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3.17: Surgical Treatment of Pediatric Drooling

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    Katherine Pollaers, Shyan Vijayasekaran

    Drooling is normal in children until 4 years of age. However, simple drooling can have negative social consequences, and chronic posterior drooling can have serious clinical sequelae.

    Anterior drooling is characterized by unintentional saliva loss from the mouth, which has social and cosmetic consequences.

    Posterior drooling is when saliva spills over the tongue into the hypopharynx, which leads to chronic pulmonary aspiration (CPA) of saliva. Chronic pulmonary aspiration results in recurrent lower respiratory tract infections, antibiotics use, medical consultations, interventions, and hospitalizations. The severity and complications of aspiration depend on the quantity and quality of the aspirated material, the patients defense mechanisms and pulmonary status1.

    Assessment (Figures 1, 2)


    Figure 1: Serial flexible nasendoscopy images show salivary penetration through glottic inlet


    Figure 2: Management of drooling

    Children are best evaluated by a multidisciplinary feeding team. The assessment of drooling and aspiration initially involves a history and examination and bedside tests which includes flexible nasendoscopy (Figure 1) and in selected cases a Functional Endoscopic Evaluation of Swallow (FEES).

    Anterior drooling does not usually require extensive assessment. Most patients have adenotonsillar hypertrophy or delayed oromotor skills associated with neurodevelopmental pathology.

    Posterior drooling may require investigation including imaging of the chest and a contrast swallow assessment. Patient with a tracheostomy may have a dye test.

    Diagnostic microlaryngoscopy and biopsy are the investigations of choice for anatomical causes of CPA. Any structural abnormality that is identified, for example a laryngeal cleft, is then appropriately managed. Bronchial washings and brushings for microbiological assessment and histology for lipid laden macrophages may be performed.

    Assessment and treatment of gastro-esophageal disease should be considered, particularly in complex children, to reduce the risk of aspiration of gastric contents. Management is with proton pump inhibitors, prokinetic agents or thickened oral fluids. In severe cases fundoplication may be considered.

    Management of Anterior Drooling

    Patients with anterior drooling can be managed efficiently by correcting the upper airway obstruction (adenoidectomy or adenotonsillectomy) required for treatment of coexistent sleep disordered breathing.

    Patients with delayed oromotor skills and those with complex medical conditions are managed in a similar manner to the posterior drooling cohort.

    Some patients with resistant anterior drooling without posterior drooling may be managed with submandibular salivary duct diversion. However, this group of patients needs to be carefully assessed to exclude salivary aspiration before doing surgery, as the submandibular salivary duct diversion is likely to exacerbate aspiration.

    Submandibular salivary duct diversion surgical technique


    Figure 3: Anterior FOM


    Figure 4: Superior, intraoral view of SMG, duct, lingual nerve and mylohyoid and geniohyoid muscles

    The submandibular duct is located immediately deep to the mucosa of the anterior and lateral floor of mouth and opens into the oral cavity to either side of the frenulum via a puctum (Figures 3 & 4). Posteriorly the duct enters the superficial portion of the gland near the posterior border of mylohyoid muscle. The frenulum is a mucosal fold that extends between the floor of mouth and the ventral oral tongue, in the midline, between the openings of the submandibular ducts (Figure 3).


    Figure 5: Intraoral view of left sublingual gland with ducts of Rivinus, SMG and duct, lingual nerve, and mylohyoid muscles


    Figure 6: View of right sublingual gland


    Figure 7: Right sublingual salivary gland

    The paired sublingual salivary glands are located beneath the mucosa of the anterior floor of mouth, anterior to the submandibular ducts and above the mylohyoid and geniohyoid muscles (Figures 4, 5, 6, 7). The glands drain via 8-20 excretory ducts of Rivinus into the SMG duct and also directly into the mouth on an elevated crest of mucous membrane called the plica fimbriata which is formed by the gland and is located to either side of the frenulum of the tongue (Figures 4 & 5).


    Figure 8: Lingual nerve and submandibular duct after removal of sublingual gland in operation done for a ranula

    The lingual nerve lies on the surface of the mylohyoid muscle, then crosses deep to the submandibular duct in the posterolateral floor of mouth. It then runs on the surface of the hyoglossus, above the level of the duct, and is then distributed to the mucous membrane of the oral tongue (Figures 4, 5, 8).


