1. Drooling surgical options Watad waseem

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

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

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

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

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

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

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

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

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

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

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

13. Parotid duct ligation u Location of the pappila, insert lacrimal probe u 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 u Cuff of mucosa dissected around duct and marked medially and laterally u Duct dissected 3-4 cm or until gland reached u Tonsil used to create a tunnel just posterior to anterior tonsillar pillar and sutures passed with duct u Tonsillectomy performed if obstructive tonsils

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

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

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

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

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