Prospective analysis of the outcome of surgical management of drooling in the pediatric population: a 10-year 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.

Botulinum Toxin Injections for Treatment of Drooling in Children with Cerebral Palsy: A Systematic Review and Meta-Analysis

Background: We aimed to review and analyse the effectiveness and safety of botulinum toxin type A (BoNT-A) injections for drooling in children with cerebral palsy. Data sources: We searched the EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) databases from inception to January 2020. Methods: We included randomized controlled trials and observational studies which (1) involved children with cerebral palsy, (2) used BoNT-A for control of drooling, and (3) provided quantitative evaluations of drooling before and after intervention with BoNT-A. Results: Twenty-one trials met the inclusion criteria. Most studies showed that BoNT-A injections are safe and efficacious as a treatment for drooling in children with cerebral palsy. Four trials had sufficient data to pool the results for the meta-analysis. Both the drooling quotient (p = 0.002) and drooling Ffrequency and severity scale (p = 0.004) supported this conclusion. Conclusion: BoNT-A injections are a safe, reversible, effective treatment for drooling control in children with cerebral palsy that can offer effectiveness for more than 3 months with few side effects. The dosage of BoNT-A should not exceed 4 units/kg. Further studies are required to determine the optimal dosage and target glands.

Primary sialorrhea and its surgical treatment with denervation of the submandibular glands in combination with sublingual gland excision

OBJECTIVES

The purpose of this study was to evaluate the effectiveness of ablating postganglionic parasympathetic fibers of the submandibular ganglion in combination with sublingual gland excision in the treatment of primary sialorrhea.

MATERIALS AND METHODS

Healthy volunteers were initially chosen to determine a basic saliva flow rate value by saliva collection. Next, unstimulated and stimulated saliva flow rates, and a visual analog scale index for sialorrhea were recorded in all the patients pre- and postoperatively. In addition, the generalized anxiety disorder scale was used to assess preoperative anxiety symptoms. The follow-up durations ranged from 24 to 36 months after surgery.

RESULTS

A total of 10 patients were included in this study. Preoperatively, the mean unstimulated saliva flow rate for the 10 patients was 11.26 ± 4.19 ml/10 min, the stimulated saliva flow rate was 16.76 ± 3.49 ml/6 min, and the visual analog scale index was 66.29 ± 14.86. Postoperatively, the mean unstimulated and stimulated saliva flow rates were significantly reduced to 5.99 ± 1.33 ml/10 min (p = 0.001) and 13.28 ± 1.86 ml/6 min (p = 0.013), respectively, and the visual analog scale index was 25.41 ± 5.6 (p < 0.001). No complications were found after operation.

CONCLUSION

This study demonstrates that ablation of postganglionic parasympathetic fibers of the submandibular ganglion in combination with sublingual gland excision by an intraoral approach is a simple, safe, and efficient approach for treating primary sialorrhea.

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.

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.

A 10-year Retrospective Review of Botulinum Toxin Injections and Surgical Management of Sialorrhea

Background Sialorrhea is a common comorbidity among children with neurologic disorders. Botulinum toxin injections and surgical procedures are recommended for the management of pathological sialorrhea in patients who fail conservative management or with concerns for salivary aspiration. The following review evaluates outcomes following botulinum toxin injections and surgical interventions for sialorrhea over a 10-year period with a focus on treatment options and outcomes for patients with anterior and posterior drooling. Methods The study included all patients less than 25 years of age who underwent a procedure for drooling (Current Procedural Terminology (CPT) codes 42440, 42450, 42509, 42510, 64611 matched with the International Classification of Diseases (ICD)-9 and ICD-10 codes 527.7 and K11.7) from January 1, 2006 to December 31, 2015. A chart review collected demographics, drooling medication use, and type of drooling (anterior, posterior, both). Outcome variables included pre- and post-procedure number of bibs, parent-reported outcomes, post-intervention drooling medication requirement, post-procedure length of stay, and complications. Results Seventy-one patients were included in our analysis, with 88 total procedures performed. The average age at first intervention was 8.9 years; 43 patients were male and 40 patients had cerebral palsy. Thirty-one patients experienced posterior drooling or anterior/posterior drooling. These patients were more likely to undergo surgery as the first invasive intervention. The most commonly performed interventions were botulinum toxin injections (28 patients, 39%) and sublingual gland excision (SLGE) with submandibular duct ligation (SMDL) (36 patients, 51%). Improvement following injections was noted in 56% of patients versus 73% of patients following any surgical intervention. Conclusion Management of drooling is complex with 18 different procedures performed over 10 years. Surgical interventions, specifically SLGE with SMDL and submandibular gland excision (SMGE), result in substantial improvement; these are commonly performed as the first intervention in patients with posterior drooling. By reviewing our experience, we hope to guide management decisions and help manage patient and caregiver expectations.

