Evaluation and Management of Drooling

Evaluation and Management of Drooling
Presentation by:Karen Stierman, M.D. & Ronald Deskin, M.D.

* Drooling - serious medical and social problem
o maceration, infection, soiling of clothes and belongings, effects on caregiver
* Sialorrhea - increase in salivary flow
* Drooling - ineffective saliva management

Anatomy and Physiology of Drooling
* Three pairs of major salivary glands - parotid, submandibular, and lingual
* 70% of saliva comes from the submandibular glands at the resting state
* Ingestion of food causes parotid gland to secrete a higher percentage of saliva

Submandibular and Sublingual gland innervation
Parotid innervation
Salivary gland innervation
Functions of saliva
* Protective
* Swallowing
* Digestion
* Speaking

Etiology of Drooling
* Acute vs. Chronic
* Direct vs. Indirect

Pathophysiology of Drooling
* Multifactorial
* Primarily a defect in the oral phase of swallowing caused by:
o poor head control, inability to close the mouth, abnormal tongue mobility, reduced intra-oral sensation
* Sialorrhea can lead to drooling caused by:
o medications and poor fitting dentures

Diagnosis of Drooling
* History - severity, peak time, influencing factors, associated conditions, parental expectations, age and mental status of the patient
* Physical - Head posture, dental abnormalities, nasal and oral cavities, decreased intraoral sensitivity
* Other - lateral neck x-ray, audio, barium sw.

Treatment Options
* Pharmacological therapy
* Speech therapy
* Behavioral therapy
* Radiation therapy
* Surgery
* Initial approach is usually nonsurgical and reversible

Pharmacological therapy
Speech therapy
Behavioral therapy
Radiotherapy
Surgical options
* Submandibular duct rerouting
* Submandibular duct excision
* Parotid duct ligation
* Transtympanic neurectomy

Surgical indications
* Age 5-6
* Assess ability to interact with peers
* Failed nonsurgical management
* Stable neurological status

Rerouting of submandibular duct
* Success rate of 80-100%
* Cuff of mucosa dissected around duct and marked medially and laterally
* Duct dissected 3-4 cm or until gland reached
* Tonsil used to create a tunnel just posterior to anterior tonsillar pillar and sutures passed with duct
* Tonsillectomy performed if obstructive tonsils
* Sublingual adenectomy(Crysdale) versus ligating sublingual ductules(Cotton)
* Advantages: Decreased xerostomia, problems with taste and dysphagia
* Disadv: Ranula, FOM swelling, sialoadenitis, sialolithiasis, aspiration

Studies on submandibular duct rerouting
Submandibular Gland Excision
Parotid duct ligation
Transtympanic neurectomies

Summary

* Goal: decrease drooling and provide healthy oral cavity
* Order of management controversial
o Nonsurgical management first
o Submandibular duct rerouting
o Submandibular gland excision +/- parotid duct ligation
o Tympanic neurectomy

Drooling.ppt