A Case of Anorexia and Drooling Improved by Targeting “Excessive Saliva Secretion” Using Bushirichuto / 日本東洋医学雑誌

A 65-year-old man, with a history of surgery for esophagogastric junction cancer in X-3, was admitted to the Department of Internal Medicine in our hospital in March for anorexia that had developed since January X. The patient was diagnosed with adhesive small bowel obstruction, and underwent surgery to relieve the obstruction in early May. However, his symptoms did not improve, and he was referred to our department in mid-June. His drooling was considered to be due to “excessive saliva secretion.” He started taking a decoction of bushirichuto for epigastric discomfort and resistance and coldness of the hands and feet. On the 5th day, he started to feel more energetic, and on the 8th day, his saliva production decreased. Furthermore, on the 12th day, his sense of taste and appetite improved. As the oral intake increased, tube feeding could be reduced and rehabilitation progressed ; from an almost bedridden state, he was able to walk continuously for 150 m with a cane. On the 29th day, he was transferred to a chronic care hospital. His weight increased from 34.1 kg, when he was referred to our department, to 39.7 kg at the discharge time. Anorexia and drooling, which had otherwise continued for 5 months, were improved within a short period of time by using bushirichuto.

Drooling in cerebral palsy and its relationship with dysphagia and gross motor functioning / 中华物理医学与康复杂志

Objective To analyze the incidence and severity of drooling in children with cerebral palsy and explore its correlation with oral dyskinesia,dysphagia and gross motor function.Methods A hundred children with cerebral palsy treated in Qingdao Women's and Children's Hospital between July 2013 and 2016 and 50 healthy children examined in the health examination center were assessed using the drooling severity scale,oral motor assessment,a dysphagia disorders survey (DDS) and the gross motor function classification system (GMFCS).The relationship between drooling severity,oral dyskinesia,dysphagia and their gross motor function was analyzed.Results Of the 100 children with cerebral palsy,32％ displayed drooling (at levels Ⅱ through Ⅴ),which was significantly higher than among the healthy controls.Another sixty-eight displayed level Ⅰ drooling.The severity of drooling was significantly different among children with different cerebral palsies.The drooling of children with spastic quadriplegia,dyskinesia or mixed-type cerebral palsy was the most severe,followed by those with ataxia and spastic diplegia whose drooling was often mild.No hemiplegic child drooled at level Ⅱ.Drooling severity was negatively correlated with the oral motor score,but positively correlated with the average DDS and GMFCS scores.Conclusions About one third of cerebral palsy children suffer from drooling.Their drooling severity is closely associated with the type of the cerebral palsy,oral dyskinesia,dysphagia and GMFCS levels.

Rapid Improvement and Maintained Effect with Steroid for Severe Salivary Dysphagia Due to Hypopharyngeal Cancer: Report of a Case

<p>Backgrounds: Salivary dysphagia due to digestive tract obstruction from pharyngeal and cervical esophageal cancer is a major cause of drooling, and the retention of saliva in the mouth is annoying to patients. Case report: An 87-year-old woman with recurrent hypopharyngeal cancer after radiation therapy complained that she could not sleep at night because of continuous sputa accumulation, and that she had to repeatedly eliminate saliva throughout day. Intravenous betamethasone at dose of 8 mg per day provided symptom relief the day after its administration. Her score on the Support Team Assessment Schedule, Japanese version (STAS-J) for salivary dysphagia decreased from 4 before treatment to 1 within two days after the initial administration. The dose was decreased to 2 mg per day six days after the start of administration, but the symptom relief continued. No symptom recurrence was seen for the two months that steroids were administered. Discussion: Our STAS-J finding indicates that the anti-inflammatory effect of betamethasone produces a rapid response that is maintained for months in cases of stenosis due to malignancy. Conclusions: Treatment with high dose steroid has the possibility of the relief of suffering caused by difficulty swallowing saliva.</p>

The effectiveness of scopolamine ointment for drooling in a patient with tongue cancer

A decrease in swallowing function growth may lead to drooling and a diminished quality of life in patients with tongue cancer. Common ways to counteract drooling include a reduction of fluid intake, and the administration of anticholinergics. These actions, however, may not often suppress drooling sufficiently. Here we report how the application of the formulation of scopolamine ointment near the mastoid process behind the ear resulted in the alleviation of drooling in a tongue cancer patient, after continuous intravenous scopolamine butylbromide infusion was unsuccessful. Dry mouth was noted as an adverse event, which was not problematic. Also, the ointment could be used without local dermatitis. Scopolamine ointment is much more convenient to use than continuous injection, suggesting the improved treatment for drooling in patients with tongue cancer.

