Bilateral Submandibular Gland Excision Research Articles

Pulmonary and Clinical Outcomes After Bilateral Submandibular Gland Excision and Parotid Duct Ligation for Refractory Sialorrhea

Refractory sialorrhea in children can result in pulmonary aspiration and irreversible lung damage. Despite many studies devoted to the surgical treatment of sialorrhea, there is a paucity of objective outcome measures after surgery, especially with regard to pulmonary health. To assess whether bilateral submandibular gland excision and bilateral parotid duct ligation ("DROOL" procedure) is associated with reduced pulmonary inflammation in bronchoalveolar lavage (BAL) samples after surgery and to assess patient factors associated with improvement after surgery. This retrospective case series included all 112 patients undergoing the DROOL procedure at a single tertiary care pediatric children's hospital from January 1, 2012, to December 31, 2021. Statistical analysis was performed from March 30 to June 10, 2023, and August 20 to September 23, 2023. DROOL procedure for refractory sialorrhea. Degree of pulmonary inflammation (neutrophil percentage) according to BAL cytologic findings and overall bronchoscopy findings up to 12 months before and after the DROOL procedure. Secondary outcomes included number of annual hospitalizations, caregiver report of function before and after the procedure, and need for revision procedures and/or additional operations for secretion management. A total of 112 patients (median age, 3.4 years [IQR, 2.0-7.1 years]; 65 boys [58.0%]) underwent DROOL procedures and had both preoperative and postoperative BAL samples during the study period. Patients demonstrated objective improvement in pulmonary inflammation after surgery, with the median polymorphonuclear neutrophil percentage decreasing from 65.0% (IQR, 14.0%-86.0%) before the surgery to 32.5% (IQR, 3.0%-76.5%) after the surgery (median difference in percentage points, -9.0 [95% CI, -20.0 to 0.0]). Prior to the DROOL procedure, 34 patients (30.4%; 95% CI, 21.8%-38.9%) were hospitalized 2 or more times annually for respiratory illness, which decreased to 10.1% (11 of 109; 95% CI, 4.4%-15.7%) after surgery (3 patients did not have hospitalization data available following surgery). Most caretakers (73 [65.2%]) reported improved secretion management after the procedure. This study suggests that patients with impaired secretion management who underwent a DROOL procedure demonstrated improvement in pulmonary inflammation and a reduction in hospitalizations after surgery. Caretakers were also likely to report subjective improvement in secretion management and quality of life. Additional research is necessary to guide optimal timing and patient selection for this procedure.

唾液分泌過多に対する外科治療 (両側顎下腺摘出) を試みた1例

唾液分泌過多に対する外科治療 (両側顎下腺摘出) を試みた1例

Bilateral transcervical submandibular gland excision for drooling: A study of the mature scar and long-term effects.

Several surgical techniques are available to treat drooling in neurologically disabled children and adolescents, with bilateral submandibular gland excision being the only transcervical procedure. External scars can be a reason to decline for this surgical approach. We investigated which factors influenced caregiver satisfaction by evaluating the long-term scar in relation to treatment outcome. We identified a historical cohort, in which all neurologically disabled patients who underwent bilateral submandibular gland excision for drooling between January 2009 and December 2013 were identified (n=41). The Patient and Observer Scar Assessment Scale (POSAS) was used to evaluate observer and clinician satisfaction. All included patients were contacted by telephone and completed a digital questionnaire that included digital images of the scars. Of the caregivers that responded the questionnaire 76% (19/25) were satisfied with the overall outcome. Twenty-four (96%) caregivers considered the scars acceptable. Caregiver satisfaction was not correlated to the appearance of scars, but was significantly correlated with the decrease in drooling severity on a visual analogue scale (p=0.035) and decrease in lower respiratory tract infections (p=0.042). The appearance of scars does not influence satisfaction after bilateral submandibular gland excision for drooling. As expected, satisfaction is correlated to the treatment outcome.

