Management of drooling by transposition of the submandibular ducts and excision of the sublingual glands

STATEMENT OF THE PROBLEM

Persistent drooling is common in patients with neurological impairments such as cerebral palsy. Although it may be induced by an excess of saliva, it usually results from incontinence secondary to impaired cerebral control of orofacial function. Various techniques, both medical and surgical, exist to combat the problem. The patient should have a course of conservative management initially (head position, education and training, suction aids, bio-feedback and support). Non-surgical managements and medical treatment should start as early as possible. Surgery has a place, when conservative and medical treatments (drugs/botulinum toxin) have failed.

PURPOSE OF THE STUDY

Patients subjected to some of the more radical surgical methods may develop complications of the procedures themselves, it is important therefore that any intervention is based on sound principles. Physiology predicts that the most benefit would be derived from diversion of submandibular rather than parotid salivary flow (Fig. 1).

MATERIALS AND METHODS

To assess the effect of bilateral transposition of the submandibular ducts combined with excision of the sublingual glands as a treatment for drooling, a retrospective survey of 21 patients was undertaken by contacting their carers and reviewing the clinical notes.

RESULTS

Sixteen out of 21 patients had good to excellent control of their drooling with minimal side-effects and low morbidity.

CONCLUSION

Drooling should be managed with a team approach using non-surgical management in the first instance. Surgery has a place and can be beneficial with few long-term side effects. Patients require long-term paedontic/dental follow up to maintain a healthy oral cavity.

Otosialorrhö - Diagnostik und Therapie einer Speichelfistel des äußeren Gehörganges

PATIENT

We report the case of a 49 year old female patient who suffered from frequent secretion of the left external canal of the ear after the treatment of a chronic mycotic otitis externa. The secretion was seen in connection with food intake. An operative revision in another hospital remained without success. The diagnostics covered the biochemical verification of saliva-amylase in the secretion, but also a high resolution MRI of the parotid gland. By this diagnostics it was easy to locate the salivary fistula during the operation.

DISCUSSION

Salivary fistulas of the parotid gland to the external ear-canal are very rare. These fistulas develop after injury of the parenchyma or the gland ductus and also after surgery of the head- and neck-region. A otosialorrhoea rarely originates from a chronic inflammatory of the ear canal. These fistulas are assigned to the fissures of Santorini and the foramen of Huschke. The therapy of salivary fistulas to the external ear canal reaches from clossure of the fistula to total parotidectomy. But also a medicamental suppression of salivation, irradiation and a tympanic neurectomy are discussed in the literature.

[Hypersialorrhea in mental retardation: interest of salivary denervation]

Hypersialorrhea with mental retardation is a handicapping clinical situation with a greater psychoaffective impact and a risk of dyspneic attack by a pharyngeal salivary stasis and a disappointing treatment. We report an observation about a 22 years old child; as for as this child is concerned, the treatment has been a salivary denervation. This method is simple, efficient and without risk.

Sialorrhea: a management challenge

Sialorrhea (drooling or excessive salivation) is a common problem in neurologically impaired children (i.e., those with mental retardation or cerebral palsy) and in adults who have Parkinson's disease or have had a stroke. It is most commonly caused by poor oral and facial muscle control. Contributing factors may include hypersecretion of saliva, dental malocclusion, postural problems, and an inability to recognize salivary spill. Sialorrhea causes a range of physical and psychosocial complications, including perioral chapping, dehydration, odor, and social stigmatization, that can be devastating for patients and their families. Treatment of sialorrhea is best managed by a clinical team that includes primary health care providers, speech pathologists, occupational therapists, dentists, orthodontists, neurologists, and otolaryngologists. Treatment options range from conservative (i.e., observation, postural changes, biofeedback) to more aggressive measures such as medication, radiation, and surgical therapy. Anticholinergic medications, such as glycopyrrolate and scopolamine, are effective in reducing drooling, but their use may be limited by side effects. The injection of botulinum toxin type A into the parotid and submandibular glands is safe and effective in controlling drooling, but the effects fade in several months, and repeat injections are necessary. Surgical intervention, including salivary gland excision, salivary duct ligation, and duct rerouting, provides the most effective and permanent treatment of significant sialorrhea and can greatly improve the quality of life of patients and their families or caregivers.