Manejo de la sialorrea en personas con enfermedad de Parkinson mediante terapia conductivo conductual y estimulación termo-táctil / Management of sialorrhea in people with Parkinson's disease through behavioral therapy and thermotactile stimulation

This study proposes a Speech Therapy treatment for individuals with sialorrhea (saliva production perceived by patient as excessive) as a consequence of Parkinson Disease (PD). Method: A prospective study in 18 individuals with PD diagnosis was taken and divided into two groups: A) received only Cognitive Behavioral Therapy (CBT) (swallowing process awareness), while B) received CBT plus Thermal Tactile Stimulation (TTS) (cold sensory stimulation to the pharyngeal anterior pillars and oral cavity). The intervention lasted 5 weeks. The purpose of this research was to prove the effectiveness of Speech Therapy in dealing with sialorrhea and to assess a significant difference between CBT and CBT plus TTS. A t-student parameter test and the Mann-Withney test were used. Resulted: The assessment by the Clinical Scale for Parkinson Sialorrhea (SCS-PD) prior to therapy was CBT group was 2.6 and 11.5 ± 9.4 ± 4.2 group difference was not statistically significant. After therapy was 3.5 ± 2.8 and 4.6 ± 3.5 both showed a statistically significant difference compared to baseline (p < 0.001), not having statistically significant difference between them. Conclusion: These tests showed that both treatments are effective to decrease sialorrhea perception in individuals with PD. Nevertheless, no statistical significant differences were noted between both treatments.

Introducción: Este estudio propone un tratamiento Fonoaudiológico para trabajar con personas que presentan sialorrea (producción de saliva que el paciente percibe como excesiva) producto de la Enfermedad de Parkinson (EP). Método: Dieciocho personas con diagnóstico de EP y sialorrea, las cuales se dividieron en dos grupos; A: recibió sólo Terapia Cognitivo Conductual (TCC) (concientización del proceso deglutorio), mientras el B: recibió TCC más Estimulación Termo Táctil (ETT) (se realiza estimulación sensorial con frío a los pilares faríngeos anteriores y cavidad oral), la intervención se realizó por 5 semanas. El objetivo de la presente investigación es evidenciar la efectividad de la terapia Fonoaudiológica en el abordaje de la sialorrea y evaluar si existe una diferencia significativa entre la TCC y la TCC más ETT. Se utilizó la prueba paramétrica t-student, y Test de Mann-Withney, se consideró significativo un p < 0,05. Resultados: La valoración mediante la Escala Clínica de la Sialorrea para Parkinson (SCS-PD) previo a la terapia en grupo con TCC 11,5 ± 2,6 y el grupo 9,4 ± 4,2 diferencia que no es estadísticamente significativa. Posterior a la terapia fue 3,5 ± 2,8 y 4,6 ± 3,5 ambos presentaron una diferencia estadísticamente significativa respecto a la basal (p < 0,001), no habiendo diferencia estadísticamente significativa entre ellas. Conclusión: Estas pruebas demostraron que ambos tratamientos son efectivos para disminuir la percepción de sialorrea en las personas con EP. Sin embargo, no se evidencian diferencias estadísticamente significativas entre ambos tratamientos.

Sialorrhea - A Management Challenge In Dental Practice.

