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Drooling is a troublesome condition, especially in children with neuromuscular and intellectual disability. Over the past decade, novel interventions have been trialled to alleviate drooling in the affected children. Kinesio tape (KT) application has shown promising results in controlling drooling in children. We reviewed the literature to determine the outcome of KT application in drooling children. A literature search was conducted from January 1, 1990 to March 2024 by searching several databases over a 1-month period (April 2024) according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome was defined as the success of the intervention determined by the improvement or resolution of symptoms, and the secondary outcome was determined by adjunct or repeated procedures and the presence of complications. Overall, 172 children from 10 studies were identified. All studies included are retrospective studies (Level III). This review included 172 children, with a mean age of 8.2 years (Male: 58.7 %). All included children had underlying comorbidities (100 %), with neurological disorders (77 %) being the most prevalent. KT application was performed predominantly over the orbicularis oris in 6 studies, 118 children[68.6 %], suprahyoid region in 3 studies, 45 children (26.2 %) and multiregion over the head and neck in 1 study of children (5.2 %). Drooling was assessed subjectively in all 100 % of children with objective measurement performed in 3 studies. KT was the only intervention in 40.7 % of the included children, whereas KT was performed in combination with oromotor therapy in 48 children, speech therapy in 44 children, and manipulation therapy in 10 children. All included children (100 %) reported improvement in drooling. No studies reported adverse reactions to KT application. KT application is a safe, effective alternative for drooling children. The effect of KT, however, may be temporary. The quality of the evidence is inadequate to recommend widespread use of the intervention until a better-quality study has been completed. Future randomised controlled studies with a large sample size are warranted to determine the efficacy of this intervention among children. [ABSTRACT FROM AUTHOR]

To describe the effects of salivary gland Botulinum Toxin-A (SG BoNT-A) on children with drooling due to neurological dysfunction. This was a 3½-year prospective observational case series design of children referred for SG BoNT-A injections at a pediatric hospital (2010–2014). Outcomes were parent-reported severity, frequency, impact of drooling, and respiratory morbidity; and, from hospital records, number of respiratory hospital admissions. Out of 17 children treated, complete data were available for 15 (including 8 boys) aged 3–14 years (Mean = 9.9 years; SD = 3.4), with a combined total of 71 injections. Most had cerebral palsy (n = 11), classified as Level V (n = 10) or IV (n = 1) on the Gross Motor Function Classification Scale (GMFCS). In almost all instances, parents reported reductions in severity, frequency, and impact of drooling, and parent-reported respiratory morbidity. Among those with posterior drooling (n = 12), most children (n = 10) did not have advanced respiratory disease. A trend towards reduced respiratory-related hospital admissions was observed during SG BoNT-A treatment periods. SG BoNT-A can improve severity, frequency, and impact of drooling. It can also reduce respiratory-related hospital admissions in children with posterior drooling without advanced respiratory disease. For children with advanced respiratory disease, it may reduce severity and impact of drooling. [ABSTRACT FROM AUTHOR]

To evaluate if drooling recurrence after surgery of the submandibular ducts is due to surgical failure or other variables. Historic cohort with prospective collected data of all patients with severe drooling who underwent unsuccessful submandibular duct surgery with subsequent re-intervention between 2003 and 2018. A reference cohort was used for comparison of clinical variables. Six males and 4 females were included (cerebral palsy n = 8 , neurodevelopmental disorders n = 2). All patients underwent submandibular gland surgery as a primary intervention (duct ligation n = 8 , submandibular duct relocation n = 2) followed by re-intervention (submandibular gland excision n = 7, parotid duct ligation n = 3). One patient underwent tertiary surgery (parotid duct ligation after re-intervention by submandibular gland excision). Three patients were successful after re-intervention. No difference was found between both re-intervention techniques. There was significantly more severe dental malocclusion (50% vs. 21%, P value = 0.047) and severe speech disorders (80% vs. 42%, P value = 0.042) in the current cohort when compared to the reference cohort. Recurrence of drooling surgery is most likely not caused by surgical failure of the primary intervention, because re-intervention (submandibular gland excision) did not lead to more success. Dysarthria and dental malocclusion might negatively influence treatment outcome. [ABSTRACT FROM AUTHOR]

Abstract Objective Sialorrhea complicated by aspiration is a primary source of morbidity and mortality in neurologically impaired children. Anticholinergics are an effective treatment option, but have traditionally been considered only adjuncts due to tachyphylaxis and drug tolerance. Similarly, Botox-A® salivary gland injections are also considered adjunctive due to the need to repeat treatment every 3 months. This retrospective case series assessed these two adjunctive strategies used in combination as definitive minimally invasive primary treatment. Methods 112 subjects diagnosed with sialorrhea and treated at UPMC Children's Hospital of Pittsburgh between 2004 and 2011 were identified. Charts were carefully reviewed for pertinent information regarding the treatment of their sialorrhea and related outcomes. Results Over half of the subject undergoing BTX-A injections were able to reduce their dosage of anticholinergics after receiving injection (58%, n = 28 for glycopyrrolate users and 61%, n = 20 for scopolamine users). Subjects experienced a significant reduction in days spent in the hospital in the year following Botox-A® injection (P-Value = 0.03), and the number of pneumonia episodes in the year following injection (P-Value = 0.04). Conclusion Patients treated effectively with both BTX-A injections into their salivary glands and anticholinergics developed neither tachyphylaxis nor drug tolerance with up to 9.6 years of continuous treatment. During the year following combined therapy, patients' average length hospital stay was reduced by a full week and the number of pneumonia episodes was statistically decreased. The failure rate of combined therapy was below that reported for any other intervention or combination of interventions in the literature. Finally, patients did not require BTX-A re-injection at the reported frequency. We hypothesize that anticholinergic medications competitively block acetylcholine attachment to post-synaptic receptors while BTX-A inhibits acetylcholine release at the pre-synaptic terminal, tachyphylaxis/drug tolerance mechanisms resulting in up-regulation of post-synaptic receptors are disrupted. Although salivary production may increase in the year following BTX-A injection, there is enough remaining activity at a molecular level to inhibit release of acetylcholine allowing salvage with anticholinergic medications at tolerable dosages. [ABSTRACT FROM AUTHOR]

