Success and complications of four-duct ligation for sialorrhea

Comparing botulinum toxin and 4-duct ligation for Sialorrhea in children - A systematic review

INTRODUCTION

Sialorrhea or drooling can result in physical and psychosocial complications, such as aspiration and social isolation. Treatment options include botulinum toxin into the salivary glands and 4-duct ligation (i.e., simultaneous ligation of the bilateral parotid and submandibular ducts). This systematic review aimed to compare the efficacy and complication rates of botulinum toxin and 4-duct ligation for the treatment of drooling in children.

METHODS

Following PRISMA guidelines, PubMed, Embase, Web of Science, and Cochrane Library were searched from inception through June 17, 2021 for studies examining the efficacy of botulinum toxin or 4-duct ligation for drooling in children. Data were summarized by pooled counts, percentages, and means. Complication rates were compared by a chi-squared test.

RESULTS

A total of 22 studies (n = 606) examining botulinum toxin and 5 studies (n = 124) examining 4-duct ligation were included. From 12 botulinum toxin studies (n = 211), mean drooling frequency and severity scores was 7.5 at baseline. Mean difference from baseline was -2.6 (n = 92) at 4 weeks follow-up, -2.1 at 8 weeks (n = 41), -2.1 at 12 weeks (n = 56), and - 2.1 at 16 weeks (n = 58). From 4 4-duct ligation studies (n = 103), mean baseline drooling frequency and severity score was 8.4. Mean difference was -3.7 at mean follow-up of 35.6 months (n = 103). Eighteen botulinum studies (n = 343) recorded 53 (15.5 %) complications, including thickened saliva (n = 9), dysphagia (n = 4), and cheek abscesses (n = 4). Four 4-duct ligation studies (n = 108) recorded 25 (23.1 %) complications, including parotid gland swelling (n = 4), aspiration pneumonia (n = 3), and oxygen desaturation (n = 3). There was no statistically significant difference in complication rates between botulinum toxin and four-duct ligation (p = 0.065).

CONCLUSION

Botulinum toxin injection and 4-duct ligation are both effective in improving sialorrhea in children and have comparable complication rates.

Plunging Ranula: A Case Report of a Rare Late Complication After Tongue Cancer Surgery

A plunging ranula is a benign cystic lesion in the neck formed due to mucin extravasated from a salivary gland, most commonly the sublingual gland. Ranulas have been described in association with congenital anomalies, trauma, diseases of the sublingual gland, and HIV; however, rarely, they may result as a complication of various oral and neck surgeries. Here, we report a rare case of plunging ranula that developed in an elderly male as a sequalae to surgery for tongue cancer. The patient had undergone a partial glossectomy with supra-omohyoid neck dissection for tongue carcinoma and nine months later presented with cystic swelling on the floor of the mouth that was followed by neck swelling. It was treated successfully by excision, and the histopathology confirmed the diagnosis of ranula. We postulate that the tongue cancer surgery could have caused an inadvertent injury to the ducts of the sublingual salivary gland and mylohyoid muscle, leading to the development of a plunging ranula. Our case reiterates that surgeons need to be aware of the anatomy of the submandibular and submental region to avoid any surgical trauma to the sublingual and submandibular glands and their ducts along with the associated mylohyoid muscle.

US-guided percutaneous microwave ablation (MWA) of submandibular gland: A new minimal invasive and effective treatment for refractory sialorrhea and treatment response evaluation with contrast-enhanced imaging techniques

A 33 years' old male complained of excessive salivation with frequent swallowing and spitting, which resulted in communication disturbance, reduced quality of life, and social embarrassment for 19 years. He had been diagnosed as sialorrhea and submandibular gland hyperfunction by stomatologist, then had unilateral submandibular gland resection 13 years ago, but the symptom relief was not satisfactory. After that, he had been treated with glycopyrrolate for less than a year, which was withdrawn because of the short duration of symptomatic control after each tablet take-in and intolerable side effects. With the wish to receive a new treatment with long term effectiveness, low re-operation risk and normal preserved saliva secretion function, the patient was subject to MWA for the right submandibular gland. After systematic clinical evaluation, US-guided percutaneous MWA was successfully performed with an uneventful post-operative course. The volume of the right submandibular gland and ablated area were measured precisely by an ablation planning software system with automatic volume measurement function based on three-dimensional reconstruction of the pre-operative and post-operative enhanced magnetic resonance imaging (MRI) raw data. Finally, the ablated volume was calculated as 62.2% of the whole right submandibular gland. The patient was discharged 1 day after the operation, with symptoms relieved significantly, the mean value of whole saliva flow rate (SFR) decreased from 11 ml to 7.5 ml per 15 minutes. During the follow up by phone three months after operation, the patient reported that the treatment effect was satisfactory, whereas the SFR value became stable as 7 ml per 15 minutes, drooling frequency and drooling severity (DFDS) score decreased from 6 to 5, drooling impact scale (DIS) score decreased from 43 to 26. US-guided percutaneous MWA of submandibular gland seems to be an alternative, minimal invasive, and effective treatment for refractory sialorrhea.We described a patient with refractory sialorrhea treated successfully with ultrasound (US) guided percutaneous microwave ablation (MWA).

