Drooling is a physiological process in infants. When it persists beyond the age of 4 years, it becomes a clinical symptom. Drooling is a common problem among children of all ages with a neurological deficit. It causes significant decrease in the quality of life of the children and their families. Parents often accept the disability because they are not aware that treatment is available. Doctors should recognise the problem during a consultation and discuss the available management options. Patients should be reffered to a drooling clinic that adopts a multi-disciplinary approach. Management of drooling has been evolving over the last thirty years. Surgery has become a safe and effective management option.published_or_final_versio

Goh, WHS

Hui, Y

Tang, KC

To, R

Wei, WI

HKU Scholars Hub

Title Surgical management of a drooling childAuthor(s) Tang, KC; Hui, Y; Goh, WHS; To, R; Wei, WICitation Hong Kong Practitioner, 2001, v. 23 n. 7, p. 285-289Issued Date 2001URL http://hdl.handle.net/10722/53460Rights Creative Commons: Attribution 3.0 Hong Kong LicenseThe Hong Kong Practitioner    VOLUME 23    July  2001 285Update ArticleSummaryDrooling is a physiological process in infants.  Whenit persists beyond the age of 4 years, it becomes a clinicalsymptom.  Drooling is a common problem amongchildren of all ages with a neurological deficit.  It causessignificant decrease in the quality of life of the childrenand their families.  Parents often accept the disabilitybecause they are not aware that treatment is available.Doctors should recognise the problem dur ing aconsultation and discuss the available managementoptions.  Patients should be referred to a drooling clinicthat adopts a multi-disciplinary approach.  Managementof drooling has been evolving over the last thirty years.Surgery has become a safe and effective managementoption.?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????HK Pract 2001;23:285-289Surgical management of a drooling childK C Tang???? Y Hui???W H S Goh???? R To????W I Wei??IntroductionDrooling, or sialorrhoea, is defined as spillage ofsaliva from the mouth.  It usually causes much physicaland psychological distress to the patients as well as theirfamilies.  Saliva overflow may cause peri-oral maceration,chapping and infection as well as soiling of clothes,carpets, toys and books.  In addition, it causes socialembarrassment leading to impairment of education anddevelopment.  This is particularly significant when a childpossesses normal intelligence.  Family members are alsoaffected.  They may avoid going out with a drooling childbecause of social stigmatisation.  In addition, the frequentneed to change soiled clothes is distressing and can affectthe relationship between the care provider and the child.Drooling is not a life-threatening condition and thusa problem that is often overlooked by the health-careprovider.  As the traditional Chinese culture stresses onendurance, parents of a drooling child often do nothighlight the problem to doctors.  Family physicians arein a good position to raise the issue, and to inform theparents of the different treatments available.  Successfulcontrol of drooling improves appearance, hygiene and self-esteem of the patient.  It reduces the work of the caretakersand improves the quality of life of the child and theirfamily members.ClassificationDrooling can be classified as physiological, acute orchronic.1  Normal infants drool and this usually stops bythe age of 18 to 24 months.  However, intermittentdrooling up to the age of 4 years may occur in childrenwith no neurological deficit.2  Many acute inflammatoryconditions, such as acute epiglottitis and acute tonsillitismay also cause drooling because of odynophagia.  Thisusually improves as the inflammation subsides.Most patients with chronic drooling usually havevarious forms of congenital or acquired muscle spasticityor incoordination.  They may also be mentally disabledK C Tang,  MBBS(HK), FRCS(Glasg)Medical & Health Officer,Department of Otorhinolaryngology, Queen Mary Hospital.Y Hui, MBBS(HK), FRCS(Edin), FACS, FHKAM(Otorhinolaryngology)Consultant,W I Wei, MS(HK), FRCS(Edin), FACS, FHKAM(Otorhinolaryngology)Professor of Otorhinolaryngology,Division of Otorhinolaryngology, Department of Surgery, University of Hong KongMedical Centre.W H S Goh, MBBS(Singapore), MMed(Paed)(Singapore), FRCP(Edin),FHKAM(Paediatric)Consultant,Department of Paediatric, Duchness of Kent Children’s Hospital.R To, BAppSc(Sp Path)Speech Therapist,Department of Speech Therapy, Children’s Habilitation Institute, Duchess of KentChildren’s Hospital.Correspondence to : Dr K C Tang, Department of Otorhinolaryngology, QueenMary Hospital, Hong Kong.286 The Hong Kong Practitioner    VOLUME 23    July  2001Update Articledue to other co-existing medical problems.  