Surgical management of chronic salivary aspiration

Aim of the studySialorrhoea and chronic salivary aspiration are a major problem in many neurologically impaired children causing embarrassment, skin issues and recurrent lower respiratory tract infections (LRTI). The aim of this study was to assess the efficacy of salivary gland surgery in the treatment of chronic salivary aspiration in such children. ObjectivesTo compare admission rates for LRTI per annum before and after surgical intervention. MethodsRetrospective review of all patients who underwent salivary management surgery for chronic aspiration under Princess Margaret Hospital's (PMH) Otolaryngology department from 2006 until 2013. ResultsTwelve patients were included in this review. Their ages ranged from 3 to 21 years (mean=11.4). Their genders were equally distributed. Two patients had underlying congenital disorders; one had an acquired brain injury, while the majority (n=9, 75%) had cerebral palsy secondary to a sustained perinatal injury.Most patients (n=11, 91.7%) had bilateral submandibular gland excision and parotid duct ligation as a primary procedure. One patient had a laryngotracheal separation. Two patients went on to have a second procedure. The mean follow up time was five years. Using Wilcoxon Signed-Rank test we showed that the median rate of admission per annum for LRTI pre-operatively was 1.0. This was reduced to 0.5 post-operatively, which was statistically significant (p≤0.05). ConclusionsWe hypothesize that the combination of bilateral submandibular gland excision and bilateral parotid duct ligation is effective in reducing admissions with aspiration pneumonia in neurologically impaired children, and therefore improves the quality of life in these patients.

Surgical management of chronic sialorrhea in pediatric patients: 10-year experience from one tertiary care institution

BackgroundChronic sialorrhea is a common problem for pediatric patients with disorders that affect swallowing. While many patients are successfully treated with medical therapies such as Robinul and Scopolamine, a number of such children are not able to tolerate the side effects of these medications. In these cases, surgical treatments can include Botulinum toxin A (Botox) injections into the major salivary glands, sublingual or submandibular gland excision (SMGE), submandibular duct ligation, parotid duct ligation (PDL), or any combination of the above procedures. The purpose of this study is to report on the 10-year experience with the surgical management of chronic sialorrhea at one tertiary care institution, and compare the efficacy of open surgical procedures versus Botox injections for reduction in salivary flow. MethodsA retrospective chart review identified 27 pediatric patients with chronic sialorrhea; 21 of whom underwent Botox injections and 15 of whom underwent surgical procedures. Preoperative and follow-up clinic notes were reviewed to determine the level and severity of drooling as well as the effectiveness of sialorrhea reduction, as assessed by the Teacher Drooling Scale (TDS). Results42% of those receiving Botox injections reported a reduction in drooling, with the average pre- and post-Botox TDS of 4.3 and 3.9, respectively (p=0.02 by the Wilcoxon signed rank test). Nine of the patients receiving Botox injections (43%) required multiple injections, with an average duration of effect of 3.9 months, and 7 patients (33%) eventually required surgery. All of the children who underwent surgery (7 bilateral SMGE with PDL, 6 SMGE only, and 2 PDL only) experienced a reduction in drooling, with average pre- and post-operative TDS of 4.5 and 2.2, respectively. This reduction was significant by the Wilcoxon signed rank test (p=0.001). ConclusionsThe ten-year experience at our institution demonstrates the safety, efficacy and long-term control of drooling in the patients undergoing surgery for intractable sialorrhea.

Toward Robot-Assisted Neurosurgical Lasers

Despite the potential increase in precision and accuracy, laser technology is not widely used in neurological surgery. This in part relates to challenges associated with the early introduction of lasers into neurosurgery. Considerable advances in laser technology have occurred, which together with robotic technology could create an ideal platform for neurosurgical application. In this study, a 980-nm contact diode laser was integrated with neuroArm. Preclinical evaluation involved partial hepatectomy, bilateral nephrectomy, splenectomy, and bilateral submandibular gland excision in a Sprague-Dawley rat model (n = 50). Total surgical time, blood loss as weight of surgical gauze before and after the procedure, and the incidence of thermal, vascular, or lethal injury were recorded and converted to an overall performance score. Thermal damage was evaluated in the liver using tissue samples stained with hematoxylin and eosin. Clinical studies involved step-wise integration of the 980-nm laser system into four neurosurgical cases. Results demonstrate the successful integration of contact laser technology into microsurgery, with and without robotic assistance. In preclinical studies, the laser improved microsurgical performance and reduced thermal damage, while neuroArm decreased intra- and intersurgeon variability. Clinical studies demonstrate dutility in meningioma resection (n = 4). Together, laser and robotic technology offered a more consistent, expedient, and precise tool for microsurgery.

