Current Series: Management of Sialorrhea in Parkinson Disease

Stuart Isaacson, MD: Let’s turn to the practical issues. There are a lot of patients with Parkinson disease. A lot have sialorrhea. We talked about how you might identify a patient and decide whom to treat and perhaps what to use to treat them with. But then what? How does a neurologist who wants to treat sialorrhea with botulinum toxic injection go about doing that? Do they have to block a certain day? What do you do? Do you have a certain day you inject? Do you do it at the end of the visit that you identify it? How do you go through the logistics of these?

Richard M. Trosch, MD: Well, it’s actually very quick. It probably adds a couple of minutes to my visit—not much. If I’m noticing or have a conversation with the patient that they’re drooling during my regular visit, I’ll say, “I notice you’re drooling,” and we’ll have a discussion. I offer them a treatment. If it’s appropriate for them and they elect to have it, I can step out and I can draw up Myobloc, come back in the room and accomplish it by adding maybe 3 or 4 minutes to the visit. I don’t have to schedule that as a separate visit, but then they will be back in 3 months. And that would be scheduled as a separate visit. It’s not going to take a whole lot of time. It’s a fairly short visit.
For most patients, I’m not doing submandibulars, I’m just doing parotids. I put the ultrasound gel on, I find the gland, and I inject. I have a chair that swirls, so I turn them around, and I do the same to the other side. It doesn’t take very long, so logistically it’s not much of a hassle. For a lot of physicians, they should consider this as a billable procedure as well that may actually help their practice.

Stuart Isaacson, MD: Because it’s a separate identifiable service, both the visit and injection can be paid on the same day by most insurance carriers.

Richard M. Trosch, MD: Right. So the E/M [evaluation and management] code is covered under G20, which is Parkinson disease. The procedure is done for K117, which is sialorrhea. So it can be done at the same time.

Stuart Isaacson, MD: Do you have the patient sitting in the chair when you do this? Or do you have to make them lie down on a table? You just come back in the room with the needle, and wherever they’re sitting, that’s where you…

Richard M. Trosch, MD: I found the perfect chair. It’s a chair that swivels but doesn’t have wheels, because you don’t want to have to hit a moving target. So it sits there. I line up my ultrasound on the left. The patient may be sitting away from me or toward me, and I inject 1 side. I rotate them, and I inject the other side without having to move my ultrasound machine.

Stuart Isaacson, MD: So you bring them to a separate room for this?

Richard M. Trosch, MD: Actually, I have a chair in each room. I have 2 ultrasound machines I use. You generally work out of 2 rooms, and I can do it in either room.

Stuart Isaacson, MD: I tend to have the medical assistant with me. Or I open the door and call for her, and they’ll go and bring the ultrasound machine in if I want to use it, and they’ll bring in the Myobloc and we draw it up. And I’ll bring in a regular chair and just swivel my chair to 1 side and then to the other side.

Richard M. Trosch, MD: OK, so you do 1 side and you swivel around to the other side.

Stuart Isaacson, MD: And then do the other side, yeah. It’s worked out pretty easily to incorporate it throughout the day. For many patients who have sialorrhea, we offer to do it. And then as part of the visit—at the end of the visit, when it ends—we just inject them, and they go on their way. They don’t need any observation, so it’s been able to add that service and not make them come back.

Richard M. Trosch, MD: How much time do you think it adds to your visit?

Stuart Isaacson, MD: Probably 3 or 4, certainly not more than 5 minutes. Probably a minute or 2. Especially if patients are being reinjected who have considerable saliva, often the medical assistant or nurse will raise it during the history and say we have a treatment for that if you’re interested in it, they’ll actually bring it into the room. When I come in, it’s already there. And then when I talk to the patient, if they want it, we can just draw it up as we’re finishing the visit and as the prescriptions are going through and inject them right there.

I think it’s been a very simple procedure for our patients. It’s nice to be able to treat not only motor symptoms but also some of the important nonmotor symptoms. This has always been a problem that’s in the top 3 or 4 nonmotor symptoms that patients point to as impacting their daily lives. Being able to address that proactively, I think, adds value to the patients’ clinic visits.

Richard M. Trosch, MD: I agree. When time is limited, people tend to have blinders on, and they’re thinking just about motor symptoms. Disability is really predictable more by nonmotor, what’s happening there. And this is one that may lead to aspiration pneumonia, which is still the most common cause of death in PD [Parkinson disease]. So it’s not one we want to miss, particularly because we can intervene and it’s a simple procedure and actually very safe for people.