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Kok SE, Lemson J, van den Hoogen FJA. Postoperative Airway Management after Submandibular Duct Relocation in 96 Drooling Children and Adolescents. J Clin Med 2023; 12:jcm12041473. [PMID: 36836008 PMCID: PMC9964703 DOI: 10.3390/jcm12041473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/17/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023] Open
Abstract
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.
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Affiliation(s)
- Saskia E. Kok
- Department of Otolaryngology-Head and Neck Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Correspondence: ; Tel.: +31-(0)24-3614450
| | - Joris Lemson
- Department of Paediatric Critical Care, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Frank J. A. van den Hoogen
- Department of Otolaryngology-Head and Neck Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Delsing CPA, Adriaansens C, van Hulst K, Erasmus CE, van den Hoogen FJA. Long-term effects of submandibular gland excision on drooling in children with neurodevelopmental disorders: A cross-sectional study. Int J Pediatr Otorhinolaryngol 2023; 164:111377. [PMID: 36403383 DOI: 10.1016/j.ijporl.2022.111377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/31/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022]
Abstract
AIM Submandibular gland excision (SMGE) is suitable for the management of drooling in patients with non-progressive neurodisabilities. We aimed to investigate the long-term effects of SMGE. METHOD Patients who had SMGE between 2007 and 2018 were included. Main outcomes were a Visual Analogue Scale (VAS), Drooling Severity (DS), and Drooling Frequency (DF) collected at baseline, 8 weeks, 32 weeks and with a median of 313 weeks after SMGE (long-term). Secondary outcomes were satisfaction with the procedure, Drooling Quotient (DQ) and adverse events (AEs). RESULTS We included thirty-five patients in the long-term analysis with a mean age of 14.5 years. A baseline VAS score of 80.4 was found, which improved on the long-term (mean difference -21.8, t(26) = 4.636, p < 0.0005)). DS and DF decreased significantly at the long-term compared to baseline (Z = -4.361, p < 0.0001 for DS, Z = -3.065, p = 0.002 for DF). Twenty-three out of 35 (66%) patients would recommend the procedure to peers. INTERPRETATION This study indicates a long-term stable effect on drooling after SMGE in patients with anterior drooling. Recurrence of drooling occurs due to unknown reasons, nevertheless most caregivers and/or patients are still satisfied and would recommend the procedure to others.
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Affiliation(s)
- Corinne P A Delsing
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Centre, Philips Van Leijdenlaan 15 (route 377), Postbus 9101, Nijmegen, 6500 HB, the Netherlands.
| | - Carleen Adriaansens
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Centre, Philips Van Leijdenlaan 15 (route 377), Postbus 9101, Nijmegen, 6500 HB, the Netherlands
| | - Karen van Hulst
- Department of Rehabilitation, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Corrie E Erasmus
- Department of Pediatric Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Frank J A van den Hoogen
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Centre, Philips Van Leijdenlaan 15 (route 377), Postbus 9101, Nijmegen, 6500 HB, the Netherlands
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Chafin JB, Bayazid L. Pediatric Salivary Gland Disease. Pediatr Clin North Am 2022; 69:363-380. [PMID: 35337545 DOI: 10.1016/j.pcl.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Salivary gland disease in the pediatric population is rare, yet it encompasses a wide spectrum of disease. It is estimated that 4.3% of salivary gland disease occurs in the pediatric population, with most classified as nonneoplastic. Further extrapolation reveals that 5% of salivary gland neoplastic diseases occur in patients younger than 20 years. Moreover, salivary gland tumors represent 1% of all head and neck tumors across all ages. Regardless, clinicians across all fields should be familiar with the workup of various pediatric salivary gland diseases and appropriate referral to a pediatric otolaryngologist.
