Dr.

Supreet Singh Nayyar, AFMC

2012

Drooling
Background
Drooling is the unintentional loss of saliva from the mouth

(emedicine)

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

Spasmodic conditions Tetanus, rabies

Paralytic conditions Diptheria Bulbar palsy CVA

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

o o
o

Secondary to neuromuscular disorders Trauma Surgical resection 1

Facial nerve paralysis www.nayyarENT.com

Dr. Supreet Singh Nayyar, AFMC

2012

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 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
2 www.nayyarENT.com

Dr. Supreet Singh Nayyar, AFMC

2012

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

3 www.nayyarENT.com