Randomized controlled trial comparing botulinum vs surgery for drooling in neurodisabilities

OBJECTIVE

To compare the effect of submandibular duct ligation (2-DL) and submandibular botulinum neurotoxin type A (BoNT-A) for drooling in children and adolescents with neurodevelopmental disabilities.

METHODS

A randomized, interventional, controlled, and partly single-blinded study was performed in which submandibular BoNT-A was compared with 2-DL to treat excessive drooling. Main outcomes included a Visual Analog Scale (VAS), drooling quotient (DQ), drooling severity (DS) scale and drooling frequency (DF) scale. Each was obtained at baseline, and 8 and 32 weeks post treatment.

RESULTS

Fifty-seven patients (mean age: 11 years, mean baseline VAS score 7.9, mean baseline DQ 27.3%) were randomized to the 2-DL or BoNT-A group. Four patients were excluded from analyses, leaving 53 patients for intention-to-treat analyses. Response to treatment, defined as a ≥50% reduction in DQ or VAS score, was higher for 2-DL after 32 weeks (63.0% vs 26.9%, p = 0.008). Both VAS score (24.5, p < 0.001) and DQ (-9.3%, p = 0.022) were significantly lower at follow-up after 2-DL vs BoNT-A. The total number of adverse events (p = 0.088, 40.7% vs 19.2%) and postoperative complaints was higher (p < 0.001, mean 9.6 vs 3.6 days) for 2-DL than for BoNT-A.

CONCLUSION

The 2-DL procedure is a more effective treatment for drooling than botulinum toxin, but carries a slightly greater risk of complications and morbidity.

TRIALREGISTERNL IDENTIFIER

NTR3537.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for children and adolescents with neurodevelopmental disabilities and severe drooling, 2-DL compared to a one-time intraglandular BoNT-A injection is more effective at reducing drooling at 32 weeks.

Cerebral Palsy: An Overview

Cerebral palsy (CP) is a neurodevelopmental disorder characterized by abnormalities of muscle tone, movement and motor skills, and is attributed to injury to the developing brain. The clinical features of this entity evolve over time and the specific CP syndrome may be recognizable only after 3-5 y of age; although suggestive signs and symptoms may be present at an earlier age. The management involves neurological rehabilitation (addressing muscle tonal abnormalities, and devising physical and occupational therapies) and diagnosis and management of co-morbidities (including epilepsy, impairment of cognition, vision, hearing, and disturbances of growth and gastrointestinal function). The management, therefore, is multidisciplinary involving the treating physician working with a team of rehabilitation-, orthopedic-, psychologic-, and social care- providers.

Pediatric Sialorrhea: Submandibular Duct Rerouting and Intraparotid Botulinum Toxin A Injection With Literature Review

OBJECTIVES:

The aim of this study was to assess the effectiveness of bilateral submandibular duct relocation and bilateral sublingual gland excision in combination with botulinum toxin A injection into the parotid glands in children with sialorrhea. Previously in the literature, either surgery or botulinum toxin injection but not their combination has been reported.

METHODS:

Preoperative and at least 6-month postoperative assessments using the Drooling Severity Scale and Drooling Frequency Scale (Thomas-Stonell and Greenberg classification) and the Teacher Drooling Scale and by interviewing parents and caregivers face to face or via telephone were performed. Also, decreases in the daily number of bib changes and hourly frequency of saliva wiping were recorded as success. Complications were recorded.

