It is a serious disability for a large number of patients with cerebral palsy, children and adults, but also for a smaller number of patients with other types of neurological (neurodegenerative) or mental disorders. A special group of children are those with neuromuscular disorders because they may be delayed in the “maturation” of oral neuromuscular control until the age of 6 years. Salivation is a normal process in children aged 18 to 24 months, until the development of oral reflexes and swallowing is complete.
However, when it persists over 4 years of age, it should be considered a pathological condition and investigated. Salivation (usually associated with cerebral palsy) causes significant problems (clinical, functional, psychological, social) in both patients and relatives. Children with salivation often develop dermatological and cervical inflammations, their clothes are constantly getting wet and they need to change, forcing the family to stay at home and socially isolate themselves. Toys and teaching and communication devices are destroyed by moisture, thus affecting their education. Posterior salivation is a more serious condition because it can cause coughing, vomiting, difficulty breathing, inability to speak and aspirations leading to recurrent pneumonia. In severe cases, dehydration causes particular health problems.
Where is it due?
Salivation is rarely due to hypersecretion of salivary glands (primary salivation). It is usually due to impaired neuromuscular control and dysfunction of the voluntary motor activity of the mouth, which leads to overflow of saliva from the mouth (secondary salivation). Inadequate or infrequent swallowing, head position, large tongue and poor oral health contribute to this dysfunction.
Treatment of the patient
Managing a patient with salivation in order to decide how to treat it requires the cooperation of a team of various specialists such as ENT, dentist, neurologist, orthopedist, speech therapist and physiotherapist. Parents and caregivers can help assess the characteristics of salivation. The peak time within 24 hours, the number of changes of bibs or clothes per day, difficulties with keyboards or other communication devices, the severity of skin wetting and peripheral inflammation are important information for assessing the severity and frequency of salivation as well as for the impact on the quality of life of the patient and his family.
After the assessment by the medical team and depending on the patient’s condition are recommended:
A. Exercises to improve mouth movements and swallowing that aim to:
• normalize muscle tone
• stabilize body and head position
• stabilize and coordinate jaw movements and lip closure
• reduce the abusive movements of the tongue
• increase the aesthetics of the oral tract
• improve swallowing
B. Behavioral therapy
Verbal and auditory stimuli are used to increase the frequency and effectiveness of swallowing.
C. Medication
• Anticholinergic drugs that reduce the volume of salivation, but show side effects creating additional problems in a population that already has similar difficulties
Botulinum toxin (type A) (BOTOX), which acts on the cholinergic parasympathetic secretory-motor fibers of the salivary gland resulting in reduced salivary secretion.
D. Surgical treatment
Surgery is indicated after the failure of at least 6 months of conservative treatment, as well as in patients with moderate to severe salivation whose cognitive function precludes treatment with conservative treatment. Surgery is best done after the age of 6, in order to give time for complete maturation of the function of coordination of oral movements and swallowing.
Writes:
Michael Tsakanikos
Surgeon-Pediatric Otolaryngologist
Coordinating Director of the 2nd Pediatric Otolaryngology Clinic of MITERA Children
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