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Affiliation(s)
- James Brett Chafin
- Department of Pediatric Otolaryngology-Head & Neck Surgery, Nemours Children's Health System, 807 Childrens Way 4th Floor, Jacksonville, FL 32207, USA.
| | - Leith Bayazid
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida College of Medicine, 12901 Bruce B. Downs Boulevard, MDC 73, Tampa, FL 33612, USA
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Kalmar CL, Patel VA, Zapatero ZD, Kosyk MS, Taylor JA, Swanson JW. Submandibular Gland Excision in Pediatric Patients. J Craniofac Surg 2021; 32:2656-2659. [PMID: 34727467 DOI: 10.1097/scs.0000000000007887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Children who require submandibular gland excision for ptyalism often have multiple associated comorbidities, including neurodevelopmental disorders and respiratory risk factors. The purpose of this study is to utilize a large multicenter database to elucidate the perioperative profile of submandibular gland excision in children, with particular focus on children who require submandibular gland excision for ptyalism. METHODS The American College of Surgeons National Surgical Quality Improvement Program Pediatric dataset was queried for submandibular gland excision performed from 2012 through 2018. Indications were subclassified based on International Classification of Disease (ICD)-9 and ICD-10 codes. Complications, readmissions, and reoperations were analyzed with appropriate statistics. RESULTS During the study interval, 304 pediatric patients underwent submandibular gland excision, which was mostly performed for ptyalism (56.9%), followed by inflammatory conditions (20.7%). Patients requiring submandibular gland excision for ptyalism were significantly younger (P < 0.001) and underwent significantly longer procedures (P < 0.001). Ptyalism was associated with significantly higher related adverse events (P = 0.010), related readmission (P = 0.013), and medical complications (P = 0.013), which included a significantly higher risk of pneumonia (P = 0.050). Children with ptyalism had significantly higher rates of overall respiratory comorbidities (P < 0.001), including chronic lung disease (P < 0.001), supplemental oxygen support (P < 0.001), tracheostomy (P < 0.001), and ventilator dependence (P < 0.001). Patients undergoing submandibular gland excision for benign (P all ≥ 0.082) and malignant (P all ≥ 0.565) neoplasms did not have significantly higher rates of any indexed postoperative adverse event. CONCLUSIONS Children requiring submandibular gland excision for ptyalism represent a unique cohort than those requiring excision for other indications, with significantly higher burden of preoperative risk factors, intraoperative durations, and postoperative adverse events.
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Affiliation(s)
- Christopher L Kalmar
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia
| | - Vijay A Patel
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Zachary D Zapatero
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia
| | - Mychajlo S Kosyk
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia
| | - Jesse A Taylor
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia
| | - Jordan W Swanson
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, Philadelphia
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Effectiveness and safety of botulinum toxin in comparison with surgery for drooling in paediatric patients with neurological disorders: a systematic review. Br J Oral Maxillofac Surg 2021; 60:e691-e701. [DOI: 10.1016/j.bjoms.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 10/27/2021] [Indexed: 11/21/2022]
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Schild SD, Timashpolsky A, Ballard DP, Horne S, Rosenfeld RM, Plum AW. Surgical Management of Sialorrhea: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2021; 165:507-518. [PMID: 33494642 DOI: 10.1177/0194599820985165] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Chronic sialorrhea commonly occurs in patients with neurodevelopmental disorders. While conservative management can provide sufficient symptom control, surgical intervention is often required. One of the most common procedures utilized is submandibular gland excision (SMGE), with or without parotid duct ligation or rerouting (PDL or PDR). This study aims to compare these surgical approaches and their outcomes. DATA SOURCES PubMed, Web of Science, and Embase. REVIEW METHODS This systematic review includes studies of patients with chronic sialorrhea treated with SMGE alone or SMGE plus PDR or PDL and reports on postintervention outcomes and complications. Two independent investigators assessed study eligibility, rated quality, and extracted data for analysis. A random effects model was used for meta-analysis of pooled data. RESULTS Of 3186 studies identified, 21 met inclusion criteria, with 708 patients: 103 underwent SMGE alone (15%); 299 (42%), SMGE and PDL; and 306 (43%), SMGE plus PDR. Overall, a majority of patients had significant improvement, with very good to excellent control of symptoms after surgery: SMGE, 82% (95% CI, 73%-89%); SMGE and PDL, 79% (95% CI, 73%-85%); and SMGE and PDR, 85% (95% CI, 75%-92%). Importantly, there was no significant difference in outcomes with the addition of PDL or PDR. Reported complications included sialocele, parotitis, dental caries, and dry mouth. CONCLUSION Our systematic review identified consistent positive outcomes with SMGE for patients with chronic sialorrhea but no additional benefit when PDR or PDL was performed as a concurrent procedure.