    Figure 9: XIIn accompanied by ranine veins

    Therefore, the entire length of the duct can be exposed from above without injuring the nerve. Ranine veins are visible on the ventral surface of the tongue and accompany the hypoglossal nerve (Figures 3 & 9).

    Surgical steps

    • General anesthesia is administered, the patient is intubated transnasally and positioned supine with a head ring
    • The jaw is held open with a bite-block and a stay suture is used to retract the tongue
    • The submandibular duct orifice is identified and cannulated with a lacrimal probe
    • The cuff of mucosa surrounding the duct orifice is infiltrated with local anesthetic (xylocaine 1% with adrenaline)
    • The mucosa around the duct is incised and the incision continued in a linear fashion, posterolaterally, for 1 cm
    • The cannula remains inside the duct, and the duct is dissected free from the surrounding soft tissue, over a length of approximately 3 cm
    • A tunnel is made just deep to mucosa from the posterior limit of the incision to posterior to the glossopharyngeus muscle (anterior tonsillar pillar)
    • A mucosal incision is made posterior to the glossopharyngeal muscle, in the mucosa of the tonsillar fossa (NB. Children with anterior drooling would usually have undergone previous adenotonsillectomy, as first-line treatment)
    • The duct with the surrounding cuff of tissue is rerouted through the tunnel to emerge from the mucosal defect in the tonsillar fossa, secured using 4-0 vicryl
    • The floor of mouth incision is closed
    • The stay suture is removed
    • Postoperative broad-spectrum oral antibiotics are administered

    Management of Posterior Drooling

    Children with posterior drooling without structural upper aerodigestive tract abnormality and CPA require a stepwise approach to management in a multidisciplinary team setting. The treatment goals are to reduce the incidence of lower respiratory tract infection, decrease hospitalization, nursing care requirements and to improve quality of life. Management options for posterior drooling are nonsurgical or surgical.

    1. Non-surgical management

    Behavioral modification and feeding programs

    Initial conservative management involves allied health interventions which aim to improve oromotor function. Oral intake textures are modified, and positioning and feeding strategies are employed to reduce risk of aspiration. In children where oral intake is deemed unsafe, a feeding gastrostomy or jejunostomy tube are introduced.


    Anticholinergic agents are the mainstay of systemic medical treatment for drooling. Glycopyrrolate is the first-line oral anticholinergic. At our institution, this is available as a liquid or crushable tablet. It is commenced at a low dose of 0.01mg/kg/dose twice a day, and increased to effect, with a maximum dose of 0.04mg/kg three times per day2. Oral atropine drops onto the tongue is another option. Dermal glycopyrrolate (scopolamine) patches are a well tolerated option; patches can be trimmed to tailor the dose. Adverse effects of anticholinergic medications include irritability, restlessness, sedation, delirium, blurred vision, urinary retention, constipation and skin flushing. Side-effects limit their use in 20% of children.

    Botulinum toxin injection

    Intraglandular botulinum toxin type A (BoNTA) injections into the major salivary glands have proven very useful. Injections are administered to the major salivary glands, usually under ultrasound guidance to avoid intravascular injection. BoNTA blocks the release of acetylcholine at parasympathetic synapses, blocking parasympathetic innervation of the salivary glands and hence saliva secretion. The dose at our institution is 2 units/kg total, given in divided doses amongst all the glands. Adverse effects are very rare. Salivary gland Botox is well-suited to children who are also having injections to their limbs under the same anesthetic - in such cases the dose to the salivary glands is reduced. An uncommon but severe complication is spread of BoNTA to the pharyngeal musculature which can cause severe dysphagia3. The procedure is repeated at 3-6 monthly intervals.

    Steps for Botulinum toxin injection

    • General anesthesia is administered
    • The patient is positioned supine with a head ring
    • The skin overlying both necks and the parotid regions are prepared and draped with sterile drapes
    • The ultrasound probe is draped
    • Botulinum toxin, type A purified neurotoxin complex powder is reconstituted, according to the manufacturer’s instructions.
    • Local guidelines should be consulted for the maximum cumulative dose in the pediatric patient. The maximum dose is divided amongst the four glands.


    Figure 10: Ultrasound guided intraparotid Botulinum Toxin A injection. The parenchyma is infiltrated, avoiding vascular structures

    • Using a 25-gauge needle, under ultrasound guidance, Botulinum toxin is infiltrated into the parenchyma of both parotid and submandibular glands (Figure 10)
    • Post-procedure antibiotics are not required

    2. Surgical management

    Patients with drooling that has not responded to medical therapy and have chronic pulmonary aspiration (CPA) of saliva are considered for surgical management. Most of these children have neurological impairments. Surgical management addresses either salivary flow or definitively separates the trachea from the larynx, or tracheostomy alone.