Postoperative cyanotic breath-holding spells in a child with Worster–Drought syndrome

We report multiple cyanotic spells in the postoperative period in a child with Worster–Drought syndrome. A male child, 3.5 years old, 12 kg, who had experienced drooling of saliva since birth, was accepted for bilateral submandibular duct translocation and sublingual gland excision. He had delayed milestones (sat at 15 months and walked at 3 years). Difficulty in swallowing resulted in frequent vomiting during feeding and recurrent upper respiratory tract infections (URI). He was fed by his parents and could mainly swallow liquids or semi-solids. He did not require a nasogastric tube or gastrostomy for feeding. There was no history of epigastric pain or discomfort following feeds that would suggest a gastroesophageal reflux disorder. He was unable to protrude his tongue despite there being no tongue-tie. He could not speak despite normal hearing (normal brainstem auditory evoked responses) and communicated with signs. There was no history of seizures. Head noncontrast computerized tomography (NCCT) showed a paucity of periventricular white matter with prominent ventricles, gliotic areas, and bilateral frontoparietal volume loss. Other systems were normal. Before surgery, the patient did not have an URI, and no adventitious sounds were heard on auscultation. In the operating room, after instituting routine monitoring, anesthesia was induced with sevoflurane in oxygen and an IV access was secured. Following the administration of fentanyl and vecuronium, nasotracheal intubation was accomplished using a 4-mm-ID uncuffed endotracheal tube and the oropharynx packed. Paracetamol suppositories (250 ? 170 mg) were inserted rectally. Anesthesia was maintained with oxygen, nitrous oxide, isoflurane, and supplemental doses of fentanyl and vecuronium. The intraoperative period was uneventful, and at the end of surgery, which lasted for 2 h, a nasogastric tube was inserted to facilitate feeding the child after the oral surgery. Neuromuscular blockade was reversed and the trachea extubated once the patient was fully awake and breathing regularly. As he was being shifted out, he sat up and started crying. He held his breath, desaturated, and became cyanosed. Saturation improved on bag-mask ventilation with 100% oxygen. Two similar episodes of desaturation occurred. After the third, a conscious effort was made to avoid any stimulation that could precipitate crying, and he was gently shifted to his mother in the post anesthesia care unit (PACU). On retrospective questioning, the parents admitted that if they force-fed the child, he would have prolonged crying with breath-holding spells; however, there was no history suggestive of cyanosis during these episodes. Worster–Drought syndrome (WDS) is a phenotypically distinct but underdiagnosed form of cerebral palsy first described in 1956 [1]. Patients share features with bilateral congenital perisylvian syndrome, a type of childhood-onset epilepsy [1]. Worster–Drought syndrome is characterized by weakness of the orofacial and bulbar muscles, leading to difficulty in feeding, swallowing, and voluntary lip, tongue, and palate movements. Attempts at feeding can cause choking and A. Chhabra D. K. Baidya Department of Anesthesiology and Intensive Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Just Another Case of Sjögren’s Syndrome?

To the Editor: A 60-year-old woman was seen at the outpatient clinic of the Department of Rheumatology because of increased complaints of xerophthalmia. In 1997, she had already been diagnosed with Sjogren’s syndrome (SS) based on xerophthalmia, xerostomia, bilateral salivary gland swelling, and positive sialography showing chronic inflammation without local obstruction. Antinuclear antibodies (ANA) and anti-SSA/SSB were negative. Because of persistent progressive salivary gland swelling at that time, a total bilateral submandibular gland excision was performed as development of non-Hodgkin lymphoma as a complication of SS was suspected. Histology showed sialoadenitis as seen in SS without signs of lymphoma. In 2002, a renal biopsy performed because of increased creatinine level without proteinuria revealed focal global glomerulosclerosis with interstitial nephritis due to SS or chronic ischemia. In an attempt to treat possible active interstitial nephritis due to SS, she was treated with 30 mg of prednisone and azathioprine. Prednisone was stopped after 6 months and azathioprine after one year, however, there was no …