RESULTS:

The Drooling Frequency and Severity Scale, the Teacher Drooling Scale, daily number of bib changes, and hourly frequency of saliva wiping decreased significantly in 21 patients (95.5%) and remained unchanged in 1 patient (4.5%). Postoperative bleeding was observed in 1 patient (4.5%).

CONCLUSIONS:

Drooling is a complex problem that benefits from a multidisciplinary approach. Many treatment methods exist, each with advantages and disadvantages. In this study botulinum toxin A injection was applied in conjunction with bilateral submandibular duct relocation and bilateral sublingual gland excision surgery, achieving a success rate of 95.5%. Moreover, minimal complications and no recurrence after at least 6-month follow-up were observed. The authors therefore recommend further use of this combination treatment. Larger and longer term studies may also help clarify its effectiveness.

[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.

Evaluation of the efficacy of cervical perivascular sympathectomy on drooling in children with athetoid cerebral palsy

OBJECTIVE

To evaluate the efficacy of cervical perivascular sympathectomy (CPVS) for drooling in children with athetoid cerebral palsy (ACP).

METHODS

The severity and frequency of drooling and the amount of salivation of 32 ACP children with drooling were evaluated before CPVS and at 4th, 12th and 24 weeks postoperatively by the teacher drooling scale (TDS) and salivary flow rate (SFR).

RESULTS

Fifteen children exhibited improvements on drooling according to the TDS score at 4th week after surgery (P < 0.05). Later, the number of children decreased to 10 at 12th week (P < 0.05) and to 8 at 24 week after surgery (P < 0.05). SFR was 0.67 mg/min at baseline, which decreased to 0.58 mg/min (P < 0.05) at 4th week after surgery. However, SFR showed a gradual increase at 12th week and 24 week with no significant difference.

CONCLUSIONS

Although CPVS was effective in improving drooling in some children with ACP, the results were not satisfactory. Thus, CPVS still needs to be cautiously used. Furthermore, more rigorous clinical studies should be performed to detect the effectiveness and safety of this procedure.

Dysphagia and aspiration in children

Aspiration is a significant cause of respiratory morbidity and sometimes mortality in children. It occurs when airway protective reflexes fail, especially, when dysphagia is also present. Clinical symptoms and physical findings of aspiration can be nonspecific. Advances in technology can lead to early diagnosis of dysphagia and aspiration, and, new therapeutic advances can significantly improve outcome and prognosis. This report first reviews the anatomy and physiology involved in the normal process of swallowing. Next, the protective reflexes that help to prevent aspiration are discussed followed by the pathophysiologic events that occur after an aspiration event. Various disease processes that can result in dysphagia and aspiration in children are discussed. Finally, the various methods for diagnosis and treatment of dysphagia in children are reviewed.

Botulinum toxin assessment, intervention and aftercare for paediatric and adult drooling: international consensus statement

Many individuals with neurological problems or anatomical abnormalities of the jaw, lips or oral cavity may drool, which can impact on health and quality of life. A thorough evaluation of the patient's history, examination of the oral region by a speech pathologist and, in individuals over 3 years, a dental examination is warranted. Questionnaires with established validity such as the Drooling Impact Scale are useful assessment tools. A hierarchical approach to treatment is taken from least invasive therapies, such as speech pathology, to more invasive, such as injection of botulinum neurotoxin type-A (BoNT-A) into the salivary glands (parotid and submandibular). The wishes of the individual and their carer are crucial considerations in determining the suitability of the intervention for the patient. In the presence of dysphagia and cerebral palsy (CP), careful assessment is required prior to the injection of BoNT-A. Favourable responses to intervention include a reduction in the secretion of saliva and in drooling, as well as psychosocial improvements. BoNT-A is usually well tolerated, although potential side effects should be discussed with the patient and carer.

Botulinum toxin versus submandibular duct relocation for severe drooling

AIM

Botulinum neurotoxin type A (BoNT-A) has been described as an effective intervention for drooling and is being increasingly adopted. However, its effectiveness compared with established treatments is still unknown. We undertook a within-participants observational study to examine this.