Abstract Introduction Drooling of saliva is the unintentional loss of saliva from the mouth resulting in excess pooling of saliva in the anterior portion of the oral cavity. It is considered normal in infants and usually resolves itself by 15–18 months of age. It is a common problem in pediatric patients with cerebral palsy or other neurological disorders. Drooling interferes with speech, impairs oral hygiene and contributes to oral dermatitis, aspiration pneumonias and fluid electrolyte imbalances. It has a profoundly negative impact on quality of life and contributes to social exclusion, self-esteem problems and significant discomfort, especially amongst school-aged children. In addition, it can present a serious challenge for caregivers. Various approaches to manage this condition have been described in the literature. Submandibular duct relocation allows salivary flow and is the surgical approach undertaken by the authors. Objectives The aim of this study is to share our experience with the surgical approach to drooling children and to evaluate clinical outcomes and long-term caregiver satisfaction outcomes. Methods The authors conducted a retrospective study with a review of the medical records of 43 children and adolescents who had been submitted to submandibular duct relocation in the Centro Hospitalar Tondela-Viseu, between January 2003 and December 2017. The authors analyzed the clinical history, bibs used per day before and after surgery, and caregivers' satisfaction was assessed by interview using a questionnaire. The results of this procedure, technical considerations and outcomes are presented in this work. Results Forty-three patients (15 girls and 28 boys), between the ages of 3 and 18 at time of surgery (mean age of 9), underwent bilateral submandibular duct transposition for drooling. All children have neurological disorders, with cerebral palsy being the predominant diagnosis. The majority were hospitalized for 1–2 days and no surgical complications were observed. The number of bib or clothing changes fell from more than ten in 23 patients (53%) pre-operatively to less than five in 33 patients (77%) post-operatively. 30% of caregivers were satisfied and 53% were very satisfied with the results of surgery. Conclusions The results of this study show that submandibular duct relocation is an effective method in the resolution of uncontrolled drooling in children, contributing to the improvement of children's quality of life. The degree of satisfaction with the surgical results is in agreement with the published international studies, proving once again the effectiveness of the surgical technique implemented in our Hospital. [ABSTRACT FROM AUTHOR]

Background Drooling of saliva is a common problem in children with cerebral palsy. In addition to causing impairment in articulation, drooling also affects socialization, interpersonal relationships and integration into society for these children. There are various methods to assess drooling which measure directly the amount of saliva drooled. However the most convenient and popular method is the use of questionnaires which are mostly western based and need slight modification for the Indian scenario Aim-Validation of a modified questionnaire for the assessment of drooling in children with cerebral palsy. Method The modified questionnaire was administered to parents of children with cerebral palsy willing to participate in the study. The drooling score was compared with objective tests, namely cotton pad test and drooling quotient. Internal consistency was assessed using the Cronbach's alpha, test retest reliability by Intraclass Correlation and sensitivity analysis by the Receiver operating characteristic curve. Results The modified questionnaire was found to be easy to administer. The Cronbach's alpha coefficient was between 0.867 and 0.879 which implies a high degree on internal consistency. The intraclass correlation and the test retest reliability was found to be statistically significant with a p value < 0.001 which show that the questionnaire was highly reliable for repeat administration as well as administration by different investigators. The ROC Area was found to be 0.94 with a standard error of 0.02 with a 95% confidence interval of 0.88–0.99, which suggests that the score has great specificity, closer agreement between specificity and sensitivity and excellent precision. Conclusion Our modified questionnaire was easy to administer, highly reliable and valid with high internal consistency. A score of 24 on the questionnaire was found to be the most sensitive and specific point to discriminate between the mild and severe droolers in children with cerebral palsy. [ABSTRACT FROM AUTHOR]

Objective To evaluate the efficacy of Castillo Morales Appliance Therapy (CMAT) in reducing the severity and frequency of problematic drooling in children. Methods A de-identified extraction of all hospital morbidity records belonging to patients with drooling who underwent treatment with CMAT was performed between June 22, 2000 and April 12, 2016. Data were obtained from Starship Children's Hospital clinical records department. Demographic, diagnostic, and procedural data were included. Severity and frequency of drooling was quantified using the Thomas-Stonell and Greenberg classification method. Results There were fifty-three children less than 17 years of age who were treated with CMAT for the indication of problematic drooling between June 22, 2000 and April 12, 2016. 72% (n = 38) of patients had a reduction in the severity and frequency of drooling with CMAT. Mean follow up was 51 months. These patients did not require further treatment for drooling with botulinum toxin or surgery. Within this group, 63% (n = 24) of patients had significant improvement in drooling as per the Thomas-Stonell and Greenberg classification method (p = 0.024). Conclusions Children who underwent CMAT for drooling were less likely to require further treatment with botulinum toxin or surgery. This result suggests that the use of CMAT in children with problematic drooling confers benefit. [ABSTRACT FROM AUTHOR]

To provide guidance for the comprehensive management of children referred for anterior drooling. The mission of the International Pediatric Otolaryngology Group (IPOG) is to develop expertise-based recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. Survey of expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The recommendations are derived from current expert consensus and critical review of the literature. Consensus recommendations include initial care and approach recommendations for health care providers who commonly evaluate children with drooling. This includes evaluation and treatment considerations for commonly debated issues in drooling management, initial work-up of children referred for anterior drooling, treatment recommendations, indications and contra-indications for rehabilitation, medical, and surgical management, as well as pros and cons of different surgical procedures in the hands of drooling management experts. Anterior drooling consensus recommendations are aimed at improving patient-centered care in children referred for sialorrhea. [ABSTRACT FROM AUTHOR]