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Affiliation(s)
- Sam D Schild
- State University of New York, Brooklyn, New York, USA
| | | | | | - Sylvia Horne
- State University of New York, Brooklyn, New York, USA
| | | | - Ann W Plum
- State University of New York, Brooklyn, New York, USA
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De Peppo F, Caccamo R, Garganese MC, Ceriati E, Marchetti P, Adorisio OD, Cerchiari A, Battaglia S. Subtotal functional sialoadenectomy vs four-duct ligation for the treatment of drooling in neurologically impaired children: Long-term follow-up. Clin Otolaryngol 2020; 46:222-228. [PMID: 32961630 DOI: 10.1111/coa.13650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 08/27/2020] [Accepted: 09/12/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Francesco De Peppo
- Unit of Pediatric Surgery, Department of Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Romina Caccamo
- Unit of Pediatric Surgery, Department of Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Maria Carmen Garganese
- Service of Nuclear Medicine, Imaging Department, Bambino Gesù Children's Hospital, Rome, Italy
| | - Emanuela Ceriati
- Unit of Pediatric Surgery, Department of Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Paola Marchetti
- Unit of Pediatric Surgery, Department of Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | | | - Antonella Cerchiari
- Feeding and Swallowing Services, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, Rome, Italy
| | - Sonia Battaglia
- Unit of Pediatric Surgery, Department of Surgery, Bambino Gesù Children's Hospital, Rome, Italy
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Bekkers S, Pruijn IMJ, Van Hulst K, Delsing CP, Erasmus CE, Scheffer ART, Van Den Hoogen FJA. Submandibular duct ligation after botulinum neurotoxin A treatment of drooling in children with cerebral palsy. Dev Med Child Neurol 2020; 62:861-867. [PMID: 32149393 PMCID: PMC7318229 DOI: 10.1111/dmcn.14510] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Stijn Bekkers
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
| | - Ineke M J Pruijn
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
| | - Karen Van Hulst
- Department of RehabilitationDonders Institute for BrainCognition and BehaviourRadboud University Medical CenterNijmegenthe Netherlands
| | - Corinne P Delsing
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
| | - Corrie E Erasmus
- Department of Paediatric NeurologyDonders Center for NeuroscienceRadboud University Medical CenterNijmegenthe Netherlands
| | - Arthur R T Scheffer
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
| | - Frank J A Van Den Hoogen
- Department of Otorhinolaryngology and Head and Neck SurgeryRadboud University Medical CenterNijmegenthe Netherlands
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Weitzman RE, Kawai K, Nuss R, Hughes A. A 10-year Retrospective Review of Botulinum Toxin Injections and Surgical Management of Sialorrhea. Cureus 2020; 12:e7916. [PMID: 32494530 PMCID: PMC7263709 DOI: 10.7759/cureus.7916] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
| | - Kosuke Kawai
- Otolaryngology, Boston Children's Hospital, Boston, USA
| | - Roger Nuss
- Otolaryngology, Boston Children's Hospital, Boston, USA
| | - Amy Hughes
- Otolaryngology, Connecticut Children's Medical Center, Hartford, USA
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An evaluation of predictors for success of two-duct ligation for drooling in neurodisabilities. J Neurol 2020; 267:1508-1515. [PMID: 32025794 PMCID: PMC7184040 DOI: 10.1007/s00415-020-09735-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 10/26/2022]
Abstract