METHOD

An historic cohort was formed of 19 children and young adults (10 males, nine females) with severe drooling who underwent BoNT-A injections followed by surgical re-routing of the submandibular duct at least 6 months later. Mean age at time of admission was 11 years 5 months (range 5-17 y) and mean age at the time of surgery was 14 years (range 6-23 y). Fifteen children were diagnosed with bilateral cerebral palsy (CP), three with unilateral CP, and one with non-progressive developmental delay. Gross Motor Function Classification System levels were the following: level I, n=1; level II, n=2; level III, n=7; level IV, n=6; and level V, n=3). The primary outcome was the drooling quotient, which was assessed before each intervention and 8 and 32 weeks thereafter. A multivariate analysis of variance of repeated measures was performed, with the measurement points as the within-participant variables.

RESULTS

The drooling quotient was reduced to a greater extent after surgery than after BoNT-A administration (p=0.001). Compared with a baseline value of 28, the mean drooling quotient 8 weeks after surgery was 10, and 32 weeks after surgery was 4 (p<0.001). Among the group treated with BoNT-A, the drooling quotient showed a significant reduction from a baseline value of 30 to 18 after 8 weeks (p=0.02), and a continued but diminished effect after 32 weeks (drooling quotient 22; p=0.05).

INTERPRETATION

Both interventions are effective, but surgery provides a larger and longer-lasting effect.

Sublingual atropine drops for the treatment of pediatric sialorrhea

Excess oral secretions or sialorrhea is a common problem affecting children and adults with neurological disorders, as well as those approaching the end of life because of a variety of underlying illnesses. Systemic anticholinergic medications are often prescribed in an attempt to improve quality of life and reduce complications; yet, response rates are variable, and a sizable proportion of patients discontinue these drugs as a result of intolerable side effects. This report describes the successful use of a local treatment, sublingually delivered ophthalmic atropine drops, to reduce sialorrhea in a child receiving palliative care. In addition, medical evidence for the safety and efficacy of traditionally prescribed systemic medications for the treatment of pediatric sialorrhea is reviewed.

Surgical treatment of dysphagia

The role of surgery in the management of dysphagia is clear in some areas and controversial in others. Evaluation for the causes of dysphagia can elucidate conditions in which surgery can improve safety, quality of life, or both. Surgical therapy, when indicated, is safe and effective for many causes of dysphagia. This article includes a general overview of the causes of dysphagia that can be addressed successfully with surgery as well as a discussion of why surgery may be less appropriate for other conditions associated with dysphagia.

A descriptive analysis of studies on behavioural treatment of drooling (1970-2005)

A descriptive analysis was conducted on studies on the behavioural treatment of drooling (published between 1970 and 2005). The 17 articles that met the inclusion criteria described 53 participants (mean age 14y 7mo, [SD 4y 9mo]; range 6-28y). Sex of 87% of the participants was reported: 28 male, 18 female. For 60% of the participants the degree of learning disability was reported, varying from severe/profound (n=24, 75%), moderate (n=4, 13%), to mild (n=2, 6%), while two participants (6%) had no learning disabilities. Forty-two participants (79%) were diagnosed with cerebral palsy. Behavioural procedures included instruction, positive and negative reinforcement, overcorrection and restitution, verbal and automatic cueing, and/or self-management. Effective behavioural procedures are reported in children with and without learning disability and/or motor impairment. Even participants with profound learning disability may benefit from behavioural intervention. However, the evidence base in terms of number of studies in this area is limited. Fifteen studies used a single participant design; two studies implemented an experimental-comparison group design. Some of these studies were poorly designed and methodological flaws were identified. Therefore, conclusions about efficacy of behaviour therapy for drooling and/or best practice cannot be drawn, although our analysis suggests that this approach is promising. However, future research on this topic is needed. After years of research focused on medical treatment, the option of behavioural treatment to reduce drooling should be reconsidered in relation to the medical management of this problem.

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.