Submandibular gland excision (SMGE) is suitable for the management of drooling in patients with non-progressive neurodisabilities. We aimed to investigate the long-term effects of SMGE. Patients who had SMGE between 2007 and 2018 were included. Main outcomes were a Visual Analogue Scale (VAS), Drooling Severity (DS), and Drooling Frequency (DF) collected at baseline, 8 weeks, 32 weeks and with a median of 313 weeks after SMGE (long-term). Secondary outcomes were satisfaction with the procedure, Drooling Quotient (DQ) and adverse events (AEs). We included thirty-five patients in the long-term analysis with a mean age of 14.5 years. A baseline VAS score of 80.4 was found, which improved on the long-term (mean difference −21.8, t (26) = 4.636, p < 0.0005)). DS and DF decreased significantly at the long-term compared to baseline (Z = −4.361, p < 0.0001 for DS, Z = −3.065, p = 0.002 for DF). Twenty-three out of 35 (66%) patients would recommend the procedure to peers. This study indicates a long-term stable effect on drooling after SMGE in patients with anterior drooling. Recurrence of drooling occurs due to unknown reasons, nevertheless most caregivers and/or patients are still satisfied and would recommend the procedure to others. [ABSTRACT FROM AUTHOR]

Purpose Moebius Syndrome is a rare congenital neurological condition often characterized by multiple cranial nerve involvement. This case study presents an eight-year old girl with Moebius Syndrome (MC) who received 30 sessions of speech therapy. This occurred after presenting to clinic 11 months after left facial reanimation with gracilis thigh muscle transfer surgery. On examination, only flickers of left facial movement were observed. There was no movement on the right side of the face. As a consequence of the minimal movement, MC presented with drooling and unintelligible speech. The purpose of speech therapy was three fold: minimise the pooling of saliva, improve the placement of the articulators so that articulation of speech sounds would be more accurate, and gain advances in overall intelligibility. Methods Therapy focussed on speech, facial movement and saliva management using a combination of speech drills, evidence-based articulation therapies, facial exercises with surface electromyography biofeedback, self-awareness training and compensatory saliva management strategies. Results After a course of 30 one-hour speech therapy sessions, substantial improvements were seen in speech sound accuracy, overall intelligibility, facial movement and saliva control. Conclusions The combination of surgery and speech therapy led to functional gains that surgery alone did not achieve. The impact of speech therapy on surgical outcomes in individuals with Moebius syndrome deserves further investigation. [ABSTRACT FROM AUTHOR]

Objective To determine the effectiveness of submandibular salivary gland Botulinum Toxin Type-A (BTX-A) injection in the treatment of drooling in children with varying degrees of neurological dysfunction. Methods A retrospective review of pre- and post-procedure drooling frequency and severity scores of patients receiving BTX-A between January 2008 and January 2013. Stratification to different subgroups of neurological impairment was performed according to Gross Motor Function Classification System (GMFCS) score. Drooling severity was assessed using Thomas-Stonell and Greenberg symptom questionnaires administered at time of initial consultation and 3 months after treatment. Results 48 sets of BTX-A injections in 26 patients with an average age of 9.45 years (range 7 months–18 years) were included in the study. Marked improvement in drooling was seen in 60.4% of patients, a marginal or brief improvement was seen in 20.8% and there was no improvement in 18.8%. No adverse events were reported following any of the BTX-A injections. BTX-A was safe and effective in the eight patients with pre-existing swallowing dysfunction. Subsequent drooling surgery was performed in 15 (57.7%) of the cohort, all 15 patients responded to BTX-A injections. In patients with Cerebral Palsy, there was no correlation between the severity of the neurological dysfunction as measured by the Gross Motor Function Classification System (GMFCS) score and the response to BTX-A treatment. Conclusions Injection of BTX-A to the submandibular glands of children with neurological disorders is a safe procedure and results in a reduction in drooling in the majority of patients. Children with severe neurological dysfunction respond to BTX-A injections as effectively as their less impaired peers and the degree of response does not appear to be associated with the severity of neurological disability. BTX-A injection is a good initial procedure when drooling surgery is being considered. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to evaluate the impact of a reduction in drooling after bilateral submandibular duct relocation (SMDR) with sublingual gland excision on daily life and care, as well as social and emotional consequences in children and adolescents with neurodevelopmental disabilities. Methods This prospective cohort study included 72 children and adolescents (46 males, 26 females) with moderate to severe drooling, and their caregivers. Mean age at the time of surgery was 15 years 2 months (SD 4y 3mo). Fifty-two children were diagnosed with cerebral palsy and 20 had other non-progressive developmental disabilities. A caregiver questionnaire to document the impact of drooling on daily care and economic consequences, social interaction and emotional development and self-esteem was administered before, and 8 and 32 weeks after surgery. Results Following bilateral SMDR the mean Visual Analogue Scale (VAS, 0–100) scores demonstrated a significant (p < 0.001) reduction in the severity of drooling from 81 at baseline to 28 and 36 after 8 and 32 weeks, respectively. This was accompanied by a decrease in the amount of daily care required and reduced economic consequences. In addition, an increase in social contact with other children and adults was reported by caregivers after surgery. Conclusion Bilateral SMDR with sublingual gland excision provides a significant positive reduction in daily care of children suffering from drooling. Caregivers also report positive changes in their child's social interaction and sense of self-esteem. [ABSTRACT FROM AUTHOR]

