Drooling Drooling surgical optionssurgical options

Watad waseem

Submandibular and Submandibular and Sublingual gland innervationSublingual gland innervation

Superior salivatory nucleus - nervus intermedius - facial nerve - chorda tympani - lingual nerve - submandibular ganglion - submandibular/lingual glands

Parotid innervationParotid innervation

Inferior salivatory nucleus - glossopharyngeal nerve - Jacobsen’s nerve - lesser superficial petrosal nerve - otic ganglion - auriculotemporal nerve

Salivary gland innervationSalivary gland innervation

Parasympathetic system stimulation causes an increase in saliva flow from all glands

Sympathetic system stimulation causes increase in saliva flow from submandibular gland but has no effect on parotid flow

Treatment OptionsTreatment Options

Multidisciplinary approach Non-invasive modalities Trial of medication Surgery

Surgical optionsSurgical options

Reduction of salivary flow

Relocation of salivary flow

combination

Surgical optionsSurgical options

Submandibular gland excision Parotid duct ligation Transtympanic neurectomy

Submandibular duct rerouting Parotid duct rerouting

Surgical indicationsSurgical indications

Age 5-6 Failed non-surgical management > 6

months Stable neurological status Drooling with non-operative patient

Surgical contra-indicationsSurgical contra-indications

High risk for operation unilateral HL for tympanic neurectomy Rerouting of salivary duct in esophagus

disoerder, ch. aspiration

Pre-operative assessmentPre-operative assessment

Lat neck x-ray , F.O for adenoids adenoidectomy if necessary Barium audiometrey

Wilke procedure - 1967Wilke procedure - 1967

Bil. submandibular gland exc. And bil. Parotd duct relocation.

Success rate 85% Postoperative complication (35%) and high

morbidity Modification of the procedure

Submandibular Gland Submandibular Gland Excision + partid duct Excision + partid duct ligationligation

High success rate(85 – 100%)- (Shot) Very common Low morbidity Mild swelling of face, external scars, xerostomia ,

parotitis

Parotid duct ligationParotid duct ligation

Location of the pappila , insert lacrimal probe

Elliptical incision made around the parotid duct. Duct dissected for 1 cm, suture ligated and resected. The buccal mucosa is then repaired.

Rerouting of submandibular Rerouting of submandibular ductduct

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

Rerouting of submandibular Rerouting of submandibular duct(cont’d)duct(cont’d)

relocation in base of ant. Pillar : no need for TE , less infection

Rate success 80-100% Sublingual gland exc. Advantages: Decreased xerostomia, problems with

taste and dysphagia Disadv: Ranula, sialoadenitis, sialolithiasis,

aspiration pneumonia

Studies on submandibular Studies on submandibular duct reroutingduct rerouting

Crysdale - 8% ranula rate O’Dywer - 15 year follow -up study, 94%

of parents stated their child benefited, 50% had complete cessation of drooling

Transtympanic neurectomiesTranstympanic neurectomies

80% success rate Must take both chorda and tympanic plexus Hypotympanic branch in 50% of patients Low speed drill Loss of taste in anterior 2/3 of tongue and

xerostomia Contraindicated in unilateral SNHL

Transtympanic neurectomiesTranstympanic neurectomies

Recurrence of drooling – regeneration of tympanic nerves

Use for completion the surgery therapy for drooling

Laser photocoagulation of Laser photocoagulation of parotid ductparotid duct

No scars no xerostomia 40/48 patient improvement (chang – 2001) Swelling of parotis, hematoma, infection