Sialorrhea also known as ptyalism or drooling, can be defined as salivary incontinence or the involuntary spillage of saliva over the lower lip. Drooling could be caused by excessive production of saliva, inability to retain saliva within the mouth, or problems with swallowing. Drooling can lead to functional and clinical consequences for patients, families, and caregivers. Physical and psychosocial complication includes maceration of skin around the mouth, secondary bacterial infection, bad odour, dehydration and social stigmatisation. This article provides a review of the physiology, pathogenesis, clinical oral manifestations, and therapeutic options for sialorrhea. Oral health care professionals should recognize the importance of sialorrhea as a possible indicator or complication of a variety of disease states of the oropharynx and esophagus as well as its impact on the patient's physical and social quality of life.

A Case of Drooling during Sleep Treated with Wharton's Duct Relocation / 대한이비인후과학회지

Sialorrhea, or drooling, is defined as excessive salivary spillage from the mouth. The exact pathophysiology of drooling is unknown but appears to be a defect in the oral phase of swallowing. The most common cause of drooling is cerebral palsy in children and Parkinson disease in adults. Drooling can cause various medical and psychosocial problems. Various treatment modalities include physical therapy, anticholinergic medications, botulinum toxin injection into salivary glands, and surgical procedures. We report a case of 22-year-old woman with excessive drooling during sleep, which was treated with Wharton's duct relocation.

Botulinum Toxin in the Treatment of Drooling in Tetraplegic Patients With Brain Injury

OBJECTIVE: To investigate the effect of botulinum toxin type A (BTA) injection into the salivary gland and to evaluate the changes of drooling in varied postures in tetraplegic patients with brain injury. METHODS: Eight tetraplegic patients with brain injury were enrolled. BTA was injected into each parotid and submandibular gland of both sides under ultrasonographic guidance. Drooling was measured by a questionnaire-based scoring system for drooling severity and frequency, and the sialorrhea was measured by a modified Schirmer test for the patients before the injection, 3 weeks and 3 months after the injection. Drooling was evaluated in each posture, such as supine, sitting, and tilt table standing, and during involuntary mastication, before and after the injection. RESULTS: The severity and frequency of drooling and the modified Schirmer test improved significantly at 3 weeks and 3 months after the injection (p<0.05). Drooling was more severe and frequent in tilt table standing than in the sitting position and in sitting versus supine position (p<0.05). The severity of drooling was significantly increased in the patients with involuntary mastication (p<0.05). CONCLUSION: Salivary gland injection of BTA in patients with tetraplegia resulting from brain injury who had drooling and sialorrhea could improve the symptoms for 3 months without complications. The severity and frequency of drooling were dependent on posture and involuntary mastication. Proper posture and involuntary mastication of the patients should be taken into account in planning drooling treatment.

Comparing the Effect of Botulinum Toxin Type B Injection at Different Dosages for Patient with Drooling due to Brain Lesion

OBJECTIVE: To investigate Botulinum toxin type B (BNT-B) injection's effect and duration depending on dose for patients with brain lesion. METHOD: Twenty one patients with brain lesion and severe drooling were included and divided into three groups. All patients received conventional dysphagia therapy. Group A patients (n=7) received an injection of 1,500 units and group B patients (n=7) received an injection of 2,500 units of BNT-B in submandibular gland under ultrasound guidance. Group C patients (n=7) received conventional dysphagia therapy. Saliva secretion was assessed quantitatively at baseline and at weeks 1, 2, 4, 8, and 12. The severity and frequency of drooling was assessed using the Drooling Quotient (DQ) by patients and/or caregivers. RESULTS: Group A and B reported a distinct improvement of the symptoms within 2 weeks after BNT-B injection. Compared to the baseline, the mean amount of saliva decreased significantly throughout the study. However, there was no meaningful difference between the two groups. The greatest reductions were achieved at 2 weeks and lasted up to 8 weeks after BNT-B injection. Group C did not show any differences. CONCLUSION: Local injection of 1,500 units of BNT-B into salivary glands under ultrasonic guidance proved to be a safe and effective dose for drooling in patient with brain lesion, as did 2,500 units.

