Table 9.

Bulbar symptoms

Symptom	Treatment approach
Sialorrhoea	Off label use of atropine 1% eye-drops (but taken orally) two drops as needed but up to three times daily should be first line treatment in patients able to self-administer or communicate their needs. Alternatively, an ipratropium bromide inhaler (1–2 puffs up to four times a day) can be used off label. Hyoscine hydrobromide patches and subcutaneous glycopyrronium bromide can help, but often patients need 12-weekly botulinum toxin injections for symptom relief.
Speech	Early referral to speech and language therapy is important to preserve communication (eg, with voice therapy or speech adjuncts) for as long as possible and to avoid missing opportunities such as voice banking. The MSA Trust provides funding for voice banking for their members living in the UK and Ireland and patients should be directed to this early.
Swallowing	Consider early speech and language therapy referral to promote patient safety and quality of life. There is no evidence that gastrostomy reduces risk of aspiration/increases survival in patients, but it can be considered a valid measure to improve quality of life (reducing meal anxiety, medication burden and improving hydration status).

MSA, multiple system atrophy.