BACKGROUND Drooling is dependent on various clinical variables. However, while drooling proves refractory to two-duct ligation in 40% of patients, predictors for treatment success are sparse and to date there is little evidence why some respond well while others are non-responders. We aim to find predictors for treatment success and study the effectiveness of two-duct ligation for drooling in neurodisabilities. METHODS Fifty-four patients with moderate to severe drooling who had undergone two-duct ligation were screened for inclusion. Four patients were excluded due to missing or unreliable primary outcomes. The average age at the time of surgery was 12 years. Predictors were evaluated for treatment success which was defined as ≥ 50% visual analog scale for severity of drooling and/or drooling quotient reduction from baseline. Treatment effect was measured after 8 and 32 weeks compared to baseline. RESULTS Age (more mature), adequate posture (no anteflexion), and normal speech are predictors for treatment success. Compared to baseline, drooling quotient was significantly lower at 8 (difference 18.6%, 95% confidence interval 12.3-24.9%) and 32 weeks (difference 10.1%, 95% confidence interval 3.9-16.4%). Compared to baseline, visual analog scale was significantly lower at 8 (difference 45.0, 95% confidence interval 37.0-52.9) and 32 weeks (difference 32.9, 95% confidence interval 25.0-40.7). CONCLUSIONS Age, adequate posture, and a normal speech are predictors for treatment success, are easily determined pre-operatively, and help the clinician providing patient-specific probability of treatment success. There is a significant subjective and objective decrease of drooling after two-duct ligation.
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Unsuccessful submandibular duct surgery for anterior drooling: Surgical failure or parotid gland salivation? Int J Pediatr Otorhinolaryngol 2019; 123:132-137. [PMID: 31102967 DOI: 10.1016/j.ijporl.2019.04.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate if drooling recurrence after surgery of the submandibular ducts is due to surgical failure or other variables. METHODS Historic cohort with prospective collected data of all patients with severe drooling who underwent unsuccessful submandibular duct surgery with subsequent re-intervention between 2003 and 2018. A reference cohort was used for comparison of clinical variables. RESULTS Six males and 4 females were included (cerebral palsy n = 8, neurodevelopmental disorders n = 2). All patients underwent submandibular gland surgery as a primary intervention (duct ligation n = 8, submandibular duct relocation n = 2) followed by re-intervention (submandibular gland excision n = 7, parotid duct ligation n = 3). One patient underwent tertiary surgery (parotid duct ligation after re-intervention by submandibular gland excision). Three patients were successful after re-intervention. No difference was found between both re-intervention techniques. There was significantly more severe dental malocclusion (50% vs. 21%, P value = 0.047) and severe speech disorders (80% vs. 42%, P value = 0.042) in the current cohort when compared to the reference cohort. CONCLUSION Recurrence of drooling surgery is most likely not caused by surgical failure of the primary intervention, because re-intervention (submandibular gland excision) did not lead to more success. Dysarthria and dental malocclusion might negatively influence treatment outcome.
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12
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Bekkers S, Delsing CP, Kok SE, van Hulst K, Erasmus CE, Scheffer ART, van den Hoogen FJA. Randomized controlled trial comparing botulinum vs surgery for drooling in neurodisabilities. Neurology 2019; 92:e1195-e1204. [PMID: 30728311 DOI: 10.1212/wnl.0000000000007081] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 11/04/2018] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Stijn Bekkers
- From the Department of Otorhinolaryngology and Head and Neck Surgery (S.B., C.P.D., S.E.K., A.R.T.S., F.J.A.v.d.H.), Radboud University Medical Centre, Nijmegen; and Departments of Rehabilitation (K.v.H.) and Paediatric Neurology (C.E.E.), Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands.
