Excessive drooling (sialorrhea, ptyalism) is estimated to occur in 10 % of patients with cerebral palsy (CP), and in other patients with neurological damage. While drooling can be considered a cosmetic problem, excessive drooling can result in significant hygienic problems, maceration of the skin and dehydration. Furthermore, excessive drooling can limit any efforts at speech therapy.
Drooling can either be related to a central neurogenic problem, as in CP, in which there is poor coordination of the muscles of deglutination, or be related to a peripheral nerve lesion, such as in facial nerve or glossopharyngeal nerve palsy. All patients should initially be treated with various physical therapy and behavior modifications regimens. Medical therapy has focused on the use of anti-cholinergic drugs, which reduce the production of saliva. However, therapeutic doses of these drugs usually result in unacceptable side effects such as constipation, urinary retention, blurred vision and restlessness. When conservative approaches fail, surgical intervention can be considered.
Surgical management of sialorrhea includes rerouting the parotid or submandibular ducts, excision of the submandibular glands or transection of the nerves innervating the parotid gland (tympanic neurectomy) or submandibular gland (chorda tympani neurectomy). Although none of the procedures has been studied in large series of patients, all seem to be associated with a success rate of greater than 82 %. Selection of the procedure seems to be largely a physician/patient preference issue, balancing the increased morbidity of the gland excision or duct relocation procedures against the threat of recurrence and the loss of taste associated with the neurectomy procedures.
Glynn and O'Dwyer (2007) stated that submandibular duct relocation plus or minus excision of the sublingual glands are relatively simple procedures with low morbidity. In a prospective study, these researchers compared both procedures including operative time, length of hospital stay, post-operative complications, drooling scores and parental satisfaction. A total of 71 submandibular duct relocation and 29 submandibular duct relocation plus excision of the sublingual glands procedures were performed. Exclusion criteria were patients with recurrent aspiration pneumonias or dental caries. Two patients were lost to follow-up and excluded from the study. Operative time and length of hospital stay were increased in the submandibular duct relocation plus sublingual gland excision group. Drooling scores and parental satisfaction results were excellent, 93 % of parents in the submandibular duct relocation group and 89 % of parents in the duct relocation plus sublingual glands excision were satisfied and would recommend the procedure. There was no statistical difference (p = 0.643) in drooling scores between the 2 procedures. Post-operative morbidity was higher with the addition of sublingual gland excision, with post-operative hemorrhage occurring in 13.7 % and 36 % of parents expressing concern over post-operative pain, compared with 3 % post-operative hemorrhage rate with submandibular duct relocation and only 12 % of parents expressing the same concerns. The authors concluded that both procedures are effective in drooling control, but the addition of sublingual gland excision increases morbidity. These researchers no longer excise sublingual glands with submandibular duct relocation.
Celet Ozden et al (2012) noted that drooling complicates many neurologic disorders including CP. Surgical treatment consists mainly of ablative (excision/ligation) or physiological (diversion) methods; combined techniques have also been proposed. These investigators have applied bilateral diversion of both submandibular and parotid ducts in 12 CP patients (age range of 7 to 15 years). Pre-operative drooling severity was grade 4/5 in 10 cases and grade 5/5 in 2 of the cases. All patients underwent physiotherapy for a minimum of 6 months and were consulted with a dentist, otolaryngologist, and a speech therapist before surgery. No bleeding, hematoma, or infection has been observed in any of the patients. Two patients had early post-operative tongue edema that regressed with conservative treatment. All patients except 1 regressed to grade 2/5 drooling by the first post-operative month. In 1 patient who had previously been classified as grade 5/5, surgery provided limited improvement with only 1 grade of step-down. Satisfactory results for the patients and their families could be achieved and sustained for a median 18 months (7 to 20 months) of follow-up. The authors concluded that the quadruple duct diversion method is an effective physiological surgical method in the control of drooling in CP.
In a prospective, non-randomized interventional study, Chanu et al (2012) evaluated the improvement in drooling in children undergoing 4-duct ligation procedure for excessive drooling and studied its effect on their quality of life. A total of 30 drooling children of both sexes aged 4 to 15 years underwent 4-duct ligation (i.e., ligation of bilateral submandibular ducts and bilateral parotid ducts). Comparison of pre-operative and post-operative drooling scores using Thomas-Stonell and Greenberg classification was done. Glasgow Children's Benefit Inventory Score was used to assess the improvement in the quality of life. Success rate in terms of improvement in drooling was 93.33 %. A complication rate of 16.67 % was found. The mean improvement in total drooling score after 12 months was 4.43. The paired t-test applied on pre-operative and post-operative combined drooling scores showed p < 0.001. The mean Glasgow Children's Benefit Inventory score was 36.15. In the post-operative period, transient swelling of cheeks, transient swelling of submandibular glands, change in the consistency of saliva, cheek abscess, collection of saliva in the cheek, and parotid duct fistula were observed. The authors concluded that the 4-duct ligation resulted in marked improvement in drooling and significantly increased the quality of life in drooling children. It has few complications, which can be managed effectively.