Submandibular duct ligation after botulinum neurotoxin A treatment of drooling in children with cerebral palsy

AIM

To assess: (1) the effect on drooling of bilateral submandibular duct ligation as surgical therapy after the administration of submandibular botulinum neurotoxin A (BoNT-A) for excessive drooling and (2) the predictive value of treatment success with BoNT-A on treatment success after bilateral submandibular duct ligation.

METHOD

This was a within-participant retrospective observational study in which 29 children with severe drooling (15 males, 14 females) received BoNT-A treatment at a mean age of 9 years 6 months (SD 2y 5mo), followed by bilateral submandibular duct ligation at a mean age of 10 years 11 months (SD 2y 4mo). Fifteen children were diagnosed with cerebral palsy (CP), with 12 children classified in Gross Motor Function Classification System levels IV and V. The 14 children without CP had non-progressive developmental disorders. The primary drooling severity outcomes were the Visual Analogue Scale (VAS; subjective assessment) and drooling quotient (objective assessment). Measurements were taken before each intervention and again at 8 and 32 weeks.

RESULTS

The VAS was significantly lower after bilateral submandibular duct ligation at follow-up compared to BoNT-A treatment (mean difference -33, p≤0.001; 95% confidence interval [CI]=-43.3 to -22.9). The mean drooling quotient did not significantly differ between BoNT-A treatment and bilateral submandibular duct ligation at follow-up (3.3, p=0.457; 95% CI=-4.35 to 9.62) or between 8 and 32 weeks (4.7, p=0.188; 95% CI=-2.31 to 11.65).

INTERPRETATION

BoNT-A treatment and bilateral submandibular duct ligation are both effective treatment modalities for drooling. At 32-week follow-up, subjective drooling severity after bilateral submandibular duct ligation was significantly lower compared to previous BoNT-A injections in participants. However, treatment success with BoNT-A is no precursor to achieving success with bilateral submandibular duct ligation.

WHAT THIS PAPER ADDS

Bilateral submandibular duct ligation is an effective therapy for drooling after treatment with botulinum neurotoxin A (BoNT-A). Treatment success with BoNT-A is not a predictor of successful therapy with bilateral submandibular duct ligation.

The burden of sialorrhoea in chronic neurological conditions: current treatment options and the role of incobotulinumtoxinA (Xeomin®)

Sialorrhoea is a frequent symptom of neurological diseases (e.g. Parkinson’s disease, motor neuron disease, cerebral palsy, and stroke) and is defined as excessive saliva accumulation leading to unintentional loss of saliva from the mouth. Sialorrhoea increases the overall burden on the patient and their caregivers, the impact of which can be both physical and psychosocial. Treatments for sialorrhoea range from lifestyle and behavioural guidance, to medications, surgery or radiation. Nonpharmacological interventions include advice on posture, swallowing control, cough management, dietary changes, eating and drinking techniques, and behavioural modification; however, these conservative measures may be ineffective for people with progressive neurological conditions. The pharmacological treatment of sialorrhoea is challenging because medications licensed for this purpose are limited, but treatments can include anticholinergic drugs and botulinum toxins. Surgical treatment of sialorrhoea is typically reserved as a last resort for patients. IncobotulinumtoxinA (Xeomin®) is the first botulinum toxin type A to receive US and UK marketing authorization for the symptomatic treatment of chronic sialorrhoea due to neurological disorders in adults. In this review, we discuss and compare the frequency and method of administration, location of treatment delivery, approximate annual costs and main side effects of botulinum toxin and different anticholinergic drugs. Management of patients with chronic neurological conditions requires input from multiple specialist teams and thus a multidisciplinary team (MDT) approach is considered fundamental to ensure that care is consistent and tailored to patients’ needs. To ensure that adult patients with neurological conditions receive the best care and sialorrhoea is well managed, we suggest a potential clinical care pathway for sialorrhoea with a MDT approach, which healthcare professionals could aspire to.

