Dr. Supreet Singh Nayyar, AFMC 2012

www.nayyarENT.com

1

Drooling for more topics, visit www.nayyarENT.com

Background

Drooling is the unintentional loss of saliva from the mouth

Drooling is a normal phenomenon in children prior to the development of oral neuromuscular control at age 18-24 months

However, drooling after age 4 years is uniformly considered abnormal

Pathophysiology

Hypersecretion (primary sialorrhea) eg effect of tranquilizers and anticholistrenases

Impaired neuromuscular control e.g. cerebral palsy

Any impairment of the oral phase of deglutition o Acute infection

Acute epiglottitis Acute pharyngitis Acute laryngitis Acute tracheobronchitis Ludwig angina Retromandibular abcess Parapharyngeal abcess Acute tonsillitis/ adenoiditis Peritonsillar abcess

o Spasmodic conditions Tetanus, rabies

o Paralytic conditions Diptheria Bulbar palsy CVA

o Obstructive lesions of pharynx Tumors of soft palate, pharynx, base of tongue or obstructive hypertrophic

tonsils o Secondary to neuromuscular disorders o Trauma o Surgical resection o Facial nerve paralysis

Presentation

History

The severity of drooling can be classified with the following scale:

Dry - Never drools

Mild - Only lips wet

Moderate - Lips and chin wet

Severe - Clothing soiled

Profuse - Clothing, hands, and tray moist and wet

The frequency of drooling can be quantitated based on the following scale

Never drools

Occasional drooling - Not every day

Frequent drooling - Every day

Constant drooling

Physical examination

Head position and control

Condition of perioral skin

Tongue size and control and the presence of thrusting behaviors

Dr. Supreet Singh Nayyar, AFMC 2012

www.nayyarENT.com

2

Tonsil and adenoid size

Occlusion: Malocclusion

Dentition: Caries may be noted.

Mandible and palatal position

Gag reflex and intraoral tactile sensitivity

Presence of mouth breathing

Nasal obstruction and the appearance of tissues upon anterior rhinoscopy

Neurologic examination: Pay particular attention to cranial nerve examination findings

Relevant Anatomy

Parasympathetic innervation of the parotid gland is from the inferior salivary nucleus via the glossopharyngeal nerve, the tympanic plexus on the medial wall of the middle ear, the lesser superficial petrosal nerve, the otic ganglion, and the auriculotemporal nerve. The submandibular and sublingual glands are innervated by fibers from the superior salivary nucleus via the facial nerve, chorda tympani in the middle ear, lingual nerve, and submandibular ganglion.

Laboratory Studies

Salivary flow rate (mL/min): increase in weight of dental rolls/time of collection o The absorbent dental rolls can be kept directly at the orifices of large salivary glands o Alternatively use of carlsten Crittenden or lashley cup

Drooling Quotient : 40 observations in 10 minutes (every 15 minutes) o DQ% = 100 x number of drooling episodes/40

Teacher Drooling Scale: 1-5 o 1= no drooling o 3= occasional drooling o 5= constantly wet saliva leaking on clothes and furniture

Imaging Studies Lateral neck film

Modified barium swallow

Radiosialography

Flexible nasopharyngoscopy

Medical Therapy

Oral motor training

Behavioral therapy

Pharmacological therapy

Transdermal scopolamine

Benztropine

Glycopyrrolate

Botulinum therapy

Radiotherapy

Surgical Therapy

Submandibular gland excision

Transtympanic neurectomy to reduce salivary flow

Procedures to Redirect Salivary Flow e.g. rerouting Wharton duct to behind ant pillar, rerouting parotid duct

for more topics, visit www.nayyarENT.com