It is estimatedthat 10% of children with cerebral palsy suffer fromdroo l ing . 3  Long- te rm use  o f  t r anqu i l l i ze r s  o ranticonvulsants might also worsen the problem because oftheir cholinergic action.PathophysiologyApproximately 1.5 litres of saliva is secreted eachday.  Most of the secretion is produced by the majorsalivary glands in the following ratios: Parotid (25%);submandibular (70%); and sublingual (5%).2  Most of theresting saliva secretion is produced by the latter twoglands, which contain higher levels of glycoproteins andis thus more viscid.  Hence the clinical troublesomesymptoms of drooling are caused mainly by secretion fromthe submandibular glands.Pathological drooling is due to either hypersecretionof saliva or neuromuscular dysfunction of swallowing.4Hypersecretion as a cause of drooling is less common.  Itmay be seen in children with gingivitis, rabies, mercurypoisoning or after anticholinesterase ingestion.5The act  of  swallowing has four  dis t inct  butcontinuous phases:1. oral preparatory;2. oral propulsive;3. pharyngeal; and4. oesophageal.This is a highly complex act with coordinated musclemovements involving the lips, tongue, palate, jaw,pharynx, larynx, oesophagus and respiratory muscles.3Drooling in general results from defect in the oral phaseof rather than the pharyngeal phase of swallowing.Clinical AssessmentA multidisciplinary team approach is essential in theevaluation and management of a drooling patient.6,7  Theteam usually consists of a paediatric otorhinolaryn-gologist, speech therapist, paediatric neurologist andpaediatric dentist.Speech therapists give assessment depending on theseverity and frequency of drooling.  Previous attempts atnon-surgical treatment should be documented.  Oral motorfunction is also assessed and the possible outcome offurther non-surgical treatment is estimated.  An oral motorhabilitation programme should be conducted beforesurgical management is recommended.The paediatric dentist provides information on thestatus of the dentition and occlusion.  The condition of theteeth and gums, and the configuration of the mandible andpalate are assessed.  The paediatric otorhinolaryngologistwill  also assess the position and control of headmovements, the nature of the drooled saliva, tongue sizeand mobility, as well as a thorough head and neckexamination.The impact of drooling on the child, parents and otherfamily members is assessed.  Management options areexplained with respect to the predicted success rate andpotential complications.ManagementNo treatmentChildren under 4 years of age who have occasionalmild to moderate drooling should be observed.  Patientswith chronic aspiration or severe global developmentaldelay are not candidates for surgical intervention becausedrooling is usually one of the least worrisome problemsin these patients.Oral motor programmesOral motor training aims at improving:1. tongue position and mobility;2. lip closure; and3. jaw position and stability.It is non-invasive and, occasionally, children maybenefit from this type of therapy alone.  It has been shownthat 75% of children who received the oral motorhabilitation programme for 6 months demonstratedimprovement in both the visual analogue scale andDrooling Quotient.11  It is generally recommended thatchildren over the age of 6 years should receive at least6 months of training before other methods are considered.However, despite some improvement in most children,oral motor programmes are unlikely to eliminate thedrooling problem entirely.10The Hong Kong Practitioner    VOLUME 23    July  2001 287Update ArticleCorrection of situational factorsSome situational factors may contribute to drooling.For example, poor sitting posture with the head tiltedforward encourages sialorrhoea.  Therefore, the correctsitting posture should be taught to the caregiver.Nasal obstruction causes open mouth breathing andaggravates drooling.  Pharmacological treatment canusually control nasal obstruction.  If there is gross nasalseptal  deviat ion or turbinate hypertrophy that  isunresponsive to medication, surgical correction can beoffered.Dental disease will also cause drooling.  For example,mal-occlusion is common among patients with cerebralpalsy.  