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
Excision of submandibular (submaxillary) gland
Parotid duct diversion, bilateral (Wilke type procedure)
with excision of both submandibular glands
with ligation of both submandibular (Wharton's) ducts
Other CPT codes related to the CPB:
Plastic repair of salivary duct, sialodochoplasty; primary or simple
secondary or complicated
Injection procedure for sialography
Sialography, radiological supervision and interpretation
HCPCS codes covered if selection criteria are met:
Excision of salivary gland, by report
Other HCPCS codes related to the CPB:
ICD-9 codes covered if selection criteria are met:
Hypertrophy of the salivary glands
Other ICD-9 codes related to the CPB:
343.0 - 343.9
Infantile cerebral palsy
351.0 - 351.9
Facial nerve disorders
Other disorders of glossopharyngeal [9th] nerve
Abscess of the salivary glands
Disturbance of salivary secretion
The above policy is based on the following references:
Myer CM. Sialorrhea. Ped Clin N Amer. 1989;36:1495-1500.
Wilkie TF, Brody GS. The surgical treatment of drooling: A ten-year review. Plas Reconstruc Surg. 1977;59(6):791-797.
Crysdale WS. The drooling patients: Evaluation and current surgical option. Laryngoscope. 1980;90:775-783.
Dundas DF, Peterson RA. Surgical treatment of drooling by bilateral parotid duct ligation and submandibular resection. Plas Reconstruc Surg. 1979;64:47-51.
Glass LW, Nobel GL, Vecchione TR. Treatment of uncontrolled drooling by bilateral excision of submandibular glands and parotid duct ligations. Plas Reconstruc Surg. 1978;62(4):523-526.
Toremalm NG, Bjerre I. Surgical elimination of drooling. Laryngoscope. 1976;86:104-112.
Becmeur F, Horta-Geraud P, Brunot B, et al. Diversion of salivary flow to treat drooling in patients with cerebral palsy. J Pediatr Surg. 1996;31(12):1629-1633.
O'Dwyer TP, Conlon BJ. The surgical management of drooling - a 15 years follow-up. Clin Otolaryngol. 1997;22(3):284-287.
Ethunandan M, MacPherson DW. Persistent drooling: Treatment by bilateral submandibular duct transposition and simultaneous sublingual gland excision. Ann R Coll Surg Engl. 1998;80(4):279-282.
Wilson SW, Henderson HP. The surgical treatment of drooling in Leicester: 12 years experience. Br J Plast Surg. 1999;52(5):335-338.
Panarese A, Ghosh S, Hodgson D, et al. Outcomes of submandibular duct re-implantation for sialorrhoea. Clin Otolaryngol. 2001;26(2):143-146.
Stern Y, Feinmesser R, Collins M, et al. Bilateral submandibular gland excision with parotid duct ligation for treatment of sialorrhea in children: Long-term results. Arch Otolaryngol Head Neck Surg. 2002;128(7):801-803.
De M, Adair R, Golchin K, Cinnamond MJ. Outcomes of submandibular duct relocation: a 15-year experience. J Laryngol Otol. 2003;117(10):821-823.
Uppal HS, De R, D'Souza AR, Pearman K, Proops DW. Bilateral submandibular duct relocation for drooling: an evaluation of results for the Birmingham Children's Hospital. Eur Arch Otorhinolaryngol. 2003;260(1):48-51.
Hockstein NG, Samadi DS, Gendron K, Handler SD. Sialorrhea: A management challenge. Am Fam Physician. 2004;69(11):2628-2634.
Meningaud JP, Pitak-Arnnop P, Chikhani L, Bertrand JC. Drooling of saliva: A review of the etiology and management options. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(1):48-57.
Jongerius PH, van Tiel P, van Limbeek J, et al. A systematic review for evidence of efficacy of anticholinergic drugs to treat drooling. Arch Dis Childhood. 2003;88(10):911-914.
Glynn F, O'Dwyer TP. Does the addition of sublingual gland excision to submandibular duct relocation give better overall results in drooling control? Clin Otolaryngol. 2007;32(2):103-107.
Heywood RL, Cochrane LA, Hartley BE. Parotid duct ligation for treatment of drooling in children with neurological impairment. J Laryngol Otol. 2009;123(9):997-1001.
Little SA, Kubba H, Hussain SS. An evidence-based approach to the child who drools saliva. Clin Otolaryngol. 2009;34(3):236-239.
Reed J, Mans CK, Brietzke SE. Surgical management of drooling: A meta-analysis. Arch Otolaryngol Head Neck Surg. 2009;135(9):924-931.
Naghavi SE, Jalali MM. Management of drooling for patients in the north of Iran: Analysis of the surgical management. J Res Med Sci. 2010;15(1):1-5.
Hornibrook J, Cochrane N. Contemporary surgical management of severe sialorrhea in children. ISRN Pediatr. 2012;2012:364875.
Celet Ozden B, Aydin A, Kuvat SV, et al. Quadruple salivary duct diversion for drooling in cerebral palsy. J Craniofac Surg. 2012;23(3):738-741.
Chanu NP, Sahni JK, Aneja S, Naglot S. Four-duct ligation in children with drooling. Am J Otolaryngol. 2012;33(5):604-607.
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