The surgical treatment of drooling in Leicester: 12 years experience

Postoperative Airway Management after Submandibular Duct Relocation in 96 Drooling Children and Adolescents

The aim of this study was to evaluate our institutions airway management and complications after submandibular duct relocation (SMDR). We analysed a historic cohort of children and adolescents who were examined at the Multidisciplinary Saliva Control Centre between March 2005 and April 2016. Ninety-six patients underwent SMDR for excessive drooling. We studied details of the surgical procedure, postoperative swelling and other complications. Ninety-six patients, 62 males and 34 females, were treated consecutively by SMDR. Mean age at time of surgery was 14 years and 11 months. The ASA physical status was 2 in most patients. The majority of children were diagnosed with cerebral palsy (67.7%). Postoperative swelling of the floor of the mouth or tongue was reported in 31 patients (32.3%). The swelling was mild and transient in 22 patients (22.9%) but profound swelling was seen in nine patients (9.4%). In 4.2% of the patients the airway was compromised. In general, SMDR is a well-tolerated procedure, but we should be aware of swelling of the tongue and floor of the mouth. This may lead to a prolonged period of endotracheal intubation or a need for reintubation which can be challenging. After extensive intra-oral surgery such as SMDR we strongly recommend a extended perioperative intubation and extubation after the airway is checked and secure.

Subtotal functional sialoadenectomy vs four-duct ligation for the treatment of drooling in neurologically impaired children: Long-term follow-up

OBJECTIVES

The best surgical option to treat drooling in neurodisabilities is still under debate. The aim of this study was to describe the technique of subtotal functional sialoadenectomy (SFS) (ie four-duct ligation (4-DL) together with bilateral sublingual gland excision) and its long-term outcomes, in comparison with 4-DL.

DESIGN

Retrospective observational cohort study.

SETTING

Unit of Pediatric Surgery of Bambino Gesù Children's Hospital (Rome).

PARTICIPANTS

Seventy-five patients surgically treated for drooling between 2002 and 2012, with at least five years of follow-up, divided into two groups: 4-DL group (19 patients) underwent four-duct ligation, and SFS group (56 patients) underwent subtotal functional sialoadenectomy.

MAIN OUTCOME MEASURES

Primary end points were the evaluation of drooling improvement after surgery (parameters: Drooling Severity and Frequency Scale, DSFS; no of bibs/day; no of shirts/day; no of pneumonia/year; use of antidrooling drugs) and the comparison between two different surgical techniques.

RESULTS

Median age at surgery was 10 years (1-35). Long-term outcomes showed significant improvement in DSFS and in no of shirts/day in both groups. Significantly better results were found in the SFS group than in the 4-DL group as far as DSFS (P value .045), no of bibs/day (P value .041), no of shirts/day (P value .032) are concerned. Reoperation rate for recurrence was 42% in the 4-DL group and 0% in the SFS group (P value < .0001). Six patients (8%; 2 in the 4-DL group and 4 in the SFS group) experienced perioperative complications, while 4 patients (5%; 2 in the 4-DL group and 2 in the SFS group) recorded long-term complications, with no difference between groups neither need for surgical treatment. No surgery-related mortality was recorded.

CONCLUSIONS

In our experience, subtotal functional sialoadenectomy ensured significantly greater long-term effects than four-duct ligation for drooling treatment in neurologically impaired child, with equal complication rate.

Correction of senile drooling using the nasolabial sling

BACKGROUND

Facial aging, resulting in lower facial ptosis often leads to downward angulation of the oral commissure, which may lead to troublesome angular chelitis. In this paper we present a treatment pathway for management of such patients.

METHODS

Treatment initially involves a combination of hyaluronic acid injection into the marionette lines and botulinum toxin A to the depressor anguli oris. If this treatment is unsuccessful patients then undergo the creation of a nasolabial sling, using bilateral superiorly-based nasolabial flaps tunnelled through the lower lip with transection of the depressor anguli oris on each side. In addition, two passes of the CO(2) laser are used to resurface the areas of chelitis and to tighten the tissues. Five patients have undergone treatment for their angular chelitis using one or a combination of these methods.

RESULTS

All cases were successfully treated and no recurrences occurred. Furthermore, all patients were satisfied with their outcome.

CONCLUSIONS

Little is available in the literature on the management of this disorder. In this paper we detail our surgical technique, discuss the issues encountered and review the current recommended treatment for this difficult problem.

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.

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 drooling for children with neurological problems in Hong Kong

OBJECTIVES

To share our experience in the management of drooling in Hong Kong, to describe the clinical profile of children with this problem, and to report the clinical outcome of oro-motor training.

METHODS

Children attending the Drooling Clinic of Alice Ho Miu Ling Nethersole Hospital, Hong Kong between January 2000 and June 2003 were included. Multidisciplinary assessment was performed to ascertain the medical condition, functional status and oro-motor difficulties of each child. Intervention might include optimization of medical condition, oro-motor training and surgery. Severity of drooling was rated by a 10-point visual analogue scale (VAS). The outcome of oro-motor training was assessed by the change in VAS from baseline.

RESULTS

Eight children, with a mean age of 11.9 years, were included. Six children suffered from cerebral palsy and two had syndromal diagnoses. All had moderate or severe mental retardation. Poor lip closure, inadequate jaw control and delay in swallowing were common oro-motor difficulties. All children received oro-motor training. The mean duration of follow-up for seven children was 17 months. The mean baseline VAS was 7.1. When compared with the baseline, VAS rating during the training period decreased with a mean difference of 3.0. The difference remained at 1.9 at 4 months after training had stopped. Other functional gains, such as improved sucking and swallowing, were identified. Six caregivers declined surgery. One child improved and did not require surgery.

CONCLUSIONS

Short-term follow-up of oro-motor training suggested beneficial outcome.

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.

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.