Success and complications of four-duct ligation for sialorrhea

OBJECTIVE

Sialorrhea can have a significant negative effect on quality of life, impeding social interactions and severely limiting employment opportunities. Many surgical options to control sialorrhea have been reported. One of the newest procedures is combined ligation of the submandibular and parotid ducts, reported only once in the literature in one series of five patients to date. We have compared results in our first 21 patients undergoing this procedure with results reported in the literature for other procedures to treat sialorrhea.

MATERIALS AND METHODS

We retrospectively reviewed medical records of all 21 children we treated with four-duct ligation, a relatively simple intraoral procedure to control sialorrhea, between August 1999 and September 2000 and contacted primary caregivers by telephone to answer a questionnaire regarding objective and subjective results of surgery. Surgery was considered successful when caregivers rated patients as 'much better' or 'better' after surgery.

RESULTS

Follow-up was completed in all 21 of the patients 1-14 months after surgery. The success rate of four-duct ligation ('much better' or 'better' after surgery) was 81%, and no patient's sialorrhea problem was worse after surgery. Major complications occurred in two (10%) of the patients (one ranula and one case of sialoadenitis), which were both successfully treated surgically. Minor complications occurred in four (19%) of the patients, tongue swelling that prolonged hospitalization, a ranula that resolved, and prolonged submandibular gland swelling that resolved (two cases). More than half of patients were discharged the day of or the day after surgery.

CONCLUSIONS

Four-duct ligation should be considered when surgery is indicated to treat sialorrhea.

[Otosialorrhoea - a rare case of a spontaneous salivary fistula of the external auditory canal]

Spontaneous salivary fistulas are rare. Extremely rare are spontaneous salivary fistulas of the external auditory canal. We report a case of otorrhoea caused by such a fistula in connection with defects of the cartilagenous and the osseous external auditory canal (Fissures of Santorini, foramen of Huschke) and its successful surgical treatment.

Bilateral parotid-duct diversion using autologous vein grafts for the management of chronic drooling in cerebral palsy

Chronic drooling is a major problem in patients with cerebral palsy and other neurological dysfunctions. Various treatments, ranging from speech therapy to radical surgery, have been used to overcome this distressing problem, with surgery the most consistently successful. In this study, we used a new surgical technique to manage severe drooling. This involved the dissection of both parotid-duct orifices, and their relocation, via a submucosal tunnel, into the tonsillar pillar using autologous vein grafts. Four patients were treated using this technique together with bilateral submandibular duct rerouting. The results were analysed by subjective judgements of drooling and retrograde sialography at 90 days postoperatively. In all cases, salivary flow was reduced and drooling was significantly improved. Retrograde sialography revealed no signs of obstruction or stricture formation in any of the cases. No postoperative complications occurred. These preliminary results suggest that the bilateral surgical transposition of Stensen's ducts into the tonsillar pillar using autologous vein grafts together with bilateral submandibular duct rerouting can provide effective control of chronic drooling.

Bilateral submandibular gland excision with parotid duct ligation for treatment of sialorrhea in children: long-term results

BACKGROUND

Multiple procedures have been advocated for the surgical control of chronic sialorrhea in children. However, some of them are associated with significant complications or only short-term success.

OBJECTIVES

To evaluate the safety of bilateral submandibular gland excision (SGE) with parotid duct ligation (PDL) and to assess its long-term complications and efficacy in the treatment of chronic sialorrhea in children.

DESIGN

Case series. Telephone interview of patients' families.

SETTING

Tertiary care children's hospital.

PATIENTS

Ninety-three patients with chronic sialorrhea who underwent bilateral SGE with PDL from 1988 to 1997.

MAIN OUTCOME MEASURES

Operative and postoperative complications, length of postoperative hospitalization, postoperative drooling, care requirements, xerostomia, dental caries, and overall satisfaction.

RESULTS

The mean postoperative stay was 2.4 days. There were 3 postoperative complications. Seventy-two families were interviewed (follow-up time, 1-10 years): 62 (87%) reported no further drooling or significant improvement; 7 reported the occurrence of dry mouth; and 2 reported an increase in dental caries.

CONCLUSION

Bilateral SGE with PDL is a safe and consistently efficient procedure for the treatment of chronic sialorrhea in children.