Surgical Management of the Drooling Child

PURPOSE OF REVIEW

Our goal is to present the most up-to-date options in the surgical management of drooling in the paediatric population. While the clinical assessment of the drooling child and conservative management options are discussed, this review focuses on the most recent evidence for surgical interventions to treat drooling in children.

RECENT FINDINGS

In terms of advances in the management of drooling, further experience and outcomes with the use of botulinum toxin injections is discussed. Moreover, the latest evidence-base for salivary duct ligation and relocation procedures are presented. Finally, the trans-oral approach to submandibular gland excision for the management of drooling may gain popularity through the aim of reducing surgical morbidity.

SUMMARY

The drooling child should be managed with an evidence-based stepwise approach delivered by a multidisciplinary team (MDT). Children with normal neurological development should be treated conservatively through parental reassurance. There are numerous interventions available for the drooling child with impaired neuromuscular development. When conservative measures fail, treatment options include botulinum toxin injections and surgical procedures such as salivary duct ligation, salivary duct relocation and salivary gland excision. Management must be targeted to the individual needs and comorbidities of the child to maximise treatment outcomes.

[Submandibular gland resection for the management of sialorrhea in paediatric patients with cerebral palsy and unresponsive to type A botullinum toxin. Pilot study]

BACKGROUND

Sialorrhoea has a prevalence of between 10% and 58% in patients with cerebral palsy. Amongst the invasive treatments, botulinum toxin-A injections in submandibular and parotid glands and various surgical techniques are worth mentioning. There are no studies in Mexico on the usefulness of surgery to manage sialorrhoea.

OBJECTIVE

To evaluate the usefulness of submandibular gland resection in improving sialorrhoea in patients with cerebral palsy and with a poor response to botulinum toxin.

MATERIAL AND METHODS

Experimental, clinical, self-controlled, prospective trial was conducted to evaluate the grade of sialorrhoea before surgery, and 8, 16 and 24 weeks after. Statistical analysis was performed using a non-parametric repetitive measure assessment, considering a p < 0.05 as significant. Complications and changes in salivary composition were evaluated.

RESULTS

Surgery was performed on 3 patients with severe sialorrhoea, and 2 with profuse sialorrhoea, with mean age of 10.8 years. The frequency and severity of sialorrhoea improved in the 5 patients, with mean of 76.7 and 87.5% improvement, respectively. The best results were seen after 6 months of surgery, with a statistically significant difference between the preoperative stage and 6 months after the procedure (p = 0.0039, 95% CI). No significant differences were observed in complications, increase in periodontal disease or cavities, or salivary composition.

CONCLUSIONS

Submandibular gland resection is an effective technique for sialorrhoea control in paediatric patients with cerebral palsy, with a reduction in salivary flow greater than 80%. It has a low chance of producing complications compared to other techniques. It led to an obvious decrease in sialorrhoea without the need to involve other salivary glands in the procedure.

Long-Term Efficacy of Intra-Oral Surgery for Sialorrhea

OBJECTIVES: To investigate the efficacy and quality of life impact of intra-oral surgery for sialorrhea and to provide long-term outcome measures.

METHODS: A retrospective review and telephone survey of patients seen in a multi-disciplinary saliva control clinic who underwent surgery between 1999 and 2003.

RESULTS: Sixteen of 31 patients underwent 4-duct ligation, 12 patients underwent submandibular gland duct ligation, and three patients underwent a 3-duct ligation procedure. The mean presurgical drooling score (maximum 10) was 9.5, 8.8, and 9, respectively. Recurrence was seen in 68% of patients at a mean of four months. Additional surgery was required in five patients. Phone survey was accomplished in 10 patients. Two of 10 caregivers reported sustained improvement of sialorrhea at two and three years.

CONCLUSIONS: Intra-oral surgery provides minimal longterm control of sialorrhea. Additional medical and surgical therapy was needed in a significant portion of patients in this long-term review.

Parotid salivary duct stenosis following caudal maxillectomy

Parotid salivary duct dilation was diagnosed in a 9-year-old male dog. The dog had undergone caudal maxillectomy on the ipsilateral side 2-years prior to presentation. Treatment consisted of parotid salivary duct excision and superficial parotidectomy that lead to the resolution of clinical signs. Transient facial neuropraxia was observed immediately after surgery and resolved spontaneously after 2-weeks. Parotid salivary duct dilation should be considered as a chronic postoperative complication following caudal maxillectomy.

Four-duct ligation in children with drooling

OBJECTIVES

The objective of this study is to assess the improvement in drooling in children undergoing 4-duct ligation procedure for excessive drooling and to study its effect on their quality of life.

