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

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Eyelid Anatomy - Entropion / Ectropion

Eyelid Anatomy - Entropion / Ectropion
Elizabeth J. Rosen, MD
Karen H. Calhoun, MD

Entropion is a medical condition in which the eyelids fold inward. Ectropion is a medical condition in which the lower eyelid turns outwards

Eyelid Anatomy
* Tarsal plates
o Length 25mm
o Thickness 1mm
o Height
+ Upper 10mm
+ Lower 4mm
* Orbicularis Oculi
o Orbital
o Palpebral
+ Preseptal
+ Pretarsal
* Medial canthal tendon
o Anterior reflection
o Posterior reflection
o Vertical fascial support
* Lateral canthal tendon
* Lateral retinaculum
* Orbital septum
o Origin
+ Arcus marginalis
o Insertion
+ Medial: posterior lacrimal crest
+ Lateral: orbital tubercle
+ Superior: levator aponeurosis
+ Inferior: inferior tarsal border
* Upper lid levators
o Levator palpebrae superioris
o Whitnall’s ligament
o Muller’s muscle
* Lower lid retractors
o Capsulopalpebral fascia
o Lockwood’s ligament
o Inferior palpebral muscle
* Lacrimal apparatus
o Gland
o Punctum
o Canaliculus
o Sac
o Duct

Entropion
* Congenital
* Involutional (senile)
* Cicatricial
* Congenital Entropion
* Epiblepharon
* Correction of congenital entropion or epiblepharon
* Correction of involutional entropion
* Correction of cicatricial entropion
* Correction of cicatricial entropion
Ectropion
* Congenital
* Paralytic
* Cicatricial
* Involutional

Ectropion
* Paralytic ectropion
* Correction of paralytic ectropion
* Correction of cicatricial ectropion
* Correction of involutional ectropion

Entropion / Ectropion.ppt

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Treatments for Meniere’s Disease

Treatments for Meniere’s Disease
Presentation lecture by:Alan L. Cowan, MD

Tomoko Makishima, MD, Ph.D
Definition:Meniere’s Disease is a disorder of the inner ear that can affect hearing and balance.

History
Physiology
* Perilymph
o Located in the Scala Vestibuli / Tympani
o Similar in composition to CSF
o High Na+, Low K+
* Endolymph
o Located in the Scala Media
o Similar in compostion to ICF
o Low Na+ High K+
o Site of production in Stria Vascularis
* Membranous Labyrinth separates the compartments
o No difference in pressure

Pathophysiology
* Endolymphatic hydrops leads to distortion of membranous labyrinth
* Reisner’s membrane can be seen bulging into the scala vestibuli in some histologic studies
* Microruptures may lead to episodic attacks which resolve when the tears heal
* Theories behind endolymphatic hydrops
o Obstruction of endolymphatic duct/sac
o Hypoplasia of endolymphatic duct/sac
o Alteration of absorption of endolymph
o Alteration in production of endolymph
o Autoimmune insult
o Vascular origin
o Viral etiology

Diagnosis
* Meniere’s is diagnosed by
o Vertigo
+ Spontaneous, lasting minutes to hours
+ Recurrent, must have more than 1 episode
+ Associated with nystagmus
o Hearing loss
+ Fluctuating sensorineural
+ Low-frequency or flat
o Tinnitus
* Vertigo treatment reporting standard
* Hearing treatment reporting standard

* Meniere’s is diagnosed by
o Vertigo
+ Spontaneous, lasting minutes to hours
+ Recurrent, must have 2 episodes > 20 min.
+ Nystagmus during episodes
o Hearing loss
+ Avg (250, 500, 1000) 15 dB < Avg (1000, 2000, 3000) or
+ Avg (500, 1000, 2000, 3000) 20 dB > than other ear
+ For bilateral disease Avg (500, 1000, 2000, 3000) > 25 dB in the studied ear
o Tinnitus
+ No guidelines
o Aural pressure
+ No guidelines

* Possible Meniere's
* Probable Meniere's disease
* Definite Meniere's disease
* Certain Meniere's disease
* Functional Level Scale

Reporting Results of Treatment
Placebo Effect
Medical Therapy
Acute Therapy
Vasodilators
Diuretics and Salt restriction
Diuretics
Water Therapy
Meniett Device
Intratympanic Therapy
Intratympanic Steroids
Intratympanic Ablation
Intratympanic Gentamicin
Low dose therapy
Multiple Daily Dosing
Titration Therapy
Intratympanic Gent
Surgical Therapy
Endolymphatic Sac Surgery
* Types of procedures
o Decompression: removal of bone overlying the sac
o Shunting: placement of synthetic shunt to drain endolymph into mastoid
o Drainage: incision of the sac to allow drainage
o Removal of sac: excision of the sac. Some believe the sac may play a role in endolymph production

Endolymphatic Sac Surgery
Vestibular Nerve Section
Labyrinthectomy
Vestibular Suppressants
Diuretics Salt Restriction
Vasodilators ? Water Therapy
Alternative Therapies Meniett
Herbal
Hypnosis
Intratympanic Steroid Therapy
Intratympanic Gentamicin Therapy
Surgical Ablation
Nerve Section
Labyrinthectomy
Mastoid Shunt
Final Thought
Bibliography

Treatments for Meniere’s Disease.ppt

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