Surgical Management of Drooling

To review and assess the current published literature regarding the efficacy of surgical management of sialorrhea in pediatric patients. The MEDLINE database was systematically reviewed for articles reporting on the use of surgical procedures to treat sialorrhea published from January 1, 1963, to November 30, 2008. Inclusion criteria included presence of data on the success of surgical treatment of sialorrhea, English language, sample size greater than 5, and presentation of extractable data regarding the subjective success of surgical management of sialorrhea. Data regarding demographic characteristics of study participants, follow-up duration, subjective success rates, and number and type of complications were extracted by blinded reviewers. A total of 325 studies were identified on initial search. Abstract review reduced the sample to 46. Cross-referencing yielded an additional 4 articles, resulting in the final sample of 50 articles. Forty-seven studies were case series (Centre for Evidence-Based Medicine level 4 evidence), 2 were cohort studies (level 2), and 1 was a prospective cohort study (level 1b). Median sample size was 18 (range, 5-181), and median follow-up duration was 8.1 months (range, 0.1-50 months). Subjective success was reported in more than 50% of patients in 49 of 50 studies. Random-effects modeling estimated the overall subjective success rate for all procedures to be 81.6% (95% confidence interval, 77.5%-85.7%; P < .001). Bilateral submandibular gland excision and parotid duct rerouting appeared to have the highest subjective success rates at 87.8% (k = 8 studies; 95% confidence interval, 80.5%-95.1%; P <.001), and 4-duct ligation was the lowest at 64.1% (4 studies; 27.6%-100%; P = .001). Most evidence regarding surgical outcomes of sialorrhea management is low quality and heterogeneous. Despite this, most patients experience a subjective improvement following surgical treatment.

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

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

Evolução de 31 crianças submetidas à ressecção bilateral das glândulas submandibulares e ligadura dos ductos parotídeos para controlar a sialorréia

OBJETIVOS: Avaliar a segurança da ressecção bilateral das glândulas submandibulares e ligadura dos ductos parotídeos em crianças para reduzir a saliva, a eficácia e as complicações em médio e longo prazo no tratamento da sialorréia. FORMA DE ESTUDO: Coorte longitudinal. MATERIAL E MÉTODO: Trinta e uma crianças, com idades entre 6 e 13 anos (média de 7,6 anos), com múltiplas deficiências de etiologia neurológica foram submetidas à ressecção bilateral das glândulas submandibulares e ligadura dos ductos parotídeos, para controle da sialorréia, entre dezembro de 1999 a dezembro de 2005, e seguimento médio de 36 meses. RESULTADOS: O critério de sucesso foi o estabelecido por Wilkie, e 87% das crianças tiveram resultados excelentes e bons, sendo a morbidade insignificante e a principal complicação foi o edema temporário na região parotídea. CONCLUSÃO: A ressecção bilateral das glândulas submandibulares e a ligadura dos ductos parotídeos constituem técnica segura e eficaz para ser realizada em crianças, com 87% de sucesso no controle da sialorréia.

Drooling: analysis and evaluation of 31 children who underwent bilateral submandibular gland excision and parotid duct ligation

SummaryAim: To evaluate the safety of bilateral submandibular gland excision and parotid duct ligation in order to control drooling in children; to assess its long-term efficacy and complications.Study designlongitudinal cohort.Materials and MethodsThirty-one children aged 6 to 13 years (7.6 years old in average), with multiple neurological disabilities were submitted to a bilateral submandibular gland excision with parotid duct ligation in order to control ptyalism between December 1999 and December 2005, mean follow up of 36 months.ResultsAccording to Wilkie's success criteria, 87% of children had excellent or good results and insignificant morbidity was insignificant; with temporary parotid edema as the major complication.ConclusionBilateral submandibular gland excision with parotid duct ligation were safe to be performed in children, with 87% of success in drooling control.