Management of drooling in individuals with neurodisability: a surgical experience

From 1975 to 1 January 1999, 1103 neurologically involved patients (mean age 13.2 years; 686 males, 417 females) referred with problematic drooling, or sialorrhea, were assessed at a pediatric rehabilitation center by a team consisting of an otolaryngologist, speech pathologist, and a dentist. The initial standard treatment for persistent sialorrhea (in the compliant or aware patient) is oral-motor training. A group of 522 patients with persistent significant drooling after a minimum of 6 months of oral-motor training, or profuse drooling in the presence of a low cognitive level, underwent surgery, usually when over 6 years of age. From 1978 to 1 January 1998, the operation of first choice was submandibular duct relocation (SDR), and was completed in a total of 226 patients. Midway through 1988, sublingual gland excision was also completed at the time of submandibular duct relocation (SDRSGE); 249 of these procedures have been completed to January 1st 1999. Those patients who had SDRSGE had significantly fewer complications that required additional surgery than those that had SDR only. However, the impact of surgery on the drooling as evaluated in subsets of both groups (SDR n=115, SDRSGE n=106) was statistically similar. The study of 11 children with salivary gland radionuclitide scans to determine the effect of submandibular duct surgery on gland function was inconclusive. The pattern of oral-motor function in 26 children studied after SDRSGE surgery suggested that those children with severe impairment of volitional motor function and profuse drooling tended to have a poorer outcome following surgery compared to those with milder impairments.

Intraductal laser photocoagulation of the bilateral parotid ducts for reduction of drooling in patients with cerebral palsy

Patients with cerebral palsy who experience drooling are often isolated from social interaction. Surgical treatment is effective in reducing abnormal, profuse drooling in patients who have low cognitive function, but it has a risk of complications. In this study, a new, simple procedure using laser intervention that minimizes surgical complications is described. Forty-eight patients with cerebral palsy and persistent drooling after more than 6 months of conservative treatment were enrolled in this study. An Nd:YAG laser (1064 nm) was used for intraductal laser photocoagulation of the bilateral parotid ducts at 7 to 10 W for 10 seconds. The outcome was evaluated by questionnaire-based, semiquantitative assessments of drooling severity and frequency, collection and measurement of stimulated saliva, and salivary amylase measurement. The entire procedure was completed in 25 to 65 minutes, with a mean duration of 38.4 minutes. Early complications included transient facial swelling in all patients. Swelling persisted for 6 to 37 days (mean, 11 days). One hematoma (2.1 percent of patients), two infections (4.2 percent of patients), and two cystic formations (4.2 percent of patients) also occurred. No obvious xerostomia or visible scar was noted after the procedure. In the final assessment, a significant improvement in drooling severity (p < 0.05) and frequency (p < 0.05) was noted in the majority of cases. Forty patients (83.3 percent) demonstrated remarkable improvement in drooling severity, seven patients (14.6 percent) showed significant improvement, and one patient (2.1 percent), who was also autistic, continued to experience severe drooling after the laser procedure. The decrease in the amount of saliva produced ranged from 20 to 60 percent at 12 weeks after surgery. The decrease in the amount of salivary amylase measured ranged from 4 to 97 percent at 12 weeks after surgery (p < 0.05). In conclusion, the intraductal laser photocoagulation of bilateral parotid ducts is a simple, effective procedure for reducing drooling in patients who have cerebral palsy. This procedure minimizes risks and complications, compared with those associated with conventional surgery.

Outcomes of submandibular duct re-implantation for sialorrhoea

Drooling is an important factor affecting the quality of lives of neurologically impaired children, and surgery often has to be performed. Submandibular duct relocation is a relatively simple procedure with a low complication rate, and has been carried out on 37 patients at the Sheffield Children's Hospital between 1986 and 1998. To determine the short-term and long-term outcome of this procedure, a questionnaire was sent to the parents/wards of the patients. Feedback was also obtained on complications, parents'/carers' perceptions and main concerns about the operation, particularly in those cases which did not improve. Both short-term (82.4%) and long-term (76.5%) control rates were high, and there were few complications, none of which had any long-term adverse effects. The most significant area of parental/carer dissatisfaction and concern in 'failed' cases was 'pain', and it was felt that proper preoperative counselling about analgesia and chances of failure is very important. We conclude that this is a safe, highly successful procedure which significantly improves the quality of lives of the majority of drooling children.