MATERIALS AND METHODS

A prospective, nonrandomized interventional study was done between November 2009 and September 2011. Thirty drooling children of both sexes aged 4 to 15 years underwent 4-duct ligation, that is, ligation of bilateral submandibular ducts and bilateral parotid ducts. Comparison of preoperative and postoperative drooling scores using Thomas-Stonell and Greenberg classification was done. Glasgow Children's Benefit Inventory Score was used to assess the improvement in the quality of life.

RESULTS

Success rate in terms of improvement in drooling was 93.33%. A complication rate of 16.67% was found. The mean improvement in total drooling score after 12 months was 4.43. The paired t test applied on preoperative and postoperative combined drooling scores showed P < .001. The mean Glasgow Children's Benefit Inventory score was 36.15. In the postoperative period, transient swelling of cheeks, transient swelling of submandibular glands, change in the consistency of saliva, cheek abscess, collection of saliva in the cheek, and parotid duct fistula were observed.

CONCLUSIONS

Four-duct ligation causes marked improvement in drooling and significantly increases the quality of life in drooling children. It has few complications, which can be managed effectively.

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.

Salivary gland surgery for control of chronic pulmonary aspiration in children with cerebral palsy

OBJECTIVE

To evaluate the outcome of surgical saliva reduction to decrease pulmonary aspiration in children with cerebral palsy and its repercussions in respiratory infection control.

METHODS

Twenty-nine children with neurological impairment and diagnosis of chronic pulmonary aspiration were submitted to bilateral submandibular gland excision and bilateral parotid duct ligation at the Association for the Welfare of Physically Handicapped Children, from December 2001 to December 2004. Postoperative frequency of lower respiratory tract infection, hospitalization rate due to pulmonary infection and airway secretion level after the surgery were compared to preoperative period.

RESULTS

Twenty-nine children with cerebral palsy aged 18 months to 9 years were submitted to submandibular glands excision and parotid ducts ligation. All children had gastrostomy and no oral intake. There were no major complications; two children had reopening of one parotid duct. Frequency of lower respiratory tract infections, rate of hospitalization for treatment of pulmonary infections and level of airway secretion were statistically reduced. Preoperative mean rate of lower respiratory tract infection was 6.9/year; in postoperative period, rate was 2.4/year (p<0.001). Pneumonia hospitalization mean rate was 63.4 days/year preoperatively and 17.5 days/year postoperatively (p<0.001). There was also a significant improvement in the need for suctioning of upper airway secretion (mean 11 times/day in preoperative period and 3.1 times/day in the postoperative period; p<0.001).

CONCLUSION

In children with cerebral palsy, surgical saliva reduction by submandibular glands excision and parotid ducts ligation is an effective and safe technique for frequency reduction of lower respiratory tract infection and level of airway secretion.

Disorders of swallowing: palliative care

This article defines palliative care for swallowing disorders as treatment for severe and chronic dysphagia or intractable aspiration when the recovery of normal swallowing is not anticipated and attempts to restore normal swallowing have been unsuccessful. Palliative treatment for dysphagia is not only for the dying patient because patients with difficulty swallowing can live for a long time. Palliative care for dysphagia is aimed at maximizing swallowing function, maintaining pulmonary health, and supporting healthy nutrition despite the impaired ability to swallow. When despite all attempts at intervention a patient becomes totally unable to swallow, the goal of therapy changes toward finding ways to provide adequate nutrition for the patient.

Parotid duct ligation for treatment of drooling in children with neurological impairment

Objective:

Multiple surgical procedures have been advocated for the management of problematic drooling in neurologically impaired children. Parotid duct ligation is a quick and simple operation conducted via an intra-oral approach and usually performed simultaneously with other procedures. In this study, we aimed to evaluate the effectiveness of parotid duct ligation as a discrete procedure.

Methods:

All children who underwent bilateral parotid duct ligation as the solitary operative intervention at that time, between February 2003 and September 2006, were included in the study.

Results:

Ten children were studied. Surgery was successful in 80 per cent of cases. One patient (10 per cent) had a post-operative wound infection.

Conclusions:

Bilateral parotid duct ligation is an effective yet conservative operation for drooling in neurologically impaired children. It requires minimal surgical dissection and has a low morbidity rate. It should be considered as a potential first-line procedure in children who aspirate, and as a further surgical option in anterior droolers or those who continue to drool unacceptably following prior surgical intervention.