Sometimes, corrective orthodontia and evenorthognathic operation is necessary.  Anticonvulsants maycause sialorrhoea, and therefore a neurologist’s opinionis required to determine whether an appropriate alternativetherapeutic agent can be given.  Nevertheless, even whenall these factors have been corrected, only 10% of patientsshow significant improvement.7Biofeedback with behaviour modificationIn this management modality, a sound stimulus isusually employed.  The therapy aims at conditioning thechild to swallow every time a signal is heard.  However,this method requires multiple sessions and is very time-consuming.  In addition, the child needs to be of averageintelligence and should be old enough (over 8 years ofage) to understand the training.  Severe drooling does notusually respond to biofeedback.  Hence only a smallnumber of patients may benefit.2PharmacotherapyUse of medication,  such as l ike transdermalscopolamine is only recommended12 for short-termmanagement.  Side effects such as constipation, urinaryretention, skin reaction and high cost make long term useof pharmacotherapy difficult.SurgerySurgical management of drooling is performed whenthe patient cannot benefit from further non-surgicaltherapy.  It is usually performed when the neurologicalstatus is stable and the patient is over 6 years of age.2Operations to treat drooling can be divided into two maintypes.  1)  to decrease saliva production; 2) to redirectsalivary flow to facilitate swallowing.Types of surgery1. To decrease the amount of saliva productiona. Tympanic neurectomy and division of the chordatympaniThe operation was first described in 1962 byGolding-Wood. 13  The  opera t ion  can  beperformed permeatally without a visible surgicalscar.  The chorda tympani which is a branch offacial nerve and the tympanic plexus which ismostly derived from Jacobson’s nerve (a branchof the glossopharyngeal nerve) are divided.Technically, the procedure is relatively simpleand has a reported drooling control rate of74%.14  The disadvantages of the operationinclude sensory loss of taste and potentialdamage to hearing.  More importantly, droolingoften returns to preoperative levels within 6months.  Therefore, this surgery has beensuperseded by other procedures.b. Excision of submandibular glandThis is a simple and safe operation.  However,it leaves an external surgical scar on the patient’sneck.  In addition, it carries the potential risk ofinjury to the lingual and hypoglossal nerves aswell as to the marginal mandibular branch of thefacial nerves.c. Ligation of submandibular ductThis is also a simple and safe procedure.However, it carries a significant morbidity interms of tender swelling of the glands, whichmay be prolonged and difficult to treat.2. To redirect salivary flowa. Fistulisation of parotid ductFistulisation of parotid ducts to the tonsillarfossae was first described by Wilkie.15  Theprocedure carries a high risk of complicationssuch as duct stenosis, septic parotitis andexternal surgical scarring.  As mentioned earlier,288 The Hong Kong Practitioner    VOLUME 23    July  2001Update Articleduct.  The incision is intraoral and leaves noexternal surgical scarring.  The submandibularduct is dissected from the floor of mouth(Figure 1) and tunneled in a submucosal planeto the tonsillar fossae on the floor of the mouth(Figure 2).  As the sublingual gland is closelyrelated to the submandibular duct, damage to itis  inevitable.   Hence,  ranula is  a  knowncomplication in 10% of patients.18  To avoid thisparticular complication, some surgeons routinelyperform sublingual gland excision.The control rate of drooling following thisprocedure is 89%.9  It has been remarked that theoperation causes scarring of the duct, which issimilarly observed with submandibular ductligation.  However, postoperative technetiumscanning showed that physiological function ispreserved in at least one of the glands if abilateral procedure is performed.18ConclusionDrooling is a common problem among children witha neurological deficit.  It causes significant morbidity aswell as decreases the quality of life of the children andtheir families.  It is a problem that can be managed by amulti-disciplinary approach.  The drooling clinicestablished in Duchess of Kent Children’s Hospital hasaround one hundred referrals over the past five years.However, this does not reflect the true incidence as someparents may not be aware of the possible treatment of theproblem.Although surgery is more invasive than othertreatment options, it is the most effective and allows long-term control of sialorrhoea.  