Sialorrea neurogénica infantil y el manejo con la toxina botulínica: revisión de la literatura y reporte del caso de un niño con traqueostomía y ventilación mecánica crónica / Neurogenic drooling child and his treatment with botulinum toxin: a review of the literature and case report of a child with chronic tracheostomy and mechanical ventilation

Drooling is defined as non-intentional salivary loss from mouth. Its presence may lead to functional, psychological and social impairments, which affect patients and caregivers as well. Anterior drooling, where salivary flow escapes from mouth to outside, affects social relations, constituting a physical contact barrier and having a negative impact on quality of life, and it also interfere on speech and communication. Posterior drooling, where salivary flow goes towards the throat is associated to severe swallowing disorders, being an important aspiration risk. Although drooling etiology is multifactorial, it’s often seen associated to a neuromuscular dysfunction. The approach to drooling should be made by a multidisciplinary team. Therapeutic approach could be non-pharmacologic, pharmacologic, systemic or local. Ultrasound guidance Botulinum toxin injection is an efficient and safe alternative. A 4-year-old male with posterior fossa astrocytoma, VI-XI CN impairment, prolonged mechanical ventilation and tracheostomy, swallowing disorder and hypersalivation is presented. Drooling management with botulinum toxin A injection in both parotid and submandibular glands under ultrasound guidance was performed, with an important salivary flow decrease, which allowed him to open his mouth without saliva loss, having a positive impact on communication and socialization, improving his quality of life as well.

La sialorrea se define como la pérdida no intencional de saliva desde la boca. Su presencia puede conducir a alteraciones funcionales, psicológicas y sociales, que afectan tanto al paciente como a sus cuidadores. La sialorrea anterior, donde la saliva es derramada desde la boca al exterior afecta la socialización, constituyéndose como una barrera para el contacto físico e impacta en forma negativa sobre la calidad de vida, además interfiere en el lenguaje, el habla y la comunicación. La sialorrea posterior que es derramada hacia del itsmo de las fauces, se asocia a trastornos severos de la deglución, constituyendo un riesgo importante de aspiración. Aún cuando la etiología de la sialorrea es multifactorial, frecuentemente la vemos asociada a una disfunción neuromuscular. Su abordaje debe ser realizado por un equipo multidisciplinario. El enfoque terapéutico puede ser, no farmacológico o farmacológico, sistémico o local. Una de las alternativas es la infiltración con toxina botulínica guiada en forma ecográfica que ha demostrado ser eficiente y segura. Se presenta el caso de un preescolar de 4 años con antecedente de astrocitoma de fosa posterior, compromiso de VI al XI pares craneanos, ventilación mecánica prolongada a través de traqueostomía, trastorno de deglución e hipersalivación secundaria. Se realiza el manejo de la sialorrea con toxina botulínica A en parótidas y glándulas submandibulares con marcación ecográfica, resultando una disminución importante del flujo de saliva que le permite abrir la boca sin escurrimiento. Lo anterior impacta positivamente en la comunicación y socialización, además de mejorar su calidad de vida.

Effect of Botulinum Toxin Type A on Morphology of Salivary Glands in Patients with Cerebral Palsy

OBJECTIVE: To investigate the effect of botulinum toxin type A (BTXA) on drooling and the morphologic change of the salivary gland in patients with cerebral palsy. METHOD: Eight cerebral palsy patients suffering from severe drooling participated in this study. BTXA was injected into both submandibular and parotid glands under intravenous sedation and with ultrasound guidance (1 unit/gland/kg: maximum 100 units) in an outpatient or inpatient procedure. The severity of drooling was measured before injection and 3 weeks after injection using the Teacher Drooling Scale, the Drooling Score-severity, frequency and the Visual Analog Scale. To investigate the morphologic change of the salivary glands, the size of salivary glands were measured before injection and 3 weeks after injection using computed tomography of the neck. The measurement values were analyzed by Wilcoxon signed rank test. RESULTS: Statistically significant improvements were shown in all three parameters for assessing the severity of drooling after BTXA injections (p<0.05). Size of the salivary glands were significantly decreased at 3 weeks after BTXA injection (p<0.05). CONCLUSION: Salivary gland injection with BTXA could be a useful treatment method to reduce drooling in patients with cerebral palsy and decreased size of salivary glands may partially explain the mechanism.