Salivary gland surgery for chronic pulmonary aspiration in children

Chronic aspiration in the neurologically impaired child has a considerable morbidity and occasional morbidity. Hospitalization, physician visits and health costs associated with the sequelae of aspiration are considerable. To assess the efficacy of salivary gland surgery to treat chronic aspiration in children. Tertiary pediatric center. A 6 year retrospective chart review of all patients undergoing salivary gland surgery to treat chronic aspiration. (1) Rate of lower respiratory tract infection (LRTI); (2) baseline oxygen saturation pre- and post-surgery. Sixty-two patients aged 7-279 months (mean 68 months) underwent four duct ligation or bilateral submandibular gland excision with unilateral or bilateral parotid duct ligation. The mean rate was 1.2/year pre-operatively and 0.7/year post-operatively (p=0.6). There was, however, a significant improvement in the baseline post-operative oxygen saturation (mean 94.3%) when compared to the pre-operative baseline oxygen saturation (mean 92.8%, p=0.003). Analysis of the cerebral palsy subgroup was performed (n=13). In this group there was no difference between mean pre- and post-operative LRTI rate (p=0.5) nor change in baseline oxygen saturation (p=0.83). Children under 3 years of age showed a reduction in the LRTI rate (mean of 2.1 versus 0.7 episodes per year, p=0.04) and an improvement in the post-operative baseline oxygen saturation (p=0.001) following surgery. Unlike a previous publication from this institution, when evaluating the population sample as a whole, there was no significant improvement in the rate of LRTI following salivary gland surgery, however, there was an improvement in baseline oxygen saturation, possibly reflecting an improvement in lung function. There was an improvement in neither outcome parameter in children with cerebral palsy and improvements in both outcome measures in children under the age of 3.

Bilateral submandibular gland excision with parotid duct ligation for treatment of sialorrhea in children: long-term results.

Multiple procedures have been advocated for the surgical control of chronic sialorrhea in children. However, some of them are associated with significant complications or only short-term success. To evaluate the safety of bilateral submandibular gland excision (SGE) with parotid duct ligation (PDL) and to assess its long-term complications and efficacy in the treatment of chronic sialorrhea in children. Case series. Telephone interview of patients' families. Tertiary care children's hospital. Ninety-three patients with chronic sialorrhea who underwent bilateral SGE with PDL from 1988 to 1997. Operative and postoperative complications, length of postoperative hospitalization, postoperative drooling, care requirements, xerostomia, dental caries, and overall satisfaction. The mean postoperative stay was 2.4 days. There were 3 postoperative complications. Seventy-two families were interviewed (follow-up time, 1-10 years): 62 (87%) reported no further drooling or significant improvement; 7 reported the occurrence of dry mouth; and 2 reported an increase in dental caries. Bilateral SGE with PDL is a safe and consistently efficient procedure for the treatment of chronic sialorrhea in children.