Surgical management of drooling: clinical and caregiver satisfaction outcomes

INTRODUCTION

Various surgical techniques are used to manage problematic drooling. These include: (1) re-routing of the submandibular ducts/excision of the sublingual glands (group 1), (2) excision of the submandibular glands/parotid duct ligation (group 2), and (3) ligation of the parotid and submandibular ducts (group 3).

PURPOSE

To compare the long-term effectiveness of three surgical techniques and to evaluate long-term caregiver satisfaction.

SETTING

Tertiary care children's hospital.

STUDY DESIGN

10 year retrospective chart review and telephone follow-up questionnaire.

METHODS

Demographic data, drooling severity, medical management and surgical outcomes using objective severity ratings were evaluated. Satisfaction scores were obtained by phone interview.

RESULTS

33 patients, 19 male and 14 female, age 1.1-27.6 years (mean 9.4+/-4.9) underwent surgery. Six patients were in group 1, 14 in group 2 and 13 patients in group 3. There was no difference in age, sex or severity of drooling among groups. Mean follow-up was 4.5 years (range 1.1-10 years). Post-operative anti-cholinergic use was most common in group 3 (53%) compared to 21% in group 2 and 33% in group 1. Overall caregiver satisfaction for each group was 83% for group 1, 79% for group 2, and 30% for group 3. Gradual return of drooling occurred in 8 of 13 (61%) patients in group 3 and resulted in dissatisfied caregivers.

CONCLUSIONS

Although recent literature advocates four-duct ligation, our long-term results do not appear favorable. Reasons for this failure and strategies for avoidance are discussed.

Videoendoscopic rehabilitation of iatrogenous Stensen-duct-acquired atresia in a patient with ring chromosome 21 syndrome and drooling

Drooling generally arises as a result of neurologic or muscular impairments, especially in subjects affected by cerebral palsies. It has never previously been described in patients with ring chromosome 21 syndrome. We describe the video-assisted surgical rehabilitation of the left parotid duct in a child with ring chromosome 21 syndrome and a persistent and painful swelling of the left parotid region after the surgical ligation of the Stensen ducts because of drooling. The diagnosis of Stensen duct dilatation as a result of iatrogenous complete distal acquired atresia was made by means of clinical and magnetic resonance evaluations. Video-assisted sialoendoscopical surgical rehabilitation of the left parotid duct was successfully performed; based on this experience, this minimally invasive procedure is preferred before traditional invasive parotid surgery in these cases. Other therapeutical options such as botulinum toxin therapy might be considered for the management of drooling in such young patients.

Traitement du bavage : revue de la littérature

An exhaustive review of the literature shows the very relative efficiency of diverse treatments for chronic drooling. Morbidity is too high with medical treatments and behavioral treatments require active collaboration from the patient. The different surgical techniques, either based on derivation or ligature of the principal salivary ducts combined with glandular tissue extirpation, are not free of complications. There is much controversy over their efficiency due to the lack of sound evidence. Caution is therefore primordial before proposing surgery for chronic drooling: the available surgical procedures all have technical limitations and clinical trials have demonstrated many failures. At the most, the patient can expect a 50 to a maximum 80% reduction of drooling.

Drooling of saliva: A review of the etiology and management options

Drooling of saliva appears to be the consequence of a dysfunction in the coordination of the swallowing mechanism, resulting in excess pooling of saliva in the anterior portion of the oral cavity and the unintentional loss of saliva from the mouth. Drooling can produce significant negative effects on physical health and quality of life, especially in patients with chronic neurological disabilities. Various approaches to manage this condition have been described in the literature, including oral motor therapy, behavior modification via biofeedback, orofacial regulation therapy, drug therapy, radiotherapy, and surgical treatments. Minimally invasive modalities, such as injection of botulinum toxin, photocoagulation, and acupuncture, have also been reported. This article provides a comprehensive and thorough overview of drooling, with an emphasis on understanding its etiologies and modalities of treatment.

Management of Oropharyngeal and Tracheobronchial Secretions in Patients with Neurologic Disease

BACKGROUND

Neurologic disorders may impair the normal clearance of secretions. Effective palliation requires the management of excessive oral, pharyngeal and/or tracheobronchial secretions. This requires an understanding of underlying mechanisms and familiarity with the many available medical and surgical treatment options.

OBJECTIVES

The authors intend to review the relevant anatomy and physiology along with the available medical, surgical and physical therapies available to treat this commonly encountered problem.

DESIGN

A review of current management and the supporting literature.

CONCLUSIONS

Clinicians have many effective therapeutic options to choose from when managing the excessive oral, pharyngeal and/or tracheobronchial secretions caused by neurologic disorders. Treatment choices that are predicated upon pathophysiologic causes and patient status are the most likely to succeed.