Effects of Botulinum Toxin A Injection into Salivary Glands of Patients with Brain Lesion Suffering from Posterior Drooling

OBJECTIVE: The aim of the study was to evaluate the effectiveness of ultrasouond-guided salivary gland injection of botulinum toxin A (BTX-A) for posterior drooling. METHOD: 11 patients with brain lesion (9 cerebral palsy, 1 hypoxic ischemic encephalopathy and 1 mental retardation) with posterior drooling (an initial PDAS score greater than 2) and related pulmonary problems were recruited. Drooling severity was measured at baseline, 4 weeks, 3 months and 6 months after botulinum toxin A injection, by using Teacher Drooling Scale (TDS), Visual Analogue Scales (VAS), Drooling Score System (DSS)-severity, frequency and Posterior Drooling/Aspiration System (PDAS). RESULTS: The TDS, DSS-severity, DSS-frequency, VAS, PDAS were significantly reduced at 4 weeks and 3 months after BTX-A injection into salivary glands compared to pre-injection (p<0.05). However, there were no significant changes at 6 months compared to pre-injection level. CONCLUSION: BTX-A injection into salivary glands may improve anterior drooling in patients with brain lesions. Furthermore BTX-A injection into salivary glands may also decrease the posterior drooling which might related to respiratory symptoms in aspiration pneumonia.

Short Term Effects of Transdermal Scopolamine Patch for Drooling of Saliva in Patients with Cerebral Palsy

OBJECTIVE: To investigate the clinical usefulness of the transdermal scopolamine patch applied to control drooling of saliva in patients with cerebral palsy. METHOD: We enrolled twenty two patients with cerebral palsy residing in a rehabilitation center. The mean age of the patients was 24.0 years old. Transdermal scopolamine patch was applied to the patients for 2 weeks. We measured drooling quantity, severity of drooling, and visual analog scale of care givers' labor intensity at pre-application, post 1 week, and post 2 weeks. RESULTS: Drooling quantity decreased significantly from 4.1+/-1.9 ml to 2.8+/-1.5 ml at post 1 week (p<0.01), and 2.2+/-1.6 ml at post 2 weeks (p<0.01). Severity of drooling decreased from 4.1+/-0.8 to 2.9+/-1.1 at post 2 weeks (p<0.01). Visual analog scale of care givers' labor intensity decreased from 78.2+/-17.4 (mm) to 52.7+/-18.6 at post 1 week (p<0.01), and 45.9+/-22.8 at post 2 weeks (p<0.01). CONCLUSION: These findings suggested that the transdermal scopolamine patch is effective to reduce the drooling of saliva in patients with cerebral palsy within short term.

Advance in Control and Management of Drooling for Children with Cerebral Palsy / 中国康复理论与实践

@#Drooling caused by cerebral palsy has brought negative influencees on social psychology, educational opportunity and phycial potential of children with cerebral palsy. So taking some comprehensive measures to control and manage drooling is the very important part of rehabilitation for children with cerebral palsy. This paper focuses on the various effective approaches for managment of drooling.

Parotid and Submandibular Botulinum Toxin A Injection for Excessive Drooling Children / 대한소아신경학회지

PURPOSE: The aim of this study was to evaluate the data of 11 patients who had excessive drooling attributable to various diseases such as hypoxic ischemic encephalopathy, spinal muscular atrophy, and esophageal stricture treated with the injection of botulinum toxin A. METHODS: Eleven children with excessive drooling were enrolled in a retrospective clinical evaluation. Eighty to a hundred units of botulinum toxin A were injected into the patients' parotids, submandibular glands under sonographic guide. Subjective measures including Teacher Drooling Scale(TDS) by the patients' parents or caregivers were used to determine the effect of botulinum toxin A on drooling and to document the severity and frequency of children's drooling. RESULTS: The TDS and number of suctions per day demonstrated a significant reduction at 1 week, 1 month, and 3 months in most of the patients. We defined a 2 point decrease on the TDS as "success to therapy". Five of the eleven patients(45.5%) responded to botulinum toxin A injections. Of children who responded, the definite reduction of drooling was noticed at 4 weeks after the injections in three children, at 12 weeks in one, and at 1 week in the other. No adverse effects were observed during and after the injections in this study. CONCLUSION: Parotid and submandibular botulinum toxin A injection is an effective method for the reduction of excessive drooling, demonstrating a high response rate up to 12 weeks. The procedure is simple to perform, and safe when ultrasonographic guidance is used.

