Abstract
Objectives
The objective of this study is to assess the improvement in drooling in children undergoing 4-duct ligation procedure for excessive drooling and to study its effect on their quality of life.
Materials and methods
A prospective, nonrandomized interventional study was done between November 2009 and September 2011. Thirty drooling children of both sexes aged 4 to 15 years underwent 4-duct ligation, that is, ligation of bilateral submandibular ducts and bilateral parotid ducts. Comparison of preoperative and postoperative 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.
Results
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 preoperative and postoperative combined drooling scores showed P < .001. The mean Glasgow Children’s Benefit Inventory score was 36.15. In the postoperative 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.
Conclusions
Four-duct ligation causes marked improvement in drooling and significantly increases the quality of life in drooling children. It has few complications, which can be managed effectively.
1
Introduction
Children with neurologic disorders such as cerebral palsy, neuromuscular disease, autism, or mental retardation have drooling problems. Impaired neurologic control of oromotor and palatofacial muscles results in poor swallowing function. This leads to excessive pooling of saliva in the oral cavity with unintentional loss of saliva from the mouth, known as anterior drooling. If pooled saliva is spilled over the tongue through the faucial isthmus, it leads to posterior drooling . Drooling is physiological in infants and usually resolves after 15 to 18 months of age. It is abnormal in a child older than 4 years in the awake state . Drooling can be highly distressful for both the patients and their caregivers. It causes social rejection, physical discomfort, perioral skin maceration, and loss of fluid and electrolytes. Posterior drooling can lead to aspiration pneumonitis .
Nonsurgical treatment modalities include oral motor therapy, orofacial regulation therapy, behavioral modification by biofeedback, and drug therapy . Minimally invasive methods such as botulinum toxin A injection and tongue acupuncture are also available . Surgical methods include tympanic and chorda tympani neurectomies and salivary duct and gland procedures (duct ligation or rerouting and resection of > 1 salivary glands) . None of these methods is universally accepted.
Four-duct ligation, that is, bilateral submandibular ducts and bilateral parotid ducts ligation, in the management of drooling, has been reported to be a simple, safe, and effective method for control of drooling with few complications. The physiologic basis for the procedure is that after duct ligation, the gland undergoes functional atrophy. The saliva for the daily needs of the child is produced by the sublingual glands and minor salivary glands. So, dryness of mouth and the consequent side effects are avoided. Various studies have been done in different parts of the world with variable results. This study was undertaken to see the outcome of 4-duct ligation and its effect on the quality of life of the patients.
2
Materials and methods
A prospective, nonrandomized, interventional study was done to assess the improvement in drooling in children undergoing 4-duct ligation and to study its effect on their quality of life. The study was done in the Department of Otorhinolaryngology and Head and Neck Surgery, Lady Hardinge Medical College and Associated Hospitals (Smt Sucheta Kriplani Hospital and Kalawati Saran Children’s Hospital), New Delhi, between November 2009 and September 2011. Thirty drooling children of both sexes aged between 4 and 15 years were subjected to the procedure. All the children had neurologic deficit. Twenty-one children had cerebral palsy, 8 had mental retardation, and 1 had fragile X syndrome. Ethical clearance for the study was obtained from the institute. Preoperative assessment of drooling was done by Thomas-Stonell and Greenberg classification ( Table 1 ). The classification consists of 5-point scale for severity and 4-point scale for frequency. Combined drooling score (severity score + frequency score) was calculated. All children with frequent and constant drooling were included in the study irrespective of the severity of drooling. In addition, all children with severe or profuse drooling were included. However, children with moderate drooling were selected only if they had failed to improve after 6 months of conservative treatment or had low cognitive levels.
| Severity of drooling | Frequency of drooling |
|---|---|
| 1. Dry: never drools | 1. Never drools |
| 2. Mild: only lips wet | 2. Occasionally drools |
| 3. Moderate; wet on lips and chin | 3. Frequently drools |
| 4. Severe: drools to extent that clothing becomes damp | 4. Constantly drools |
| 5. Profuse: clothing, hands, tray, and objects become wet |
2.1
Operative procedure
Surgery was done under general anaesthesia with nasotracheal intubation. Neck extension was given, and oral cavity was exposed using mouth gag. Bupivacaine 0.25% with 1:100000 adrenaline was infiltrated around the distal submandibular duct papilla. A circular incision was made around the papilla with 15 no. surgical blade, and meticulous submucosal dissection was done to expose the distal portion of the submandibular duct. Care was taken not to extend dissection further than 1 cm along the duct to avoid disruption of sublingual ductile structures. Duct was ligated with 4-0 prolene suture, and the distal tip was excised. The procedure was repeated for the submandibular duct of the other side, and the overlying mucosa was closed with 4-0 vicryl .For parotid duct ligation, the papilla was dilated with punctum dilator and cannulated with a lacrimal probe. The mucosa surrounding the duct papilla was injected with the same infiltration, and circumferential incision was made through the mucosa. Dissection was carried out along the duct submucosally, guided by the lacrimal probe for approximately 0.5 cm. The probe was then removed, duct ligated with 4-0 prolene suture, and distal portion of the duct was amputated. The mucosa overlying the duct was then closed with a 4-0 vicryl suture. The procedure was repeated for the other parotid duct.
The children were given parenteral amoxicillin-clavulinic acid for 2 days and thereafter maintained orally for 1 week. Ibuprofen was given for analgesia for 3 days. Injection dexamethasone was given for 2 days, and tablet serratiopeptidase was given for 1 week. Cold compresses were given on the cheeks for 20 minutes duration every hour during daytime for 3 days. Antiseptic mouth washes were given. Patients were orally allowed from the second postoperative day.
2.2
Outcome measures
Follow-up was done 24 and 48 hours after surgery and, subsequently, on eighth postoperative day, first month, second month, third month, sixth month, and 12th month.
Improvement in drooling was measured by comparing the presurgery and postsurgery combined drooling scores. Successful treatment with 4-duct ligation was defined as a decrease in the combined drooling score by at least 1.
Postoperative benefit in quality of life was assessed by Glasgow Children’s Benefit Inventory (GCBI) score . The parents rated their overall satisfaction with the surgery on a 5-point Likert Scale. A summary score was calculated by assigning the individual question response a numerical value from − 2 to + 2, then adding these up, dividing by the number of questions (24), and then multiplying by 50 to produce a result on a scale from − 100 (maximum harm) to + 100 (maximum benefit).
GCBI score = ∑ x × 50 ÷ 24 x = Individual score of each question Maximum harm = − 100 ; Maximum benefit = + 100
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