Surgical reduction of salivary flow in children with spastic disorders

Neurologically impaired children with orofacial dysfunction may present with problematic drooling. Surgical endeavors to control this problem have consisted of either ablating nerves leading to the salivary glands, affecting salivary drainage, or removal of the salivary glands themselves. This article compares 2 surgical approaches on the basis of parental satisfaction. The submandibular duct rerouting procedure is compared with the submandibular gland excision and sublingual gland debulking procedure. The sublingual gland debulking procedure is described and pertinent anatomy discussed. Eighteen neurologically impaired children ranging in age from 5 to 15 years of age were studied. From 1987 to 1991, 7 children underwent bilateral submandibular duct rerouting procedures. From 1991 to 1995, 11 children underwent bilateral submandibular gland excision and sublingual gland debulking procedure. Because of the parental concern about the long-term efficacy of the submandibular duct rerouting procedure in some children, the surgical approach offered to these children was changed in 1991. Four children are in the “rerouting” group and the “excision group,” and therefore served as their own controls. The outcome being monitored was that of parental satisfaction and their assessment of several parameters. These assessments were obtained retrospectively at least 1 year after the surgical procedure was undertaken. Parental satisfaction was higher in the “excision” group of children as compared with the satisfaction expressed by parents in the “rerouting” group. Parameters assessed were: effectiveness of the procedure (0%–90% reduction in salivary flow), difficulty in tolerating the procedure, and willingness of the parent to have the child undergo the procedure again. On the basis of a parental-satisfaction survey, children who underwent the submandibular gland excision with the sublingual gland debulking procedure tolerated the procedure more easily, experienced greater reduction in salivary flow, and their parents were more willing to submit their child to the procedure again in comparison with the parents of children who were treated with the submandibular duct rerouting procedure. Neurologically impaired children with orofacial dysfunction may present with problematic drooling. Surgical endeavors to control this problem have consisted of either ablating nerves leading to the salivary glands, affecting salivary drainage, or removal of the salivary glands themselves. This article compares 2 surgical approaches on the basis of parental satisfaction. The submandibular duct rerouting procedure is compared with the submandibular gland excision and sublingual gland debulking procedure. The sublingual gland debulking procedure is described and pertinent anatomy discussed. Eighteen neurologically impaired children ranging in age from 5 to 15 years of age were studied. From 1987 to 1991, 7 children underwent bilateral submandibular duct rerouting procedures. From 1991 to 1995, 11 children underwent bilateral submandibular gland excision and sublingual gland debulking procedure. Because of the parental concern about the long-term efficacy of the submandibular duct rerouting procedure in some children, the surgical approach offered to these children was changed in 1991. Four children are in the “rerouting” group and the “excision group,” and therefore served as their own controls. The outcome being monitored was that of parental satisfaction and their assessment of several parameters. These assessments were obtained retrospectively at least 1 year after the surgical procedure was undertaken. Parental satisfaction was higher in the “excision” group of children as compared with the satisfaction expressed by parents in the “rerouting” group. Parameters assessed were: effectiveness of the procedure (0%–90% reduction in salivary flow), difficulty in tolerating the procedure, and willingness of the parent to have the child undergo the procedure again. On the basis of a parental-satisfaction survey, children who underwent the submandibular gland excision with the sublingual gland debulking procedure tolerated the procedure more easily, experienced greater reduction in salivary flow, and their parents were more willing to submit their child to the procedure again in comparison with the parents of children who were treated with the submandibular duct rerouting procedure.

Chronic Aspiration in Children

Objective: To assess the efficacy of bilateral submandibular gland excision and bilateral parotid duct ligation in treatment of chronic aspiration in neurologically impaired children. Design: Retrospective chart review and telephone follow-up interview. Setting: Tertiary care center. Patients: All patients from 1986 through 1994 who underwent bilateral submandibular gland excision and bilateral parotid duct ligation and had evidence of at least 1 episode of aspiration pneumonia in the year prior to undergoing surgery. Main Outcome Measure: Two main outcomes measures were (1) the change in number of hospitalizations for pneumonia and total number of lower respiratory tract infections between 1 year before and 1 year after surgical intervention and (2) telephone assessment of patient outcome with respect to parental satisfaction, effect on quality of life, care requirements, amount of suctioning, and use of voice. Results: Sixteen patients aged 16 months to 18 years were included. After surgical intervention, there was a significant decrease in the mean (±SD) number of pneumonias (2.3±1.44 before surgery, 0.9±1.2 after surgery; P Conclusion: Bilateral submandibular gland excision and bilateral parotid duct ligation reduce the incidence of aspiration pneumonias and hospitalization, and decrease overall care requirements in a select group of neurologically impaired children. Because they are voice sparing, are efficacious, and have a low morbidity, they should be considered before laryngotracheal separation or tracheoesophageal diversion. Arch Otolaryngol Head Neck Surg. 1996;122:1368-1371

Chronic aspiration in children. When are bilateral submandibular gland excision and parotid duct ligation indicated?