An experimental study of bilateral repositioning of the Stensen's duct orifices with autologous vein and artery grafts in dogs

Sialorrhoea is an indication of dysfunction in the coordination of the swallowing mechanism. Disturbance in this coordination results in excess pooling of saliva in the anterior mouth and resultant drooling. Several surgical techniques have been described for the management of sialorrhoea. In this experimental study, we planned to try a more safe and physiologic technique by repositioning of the parotid duct orifices into the glossopalatal arch, using autologous free grafts of vein and artery in dogs. Ten adult dogs were used. In each dog, both of the parotid duct orifices were included in the study. The surgical procedure involved the dissection of both parotid duct orifices and their relocation via a submucosal tunnel into the glossopalatal arch, using a vein graft for the right side and an artery graft for the left side. Functional assessment was based on the clinical observations and retrograde sialography done on the 60th day. Results were excellent. No stricture or obstruction was noted. Histological examinations done on the 90th day showed the replacement of endothelium by multilayered cubic Stensen's duct epithelium in both artery and vein grafts. There was no difference between the results of artery and vein grafts. Surgical transposition of Stensen's duct into the glossopalatal arch with autologous vein or artery graft is a safe technique which may be used in clinical cases of drooling as an alternative to the other techniques described.

The surgical treatment of drooling in Leicester: 12 years experience

The experience of the surgical treatment of drooling in the 12-year period 1985-1997 has been retrospectively reviewed. Details of 71 out of a total of 79 patients were available. Of these, 69% underwent bilateral submandibular duct diversion and unilateral parotid duct ligation. Excellent or good control of drooling was obtained in 65 patients (92%) which compares favourably with other series. A ranula occurred in 10% and settled spontaneously. Transient airway obstruction occurred in one patient.

Four-duct ligation: a simple and effective treatment for chronic aspiration from sialorrhea

OBJECTIVES

To determine the effectiveness of bilateral submandibular and parotid duct ligation on children with severe neuromuscular impairment and chronic aspiration of salivary secretions and to identify any predictable anatomical connections between the submandibular duct and sublingual glands.

DESIGN

Case series; retrospective anatomical study of adult cadaveric submandibular gland specimens.

SETTING

Academic tertiary referral medical center.

PATIENTS

Five children with severe neuromuscular impairment and recurrent aspiration pneumonitis.

INTERVENTION

The children underwent bilateral submandibular and parotid duct ligation. The oral cavities of 8 cadavers were dissected to identify anatomical connections between the submandibular duct and sublingual glands.

MAIN OUTCOME MEASURES

Incidence of postoperative aspiration pneumonitis; gross anatomical connections between the submandibular duct and sublingual gland in cadaveric specimens.

RESULTS

No postoperative airway obstruction, infection, or xerostomia was noted, and technetium scanning confirmed control of salivary secretions from major salivary glands. Caregivers noted diminished salivary secretions and no aspiration pneumonia.

CONCLUSIONS

This new, simple intraoral procedure controls aspiration pneumonitis with minimal surgical dissection and has less morbidity than procedures involving major salivary gland excision. Ranula formation, a common complication of submandibular duct transposition, is unlikely in this procedure because the sublingual ducts are not interrupted.

Long-term follow-up of submandibular duct rerouting for the treatment of sialorrhea in the pediatric population

OBJECTIVE

To determine the long-term control of sialorrhea in children who underwent submandibular duct rerouting (SMDR) and to identify potential preoperative predictors of outcome.

DESIGN

Retrospective chart review of children who underwent SMDR; information updated by discussion with the permanent caregiver.

SETTING

Tertiary care center.

PATIENTS

Children who had significant sialorrhea resulting from a variety of neuromuscular disabilities between January 1980 and December 1995.

OUTCOME

We report the outcome on 59 patients who underwent SMDR for the treatment of sialorrhea. Patients were ascribed a preoperative sialorrhea and global neurologic deficit score. Postoperative outcome was scored as marked, moderate, no improvement, or worse. Twenty-eight of 59 (47.4%), 28 of 59 (47.4%), and 3 of 59 (5.1%) of the patients had preoperative sialorrhea scores of 3 (profuse), 2 (moderate), and 1 (mild), respectively. Twenty of 59 (33.9%), 29 of 59 (49.2%), and 10 of 59 (16.9%) had preoperative scores of 3 (severe), 2 (moderate), and 1 (mild) neurologic impairment, respectively. Mean time to follow-up of the 59 patients was 5.46 years. Postoperative improvement scores were as follows: 50.8% had marked, 28.8% had moderate, and 20% had no to minimal improvement in their sialorrhea. Two patients were transiently worse. A complication rate of 11.3% (9 of 79) was demonstrated: 7 ranulae, 1 transient swelling of the floor of the mouth, and 1 submandibular gland infection. The preoperative global neurologic deficit score was found to be more predictive of surgical outcome than sialorrhea score.

