Drooling
surgical options
Watad waseem
Submandibular and
Sublingual gland innervation
 Superior
salivatory nucleus - nervus
intermedius - facial nerve - chorda tympani
- lingual nerve - submandibular ganglion submandibular/lingual glands
Parotid innervation
 Inferior
salivatory nucleus glossopharyngeal nerve - Jacobsen’s nerve lesser superficial petrosal nerve - otic
ganglion - auriculotemporal nerve
Salivary gland innervation
 Parasympathetic
system stimulation causes
an increase in saliva flow from all glands
 Sympathetic system stimulation causes
increase in saliva flow from submandibular
gland but has no effect on parotid flow
Treatment Options
 Multidisciplinary
approach
 Non-invasive modalities
 Trial of medication
 Surgery
Surgical options
 Reduction
of salivary flow
 Relocation
of salivary flow
 combination
Surgical options
 Submandibular
gland excision
 Parotid duct ligation
 Transtympanic neurectomy
 Submandibular
duct rerouting
 Parotid duct rerouting
Surgical indications
 Age
5-6
 Failed non-surgical management > 6
months
 Stable neurological status
 Drooling with non-operative patient
Surgical contra-indications
 High
risk for operation
 unilateral HL for tympanic neurectomy
 Rerouting of salivary duct in esophagus
disoerder, ch. aspiration
Pre-operative assessment
 Lat
neck x-ray , F.O for adenoids
 adenoidectomy if necessary
 Barium
 audiometrey
Wilke procedure - 1967
 Bil.
submandibular gland exc. And bil.
Parotd duct relocation.
 Success rate 85%
 Postoperative complication (35%) and high
morbidity
 Modification of the procedure
Submandibular Gland
Excision + partid duct
ligation
High success rate(85 – 100%)- (Shot)
 Very common
 Low morbidity
 Mild swelling of face, external scars, xerostomia ,
parotitis

Parotid duct ligation
 Location
of the pappila , insert lacrimal
probe
 Elliptical incision made around the parotid
duct. Duct dissected for 1 cm, suture ligated
and resected. The buccal mucosa is then
repaired.
Rerouting of submandibular
duct
Cuff of mucosa dissected around duct and marked
medially and laterally
 Duct dissected 3-4 cm or until gland reached
 Tonsil used to create a tunnel just posterior to
anterior tonsillar pillar and sutures passed with
duct
 Tonsillectomy performed if obstructive tonsils

Rerouting of submandibular
duct(cont’d)
relocation in base of ant. Pillar : no need for TE ,
less infection
 Rate success 80-100%
 Sublingual gland exc.
 Advantages: Decreased xerostomia, problems with
taste and dysphagia
 Disadv: Ranula, sialoadenitis, sialolithiasis,
aspiration pneumonia

Studies on submandibular
duct rerouting
 Crysdale
- 8% ranula rate
 O’Dywer - 15 year follow -up study, 94% of
parents stated their child benefited, 50% had
complete cessation of drooling
Transtympanic neurectomies
 80%
success rate
 Must take both chorda and tympanic plexus
 Hypotympanic branch in 50% of patients
 Low speed drill
 Loss of taste in anterior 2/3 of tongue and
xerostomia
 Contraindicated in unilateral SNHL
Transtympanic neurectomies
of drooling – regeneration of
tympanic nerves
 Use for completion the surgery therapy for
drooling
 Recurrence
Laser photocoagulation of
parotid duct
 No
scars no xerostomia
 40/48 patient improvement (chang – 2001)
 Swelling of parotis, hematoma, infection