| | - Corinne P Delsing
- From the Department of Otorhinolaryngology and Head and Neck Surgery (S.B., C.P.D., S.E.K., A.R.T.S., F.J.A.v.d.H.), Radboud University Medical Centre, Nijmegen; and Departments of Rehabilitation (K.v.H.) and Paediatric Neurology (C.E.E.), Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Saskia E Kok
- From the Department of Otorhinolaryngology and Head and Neck Surgery (S.B., C.P.D., S.E.K., A.R.T.S., F.J.A.v.d.H.), Radboud University Medical Centre, Nijmegen; and Departments of Rehabilitation (K.v.H.) and Paediatric Neurology (C.E.E.), Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Karen van Hulst
- From the Department of Otorhinolaryngology and Head and Neck Surgery (S.B., C.P.D., S.E.K., A.R.T.S., F.J.A.v.d.H.), Radboud University Medical Centre, Nijmegen; and Departments of Rehabilitation (K.v.H.) and Paediatric Neurology (C.E.E.), Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Corrie E Erasmus
- From the Department of Otorhinolaryngology and Head and Neck Surgery (S.B., C.P.D., S.E.K., A.R.T.S., F.J.A.v.d.H.), Radboud University Medical Centre, Nijmegen; and Departments of Rehabilitation (K.v.H.) and Paediatric Neurology (C.E.E.), Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Arthur R T Scheffer
- From the Department of Otorhinolaryngology and Head and Neck Surgery (S.B., C.P.D., S.E.K., A.R.T.S., F.J.A.v.d.H.), Radboud University Medical Centre, Nijmegen; and Departments of Rehabilitation (K.v.H.) and Paediatric Neurology (C.E.E.), Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Frank J A van den Hoogen
- From the Department of Otorhinolaryngology and Head and Neck Surgery (S.B., C.P.D., S.E.K., A.R.T.S., F.J.A.v.d.H.), Radboud University Medical Centre, Nijmegen; and Departments of Rehabilitation (K.v.H.) and Paediatric Neurology (C.E.E.), Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
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Nahlieli O. Complications of traditional and modern therapeutic salivary approaches. ACTA OTORHINOLARYNGOLOGICA ITALICA 2018; 37:142-147. [PMID: 28516977 PMCID: PMC5463522 DOI: 10.14639/0392-100x-1604] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/12/2016] [Indexed: 12/15/2022]
Abstract
The morbidity following traditional surgery of the salivary glands is well documented and includes postsurgical complications such as the Frey's syndrome, complete or partial facial nerve damage, facial scarring, greater auricular nerve numbness, sialocoeles and salivary fistula. The avulsion of the salivary duct, secondary strictures, gland swelling, salivary fistulas and perforations (false rout), traumatic ranulas, and the lingual nerve paraesthesia are the main endoscopy-related complications. In general, the rate of postsurgical complications after modern advanced minimally invasive surgical interventions is significantly lower compared with traditional surgery of the salivary glands. However, such comparisons cannot be performed because up-to-date traditional and minimally invasive surgical techniques are applied to different salivary disorders. Combinations of various minimally invasive techniques are also possible. There is no clear borderline between "traditional" and "modern" surgery of the salivary glands. It is appropriate to write about gradual replacement of old techniques with newer ones, and this process has no traffic lights.
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Affiliation(s)
- O Nahlieli
- Oral and Maxillofacial Surgery Department Barzilai Medical Center, Ashkelon, Israel. Affiliated to the Faculty of Medicine, Ben Gurion University of the Negev, Beer Sheva, Israel
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Abstract
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.
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Affiliation(s)
- Rachael Lawrence
- Specialist Registrar in ENT, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Neil Bateman
- Paediatric ENT, Royal Manchester Children’s Hospital, Oxford Road, Manchester, M13 9WL UK
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