Surgery for drooling
Reviewed by Suzanne Jervis

This paper looks at the surgical options for sialorrhoea once the first two options of behavioural and physiotherapy interventions and pharmacotherapy have been exhausted. The social impact of sialorrhoea on patients and their families is significant and often lifelong therefore good, permanent outcomes are key. To avoid external incisions, four duct ligation techniques have been utilised with the aim of gland atrophy. Since the submandibular gland produces the largest amount of saliva (70%), as a bare minimum their ducts should be ligated, with the parotid ducts as optional, although these authors consider them required. They revise the anatomy in detail with regards to the ducts and their important structural neighbours to avoid damaging. The principle is the same for each duct in that the duct should be identified using a lacrimal probe and an incision placed proximally over the duct in the mucosa after infiltration with lignocaine and adrenaline. Blunt dissection is then used to identify and isolate the duct and this is then ligated in two areas and the ampulla diathermied. It helpfully concludes that the four published case series to date have reported low complication rates of less than 17% and these have included transient gland swelling, sialadenitis and ranula. Xerostomia and dental caries were not noted. This was a straightforward article with useful revision of the anatomy of the floor of the mouth (although a diagram in this regard would have been a useful addition). However, it would have been interesting to have included other surgical options such as duct relocation or gland excision to draw more informed decisions regarding which approach is more suitable on a case-by-case basis. 

Four duct ligation.
Heffernan C, Adil E.
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY
2015;26(1):39-41.