    Procedures to reduce salivary flow include:
    1) Salivary duct ligation
    2) Submandibular gland excision
    3) Tympanic neurectomy: not recommended as it is ineffective, risks hearing loss and results in loss of taste5

    Airway procedures include
    1) Tracheostomy
    2) Laryngotracheal separation

    At our institution, children who fail medical therapy are offered bilateral submandibular gland excision and bilateral parotid duct ligation. Long-term side effects are rare, xerostomia being the most commonly encountered complication. This procedure has been shown to reduce readmission rates for children with chronic salivary aspiration6,7.

    Procedures to reduce salivary flow

    1) Salivary duct ligation

    • The salivary ducts of the submandibular (SMG) and parotid glands are amenable to ligation. Short-term morbidity includes sialadenitis and discomfort which is managed supportively as an inpatient, until symptoms have improved. Parotid duct ligation reduces salivary gland secretions in response to food stimulation,4 as the parotid produces more saliva in response to food than the other salivary glands. Ducts are ligated using a transoral approach. All four ducts can be ligated in the same procedure (‘4- duct ligation’).

    Surgical steps

    • General anesthesia is administered
    • The patient is intubated transnasally and positioned supine with a head ring
    • Intraoperative cephazolin and metronidazole are administered
    • The jaw is held open with a bite-block
    • A stay suture is used for tongue retraction
    • The parotid duct orifice is identified and cannulated with a lacrimal probe
    • The mucosa surrounding the orifice is infiltrated with local anesthetic (xylocaine 1% with adrenaline)
    • The mucosa around the duct orifice is incised in an elliptical fashion
    • The terminal duct is dissected free from the surrounding soft tissues
    • The duct is ligated with a 3-0 silk suture
    • The terminal duct and surrounding mucosa are amputated
    • The duct is buried in the soft tissues
    • The elliptical mucosal defect is closed with 4-0 vicryl
    • The same is repeated on the contralateral side
    • Attention then turns to the SMG duct orifice, which is identified and cannulated
    • The mucosa surrounding the orifice is infiltrated with local anesthetic (xylocaine 1% with adrenaline)
    • The mucosa around the orifice is incised in an elliptical fashion (along the direction of the duct)
    • The duct is dissected free over a length of <1 cm
    • The duct is ligated with a 3-0 silk suture
    • The terminal duct and surrounding mucosa are amputated
    • The duct is buried
    • The elliptical mucosal defect is closed with 4-0 vicryl
    • Postoperative broad-spectrum oral antibiotics are administered, and low dose amoxicillin is administered for 2 weeks postoperatively.

    Wiatrak BJ. Salivary gland 4-duct ligation for the management of chronic sialorrhea in children. Oper Tech Otolaryngol - Head Neck Surg. 2002;13(1):68–70

    Varma SK, Henderson HP, Cotton BR. Treatment of drooling by parotid duct ligation and submandibular duct diversion. Br J Plast Surg. 1991;44(6):415–7.

    2) Submandibular gland excision

    Transcervical submandibular gland excision is utilised to treat drooling. It eliminates saliva production in the resting state, as 70% of resting state saliva production occurs from the SMG glands. (See Figure 2) This procedure results in 2-3 cm unilateral or bilateral cervical scars. Complications are the same as with routine SMG excision. A detailed description of SMG excision can be read in the Open Access Atlas.

    Airway procedures

    1) Tracheostomy

    Children with neurological impairment often have tracheostomy placement for pulmonary toilet and to manage multiple medical comorbidities. In some cases, tracheostomy alone can be used to manage CPA secondary to drooling. This option requires intensive nursing care with regimented, very frequent tracheostomy tube suctioning.

    2) Laryngotracheal separation/diversion

    These are definitive surgical procedures for CPA cases that have proven to be unresponsive to all other management. They are offered to patients who are tracheostomy dependent, gastrostomy tube fed and non-verbal, and who continue to have CPA. These procedures completely separate the lower respiratory tract from the upper aerodigestive tract and eliminate any risk of aspiration. Children have a permanent tracheostomy tube and phonation is no longer possible. Both these procedures are potentially reversible, but it is best not to consider either option unless the need to reverse was considered only a remote possibility.

