Making decisions about surgical intervention for drooling in children with neurodisability

EDITOR–We read with great interest the paper ‘Posterior drooling in children cerebral palsy and other neurodevelopmental disorders’ by Desling et al.1 Our own clinical experience echoes these findings conclusions. The interdisciplinary clinic Victoria, Australia consists of a general paediatrician, speech pathologist, dentist, plastic surgeon, ear nose throat surgeon. We see approximately 80 annually. Given significant morbidity mortality severe neurological impairment from respiratory illness, our practice has been evolving to reflect seriousness this condition. are leaning towards earlier surgery, especially infants requiring intensive care unit admissions, non-invasive ventilation, or tracheostomy. In select cases, definitive surgical interventions have facilitated discharge reduced hospital admissions. With use botulinum neurotoxin A (BoNT-A), we support initial improvement, subsequent injections becoming less effective.2 rare complication leakage BoNT-A, out salivary glands into surrounding muscles may lead temporary worsening oropharyngeal dysphagia, which is not always associated level physical impairment. ultrasound guide needle gland minimize complication. now using for posterior find it more helpful whose families ‘not ready’ surgery. Submandibular excision (SMGE) without parotid duct ligation increasingly being offered within stepwise approach. concur that submandibular as effective,3 SMGE reliable. There also seems be beneficial role removal sublingual glands, they provide basal production. For those anterior drooling, recognize phenotypes based on child’s underlying disorder impairment/Gross Motor Function Classification System (Fig. 1). It consider origins open mouth breathing posture. Is related adenotonsillar obstruction? there adequate motivation, social awareness, postural stability, even motor control close mouth? found over time, an posture leads short upper lip, maxillary protrusion, high-arched palate, relative retrusion mandible. Subsequently, become difficult mouth. Early treatment therapy reduce secondary dentofacial changes. addition, autism spectrum develop slurping habits obsessional thoughts saliva, warrant psychological psychotropic development learned some will acquire skill saliva control. impression procedure chosen should impairment, rather than just direction spillage. example, child disability tolerate volume load redirection excision. They benefit ligation. Suctioning, optimizing positioning (e.g. fitted wheelchair tilt-in-space chair), skin barrier creams additional important adjuncts. Informing parents carers swallowing issue caused hypersalivation essential. Anticholinergics only thicken making safer easier swallow. shifting paradigm behavioural who never master swallowing.