SialorrheaSialorrhea SalivarySalivary disordersdisorders SialoendoscopySialoendoscopy Sam J Daniel, MD Director Pediatric Otolaryngology Associate Professor Montreal Children’s Hospital McGill University Objectives • Review the rehabilitative, medical, and surgical treatment options for sialorrhea • Discuss novel therapies such as Botox injections in the salivary glands • Discuss the technique and pitfalls of sialoendoscopy • Review selected salivary gland disorders Sialorrhea • Sialorrhea (drooling) is the loss of saliva from the oral cavity • It occurs in healthy children frequently until age 2 Introduction • Neurological disorders in which drooling is problematic: – Parkinson’s disease (close to 80%) – Atypical Parkinsonian syndromes – Amyotrophic lateral sclerosis – Cerebral palsy – Pseudobulbar palsy – Stroke ANATOMYANATOMY && PHYSIOLOGYPHYSIOLOGY ofof thethe salivarysalivary glandsglands Autonomic innervation •Parasympathetic –Abundant, watery saliva –Amylase down •Sympathetic –Scant, viscous saliva –Amylase up Parotid gland Parasympathetic innervation: • Originates in inferior salivary nucleus in medulla. • CN9->sup & inf glossopharyngeal ganglions->tympanic plexus (Jacobson’s nerve) lesser superficial petrosal nerve- >foramen ovale > otic ganglion- synapse with post- ganglionic fibers >auriculotemporal n. • M3 muscarinic receptors of parotid gland Sympathetic innervation: • Postganglionic innervation is provided by the superior cervical ganglion and distributes with the arterial system. Submandibular glands Parasympathetic innervation: • Originates in superior salivary nucleus in pons. • Passes through the nervus intermedius and IAC to join CN7> chorda tympani. The lingual nerve carries presynaptic fibers to the submandibular ganglion. Post- synaptic fibers innervate the submandibular & sublingual glands. M3 muscarinic receptors Sympathetic innervation: • Postganglionic innervation is provided by the superior cervical ganglion and distributes with the arterial system. Saliva Production • Normal saliva production 1- 1.5 liter per day. • Unstimulated salivation- “resting saliva” – 0.5 cc per minute – 70% from submandibular gland, 25% from parotid • Stimulation with a sialogue increases secretions up to 3 to 4 cc per minute. The increase is primarily from the parotid glands (2/3 of secretions). Function of Saliva • Moistens oral mucosa • Digestion (Amylase, • Moistens & cools food Lipase) • Medium for dissolved • Antibacterial food (Lysozyme, IgA, • Buffer (HCO3) Peroxidase, FLOW) • Mineralization • Protective Pellicle Etiology of sialorrhea • Poor oral motor control • Inefficient swallow • Decreased frequency of swallow • Mental delay • Malocclusion or oral structural problem • Mouth-breathing / upper airway obstruction • Postural problem • Medication IMPAIRED OROMOTOR CONTROL IS THE CRUCIAL FACTOR Impact on patient • Physical discomfort • Skin infection • Dehydration • Recurrent pneumonias • Hygiene • Stigmatizing • Rejection • Isolation • Low self-esteem Impact on caregiver • Burden of care: • wiping the child ( mean of 73 times/day) • changing of clothing • soiling of the environment • up to 25 loads of laundry/week (Van Der Burg JJW et al 2006) • Hospitalization of the child • Anxiety and worry for the future • Social isolation Where to start? “Drooling Team” Pediatrician OT PT Dentist Otolaryngologist Neurologist Social worker ApproachApproach toto thethe droolingdrooling patientpatient Evaluation Thomas-Stonell and Greenberg Classification for Drooling Frequency Never Occasional (not every day) Frequent (every day) Constant (every day and night) Severity Dry Mild (wets only lips) Moderate (wets lips and chin) Severe (wets clothing) Profuse (wets environment: objects, floor, other people) Evaluation Teacher Drool Scale (TDS; Camp-Bruno,Winsberg, Green-Parsons, & Abrams, 1989). 5-point scale, measuring (a) no drooling; (b) infrequent drooling, small amount; (c) occasional drooling, on and off all day; (d) frequent drooling, but not profuse; and (e) constant drooling, always wet. Visual Analogue Scale (Jongerius et al., 2004) Treatment Options - No Treatment - Rehabilitative options - Medical Treatment - Surgical Treatment No Treatment - INSIGNIFICANT PROBLEM - ANTICIPATED IMPROVEMENT - DROOLING LOW PRIORITY - UNCONCERNED CAREGIVER Rehabilitative options - Correct situational factors - Oral motor therapy - Behaviour therapy Rehabilitative options - Correct situational factors - Oral motor therapy - Behaviour therapy Rehabilitative options - Correct situational factors - Oral motor therapy - Behaviour therapy Behaviour therapy - In recent years, there has been a paucity of behavioral studies on drooling- 19 since 1970!!! - The focus has been on medication and surgical interventions. However, medication