Source: Greensmith AL, Johnstone BR, Reid SM, et al. Prospective analysis of the outcome of surgical management of drooling in the pediatric population: a 10-year experience. Plast Reconstr Surg. 2005;116:1233–1242.Sialorrhea (excessive drooling) is a frequent problem in neurologically impaired children. Surgical intervention may be appropriate when conservative measures are ineffective. For this study, data were reviewed on 72 consecutive patients attending a multidisciplinary Salivary Control Clinic at The Royal Children’s Hospital in Melbourne, Australia who underwent bilateral submandibular duct transposition combined with sublingual gland excision from 1993–2001. The mean age at surgery of patients was 10.4 years (range 4–19 years). Results were analyzed prospectively at 2 and 5 years postoperatively.Sixty-seven patients were available for follow-up at 2 years. A drooling score was assigned to each patient by caregivers and clinicians using a 4-point frequency and 5-point severity scale.1 If more than 1 observer completed an assessment, the scores were averaged. Frequency was defined as: 1) never, 2) occasional, 3) frequent, and 4) constant. Severity was classed as: 1) dry, 2) mild – wet lips, 3) moderate – wet lips and chin, 4) severe – clothing damp, and 5) profuse – clothing, hands, and objects wet. Reductions in frequency from 4.0 to 2.9 (P<.001) and severity from 4.8 to 3 (P<.001) were recorded for the study group as a whole. In addition, there was a fall in number of clothing or bib changes from 4 to 0. Results were similar at 5 years postoperatively. A total of 13 surgical complications were reported, and 5 patients had unsatisfactory outcomes and subsequently required parotid duct ligation. The procedure was found to be effective in most patients, with 58% showing significant improvement in drooling frequency and 77% having decreased severity of drooling.Dr. Burstein has disclosed no financial relationships relevant to this commentary.Up to 37% of patients with cerebral palsy have been reported to have excessive drooling.2 Sequelae include social ostracism, skin maceration, fluid depletion, and aspiration pneumonia. Normally between 500 and 2000 ml of saliva are produced per day. In affected individuals, the basal salivary production rate is normal; however, there is inefficient involuntary swallowing of the saliva. According to these authors, 60% of saliva production is by the submandibular gland, 10% from the sublingual glands, and 20% from the parotid glands. Non-surgical treatments include correction of posture, nasopharyngeal obstruction, and malocclusion; biofeedback; and oral appliances. Pharmacologic remedies include various anticholinergic agents such as atropine, as well as Botox injection of the salivary glands.Parotid duct relocation followed by submandibular gland excision as a treatment for excessive drooling was reported in 1967.3 In that initial case series, although 90% of patients had effective control, over 30% had complications ranging from parotid duct stenosis and increased dental caries to septic parotitis. In the current study, the decision to focus surgical therapy on the main salivary secretors while avoiding the parotid gland was based on sound anatomic and physiologic principles. The avoidance of external incisions and parotid ligation appears to have markedly decreased dental and gingival problems as well as overall morbidity.This study illustrates why a case series can be of value even though it is methodologically a relatively weak study design. Herein, case selection was not random, interobserver reliability was not assessed, and the clinical meaningfulness of the observed effect size may be debated. Nonetheless, this study is a valuable, albeit not methodologically robust, critical analysis of a new therapy of a terribly difficult clinical problem. It will undoubtedly serve as the basis of an improved method to control continuous drooling.
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Jan 1, 2022
Haipeng Chen + 3
