Parasympathetic nerve section for control of sialorrhea

Sialorrhea in children with cerebral palsy

OBJECTIVE

To review the literature on sialorrhea in children with cerebral palsy.

SOURCE OF DATA

Non-systematic review using the keywords "sialorrhea" and "child" carried out in the PubMed®, LILACS®, and SciELO® databases during July 2015. A total of 458 articles were obtained, of which 158 were analyzed as they were associated with sialorrhea in children; 70 had content related to sialorrhea in cerebral palsy or the assessment and treatment of sialorrhea in other neurological disorders, which were also assessed.

DATA SYNTHESIS

The prevalence of sialorrhea is between 10% and 58% in cerebral palsy and has clinical and social consequences. It is caused by oral motor dysfunction, dysphagia, and intraoral sensitivity disorder. The severity and impact of sialorrhea are assessed through objective or subjective methods. Several types of therapeutic management are described: training of sensory awareness and oral motor skills, drug therapy, botulinum toxin injection, and surgical treatment.

CONCLUSIONS

The most effective treatment that addresses the cause of sialorrhea in children with cerebral palsy is training of sensory awareness and oral motor skills, performed by a speech therapist. Botulinum toxin injection and the use of anticholinergics have a transient effect and are adjuvant to speech therapy; they should be considered in cases of moderate to severe sialorrhea or respiratory complications. Atropine sulfate is inexpensive and appears to have good clinical response combined with good safety profile. The use of trihexyphenidyl for the treatment of sialorrhea can be considered in dyskinetic forms of cerebral palsy or in selected cases.

Salivary gland diseases in children

Salivary gland diseases in children are rare, apart from viral-induced diseases. Nevertheless, it is essential for the otolaryngologist to recognize these uncommon findings in children and adolescents and to diagnose and initiate the proper treatment.

The present work provides an overview of the entire spectrum of congenital and acquired diseases of the salivary glands in childhood and adolescence. The current literature was reviewed and the results discussed and summarized.

Besides congenital diseases of the salivary glands in children, the main etiologies of viral and bacterial infections, autoimmune diseases and tumors of the salivary glands were considered. In addition to the known facts, new developments in diagnostics, imaging and therapy, including sialendoscopy in obstructive diseases and chronic recurrent juvenile sialadenitis were taken into account. In addition, systemic causes of salivary gland swelling and the treatment of sialorrhoea were discussed. Although salivary gland diseases in children are usually included in the pathology of the adult, they differ in their incidence and some­times in their symptoms. Clinical diagnostics and especially the surgical treatment are influenced by a stringent indications and a less invasive strategy. Due to the rarity of tumors of the salivary glands in children, it is recommended to treat them in a specialized center with greater surgical experience.

Altogether the knowledge of the differential diagnoses in salivary gland diseases in children is important for otolaryngologists, to indicate the proper therapeutic approach.

Contemporary surgical management of severe sialorrhea in children

The causes of severe sialorrhea (drooling) are reviewed, and in particular in children in whom it can become a life-long disability. The history of medical and surgical treatments is discussed. A major advance has been the surgical relocation of the submandibular gland ducts with removal of sublingual glands. The results of this operation, technical considerations, and its outcomes in 16 children are presented. There were no significant complications. Caregivers judged the efficacy with a median score of “75%” improvement. The technique has become the most logical and reliable surgical treatment for drooling, with very good control in most cases. In contrast to “Botox” its effects are permanent.

Drooling in children

Although drooling may occur in healthy children under two years of age, it is commonly observed in neurologically impaired children and carries a considerable social stigma. Drooling can be socially embarrassing, and at times may cause serious medical complications. Drooling may result from the hypersecretion of saliva or, more commonly, the impairment of swallowing. Most of the causes of drooling can be diagnosed from a history and physical examination of the patient. Laboratory investigations are usually unnecessary. Treatment should be directed at the underlying cause whenever possible. No active management is necessary for patients who have little functional and psychological impairment from their objectively mild or intermittent drooling. Treatment options for moderate and severe drooling include physiotherapy, behavioural or biofeedback modification, pharmacotherapy and surgery.