    Laryngotracheal separation technique

    • General anesthesia is administered
    • The patient is positioned supine with a head ring
    • The skin overlying both necks are prepared and draped with sterile drapes
    • Administer perioperative broad spectrum antibiotics
    • Make transverse cervical skin incision
    • Elevate subplatysmal flaps superiorly and inferiorly
    • Separate the infrahyoid strap muscles
    • Expose and divide thyroid isthmus
    • Expose and bluntly mobilize the trachea with finger dissection or a blunt hemostat to the upper mediastinum
    • Avoid injury to recurrent laryngeal nerves in the tracheo-oesophageal grooves
    • Horizontally incise the trachea distal to 1st of 2nd tracheal rings; depending on the length of the neck the incision may be made lower between 2nd and 3rd rings or even more inferiorly
    • Angle the tracheal incision superiorly to create a beveled tracheostoma
    • Carefully separate the posterior tracheal wall from esophagus, taking care not to enter the esophageal lumen


    Figure 11: The trachea is separated, and the distal segment is intubated

    • Place a small anesthetic tube through skin incision into the trachea to reroute gas administration from transoral to the stoma (Figure 11)
    • Make a circular skin incision in the anterior neck above the suprasternal notch
    • Formalize the tracheostomy by suturing the distal trachea circumferentially to the lower circular skin incision using 3-0 vicryl deep and 4-0 chromic running in 4 separate quadrants in a similar fashion to a laryngectomy stoma
    • Create a blind pouch of the superior tracheal end:
      • Remove the 2nd tracheal ring Invert the underlying subglottic mucosa with interrupted 4-0 vicryl
      • 12.png
      • Figure 12: A blind pouch is created by removing 2nd tracheal ring, the subglottic mucosa is inverted and closed with interrupted 4-0 vicryl and oversewn with running 3-0 vicryl
      • Oversew with running 3-0 vicryl (Figure 12)
      • Reinforce the subglottic pouch with strap muscles and fibrin glue
    • Insert a corrugated drain
    • Close the skin is closed in layers.

    Laryngeal diversion

    The trachea is separated, and a cervical stoma is created as with laryngotracheal separation. However, the distal end of the proximal segment of trachea is anastomosed to an anterior esophagostomy in an end-to-end fashion. Saliva is therefore diverted into the esophagus. The risk of surgical complications is higher with diversion, due to the anastomosis between the proximal trachea and esophagus.


    Laryngectomy results in permanent separation of the trachea from the upper aerodigestive tract and is very rarely performed in children with CPA secondary to drooling. It is not reversible, and children are rendered aphonic.


    1. Terry P, Fuller S. Pulmonary consequences of aspiration. Dysphagia. 1989; 3(4):179–83
    2. The Royal Children’s Hospital Melbourne. Saliva Control in Children [Internet]. 2017 [cited 2020 May 9].
    3. Patterson A, Almeida L et al. Occurrence of Dysphagia Following Botulinum Toxin Injection in Parkinsonismrelated Cervical Dystonia: A Retrospective Study. Tremor Other Hyper kinet Mov (N Y). 2016;6:379
    4. Khan WU, Islam A, Fu A, Blonski DC, Zaheer S, McCann CA, et al. Four-duct ligation for the treatment of sialorrhea in children. JAMA Otolaryngol - Head Neck Surg. 2016;142(3):278–83
    5. Gallagher TQ, Hartnick CJ. Bilateral submandibular gland excision and parotid duct ligation. Adv Otorhinolaryngol. 2012;73:70–5
    6. Noonan K, Prunty S, Ha JF, Vijaya - sekaran S. Surgical management of chronic salivary aspiration. Int J Pediatr Otorhinolaryngol [Internet]. 2014;78 (12):2079 –82
    7. Manrique D, Sato J. Salivary gland surgery for control of chronic pulmonary aspiration in children with cerebral palsy. Int J Pediatr Otorhinolaryngol. 2009;73(9):1192 –4


    Katherine Pollaers
    MBBS M Surg
    Perth Children’s Hospital
    Western Australia

    Shyan Vijayasekaran
    Perth Children’s Hospital
    Western Australia


    Johan Fagan MBChB, FCS (ORL), MMed
    Professor and Chairman
    Division of Otolaryngology
    University of Cape Town
    Cape Town, South Africa

    This page titled 3.17: Surgical Treatment of Pediatric Drooling is shared under a CC BY-NC 3.0 license and was authored, remixed, and/or curated by Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery.