Sialorrhea (Excessive Drooling)

Sialorrhea, also known as hypersalivation or excessive drooling, literally means excessive saliva flow. 

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What is Sialorrhea (Excessive Drooling)?

Sialorrhea or hypersalivation literally means excessive saliva flow. Patients with sialorrhea will manifest this problem in one of two principle ways. Anterior sialorrhea is when patients have excessive anterior or forward spillage of saliva from their mouths, commonly called drooling, onto their faces and clothes causing difficulty with cleanliness, skin care, and socialization. Posterior sialorrhea is when patients have excessive posterior spillage of saliva from their mouths down their airways (tracheas) rather than being swallowed normally. This results in chronic lung irritation called aspiration which can sometimes progress to pneumonia. Often patients have a mixture of both of these types of sialorrhea.

What Causes Excessive Drooling?

Usually sialorrhea results from a decrease in normal control of oral (mouth and throat) sensation and motor function. This diminished oral control results in the inability to manage normal swallowing of saliva or inattention to the need to swallow saliva. There are a variety of causes for this condition but usually it results from brain abnormalities such as cerebral palsy, prior brain injury such as stroke, congenital abnormalities of brain development, or traumatic brain injury. Usually the sialorrhea does not worsen over time if the patient has a brain injury which does not progress with time (static brain injury). Sometimes, if the child’s underlying condition leads to a deterioration in function over time, the degree of sialorrhea will increase as the child ages.

What are the Symptoms of Excessive Drooling? 

Anterior sialorrhea is easy to identify as the drooling is readily visible. Often there is constant drooling with resultant chronic wet clothing or bibs. Sometimes the drooling is worse at night with wet bedding every morning. Posterior sialorrhea can be more difficult to appreciate but may need to be considered if the child is constantly visibly choking and coughing or seems to be prone to repeated episodes of aspiration pneumonia.

How is Excessive Drooling Diagnosed? 

Anterior sialorrhea is diagnosed by the family or their caregivers via the observation of excessive drooling. Posterior sialorrhea can be suggested by the history of choking and repeated pneumonias.  Occasionally, additional tests can be helpful including swallowing evaluations done jointly between the Speech Pathologists and Radiologists where the child is examined with x-ray imaging during the act of swallowing.

How is Excessive Drooling Traditionally Treated? 

Treatment options center around medical and surgical therapies to diminish the amount of saliva present in the mouth. Approximately 1 liter of saliva is produced each day primarily by three salivary glands on either side of the mouth: the parotid glands, the submandibular glands, and the sublingual glands.

Traditional treatment options include daily oral medications to diminish saliva production, periodic injections of a medication called Botox for temporary reduction in saliva production, or a variety of open surgical procedures to remove some salivary glands or disconnect others from the mouth.

How is Excessive Drooling Treated at Nationwide Children's?

In order to effectively treat this problem and diminish the invasiveness of operative interventions, Interventional Radiologists at Nationwide Children’s Hospital, developed an alternative percutaneous procedure called Salivary Gland Ablation around 2004.

Instead of operatively removing salivary glands, we inject them with medications such as alcohol in order to shrink them and decrease saliva production. No incisions are made. Some injections are delivered through the normal salivary gland drainage tubes (parotid ducts), while other injections are delivered through the skin directly into the sublingual and submandibular glands. In all cases, image guidance is employed for accurate placement of the medications. After injection the glands decrease in size and produce less saliva.

All injections are performed under anesthesia. In most cases all the glands on one side of the face are injected in a single procedure. At follow-up appointments, if the problem persists, injection of the other side can be considered.

What are the Risks and Potential Complications of this Procedure?

Salivary Gland Ablations have been safely performed at Nationwide Children’s Hospital since around 2004. The aim of the procedure is to diminish the patients’ dependence upon daily medications and to permanently decrease the amount of saliva production without open surgical procedures. While there are no incisions or stiches and therefore no post-treatment wound care, Salivary Gland Ablation does result in significant, usually painless, facial swelling for several weeks after injection.

While our percutaneous procedure is very safe, all treatments carry risks. The primary serious risk that can occur with alcohol injection of salivary glands is injury to a nearby nerves which can result in temporary facial muscle weakness in rare cases (2-3%). As the glands are not physically removed with salivary gland ablation, after injection they continue with some saliva production and to date no child has suffered from an overly dry mouth.

Can Excessive Drooling be Cured?

Sialorrhea is a chronic condition that sometimes be can be managed with conservative measures such as attention to oral hygiene and skin care together with therapy to maximize swallowing function. If symptoms remain severe enough then daily medications can be added to decrease saliva production though these medications can have unwanted side effects. Beyond that, salivary gland ablation or operative interventions may be considered.

Sialorrhea can rarely be completely eliminated with any strategy and all treatments are designed to decrease symptoms without overly limiting salivary production. As this is a benign condition, treatment options also are chosen to minimize risk to the patient undergoing those procedures.

When Should we See a Doctor?

If a child’s symptoms are felt to be severe enough by his or her physicians salivary gland ablation can be considered to further diminish saliva production.