Objectives Sialorrhoea (drooling) is defined as the involuntary escape of saliva from the mouth. It is considered normal in young children but may cause social problems in older children. Sialorrhoea is frequently seen in children with cerebral palsy, with rates between 10% and 58% and in other neurodevelopmental diseases. Management of these children can be challenging and often requires an individual and stepwise approach. This is a large case series of children managed at the saliva control clinic in Glasgow, Scotland. Methods A chart review of all children attending the saliva control clinic between 2006 and June 2012 was performed. This was to ensure that all children would have long term follow up (3 years minimum). Drooling severity was assessed on the child's first attendance at clinic, and at review following a treatment option, using the Teacher Drooling Scale (TDS). Results The total number of children attending this clinic was 301, of which 274 had adequate records for inclusion in the study. 176 (64%) were male. The mean age was 7.3 (median 5) years. In terms of development 35 (13%) of children were developing normally and 50 (18%) had general developmental delay. There were 105 (38%) children with cerebral palsy. The final management of sialorrhoea in these children was simple reassurance and advice for 34 (12%), speech and language therapy for 62 (23%) anticholinergics in 90 patients (33%), botox for 30 (11%) and surgery for 71 (26%) children. The rate of non-tolerance of anticholinergics is 30%; 90 of the 298 children tried on anticholinergics had side effects leading to the treatment being stopped. The average teachers drooling score was 4.24 before clinic and 1.59 after clinic. Satisfactory results were achieved in 215 (78%) of children. Conclusion Our data illustrates that effective patient management requires all treatment options to be available, including speech therapy, medications, botulinum toxin and surgery. This is one of the larger case series of children attending a saliva control clinic. [ABSTRACT FROM AUTHOR]

Objectives Neurologically impaired children often drool and aspirate saliva leading to recurrent aspiration pneumonia and frequent hospitalizations. Salivary botulinum toxin injection is known to reduce sialorrhea. This study evaluates whether this intervention affects the frequency and duration of respiratory infections including aspiration pneumonia and hospitalizations in neurologically impaired children. Methods Retrospective review of patients treated with salivary botulinum toxin at a tertiary care pediatric hospital from January 2009 to December 2013. Each patient was their own control and 180 day pre-injection and post-injection time periods were compared. Outcomes evaluated included: number of hospital days, intensive care unit days, days of antibiotic treatment, chest X-rays, and infiltrates on chest X-ray. Results 13 patients accumulated 539 hospital days. All children were gastrostomy tube dependent. 54% were tracheostomy tube dependent. Amongst all patients, the total hospital days decreased from 385 to 154 ( P = 0.02), the mean days treated with antibiotics decreased from 214 to 47 ( P = 0.02), and the number of chest X-ray confirmed infiltrates decreased from 20 to 6 ( P = 0.02) after injection. Conclusion In this review, there was a decrease in hospitalized days, antibiotic usage, and chest X-ray infiltrates after the salivary botulinum toxin injection. A prospective study is needed to evaluate whether this treatment can prevent aspiration pneumonia in neurologically impaired children. [ABSTRACT FROM AUTHOR]

To determine the patient demographics and the efficacy and safety profile of botulinum toxin (BTX) injections for sialorrhea control in patients under the age of three. This is a retrospective chart review study. Patients under three years of age who received BTX injections for sialorrhea management from 2010 to 2021 were assessed. Patient demographics, comorbidities, medical and surgical histories, indications, BTX injection details, and post injection complications were documented. Forty-nine patients met inclusion criteria. The most common patient under three years of age with sialorrhea to receive BTX injections were white (51.0%) male (51.0%) with congenital (73.5%) and/or neurologic (53.1%) comorbidities. Thirty-six (73.5%) patients were from medically underserved areas/populations. Our patients on average received 1.7 injections, with 44.9% requiring multiple BTX injections. Bilateral parotid and bilateral submandibular glands (four-gland) BTX injections were associated with significant decrease in admissions for pneumonia and cessation of anticholinergics usage (both P < 0.05). Post BTX injections, 15 (30.6%) patients required additional surgeries for sialorrhea control. No adverse outcomes due to BTX injections were reported. Pediatric sialorrhea was commonly associated with congenital and/or neurologic comorbidities and disproportionately impacted medically underserved black patients. BTX injections offered multifaceted benefits for controlling sialorrhea in patients under the age of three. Four-gland BTX injections led to reduction of unnecessary hospitalization, usage of anticholinergics, and additional surgeries for sialorrhea management. • Patients with sialorrhea often have multifactorial risk factors, warranting comprehensive assessment and treatment plans. • Botulinum toxin injections may be beneficial for reducing sialorrhea induced pneumonia and its related hospitalizations. • Botulinum toxin injections are beneficial for weaning patients off anticholinergics and for reducing associated side effects. • Nearly 2/3 of patients post botulinum toxin injections do not require additional surgeries for sialorrhea control. • Botulinum toxin injections are safe and effective for sialorrhea management for patients less than three years of age. [ABSTRACT FROM AUTHOR]

Objective This study is the first in the literature to characterize and detail the clinical and surgical experience of one of the few multidisciplinary salivary gland disorder clinics in North America. Methods This is a retrospective chart review of a descriptive nature, including patient information from February 2013 to August 2014. The Salivary Gland Disorder Clinic (SGDC) is located at Nationwide Children's Hospital, a public academic hospital. All patients seen at the SGDC were included in this study, 54 in total. Patients were seen for any salivary gland disorder presentation, ranging from sialorrhea to glandular masses. Results A total of 70.4% of patients presented to the SGDC with a chief complaint of sialorrhea. Nearly 28% had previously experienced documented aspiration, and drooling severity and frequency was 4.06 and 3.3 on the Thomas-Stonell and Greenberg Drooling Rating Scales. 50% of patients presented with neurologic comorbidities and 25.9% with aerodigestive tract anatomic defects. Over 35% of patients had previously attempted medical treatment and 31.5% had no prior treatment attempts. 87% of all patients were offered further treatment options, including interventional, surgical, medical, and conservative measures. Conclusions Pediatric salivary gland disorders, especially sialorrhea, can profoundly impact overall health and quality of life. Appropriate management of this symptom requires expert training and knowledge of the upper aerodigestive tract anatomy and appropriate treatment modalities. Our study demonstrates that there is community need for a centralized salivary gland disorder clinic given the complex comorbidities and social challenges that face this population. Many patients present with great risk for aspiration-related complications and the vast majority are offered new treatment options. [ABSTRACT FROM AUTHOR]

