Management of Drooling
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can be a normal occurrence in the first 6 to 18 months of life until oral-motor
function is more developed
considered abnormal for a child older than 4 years to exhibit persistent drooling
Sialorrhea or excessive drooling is frequently a major problem in the
neurologically impaired
o Cerebral palsy
 Incidence in CP: 15-37%
 The problem is not normally overproduction but inefficient
voluntary swallowing of saliva.
 lack of appreciation of external salivary loss, intraoral sensory
dysfunction, intraoral motor impairment, or a combination of
these factors
 three areas of difficulty: incomplete lip closure, low suction
pressure, and prolonged delay between suction and propelling
stage.
o intellectual disability
o Parkinsons disease
o Amyotrophic lateral sclerosis
Problems:
1. social implications
2. skin maceration
3. cellulitis, and candidal infection
4. frequent changes in clothing
5. fluid depletion
6. aspiration
aim is to stop drooling while at the same time maintain a moist healthy oral
environment
surgery is the mainstay of treatment for severely affected patients refractory to
conservative or medical treatment
Measuring Salivary Flow
 gold standard for drool measurement is the cannulation of the salivary ducts, but
this has obvious difficulties
 weighing of dental rolls pre- and postinjection
Physiology
 500 and 2000 ml of saliva is produced per day
 Basal secretions – 60% from submandibular, 30% from parotid, 10%
sublingual
Treatment
Non-surgical
1. Topical medications
1. atropine eye droplets
2. Systemic medications (mainstay)
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1. anticholinergics
 transdermal scopolamine (side effects loss of appetite, increased
swallowing difficulties, sedation, and conjunctival irritation.)
 glycopyrrolate - longer half-life, does not cross blood brain barrier
 benztropine
Behavior modification programs - use of various combinations of cueing, or
positive reinforcement
oromotor (speech) therapy uses primarily sensorimotor techniques, education, and
sometimes the use of oral appliances
1. effects are short lived and require continuous intensive therapy.
Correction of posture
Radiotherapy
laser ablation of the parotid ducts
Botox
1. use for sialorrhoea first described for Parkinson’s and ALS in 2000
 injected into parotid gland
 66-80% success
2. use in CP children described in 2002 (Suskind – Laryngoscope 2002)
 33% response rate with submandibular injection and an 80%
response rate with submandibular and parotid injections
 most patients returned to their baseline levels of drooling by 6 mos.
3. Complications – dysphagia, paralysis of CN VII
Surgical
Combinations of
1. gland excision
2. duct relocation
3. duct ligation
4. transtympanic neurectomies
 benefits lost within a year, possibly due to reinnervation
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Gold standard is bilateral submandibular gland excision and parotid duct ligation
Other options:
o bilateral submandibular duct transposition with ligation of a single parotid
duct.
Maturation of orofacial function can continue at least up until the age of 6 in
developmentally delayed children so surgery is not usually offered before this age.
Wilkie and Brody (PRS 1977)
 86% success rate in controlling drooling with parotid duct relocation and
submandibular gland excision
 35% complication rate -increased dental caries, gingival problems, parotitis,
and postoperative cysts and fistulas.
Crysdale (Laryngoscope 1980)
 Transtympanic neurectomy – 60% success
 Complications- edema of the mouth floor, submandibular gland swelling, and
otitis media, irreversible loss of taste in the anterior two-thirds of the tongue
Johnstone
 unilateral parotid duct ligation plus bilateral submandibular duct relocation
 ranula rate 13%
 xerostomia 32%
 problems swallowing 21%
 thicker saliva 46%
Greensmith, Johnstone (PRS 2005)
 bilateral sublingual gland excision in combination with bilateral
submandibular duct transposition
 eliminates the risk of ranula due to sublingual gland excision
 Technique
o Nasotracheal tube
o Extend neck
o two small mucosal islands incorporating each submandibular duct
papillae/orifice
o there is frequently an accessory duct from the sublingual glands
entering the submandibular duct – divide this
o submandibular ducts are transposed to the base of the tongue just
behind the vallate papillae
 nearly 80 percent of patients have substantial benefit
 initial improvement seen at 2 years is maintained at 5 years.
 if results unsatisfactory – undergo parotid duct ligation
 18% complications
 Complications
1. Xerostomia
o increased dental caries, and worsening of swallowing problems
2. septic parotiditis
3. Parotid/submandibular duct stenosis
4. Ranula
o Up to 10% in procedures where sublingual gland not removed