As submandibular ductrepositioning with sublingual gland excision is simple andeffective with low morbidity and complication in experthands, this is the treatment of choice for a droolingchild.  ? ?References1. Cinnamond MJ.  The drooling child.  In: Kerr AG, general editor.  Scott-Brown’s Otolaryngology.  Vol. 5 Paediatric Otolaryngology.  6th ed.Butterworth-Heinemann, International Editions.  1997;(33):1-8.2. Crysdale WS,  Gaffney RJ.  The management of drooling.  In: BluestoneCD, Stool SE, Kenna MA, (eds).  Paediatric Otolaryngology.  3rd ed.Saunders; 1996:974-983.the problem of resting drooling is due to salivaproduction by the submandibular gland.  It ist h e r e f o r e  m o r e  l o g i c a l  t o  r e r o u t e  t h esubmandibular duct.b. Submandibular duct relocation (SMDR) withsublingual gland excisionThis is one of the most commonly performedsurgical procedures for drooling in whichconsistent control can be expected.16  It was firstdescribed in 1974 by Ekedahl.17  The aim of theprocedure is to direct the opening of thesubmandibular ducts from the anterior floor ofmouth to the tonsillar fossae.  Saliva in theoropharynx triggers the pharyngeal phase ofswallowing that is usually intact in mostdrooling patients.  Tonsillectomy is usuallyperformed first to facilitate the placement of theFigure 1: Operative photo showing right submandibularduct is dissected from the floor of mouthFigure 2: Operative photo showing right submandibularis delivered to right tonsillar fossaThe Hong Kong Practitioner    VOLUME 23    July  2001 289Update ArticleKey messages1. Drooling is a common problem among children withneurological problem.2. Medical profession should be aware of the possiblemanagement options for a drooling child as thismay not be known to the parents.3. A drooling clinic with multi-disciplinary approachis required for proper management of drooling.4. Submandibular duct repositioning with sublingualgland excision is an effective treatment for droolingwith minimal risk of complication.3. O’Dwyer TP,  Timon C,  Walsh MA.  Surgical management of droolingin the neurologically damaged child.  J Laryngol Otol  1989;103(8):750-752.4. Finkelstein DM,  Crysdale WS.  Evaluation and management of the droolingpatient.  J Otolaryngol  1992;21(6):414-418.5. Stuchell RN,  Mandel ID.  Salivary gland dysfunction and swallowingdisorders.  Otolaryngol Clin North Am  1988;21:649-661.6. Crysdale WS.  Drooling: experience with team assessment and management.Clin Pediatr  1992;31:77-80.7. Crysdale WS,  Greenberg JD,  Doheil R, et al.  The drooling patient: teamevaluation and management.  Int J Pediatr Otorhinolaryngol  1985;9:241-248.8. Reddihough D,  Johnson H,  Ferguson E.  The role of a saliva control clinicin the management of drooling.  J Paediatr Child Health  1992;28(5):395-397.9. Crysdale WS.  Management options for the drooling patient.  Ear NoseThroat J  1989;68(11):825-826,829-830.10. Crysdale WS.  The drooling patient: evaluation and current surgical options.Laryngoscope  1980;90:775-783.11. To R,  Wong V,  Hui Y, et al.  Pilot study of oro-motor habilitation programfor children with drooling problem: a pilot observation.  HK J Paediatr (newseries).  1999;4:96-100.12. Talmi YP,  Finkelstein Y,  Zohar Y.  Reduction of salivary flow withtransdermal scopolamine: a four-year experience.  Otolaryngol Head NeckSurg  1990;103:615-618.13. Golding-Wood PH.  Tympanic neurectomy.  J Laryngol Otol  1962;76:683-693.14. Mullins WM,  Gross CW,  Moore JM.  Long-term follow-up of tympanicneurectomy for sialorrhoea.  Laryngoscope  1979;89:1219-1223.15. Wilkie TF.  The problem of drooling in cerebral palsy.  A surgical approach.Can J Surg  1967;10:60-67.16. Shott SR,  Charles MM,  Cotton RT.  Surgical management of sialorrhea.Otolaryngol Head Neck Surg  1989;101:47-5017. Ekedahl C.  Surgical treatment of drooling.  Acta Otolaryngol  1974;77:215-220.18. Crysdale WS,  Mendelsohn JD,  Conley S.  Ranulas-mucoeles of the oralcavity: experience in 26 children.  Laryngoscope  1988;98:296-298.19. Hotaling AJ,  Madgy DN,  Kuhns LR, et al. Postoperative technetiumscanning in patients with submandibular duct diversion.  Arch OtolaryngolHead Neck Urg  1992;118:1331-1333.

Surgical management of a drooling child

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Surgical management of a drooling child

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