Evolução de 31 crianças submetidas à ressecção bilateral das glândulas submandibulares e ligadura dos ductos parotídeos para controlar a sialorréia

OBJETIVOS: Avaliar a segurança da ressecção bilateral das glândulas submandibulares e ligadura dos ductos parotídeos em crianças para reduzir a saliva, a eficácia e as complicações em médio e longo prazo no tratamento da sialorréia. FORMA DE ESTUDO: Coorte longitudinal. MATERIAL E MÉTODO: Trinta e uma crianças, com idades entre 6 e 13 anos (média de 7,6 anos), com múltiplas deficiências de etiologia neurológica foram submetidas à ressecção bilateral das glândulas submandibulares e ligadura dos ductos parotídeos, para controle da sialorréia, entre dezembro de 1999 a dezembro de 2005, e seguimento médio de 36 meses. RESULTADOS: O critério de sucesso foi o estabelecido por Wilkie, e 87% das crianças tiveram resultados excelentes e bons, sendo a morbidade insignificante e a principal complicação foi o edema temporário na região parotídea. CONCLUSÃO: A ressecção bilateral das glândulas submandibulares e a ligadura dos ductos parotídeos constituem técnica segura e eficaz para ser realizada em crianças, com 87% de sucesso no controle da sialorréia.

Drooling: analysis and evaluation of 31 children who underwent bilateral submandibular gland excision and parotid duct ligation

Summary

Aim: To evaluate the safety of bilateral submandibular gland excision and parotid duct ligation in order to control drooling in children; to assess its long-term efficacy and complications.

Study design

longitudinal cohort.

Materials and Methods

Thirty-one children aged 6 to 13 years (7.6 years old in average), with multiple neurological disabilities were submitted to a bilateral submandibular gland excision with parotid duct ligation in order to control ptyalism between December 1999 and December 2005, mean follow up of 36 months.

Results

According to Wilkie's success criteria, 87% of children had excellent or good results and insignificant morbidity was insignificant; with temporary parotid edema as the major complication.

Conclusion

Bilateral submandibular gland excision with parotid duct ligation were safe to be performed in children, with 87% of success in drooling control.

Management of drooling

Drooling is a frequent complaint for individuals with developmental disabilities and their families. A variety of treatment options exist including behavioral or oral motor therapies, medications and surgical interventions. Several novel alternative therapies are also being explored. However, most treatments lack evidence-based demonstration of efficacy. Management of problem drooling benefits from a team approach.

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.

The surgical management of drooling

As with all branches of surgery, selection of the appropriate operative procedure for a particular patient involves careful weighing of all the alternatives and full discussion with the patient and carers. Each of the procedures described has its devotees and detractors. For an individual patient, however, the risks of each, the likely postoperative course and the results of the surgery--both in terms of the expected chance of improvement in drooling and the presence or otherwise of residual scarring or taste--must be balanced to determine the optimum plan for treatment. The long-term results of submandibular duct transposition for drooling in the author's own institution have recently been reported. An initial improvement in the drooling of all patients was maintained for at least two years in 17 of 20 patients. Only two patients experienced complications requiring further surgery (ranulas in each case). It is suggested that these very satisfactory results, achieved without external scarring and without compromising the sense of taste, support the contention that submandibular duct transposition is the surgical treatment of choice for children and young people with cerebral palsy who drool excessively.

Experience with the Wilkie procedure for sialorrhea

Sialorrhea (drooling) is most commonly seen in children with cerebral palsy or mental retardation. Surgical procedures for the control of sialorrhea include salivary gland excision, parasympathetic nerve section, and salivary duct ligation and/or rerouting. Eighteen children between the ages of 5 and 17 years underwent bilateral submandibular gland excision and rerouting of Stensen's duct (Wilkie procedure). All children had severe drooling associated with cerebral palsy or mental retardation. Follow-up at 7 years showed satisfactory control of sialorrhea in 16 of 18 patients (89%). There was one major complication: xerostomia. Our results indicate that submandibular gland excision together with parotid duct retropositioning provides effective control of sialorrhea in most cases. Unfavorable head and mandibular posturing seemed to cause persistent sialorrhea in one case.

The effect of chorda tympani section on ipsilateral and contralateral salivary secretion and taste in man

Bilateral chorda tympani section is an accepted treatment for troublesome sialorrhoea. Nevertheless the effects of this operation have been poorly studied. Twenty patients were studied with unilateral chorda tympani section and a healthy contralateral ear. The effects on ipsilateral and contralateral stimulated submandibular and parotid flow and taste recognition and detection thresholds were measured. Stimulated submandibular flow accounted for only 27% of the total salivary flow. Chorda tympani section had no effect on submandibular flow in seven patients and only reduced submandibular flow by approximately 54% in the remaining 13 patients. No significant effect was observed on ipsilateral parotid flow rate. Electrogustometric taste detection thresholds were more than twice the accepted upper limit of normal on the lesioned side and taste recognition thresholds were also markedly abnormal. Chorda tympani section alone is a poor method of reducing stimulated salivary flow.

Efficacy of benztropine therapy for drooling

This study assessed the efficacy of synthetic anticholinergic benztropine and incidence of side-effects in 20 developmentally-disabled patients with severe drooling. The double-blind, placebo-controlled, crossover protocol included one-week baseline, two-week placebo and two-week benztropine conditions (mean dose 3.8 mg). A significant decrease in drooling during the benztropine condition relative to placebo was demonstrated and conservative response rates (calculated by deleting placebo responders), ranged up to 65 to 70 per cent. For patients completing the protocol the incidence of side-effects did not differ across conditions and minor problems such as a dry mouth were eliminated by small dose adjustments. More serious cholinergic side-effects, which resolved within 24 to 48 hours, necessitated discontinuation of the drug in three patients. This study demonstrates that synthetic anticholinergics can provide an important therapeutic alternative to surgical and behavioral therapies for drooling.

Reduction of salivary flow with Scopoderm TTS

Scopoderm transdermal therapeutic system (TTS) is a form of application permitting programmed release of scopolamine through the skin into the bloodstream. Scopoderm TTS is indicated for prevention of nausea and vomiting associated with motion sickness. The most common side effect associated with its use is dryness of the mouth. We have been using Scopoderm TTS for reducing salivary flow in patients with sialorrhea or with difficulties in swallowing normal amounts of salivary secretions. Good results were achieved with minimal discomfort from adverse effects. We recommend the use of Scopoderm TTS in selected cases of sialorrhea and drooling, preoperatively and postoperatively in patients undergoing surgery of oral, laryngeal, and pharyngeal lesions.

Long-term follow-up of the effect of tympanic neurectomy on sialadenosis and recurrent parotitis

We examined the effect of tympanic neurectomy on the clinical symptoms and secretory function of the parotids in 13 patients with chronic parotitis or sialadenosis for 3 years. Each patient had significantly fewer complaints immediately after the surgery. In quite a few patients the improvement was transient only. Three years after neurectomy 3 of the 10 examined patients were free from complaints and 4 further patients had less severe complaints than before the surgery. Neurectomy was followed by a significant decrease in parotid flow rate and an increase in the sodium concentration of parotid saliva, while potassium concentration showed a slight decrease. Three years after the surgery the flow rate and the sodium concentration were moderately higher than before that. There was a significant, long-lasting change in the amylase activity of parotid saliva; 3 years after neurectomy it attained one-third of the preoperative value. A pharmacological test, carried out 3 years after neurectomy in 2 patients, suggested parasympathetic reinnervation of the parotid.

