the left ventricular myocardium is a feasible, relatively invasive, satisfactory, repeatable, and effective cellular therapy.

Ultrasound-guided cell delivery around the site of myocardial infarction in mice is a safe, effective, and convenient way of cell transplantation.

The key objective of cell therapy after myocardial infarction (MI) is to effectively enhance the cell grafted rate, and human induced pluripotent stem ...

Intravitreal Injections in the Ovine Eye

There are several methods for the delivery of therapeutic agents to the retina, including intravitreal (IVT), subretinal, suprachoroidal, periocular, or topical administration. IVT drug delivery involves an injection into the vitreous humor of the eye, a gelatinous substance that fills the posterior chamber of the eye and maintains the shape of the eye globe. Although the IVT route is less specifically targeted than subretinal delivery, it is much less invasive and is widely used in clinical settings for a range of ocular diseases. 
We previously demonstrated the efficacy of intravitreal delivery of an adeno-associated virus (AAV)-mediated gene therapy product (AAV9.CLN5) in sheep with a naturally occurring CLN5 form of neuronal ceroid lipofuscinosis (NCL). Affected sheep received IVT gene therapy in one eye, with the other untreated eye serving as an internal control. Retinal structure and function were maintained in the treated eye up to 15 months after treatment, while the untreated eye displayed progressively declining function and severe atrophy during postmortem examination. Based on the sheep studies, the CLN5 gene therapy product was cleared as a candidate investigational new drug (IND) by the United States Food and Drug Administration in September 2021. This paper details the surgical protocol for IVT delivery of a therapeutic viral vector to the ovine eye.

Intravitreal injections were performed in the sheep eye with the aim of delivering viral-mediated gene therapy to the retina.

There are several methods for the delivery of therapeutic agents to the retina, including intravitreal (IVT), subretinal, suprachoroidal, periocular, or ...