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Bilateral Submandibular Gland Excision With Parotid Duct Ligation for Treatment of Sialorrhea in Children
Long-term Results
Yoram Stern, MD;
Rafael Feinmesser, MD;
Michael Collins, BSc;
Sally R. Shott, MD;
Robin T. Cotton, MD
Arch Otolaryngol Head Neck Surg. 2002;128:801-803.
ABSTRACT
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Background 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.
Objectives 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.
Design Case series. Telephone interview of patients' families.
Setting Tertiary care children's hospital.
Patients Ninety-three patients with chronic sialorrhea who underwent bilateral
SGE with PDL from 1988 to 1997.
Main Outcome Measures Operative and postoperative complications, length of postoperative hospitalization,
postoperative drooling, care requirements, xerostomia, dental caries, and
overall satisfaction.
Results 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.
Conclusion Bilateral SGE with PDL is a safe and consistently efficient procedure
for the treatment of chronic sialorrhea in children.
INTRODUCTION
SIALORRHEA, OR drooling, may be a persistent feature in children with
conditions affecting the neurologic or muscular systems.1
Chronic sialorrhea may cause significant social isolation, embarrassment,
and discomfort. It also increases and complicates patient care, imposing significant
problems for the patients and their family members or caregivers. Many approaches
have been used to diminish the amount of drooling, including behavior modification,
medical regimens, and surgical intervention. Surgical correction of chronic
sialorrhea in children has proved to be the best solution. Several procedures
have been advocated. However, some of the procedures may be associated with
significant complications or only a short-term solution.2
Bilateral submandibular gland excision (SGE) with parotid duct ligation
(PDL) has been the treatment of choice for chronic sialorrhea in children
at our hospital since 1984. The objectives of the present study were to evaluate
the safety of bilateral SGE with PDL and to assess its long-term complications
and efficacy in the treatment of chronic sialorrhea in children.
PATIENTS AND METHODS
SURGICAL PROCEDURE
Antibiotic therapy was preoperatively administered to cover intraoral
flora and was continued for 7 days after surgery. The procedure was performed
with the patients under general anesthesia. Bilateral submandibular incisions
were used. The submandibular glands were identified and excised with preservation
of the surrounding neural structures, including the marginal mandibular branch
of the facial nerve and the hypoglossal and lingual nerves. A mouth gag was
inserted, and each parotid opening was identified in the buccal mucosa. Then
the duct was cannulated with a probe, and an elliptical incision was made
around the duct papilla. The duct was dissected for approximately 1 cm, and
the suture was ligated and then resected. The buccal mucosa was closed with
interrupted absorbable sutures.
Intravenous hydration was begun after surgery, and the patients were
encouraged to take fluids by mouth as soon as they were able. They were not
discharged until all drains had been removed and their oral intake was adequate.
PATIENTS
Ninety-three children with chronic sialorrhea underwent bilateral SGE
with PDL from January 1988 to December 1997 at the Children's Hospital, Cincinnati,
Ohio. The parents or caregivers of the patients were contacted by telephone
and questioned about the results of the surgical procedure. Inquiries were
made into the preoperative and postoperative levels of sialorrhea, care requirements,
thick secretions, dry mouth, overall satisfaction with the procedure, and
any complications that may have occurred and were not documented in the patient's
chart. The parents or caregivers were also questioned about the number of
dental caries and lower respiratory tract infections before and after the
surgery. Postoperative drooling was assessed as to whether it was the same
as, or better or worse than, the preoperative state, based on the family's
or primary caregiver's description. The patients' improvement was measured
according to the number of shirts or bibs that needed to be changed each day
before and after the surgery. Patients were characterized as having no improvement
of drooling if the rate was the same as the preoperative level, or worse.
If no overall improvement was noted after surgery, the family or caregiver
was questioned regarding any initial improvement and the interval of time
before relapse occurred. The patients' charts were retrospectively reviewed
to determine operative and postoperative complications and length of postoperative
hospitalization.
RESULTS
The medical records of all children who underwent bilateral SGE with
PDL (N = 93) were available for review. There were no operative complications.
Postoperative complications occurred in 3 patients: 1 had a wound hematoma
in the immediate postoperative period that required evacuation in the operating
room; 1 had significant bilateral swelling of the parotid glands that resolved
spontaneously; and 1 had unilateral infection of the parotid gland that resolved
after a course of intravenous antibiotics.