Objectives The aim of this study is to evaluate the correlation of the Drooling Quotient (DQ) score with the questionnaire-based Drooling Severity and Frequency Scale (DSFS) and the number of bib changes in a day. It is hypothesized that there is a significant positive correlation between these methods of assessment. Methods Using a prospectively collected database from a cohort of one hundred and fifty five children referred to our saliva management clinic, a comparison of the following three measurements was made to assess the level of correlation between them: (1) Drooling Quotient (DQ) (performed in two 10-min sessions), (2) Drooling Severity and Frequency Scale (DSFS) (as judged by parents or caregivers) (3) number of bib changes (as reported by parents or caregivers). Results The results showed that there is a high level of agreement between the Drooling Quotient and the Drooling Severity and Frequency Scale. However, the Drooling Quotient and number of bib changes did not show significant correlation. Conclusions The Drooling Severity and Frequency Scale (DSFS) has been shown to be a quick and accurate measure of drooling that can be used to help guide clinical management of drooling, particularly in patients who are unable to undergo the Drooling Quotient assessment. [ABSTRACT FROM AUTHOR]

Objectives There is no literature about the average size of the salivary glands in the pediatric population with drooling (sialorrhea). Studies have shown that some pathologies affect the functionality of the salivary glands. We assessed via ultrasonography the sizes of the submandibular and parotid glands in 9 healthy children who were not suffering from local or systemic diseases that could affect the salivary glands. We also compared this group with a group of 9 patients with sialorrhea. Methods Volunteers were matched based on age, gender, and BMI. Body weight did not differ more than 20% from ideal weight. The parotid and submandibular glands of 9 patients with sialorrhea without any previous treatment were measured via ultrasound and matched to a healthy control. Children with various causes for drooling were included (neurological disorders, neuromuscular disorders, lack of oral motor control). Results Dimensions of the parotid glands in drooling and healthy patients were: surface area 2.96 cm 2 (SD ±0.90) and 2.81 cm 2 (SD ±0.54); in depth 1.68 cm (SD ±0.24) and 1.61 cm (SD ±0.27); in the axis longitudinal to the horizontal mandibular ramus 3.18 cm (±0.46) and 3.15 cm (SD ±0.45) in drooling and healthy groups respectively. The means of submandibular glands of drooling and healthy patients measured in surface area: 3.20 cm 2 (SD ±0.66) and 3.08 cm 2 (SD ±0.65); anterior–posterior length 1.55 cm (SD ±0.23) and 1.46 cm (SD ±0.23), medio-lateral length 3.07 cm (SD ±0.39) and 3.07 cm (SD ±0.32). There was no statistical significance in comparison with the healthy group control. Conclusion The parotid and submandibular salivary glands in the pediatric population do not differ in size in children with or without drooling. Measuring the glands at baseline and post treatment with botulinum toxin injections allows one to evaluate if there are changes in the gland related to the treatment. [ABSTRACT FROM AUTHOR]

Aim of the study Sialorrhoea and chronic salivary aspiration are a major problem in many neurologically impaired children causing embarrassment, skin issues and recurrent lower respiratory tract infections (LRTI). The aim of this study was to assess the efficacy of salivary gland surgery in the treatment of chronic salivary aspiration in such children. Objectives To compare admission rates for LRTI per annum before and after surgical intervention. Methods Retrospective review of all patients who underwent salivary management surgery for chronic aspiration under Princess Margaret Hospital's (PMH) Otolaryngology department from 2006 until 2013. Results Twelve patients were included in this review. Their ages ranged from 3 to 21 years (mean = 11.4). Their genders were equally distributed. Two patients had underlying congenital disorders; one had an acquired brain injury, while the majority ( n = 9, 75%) had cerebral palsy secondary to a sustained perinatal injury. Most patients ( n = 11, 91.7%) had bilateral submandibular gland excision and parotid duct ligation as a primary procedure. One patient had a laryngotracheal separation. Two patients went on to have a second procedure. The mean follow up time was five years. Using Wilcoxon Signed-Rank test we showed that the median rate of admission per annum for LRTI pre-operatively was 1.0. This was reduced to 0.5 post-operatively, which was statistically significant ( p ≤ 0.05). Conclusions We hypothesize that the combination of bilateral submandibular gland excision and bilateral parotid duct ligation is effective in reducing admissions with aspiration pneumonia in neurologically impaired children, and therefore improves the quality of life in these patients. [ABSTRACT FROM AUTHOR]

Drooling occurs commonly in children below the age of two. In a small group of children this persists and an otorhinolaryngology consultation is sought. In children with no neurological abnormality or comorbidity, reassurance and behavioural management is often suggested. We present a case where drooling was the presenting feature of brain stem malignancy. Diagnosis was suggested following a sleep study demonstrating central apnoeas. Magnetic resonance imaging (MRI) showed an intra-axial brainstem tumour. This case highlights the importance of multidisciplinary team (MDT) management of children with persistent drooling of unknown cause. [ABSTRACT FROM AUTHOR]