Persistent drooling: treatment by bilateral submandibular duct transposition and simultaneous sublingual gland excision

Persistent drooling in a neurologically impaired patient is often multifactorial and various treatment modalities have been employed to overcome this distressing condition. This study analysed the outcome after bilateral submandibular duct transposition and simultaneous sublingual gland excision in 20 patients with persistent drooling treated between January 1989 and July 1994. Twelve were male and eight were female and were aged 5 years to 40 years. The outcome was considered much better/excellent in 11 cases (55%), better/good in eight cases (40%), no significant improvement in one case (5%) and none were considered worse after the procedure, in the 'early' postoperative period. Long-term results, judged by an 18-point questionnaire sent to the carers after an average duration of 3.2 years post-operatively, were available for 19 patients. In all, 16 carers (84%) felt the drooling had significantly reduced, and three carers (16%) felt that there was no improvement. The three patients who were considered not to have improved were all found to have made a 'good' improvement in the early post-operative period. The morbidity associated with the procedure was of a mild and transient nature and there was a complete absence of ranula formation in our series. The procedure was well accepted by the carers, who were also willing to recommend the procedure to others with a similar problem.

Laser intraductal photocoagulation of bilateral parotid ducts for reducing drooling of cerebral palsied children: a preliminary report

Previous reports suggested that surgical treatment was effective to reduce abnormal, profuse drooling in children with low cognitive function, but with risk of complications. Laser photocoagulation might be an option to simplify the procedure and decrease complications. Our study considered whether laser photocoagulation could improve drooling in children with cerebral palsy (CP). CP children with drooling were recruited from the pediatric rehabilitation clinic, all of whom had persistent profuse drooling after 6 months of conservative treatment. They received neodymium:yttrium aluminum garnet (Nd:YAG) laser for intraductal photocoagulation to bilateral parotid ducts, and were followed up for 2 to 3 months. Each patient was assessed before and after the procedure by: 1) questionnaire-based semiquantitative assessment of drooling severity and frequency (Thomas-Stonell and Greensberg 1988); 2) quantitative assessment of saliva amount by collection of stimulated saliva for 2 minutes in cooperative children. Six CP children with severe drooling received laser photocoagulation, five of them had remarkable decrease of drooling 1 month later. Patients had cool liquid intake soon after the procedure, and were discharged on the second day after treatment. A period of transient face swelling ranged from 6 to 37 days. No antibiotic treatment was indicated nor were any complications noted after the procedure. As a result of these studies, it is suggested that laser intraductal photocoagulation of bilateral parotid duct could be used as a simple and effective procedure for reducing drooling in CP children, and would avoid complications from conventional surgery.

Surgery of the salivary ducts

Successful surgery of the salivary ducts relies on an understanding of the surrounding anatomy and the delicate dissection of tissues in order to reduce morbidity. Trauma to the ducts should be assessed when lacerations or wounds encroach on their paths. Early diagnosis and treatment will reduce the complications of stricture and fistula formation from these injuries. Sialoliths can be located in several places along the length of the salivary ducts. The correct diagnosis and positioning of the stone in the duct is important in establishing the appropriate surgical approach. Imaging using plain films, ultrasonography, and endoscopy can be very valuable, with sialography and CT scans helpful in cases of radiolucent stones, glandular atrophy, or suspected tumor. As the condition becomes more chronic, resulting in glandular atrophy, excision of the diseased gland is often indicated. Treatment of excessive salivary flow in patients with cerebral palsy can be managed by a combination of ductal repositioning and glandular excision. Redirection of both the parotid and submandibular glands can be accomplished, either to reroute excess salivary flow or salvage the duct in cases of lesion excision.

