1. Drooling surgical options Watad waseem

2. Submandibular and Sublingual gland innervation • Superior salivatory nucleus - nervus intermedius - facial nerve - chorda tympani - lingual nerve - submandibular ganglion - submandibular/lingual glands

3. Parotid innervation • Inferior salivatory nucleus - glossopharyngeal nerve - Jacobsen’s nerve - lesser superficial petrosal nerve - otic ganglion - auriculotemporal nerve

4. Salivary gland innervation • Parasympathetic system stimulation causes an increase in saliva flow from all glands • Sympathetic system stimulation causes increase in saliva flow from submandibular gland but has no effect on parotid flow

5. Treatment Options • Multidisciplinary approach • Non-invasive modalities • Trial of medication • Surgery

6. Surgical options • Reduction of salivary flow • Relocation of salivary flow • combination

7. Surgical options • Submandibular gland excision • Parotid duct ligation • Transtympanic neurectomy • Submandibular duct rerouting • Parotid duct rerouting

8. Surgical indications • Age 5-6 • Failed non-surgical management > 6 months • Stable neurological status • Drooling with non-operative patient

9. Surgical contra-indications • High risk for operation • unilateral HL for tympanic neurectomy • Rerouting of salivary duct in esophagus disoerder, ch. aspiration

10. Pre-operative assessment • Lat neck x-ray , F.O for adenoids • adenoidectomy if necessary • Barium • audiometrey

11. Wilke procedure - 1967 • Bil. submandibular gland exc. And bil. Parotd duct relocation. • Success rate 85% • Postoperative complication (35%) and high morbidity • Modification of the procedure

12. Submandibular Gland Excision + partid duct ligation • High success rate(85 – 100%)- (Shot) • Very common • Low morbidity • Mild swelling of face, external scars, xerostomia , parotitis

13. Parotid duct ligation • Location of the pappila , insert lacrimal probe • Elliptical incision made around the parotid duct. Duct dissected for 1 cm, suture ligated and resected. The buccal mucosa is then repaired.

14. Rerouting of submandibular duct • Cuff of mucosa dissected around duct and marked medially and laterally • Duct dissected 3-4 cm or until gland reached • Tonsil used to create a tunnel just posterior to anterior tonsillar pillar and sutures passed with duct • Tonsillectomy performed if obstructive tonsils

15. Rerouting of submandibular duct(cont’d) • relocation in base of ant. Pillar : no need for TE , less infection • Rate success 80-100% • Sublingual gland exc. • Advantages: Decreased xerostomia, problems with taste and dysphagia • Disadv: Ranula, sialoadenitis, sialolithiasis, aspiration pneumonia

16. Studies on submandibular duct rerouting • Crysdale - 8% ranula rate • O’Dywer - 15 year follow -up study, 94% of parents stated their child benefited, 50% had complete cessation of drooling

17. Transtympanic neurectomies • 80% success rate • Must take both chorda and tympanic plexus • Hypotympanic branch in 50% of patients • Low speed drill • Loss of taste in anterior 2/3 of tongue and xerostomia • Contraindicated in unilateral SNHL

18. Transtympanic neurectomies • Recurrence of drooling – regeneration of tympanic nerves • Use for completion the surgery therapy for drooling

19. Laser photocoagulation of parotid duct • No scars no xerostomia • 40/48 patient improvement (chang – 2001) • Swelling of parotis, hematoma, infection