Background Chronic sialorrhea is a common problem for pediatric patients with disorders that affect swallowing. While many patients are successfully treated with medical therapies such as Robinul and Scopolamine, a number of such children are not able to tolerate the side effects of these medications. In these cases, surgical treatments can include Botulinum toxin A (Botox) injections into the major salivary glands, sublingual or submandibular gland excision (SMGE), submandibular duct ligation, parotid duct ligation (PDL), or any combination of the above procedures. The purpose of this study is to report on the 10-year experience with the surgical management of chronic sialorrhea at one tertiary care institution, and compare the efficacy of open surgical procedures versus Botox injections for reduction in salivary flow. Methods A retrospective chart review identified 27 pediatric patients with chronic sialorrhea; 21 of whom underwent Botox injections and 15 of whom underwent surgical procedures. Preoperative and follow-up clinic notes were reviewed to determine the level and severity of drooling as well as the effectiveness of sialorrhea reduction, as assessed by the Teacher Drooling Scale (TDS). Results 42% of those receiving Botox injections reported a reduction in drooling, with the average pre- and post-Botox TDS of 4.3 and 3.9, respectively (p = 0.02 by the Wilcoxon signed rank test). Nine of the patients receiving Botox injections (43%) required multiple injections, with an average duration of effect of 3.9 months, and 7 patients (33%) eventually required surgery. All of the children who underwent surgery (7 bilateral SMGE with PDL, 6 SMGE only, and 2 PDL only) experienced a reduction in drooling, with average pre- and post-operative TDS of 4.5 and 2.2, respectively. This reduction was significant by the Wilcoxon signed rank test (p = 0.001). Conclusions The ten-year experience at our institution demonstrates the safety, efficacy and long-term control of drooling in the patients undergoing surgery for intractable sialorrhea. [ABSTRACT FROM AUTHOR]

Drooling is an unintentional spillage of saliva, which can be caused by any condition that affects the neuromuscular control of mouth muscles. There are different treatments for drooling, some of which are novel therapies with unknown efficacy like Kinesio Taping (KT). This study aimed to investigate the effects of adding KT to oral-motor training (OMT) on drooling in children with intellectual disability. This is a double-blind randomized controlled trial in which 18 children with intellectual disabilities participated through convenience sampling. Participants were randomly assigned into 2 groups by block randomization method. Kinesio taping of orbicularis oris, supra-hyoid and masseter muscles and routine OMT were performed for the intervention group. The control group received taping with no stretch as placebo. Pre-post assessment was carried out after four weeks of intervention by the drooling rating scale (DRS) and drooling quotient (DQ) test. Within-group analysis showed a significant reduction in drooling post-intervention in both groups based on DRS and DQ (p < 0.001). Between-group analysis indicated a significant improvement in the intervention group (P = 0.008) with moderate effect size using DQ assessment but this difference was not significant with moderate effect size based on parental reports using DRS. DQ assessment revealed that using KT plus OMT can produce greater improvement than sham taping plus OMT. However, there was not a statistically difference between the two groups based on parental reports using DRS. In addition, within-group analysis showed that drooling reduced in both groups after the intervention both based on DRS and DQ assessments. It can be concluded that adding taping with and without stretch to OMT can be considered as a complementary method to mitigate drooling in children with intellectual disabilities. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To evaluate the sclerotic effect of bleomycin on the submandibular gland histopathologically and assess it as a possible alternative therapy for sialorrhea. Methods: An experimental model was designed and 18 New Zealand white rabbits were used. The rabbits were divided into two groups: a bleomycin group (n =9) and a sham group (n =9). The submandibular glands of the bleomycin group were injected with 0.3ml bleomycin (3mg/ml) while the sham group received 0.3ml saline. Four weeks after the procedure, the glands were removed. Histopathological studies including hematoxylin–eosin and Masson's trichrome stain were carried out. The glands were evaluated for tissue inflammation, fibrosis, edema, lipomatosis, atrophy and congestion. To investigate apoptosis, terminal deoxynucleotidyl transferase (TdT)-mediated digoxigenin-11-dUTP nick-end labeling (TUNEL) immunohistochemical staining was used. Results: In the group injected with bleomycin, inflammation (n =8), edema (n =4), fibrosis (n =3), congestion (n =4) and lipomatosis (n =7) were observed. In the sham group, only lipomatosis was observed. The TUNEL assay results were 5.06±1.18 (p <0.05) for acinar cells and 8.46±0.82 (p <0.05) for ductal cells in the bleomycin group. This was significantly different from the results in the sham group. Conclusions: Apoptosis, inflammation, fibrosis, edema, lipomatosis and congestion were observed in the ductal and acinar cells of the bleomycin group. Bleomycin may be an alternative treatment for sialorrhea cases. However, more research is needed. [Copyright &y& Elsevier]

Abstract: Background: Sialorrhea can have major negative effects on the physical and social well-being. Sclerotherapy may be useful in patients with sialorrhea by decreasing the amount of saliva production. The aim of this study was to test the effect of ethanolamine oleate (EO) in an experimental model as a preliminary step for its application in humans. Methods: Histopathological and morphometric analysis of submandibular glands from thirteen dogs was preformed. A total of 25 glands were injected with 1ml of 2.5% EO (n =5), 1ml of 5% EO (n =5), 5ml of 2.5% EO (n =5) and 5ml of 5% EO (n =5). Five glands were used as control. Results: EO significantly induced a dose dependent scaring of the gland ending in lobular transformation (salivary gland cirrhosis). Morphometric measurements showed that 1ml of 2.5% or 5% EO significantly induced fibrosis compared to normal glands (p =0.014 and 0.021, respectively). Fibrosis significantly increased and was more apparent when a dose of 5ml of 2.5% EO or 5% EO were injected [by semi-quantitative evaluation (p =0.016 and 0.002, respectively) and morphometric measurements (p =0.016 and 0.008, respectively)]. This scarring effect was significantly associated with reduction of area of acinar cells when a dose of 1ml–5%, 5ml–2.5% or 5ml–5% EO were applied (p =0.03. 0.012 and 0.004, respectively). Moreover, ductal injury was only significant when a dose of 5ml of 5% EO was used (p =0.034). This dose and concentration (i.e. 5ml–5% EO) had a significant synergetic effect [p =0.0119]. Conclusion: In this model, treatment with EO proved to permanently reduce the acinar area through induction of progressive, irreversible and dose dependant scarring (medical sialoadenectomy). [Copyright &y& Elsevier]

