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

Which surgery for drooling in patients with cerebral palsy?

BACKGROUND

Surgery for drooling in patients with cerebral palsy should not produce xerostomia in order not to deteriorate speech, taste, or the status of oral hygiene. It must be a compromise between drooling and quality of life. The purpose of the present report is to describe our surgical strategy that respects the above principles.

MATERIALS AND METHODS

Patients were initially operated on depending on the drooling severity. The results were evaluated according to the frequency of residual drooling and the Thomas-Stonel and Greenberg classification. Quantitative assessment was proposed 6 months after surgery. The data have been compared using the nonparametric Wilcoxon matched-pairs test.

RESULTS

Thirty-five patients underwent surgery between 1991 and 2012. Owing to incomplete data, only 31 patients could be included, aged 5 to 24 years (mean: 12 years). All patients underwent surgery on the submandibular duct. Only 16 patients underwent a simultaneous surgery on the parotid duct. Six patients were reoperated: 3 because of an insufficient result and 3 because of a surgical complication. Changes/Day ranged from 1 to 7 (median: 3) before surgery and 0 to 2 (median: 1) after surgery (p < 0.01). Number of bibs/day ranged from 0 to 30 (median: 4) before surgery and 0 to 4 (median: 1) after surgery (p < 0.01). No dental deterioration and no caries occurred after surgery.

CONCLUSION

Good results for drooling can be obtained with a simple surgical procedure on the submandibular ducts, maintaining quality of life, avoiding deterioration of speech, taste, and the status of oral hygiene.

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.

Early laparoscopic fundoplication and gastrostomy in infants with spinal muscular atrophy type I

BACKGROUND/PURPOSE

Spinal muscular atrophy (SMA) in children leads to progressive muscle weakness, dysphagia, aspiration, and death. We hypothesized that early laparoscopic fundoplication and gastrostomy in infants with SMA type I could be performed safely perhaps leading to fewer aspiration events and improved nutritional status.

METHODS

Children diagnosed with SMA type I from 2002 through 2005 were included (n = 12). All children underwent laparoscopic Nissen fundoplication with gastrostomy shortly after diagnosis. Postoperative respiratory management and discharge criteria were standardized.

RESULTS

All patients were extubated immediately postoperatively. There were no significant complications. Average time to full feeding and inpatient length of stay were 42 +/- 4.9 hours (range, 30-48 hours) and 78 +/- 22.5 hours (range, 44-120 hours), respectively. Mean weight-for-length percentile was doubled at 1 year postoperatively (P = .03). The number of respiratory-related hospitalizations in the cohort decreased by almost 50% in the ensuing 12 months after surgery, although this did not reach statistical significance in this small cohort (P = .34).

CONCLUSIONS

Early laparoscopic fundoplication and gastrostomy is safe and is associated with improved nutritional status. A trend toward fewer significant long-term aspiration-related events was seen after fundoplication. To better assess the long-term benefits of performing an antireflux procedure in these high-risk patients, a larger prospective trial comparing current nutritional support practices is needed.