Treatment of the drooling child by submandibular duct transposition

Drooling is frequently a major problem in the neurologically damaged child, and carries a considerable social stigma. Current methods of treatment are reviewed, and the authors' experience using the technique of bilateral submandibular duct transposition in a series of 25 consecutive cases is evaluated. The operation is technically straightforward, with a high success rate and low morbidity, and is considered to be the procedure of choice.

The effects of tympanic neurectomy and chorda tympanectomy on experimentally induced parotid duct fistulae in rabbits

To study the effects of parasympathetic denervation on the secretory activity of parotid fistulae, polyethylene catheters were introduced bilaterally into the parotid main excretory ducts of 10 rabbits, followed by unilateral parasympathectomy performed by segmental resection of the tympanic plexus and the chorda tympani nerve. Although salivary flow from the fistulae of the denervated parotid glands stopped up to 8 days earlier than that from the healthy (control) glands, the effect of parasympathectomy was not strong enough to recommend this operation as the method of choice for the clinical inactivation of persistent parotid fistulae.

Ptyalism and partial hydatidiform mole associated with a normal term male fetus

The case is described of a subfertile woman whose only successful pregnancy was complicated by the unusual combination of ptyalism and a partial hydatidiform mole. Review after delivery of an ultrasonic scan taken at 17 weeks showed the mole to be present at that time. A normal male child was delivered at term. It is concluded that there was no causal relationship between these 2 conditions.

Late sequelae of iatrogenic damage to chorda tympani nerve

Four and a half years following middle ear surgery involving damage to the chorda tympani nerve we conducted a follow-up study in 10 out of 14 patients in whom we had previously investigated gustatory and submandibular gland function, pre- and immediately postoperatively. Following transection of the chorda tympani nerve (5 patients) the secretory volume of the affected gland has risen again but is still lower than that of the healthy gland. The secretory volume of the latter is increased, possibly by compensatory hypertrophy. The still existing dysgeusia, not noticed by the patients, is occasionally slightly improved. After stretching of the chorda tympani nerve (5 patients) the function of the submandibular gland and taste perception on the involved side of the tongue are now nearly fully restored.

The effect of submandibular duct rerouting in the treatment of sialorrhea in children

Sialorrhea is an indication of an upset in the coordinated mechanism control of facial tone and palate musculature. Disturbance in this coordination results in excess pooling of saliva in the anterior mouth and resultant drooling. In addition to the hygienic problems associated with drooling, sialorrhea also interferes with speech clarity and nutrition. It may also cause increased infections and dehydration, and may provide for further isolation of the afflicted from the mainstream of life. Current therapeutic modalities are reviewed and compared with submandibular duct rerouting. Twenty-five consecutive pediatric patients in whom submandibular duct rerouting was performed are evaluated for postoperative drooling and submandibular gland function. The procedure was found to have low morbidity and to be effective in control of sialorrhea in pediatric patients.

The surgical treatment of drooling in healthy children

Drooling is a distressing symptom. It is usually found in children suffering from cerebral palsy, but may also be encountered in healthy children. There are different known surgical methods to stop drooling. We think that the most adequate method to stop drooling in healthy children is the transposition of Wharton's duct to the floor of the mouth, behind the posterior pillar of the tonsil. In our department, 7 healthy children suffering from drooling underwent this operation with good results. The surgical procedure is fully described and the literature on the subject is reviewed.

Long-term follow-up of tympanic neurectomy for sialorrhea

Thirty-one patients who had undergone a bilateral tympanic neurectomy (sectioning of both Jacobson's nerve and the chorda tympani) for sialorrhea are evaluated after two years (ranging from 24--45 months). Drooling control improved in 74%. There was a significant difference of improvement in the group where a diligent search was made to sever all branches of the tympanic plexus. A 50% improvement was attained in two failures of a tympanic neurectomy who underwent transposition of Stenson's ducts into the tonsillar fossa.