Abstract: We describe an unusual localization of methicillin-resistant Staphylococcus aureus infection (MRSA) in a very young newborn. A 3-week-old male infant was admitted with fever, irritability, sialorrhea and stiffed left neck. The ENT examination revealed a deep neck mass and an ultrasound examination showed diffuse swelling of the left latero-pharyngeal area. A CT examination confirmed a deep neck abscess with difficult-to-define borders. Blood and nasopharyngeal cultures returned positive for MRSA. Treatment was started with intravenous teicoplanin and continued for 14 days with a marked decrease in abscess''s dimensions and improvement in patient''s general condition. MRSA should be suspected in the etiology and treatment of neck abscesses in newborns, infants and young children. [Copyright &y& Elsevier]

Summary: Introduction: Various surgical techniques are used to manage problematic drooling. These include: (1) re-routing of the submandibular ducts/excision of the sublingual glands (group 1), (2) excision of the submandibular glands/parotid duct ligation (group 2), and (3) ligation of the parotid and submandibular ducts (group 3). Purpose: To compare the long-term effectiveness of three surgical techniques and to evaluate long-term caregiver satisfaction. Setting: Tertiary care children’s hospital. Study design: 10 year retrospective chart review and telephone follow-up questionnaire. Methods: Demographic data, drooling severity, medical management and surgical outcomes using objective severity ratings were evaluated. Satisfaction scores were obtained by phone interview. Results: 33 patients, 19 male and 14 female, age 1.1–27.6 years (mean 9.4±4.9) underwent surgery. Six patients were in group 1, 14 in group 2 and 13 patients in group 3. There was no difference in age, sex or severity of drooling among groups. Mean follow-up was 4.5 years (range 1.1–10 years). Post-operative anti-cholinergic use was most common in group 3 (53%) compared to 21% in group 2 and 33% in group 1. Overall caregiver satisfaction for each group was 83% for group 1, 79% for group 2, and 30% for group 3. Gradual return of drooling occurred in 8 of 13 (61%) patients in group 3 and resulted in dissatisfied caregivers. Conclusions: Although recent literature advocates four-duct ligation, our long-term results do not appear favorable. Reasons for this failure and strategies for avoidance are discussed. [Copyright &y& Elsevier]

Abstract This study aims to evaluate the medium to long-term (1–12 years) effectiveness of two-duct ligation (2-DL) in patients with nonprogressive neurodisabilities. Main outcomes included a Visual Analogue Scale (VAS), Drooling Severity (DS) and Drooling Frequency (DF), collected at baseline, 32 weeks postintervention and 1–12 years postintervention. Secondary outcomes were adverse events (AEs), and satisfaction. Forty-two patients were analyzed (mean age 17 years, mean baseline VAS 82). VAS decreased significantly from baseline to long-term (n = 30. Mean difference −36.5, CI -47.0 to −26.0, p ≤ 0.001; −26.1, CI -36.2 to −15.9, p ≤ 0.001). However, long-term VAS significantly increased compared to VAS at 32 weeks (+10.4, CI 1.0–19.8, p = 0.031). Out of 42 patients, 64% would recommend 2-DL to peers. There is a significant subjective 2-DL effect on drooling severity in the medium to long-term as reported by patients and caregivers, but there is also a certain degree of recurrence in this time span, and 33% of the patients required subsequent treatment. However, the majority of patients and/or caregivers would recommend 2-DL to peers. [ABSTRACT FROM AUTHOR]

Summary: Objective: The objective of this paper is to report the experience of a multidisciplinary team (otolaryngologist, speech-language pathologists, pediatric dentist, and social worker) functioning at a pediatric rehabilitation center have had in the management of 1487 neurologically challenged individuals with saliva control issues assessed from 1976 to the end of 2004. Method: The role of each team member is outlined. Management decisions have consisted of no treatment, utilization of oral-motor training program, elimination of contributing situational factors, utilization of medication, surgery and Botox® injections of the major salivary glands. Results: Oral-motor programs to improve oral-motor function is essential initially if there is patient compliance. Surgery was recommended in the majority of patients. Submandibular duct relocation with simultaneous sublingual gland excision remains the procedure of first choice for persistent significant drooling. Aspiration is much less common than drooling and is more problematic to treat. Simultaneous ligation of the submandibular and parotid ducts (aka 4-duct ligation) is promising. A recent initiative to inject the major salivary glands with Botox® is being evaluated. Conclusions: Team evaluation with consensus decision making has worked well in this patient population with complex medical conditions. [Copyright &y& Elsevier]

Objective: To obtain reference data on the unstimulated salivary flow rate in healthy 6–11-year-old boys and girls, for use in the treatment of drooling in mentally and physically handicapped children. Methods: Under standard conditions unstimulated saliva was collected from 62 healthy children using the swab method. Flow rate was determined by calculating the increase in weight of cotton rolls placed in the mouth for 5 min. The influence of the variables age, gender and type of gland were evaluated. Results: No significant difference was found between the flow rate in boys and girls or between the children in this age window. The swab method showed good reproducibility. The right and left parotid glands had equal flow rates of 0.15 ml/min. The flow rate in the floor of the mouth secreted by the submandibular and sublingual glands was 0.32 ml/min. Conclusions: In healthy children of 6–11 years, age and gender did not influence the salivary flow rate and therefore do not have to be taken in consideration when measuring salivary flow rate. The swab method was reliable, easy to carry out and well-tolerated by the group of schoolchildren. [Copyright &y& Elsevier]

Objective: Sialorrhea can have a significant negative effect on quality of life, impeding social interactions and severely limiting employment opportunities. Many surgical options to control sialorrhea have been reported. One of the newest procedures is combined ligation of the submandibular and parotid ducts, reported only once in the literature in one series of five patients to date. We have compared results in our first 21 patients undergoing this procedure with results reported in the literature for other procedures to treat sialorrhea. Materials and methods: We retrospectively reviewed medical records of all 21 children we treated with four-duct ligation, a relatively simple intraoral procedure to control sialorrhea, between August 1999 and September 2000 and contacted primary caregivers by telephone to answer a questionnaire regarding objective and subjective results of surgery. Surgery was considered successful when caregivers rated patients as ‘much better’ or ‘better’ after surgery. Results: Follow-up was completed in all 21 of the patients 1–14 months after surgery. The success rate of four-duct ligation (‘much better’ or ‘better’ after surgery) was 81%, and no patient''s sialorrhea problem was worse after surgery. Major complications occurred in two (10%) of the patients (one ranula and one case of sialoadenitis), which were both successfully treated surgically. Minor complications occurred in four (19%) of the patients, tongue swelling that prolonged hospitalization, a ranula that resolved, and prolonged submandibular gland swelling that resolved (two cases). More than half of patients were discharged the day of or the day after surgery. Conclusions: Four-duct ligation should be considered when surgery is indicated to treat sialorrhea. [Copyright &y& Elsevier]

Colonic pseudo-obstruction (Ogilvie's Syndrome) in children is relatively uncommon. We report an unusual case of colonic pseudo-obstruction in an 8-year-old child with cerebral palsy and long-term hypomotility issues being treated for drooling with the anticholinergic medication trihexyphenidyl. He presented as an emergency with severe abdominal distension, abdominal tenderness and vomiting. An emergency laparotomy revealed colonic dilatation and a defunctioning ileostomy was created. To our knowledge, this is the first case reporting colonic pseudo-obstruction as a possible complication of treatment with trihexyphenidyl. We suggest prescribers should exercise caution when prescribing trihexyphenidyl in patients with long-term intestinal hypomotility issues. [ABSTRACT FROM AUTHOR]

Bib count is a frequently used measure amongst pediatric otolaryngologists to quantify drooling status. The plethora of bibs used, including important differences in material, size, and shape, makes one question the validity of bib count as an accurate surrogate measure of drooling frequency or severity. To date, no study has addressed this question in the literature. We evaluated the correlation between drooling frequency, drooling severity, and number of bibs changed to better guide clinical practice in saliva management in a large pediatric patient population. This was a retrospective cohort study comprising 414 pediatric patients from 2014 to 2019. Patients were included if there was presence of drooling and completed the Daniel Drooling Impact Score Questionnaire. The primary outcome was the severity of drooling, frequency of drooling, and number of bibs changed. Age, sex, feeding type and diagnosis were also data points collected. Pearson's coefficient of correlation and multiple regression analysis were used to analyze association between variables. Bib count, frequency of drooling, and severity of drooling were all positively correlated. The strongest positive correlation was between drooling frequency and drooling severity (r = 0.659; p < 0.01), followed by bib count and drooling severity (r = 0.541; p < 0.01), then bib count and drooling frequency (r = 0.416; p < 0.01). In multivariate regression analysis, only bib count was a statistically significant positive predictor of drooling severity (β =1.14, p < 0.01). Feeding type and underlying diagnosis also influenced bib count. The number of bibs changed per day is an accurate predictor of sialorrhea that correlates positively with drooling severity and frequency despite the variability and lack of standardization in bibs. Consistent definitions of what constitutes a bib and its characteristics should be collected during drooling evaluation. [ABSTRACT FROM AUTHOR]

Abstract: Familial dysautonomia is a rare disease affecting the nervous system. Symptoms include speech and movement problems, anterior sialorrhea (drooling) due to hypersalivation as a consequence of poor oropharyngeal coordination; dysphagia and aspiration pneumonia secondary to recurrent posterior sialorrhea. The treatment for sialorrhea in this population is very challenging. Traditional drugs carry a number of side-effects that are difficult to control in this disease. We report the first documented case series of 3 patients with this condition that successfully responded to Onabotulinum toxin A injection into their salivary glands. This is an innovative, safe method for drooling control in this population. [Copyright &y& Elsevier]

Summary: Objective: To evaluate the outcome of surgical saliva reduction to decrease pulmonary aspiration in children with cerebral palsy and its repercussions in respiratory infection control. Methods: Twenty-nine children with neurological impairment and diagnosis of chronic pulmonary aspiration were submitted to bilateral submandibular gland excision and bilateral parotid duct ligation at the Association for the Welfare of Physically Handicapped Children, from December 2001 to December 2004. Postoperative frequency of lower respiratory tract infection, hospitalization rate due to pulmonary infection and airway secretion level after the surgery were compared to preoperative period. Results: Twenty-nine children with cerebral palsy aged 18 months to 9 years were submitted to submandibular glands excision and parotid ducts ligation. All children had gastrostomy and no oral intake. There were no major complications; two children had reopening of one parotid duct. Frequency of lower respiratory tract infections, rate of hospitalization for treatment of pulmonary infections and level of airway secretion were statistically reduced. Preoperative mean rate of lower respiratory tract infection was 6.9/year; in postoperative period, rate was 2.4/year (p <0.001). Pneumonia hospitalization mean rate was 63.4 days/year preoperatively and 17.5 days/year postoperatively (p <0.001). There was also a significant improvement in the need for suctioning of upper airway secretion (mean 11 times/day in preoperative period and 3.1 times/day in the postoperative period; p <0.001). Conclusion: In children with cerebral palsy, surgical saliva reduction by submandibular glands excision and parotid ducts ligation is an effective and safe technique for frequency reduction of lower respiratory tract infection and level of airway secretion. [Copyright &y& Elsevier]