DEFINITION:
Sialorrhea is classified as excessive salivation or drooling and can be a result of increased production, decreased clearance or poor containment of the saliva. The problem may be anterior towards the lips or posterior usually associated with a swallowing issue.
PATHOPHYSIOLOGY:
There are three pairs of major salivary glands that produce 90% of the saliva. These are the sublingual, submental and the parotid glands. The other 10% is made up of minor salivary glands. The sublingual and the submandibular glands secrete saliva in an ongoing base line fashion where as the parotid will release saliva if stimulated by eating or by smell. The body makes approximately on and a half litres of saliva per day and is cleared during swallowing when there is also breath-holding. Lip closure is important to maintain the saliva in the oral cavity.
CAUSES:
Neuro-muscular problems may exist such as Cerebral Palsy, Parkinsons, after head injury, after stroke or as a result of other neuro degenerative disorders. Sialorrhea can also occur post-trauma and post-surgery and may also occur if there is cancer in the oral cavity or oropharynx.
EFFECTS:
Effects of excessive salivation includes difficulty in eating and speaking, aspiration and pneumonia, excoriation of the lips and chin, dental cares and obviously the huge psycho-social effects.
MANAGEMENT:
Management is multi-disciplinary involving ENT surgeons, dietitians and speech therapists. Generally suctioning of the oral cavity and nursing with bibs are important.
MEDICATION:
Anti-cholinergic have been used in the past to decrease saliva but there are many complications including constipation.
INJECTIONS:
Botox has been used for more than 20 years but has to be repeated every four months. Usually both submandibular and parotid glands are injected usually under ultrasound guidance. The problem apart from having to repeat the Botox is the cost and the possible side effect of swallowing. Other injections may be considered by the interventional radiologist such as injecting alcohol directly into the glands. Radiotherapy has been used in the past but there are many side effects including dry mouth, thick saliva, taste changes and swallowing problems. As a result this is often omitted. Surgery is a last resort and maybe duct ligation or even transposition of the submandibular duct. There are high risks is the surgery and include aspiration and the innate risks of operating on, for instance, a Cerebral Palsy child.
In conclusion then, Sialorrhea is extremely common especially in Cerebral Palsy children and the management is complex and ideally fully assessed by an ENT surgeon and then relying on speech therapists and the nursing staff to optimise the condition.