To assess the efficacy of bilateral submandibular gland excision and bilateral parotid duct ligation in treatment of chronic aspiration in neurologically impaired children. Retrospective chart review and telephone follow-up interview. Tertiary care center. All patients from 1986 through 1994 who underwent bilateral submandibular gland excision and bilateral parotid duct ligation and had evidence of at least 1 episode of aspiration pneumonia in the year prior to undergoing surgery. Two main outcomes measures were (1) the change in number of hospitalizations for pneumonia and total number of lower respiratory tract infections between 1 year before and 1 year after surgical intervention and (2) telephone assessment of patient outcome with respect to parental satisfaction, effect on quality of life, care requirements, amount of suctioning, and use of voice. Sixteen patients aged 16 months to 18 years were included. After surgical intervention, there was a significant decrease in the mean (+/-SD) number of pneumonias (2.3 +/- 1.44 before surgery, 0.9 +/- 1.2 after surgery; P < .001) and hospitalizations (1.2 +/- 0.8 before surgery, 0.4 +/- 0.8 after surgery; P < .005). Six patients had a tracheostomy at the time of surgery, and 1 required a tracheostomy 2 years after surgery. No individual required laryngotracheal separation. Eleven families were able to be contacted by telephone. Caretakers reported that in 8 of 11 patients, quality of life was improved and care requirements decreased. Seven patients used voice for at least some degree of communication. Three patients had postoperative complications involving the parotid glands; all resolved after further therapy. Bilateral submandibular gland excision and bilateral parotid duct ligation reduce the incidence of aspiration pneumonias and hospitalization, and decrease overall care requirements in a select group of neurologically impaired children. Because they are voice sparing, are efficacious, and have a low morbidity, they should be considered before laryngotracheal separation or tracheoesophageal diversion.

Experience with the Wilkie Procedure for Sialorrhea

Sialorrhea (drooling) is most commonly seen in children with cerebral palsy or mental retardation. Surgical procedures for the control of sialorrhea include salivary gland excision, parasympathetic nerve section, and salivary duct ligation and/or rerouting. Eighteen children between the ages of 5 and 17 years underwent bilateral submandibular gland excision and rerouting of Stensen's duct (Wilkie procedure). All children had severe drooling associated with cerebral palsy or mental retardation. Follow-up at 7 years showed satisfactory control of sialorrhea in 16 of 18 patients (89%). There was one major complication: xerostomia. Our results indicate that submandibular gland excision together with parotid duct retropositioning provides effective control of sialorrhea in most cases. Unfavorable head and mandibular posturing seemed to cause persistent sialorrhea in one case.

Sialorrhea

Sialorrhea is a frequent problem in children with mental retardation and cerebral palsy. In addition to cosmetic considerations, serious medical and psychosocial consequences may result from the situation. The most effective treatment at the present time is bilateral submandibular gland excision and parotid duct ligation. Various means of physical therapy may play a valuable adjunctive role. Control of sialorrhea improves appearance, hygiene, and self-esteem as well as reduces the demands of those who care for the child with sialorrhea.

Surgical Management of Sialorrhea

Sialorrhea is a distressing problem in children with cerebral palsy, in children with other neurologic disorders, and in normal children. The constant need for clothing or bib changes in handicapped patients frequently results in further social isolation and causes normal children to be viewed as "impaired." The surgical treatment of sialorrhea at Children's Hospital Medical Center, Cincinnati, Ohio, has evolved over the past 5 years. Since 1981, 70 surgical procedures have been performed for drooling at this institution; follow-up information is available on 52 patients. The surgical procedures performed included submandibular rerouting alone, submandibular duct rerouting with bilateral tympanic neurectomy with bilateral submandibular gland excision, and bilateral submandibular gland excision with bilateral parotid duct ligation. Our review indicates that bilateral submandibular gland excision with parotid duct ligation is the only procedure in which consistent control of sialorrhea can be expected. Postoperative complications after this procedure were minimal and only one parent complained that the child had a dry mouth after the procedure. Postoperative hospitalization after bilateral submandibular gland excision and bilateral parotid duct ligation was not significantly different from that required after any of the other procedures. In conclusion, this surgical procedure appears to be the most effective surgical treatment for sialorrhea and precludes the need for multiple operative procedures for this problem.