The average length of postoperative hospitalization was 2.4 days (range,
1-5 days). The families or caregivers of 72 children (77%) were interviewed.
The average time of follow-up was 4.2 years (range, 1-10 years). Significant
improvement in drooling was reported in 47 patients (65%), and no further
drooling was noted after surgery in 15 patients (21%). All the families or
primary caregivers reported that the overall care requirements and quality
of life of the children were improved. There was no long-term postoperative
improvement in drooling in 10 children (14%); however, 2 of the 10 had fewer
lower respiratory tract infections after the surgery. Six of the 10 children
had 1 to 2 months of improvement after surgery, but then the drooling recurred.
Postoperative dry mouth occurred in 7 children, and there was an increase
in dental caries in 2 children.
COMMENT
Various methods have been advocated for the management of drooling in
the pediatric patient. Depending on the severity of the drooling and the patient's
cognitive level, the initial treatment could be nonsurgical, eg, behavioral
programs, biofeedback techniques, physiotherapy, and prosthetic devices. Medical
therapy for drooling that is not controllable by these methods may be initiated
using antihistaminic and anticholinergic agents. However, the long-term use
of these agents may be associated with significant adverse effects.3-4
Surgery is recommended primarily for patients who have profuse and consistent
drooling or significant cognitive impairment, making nonsurgical therapy impractical.5 It is also recommended for those children who continue
to have significant sialorrhea despite appropriate nonsurgical therapy. Several
procedures for surgical control of drooling in children, including destruction
of the parasympathetic control fibers, salivary gland excision, ductal ligation,
ductal rerouting, and various combination procedures, have been reported in
the literature. However, there is significant disagreement regarding their
safety and long-term efficacy.
Parasympathetic denervation is initially successful, but drooling may
return,6 and because of the otological risks,
this procedure is contraindicated in a patient with compromised hearing. Submandibular
duct rerouting has very good results7; however,
the increase in salivary flow to the oropharynx may cause salivary contamination
of the lower respiratory tract. This procedure has few complications, although
ranulas may occur.8 Parotid duct ligation is
commonly performed to control sialorrhea. In contrast, submandibular duct
ligation has not been routinely performed. Ligation of the submandibular duct
may increase the likelihood of calculus formation compared with ligation of
the parotid duct because of the higher alkalinity and viscosity of submandibular
saliva, the higher concentration of calcium and phosphate salts, the longer
duct system, and the stasis that is associated with the orifice being superior
to the gland. Klem and Mair9 recently reported
on their experience with 4-duct ligation in 5 patients. The procedure was
able to control aspiration pneumonia in these patients. No major complications
were noted; however, the period of follow-up was relatively short. Larger
series and longer follow-up periods will be needed to determine the role of
this procedure in the management of chronic sialorrhea.
At our hospital, the preferred treatment for children with drooling
is bilateral SGE with PDL. Removal of the submandibular glands eliminates
resting salivary flow in the majority of children, while ligation of the parotid
ducts eliminates the major source of food-stimulated salivary production.
In our experience, the morbidity associated with this procedure was not significant,
and the hospital stay was relatively short. Significant postoperative swelling
of the parotid glands was quite rare in our series, possibly because of the
use of preoperative and perioperative antibiotic treatment in our patients.
Some authors have suggested that xerostomia, with its associated increase
in dental caries, is a major complication of the surgical procedures to control
drooling.10 However, in our experience, this
was not a significant problem. Most likely, an adequate amount of saliva continues
to be produced from the minor salivary glands, which prevents xerostomia and
dental caries in most of the patients.
As with other authors,2, 11-13
we found that bilateral SGE with PDL was a safe and effective technique. Our
study demonstrates that this procedure is beneficial in the majority of patients
and should be considered an option in cases in which surgical management of
drooling is appropriate.
AUTHOR INFORMATION
Accepted for publication January 8, 2002.
Corresponding author: Yoram Stern, MD, Department of Pediatric Otolaryngology,
Schneider Children's Medical Center of Israel, 14 Kaplan St, Petah Tiqva 49 202,
Israel (e-mail: sterngoldberg{at}bezeqint.net).
From the Departments of Pediatric Otolaryngology, Schneider Children's
Medical Center of Israel, Petah Tiqva, Israel (Drs Stern and Feinmesser),
Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Dr Stern),
and Children's Hospital Medical Center, Cincinnati, Ohio (Mr Collins and Drs
Shott and Cotton).
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ABSTRACT
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