has only a temporary effect (Jongerius et al., 2004), and surgery does not always totally eliminate drooling (Greensmith et al. 2005). - “ Given their potential effectiveness, behavioral procedures should be reconsidered.” (Van der Burg 2007) Behaviour therapy - The goal is to establish, increase, or decrease specific behavior by systematically manipulating its antecedent stimuli (events preceding the target behavior) and/or consequent (events following the target behavior) stimuli. -There are four main types of treatment procedures: - (a) instruction, prompting, and positive reinforcement; - (b) negative social reinforcement and decelarative procedures; - (c) cueing techniques; -(d) self-management procedures. Surgical Treatment Surgical Treatment - Indications - Failure of medical Rx - Obstructive factors - Profuse drooling with low awareness level - Severe aspiration Macroglossia • Pt with sialorrhea who could touch his forehead with his tongue Tongue reduction Surgical Treatment Procedures designed to redirect the salivary flow: - Relocation of the parotid ducts (Wilkie & Brody 1977) - Submandibular duct relocation - Submandibular duct relocation with sublingual gland excision (SDRSGE) SDRSGE – COMPLICATIONS 10% of patients: - Bleeding - Tongue swelling with airway obstruction - Submandibular abscess - Lingual nerve injury - Aspiration pneumonia Surgical Treatment Procedures designed to decrease the salivary flow: - Tympanic neurectomy - Parotid duct ligation - 4 Duct ligation - Bilateral excision of the submandibular glands +/- ligation of the parotid duct Tympanic Neurectomy - Loss of taste - Recurrence of symptoms within 6 months of surgery Bilateral excisions of the submandibular Glands & ligation of parotid ducts Cincinnati Children’s Hospital, 93 children (Stern 2002) 7 Xerostomia 2 dental caries 1 wound hematoma 1 parotitis Average F/up of 4.2 years: - Significant improvement in drooling in 65% - Cessation of drooling in 21% Pharmacotherapy Pharmacotherapy • Glycopyrrolate (Bachrach 1998) – In a survey of 41 caregivers of children with cerebral palsy • Improvement in drooling in 95% of patients • SIDE_EFFECTS LEAD TO DISCONTINUATION IN 1/3 • Dry mouth, thick secretions, urinary retention, flushing Pharmacotherapy • Glycopyrrolate (Mier 2000) – Placebo-controlled, double-blind, crossover dose-ranging study – 39 children with dev delay & excessive drooling – All children completing the study had a significant improvement with glycopyrrolate when compared to placebo – 20% withdrawal due to adverse effects Pharmacotherapy • Scopolamine patch (Brodtkorb 1988) – Placebo-controlled, double-blind, crossover dose-ranging study – 18 children with dev delay & excessive drooling – Significant reduction in drooling 24 to 72 hours after the patch is applied with drowsiness as the only reported side effect – Other trials less successful (Lewis 1994) Pharmacotherapy • A daily dosage of 3–3.8 mg benztropine could be effective. • An impressive reduction in the mean score for drooling is described with benzhexol hydrochloride (2x2 mg up to 2x3 mg daily). Jongerius PH, van Tiel P, van Limbeek J, Gabreels FJ, Rotteveel JJ. A systematic review for evidence of efficacy of anticholinergic drugs to treat drooling. Arch Dis Child. 2003 Oct;88(10):911-4. Review. Sialorrhea Agent Dosage Side effect Glycopyrolate Adult: start at .5 mg Dry mouth, thick secretion, orally, one to three urinary retention, flushing, and times daily constipation Children:0.04 mg per Kg per dose orally, q8- 12h Scopolamine (Transderm Apply patch every day Pruritus, urinary retention, Scop) 1.5 mg irritability, blurry vision, glaucoma Botulinum toxin A 10 units in to each Pain at injection site submandibular and parotid gland Hockstein NG, Samadi DS, Gendron K, Handler SD. Sialorrhea: a management challenge. Am Fam Physician. 2004 Jun 1;69(11):2628-34. BOTULINUMBOTULINUM TOXINTOXIN INJECTIONINJECTION FORFOR SIALORRHEASIALORRHEA BOTULINUM TOXIN Normal Neuromuscular Function Arnon et al. JAMA 2001;285(8):1059-1070 Botulinum Toxin Mechanism of Action Arnon et al. JAMA 2001;285(8):1059-1070 BOTOX Injection 60% Excellent response 20% Good response 20 % Poor response 10% no response with high doses Ideal along with oral motor therapy SAFETYSAFETY OFOF BOTULINUMBOTULINUM TOXINTOXIN FORFOR SIALORRHEASIALORRHEA • Recent reports have hit the media involving the reporting of serious side effects as a result of using Botox injections, and these reports were generated by the Ralph Nader-founded consumer advocacy group known as Public Citizen, which tracked 180 reports of problems with Botox to the FDA and found three side effects to be the most serious. • Each of these side effects is briefly described below, but if you have been injured as a result of Botox injections,