The surgical management of drooling--a 15 year follow-up

Drooling is rarely seen in the normal child after the age of 6 months, but an estimated 10% of children with neurological impairment suffer significant interference with everyday living due to excessive drooling. Submandibular duct relocation is a procedure that involves the dissection and re-routing of the submandibular ducts to the posterior tonsilar pillar. This procedure has been carried out on 53 patients over the past 15 years at the Childrens Hospital, Dublin. All patients have been followed up with a detailed questionnaire to determine symptomatic improvement, parent satisfaction and complications. Parental satisfaction regarding this procedure is high, with 94% of parents stating that their child had benefited from the operation and over half the parents reported complete cessation of all drooling within 3 months of the operation. The major complication of post-operative pneumonia presumed secondary to salivary aspiration occurred in three children. These patients all made a full recovery. Early minor complications occurred in two children, involving post-operative submandibular gland swelling, and the late complication of a ranula was seen in four patients. We believe this is a safe and highly successful procedure that can significantly improve the quality of life of these children.

Diversion of salivary flow to treat drooling in patients with cerebral palsy

The authors performed six sialodochoplasties between 1991 and 1994 to treat drooling in six children who suffered from cerebral palsy. There were three boys and three girls, aged 13 to 22 years (mean, 16 years). All patients underwent parotid duct rerouting. The first four patients (group I) also underwent associated excision of submandibular ducts, and the last two patients (group II) benefited from rerouting of the submandibular ducts. In group I, results were considered good in two cases, fair in one case, and poor in one case. A fistula of the new Stenon duct appeared in one patient, which required excision and ligation followed by progressive involution of the parotid gland. Both group II patients had excellent and rapid results. The requirements leading to surgical decision are determined. The importance of physiotherapy is emphasized. Surgical techniques are described and discussed, as are objective criteria for the assessment of surgical results, namely salivary radioisotopic scanning.

Dental health of children with cerebral palsy following sialodochoplasty

Drooling occurs commonly in children with cerebral palsy (CP). Surgical procedures, known as slalodochoplasties, are often performed for the control of drooling. These include major salivary gland excision, parasympathetic nerve section, duct ligation, and duct re-routing. Alterations in saliva amount, flow, and consistency occur following sialodochoplasty, and the resultant effect on dental homeostasis requires further investigation. This controlled study investigated 19 children with CP following sialodochoplasty (surgery group) and 75 children with CP treated nonsurgically (control group) who attended our hospital. Dental caries experience-including dmft, DMFT, and partial DMFS scores of mandibular incisors and canines only-plaque index, and enamel developmental defects index were recorded. Saliva buffering capacity and bacterial counts were assessed. The surgical group (median DMFT = 5.00) had significantly more dental caries when compared with the control group (median DMFT = 0.00), Wilcoxon Signed-rank Test, P < 0.0001. This study has shown that children with CP following sialodochoplasty have increased risk of dental caries when compared with those treated nonsurgically for drooling. Although no caries predictors were identified, alterations to the caries-protective role of saliva are considered the likely cause. Children who undergo this procedure should receive intensive pre- and postsurgical preventive dental therapy.

Use of intraoperative ultrasonography in six horses

Intraoperative ultrasonography was used in six horses to aid localization and removal of bone fragments (3 horses) and foreign bodies (3 horses). The ultrasound transducer was enclosed in a sterile sleeve containing sterile aqueous gel and the examination was performed after aseptic preparation of the surgical site. Using ultrasound guidance a needle was placed in contact with the bone fragment or foreign body and an incision was made along the path of the needle to expose and remove the object. This technique resulted in decreased operative time and minimal tissue dissection.

Long-term outcome of saliva-control surgery

Thirty-nine patients who had undergone transposition of the submandibular ducts and unilateral ligation of a parotid duct for saliva control were followed up six years after surgery. Overall improvement was documented according to a drooling quotient, drooling severity and drooling frequency measures. Despite this superficially favourable outcome, a significant proportion of patients (39 per cent) or their caregivers had not found the surgery helpful. Complications included ranula formation, complaints of dry mouth, difficulty with swallowing, and changes in the consistency of oral secretions. More knowledge is needed of the likely outcomes of this procedure in individual patients, so that appropriate advice can be given and complications minimised.

Deterioration of feeding behavior following surgical treatment of drooling

Few adverse effects of the surgical treatment of drooling are reported in the literature. This report describes a young man with severe extrapyramidal cerebral palsy and profuse drooling whose oral feeding behavior deteriorated following bilateral submandibular gland excision and parotid duct rerouting. Before surgery the patient had safe, functional oral feeding skills, and eating was enjoyable. Following surgery he developed progressive feeding difficulties, weight loss, and aspiration pneumonia. His deterioration led to the placement of a feeding gastrostomy and the end of all oral feedings. Surgery had a disturbing and apparently irreversible negative impact on the patient's quality of life.