Evolução de 31 crianças submetidas à ressecção bilateral das glândulas submandibulares e ligadura dos ductos parotídeos para controlar a sialorréia / Drooling: analysis and evaluation of 31 children who underwent bilateral submandibular gland excision and parotid duct ligation

OBJETIVOS: Avaliar a segurança da ressecção bilateral das glândulas submandibulares e ligadura dos ductos parotídeos em crianças para reduzir a saliva, a eficácia e as complicações em médio e longo prazo no tratamento da sialorréia. FORMA DE ESTUDO: Coorte longitudinal. MATERIAL E MÉTODO: Trinta e uma crianças, com idades entre 6 e 13 anos (média de 7,6 anos), com múltiplas deficiências de etiologia neurológica foram submetidas à ressecção bilateral das glândulas submandibulares e ligadura dos ductos parotídeos, para controle da sialorréia, entre dezembro de 1999 a dezembro de 2005, e seguimento médio de 36 meses. RESULTADOS: O critério de sucesso foi o estabelecido por Wilkie, e 87 por cento das crianças tiveram resultados excelentes e bons, sendo a morbidade insignificante e a principal complicação foi o edema temporário na região parotídea. CONCLUSÃO: A ressecção bilateral das glândulas submandibulares e a ligadura dos ductos parotídeos constituem técnica segura e eficaz para ser realizada em crianças, com 87 por cento de sucesso no controle da sialorréia.

AIM: To evaluate the safety of bilateral submandibular gland excision and parotid duct ligation in order to control drooling in children; to assess its long-term efficacy and complications. STUDY DESIGN: longitudinal cohort. MATERIALS AND METHODS: Thirty-one children aged 6 to 13 years (7.6 years old in average), with multiple neurological disabilities were submitted to a bilateral submandibular gland excision with parotid duct ligation in order to control ptyalism between December 1999 and December 2005, mean follow up of 36 months. RESULTS: According to WilkieÆs success criteria, 87 percent of children had excellent or good results and insignificant morbidity was insignificant; with temporary parotid edema as the major complication. CONCLUSION: Bilateral submandibular gland excision with parotid duct ligation were safe to be performed in children, with 87 percent of success in drooling control.

A Survey of Drooling in Children with Cerebral Palsy

OBJECTIVE: To evaluate the prevalence of drooling in children with cerebral palsy and to determine their parents' needs for adequate treatment. METHOD: 107 children with cerebral palsy who attended to the pediatric rehabilitational treatment center were investigated whether they had the problems related with drooling. For the children with drooling, the severity of drooling was measured with subjective and objective measurement tools, and the types of cerebral palsy were classified. The parents answered to the questionnaire for several problems caused by drooling and whether they wanted treatment for drooling or not. RESULTS: 25 (23%) out of 107 children with cerebral palsy had drooling problems. 16 (64%) of them were spastic quadriplegic, which was the most common type. Parents of 17 (68%) drooling children had much uncomfortable feeling to drooling, and of 21 (84%) parents wanted treatment. In 21 (84%) children, their therapists felt difficulties during their treatment sessions due to drooling. CONCLUSION: 23% of children with cerebral palsy in rehabilitation clinic had drooling and most of their parents wanted treatment for drooling.

Factors Affecting Drooling in Adult Patients with Traumatic Brain Injury

OBJECTIVE: To investigate whether drooling in patients with traumatic brain injury (TBI) is due to hypersalivation or cognitive dysfunction or disability. METHOD: The subjects were 24 TBI patients with drooling and 17 TBI patients without drooling and 20 unaffected healthy volunteers who had no known physical or mental disabilities. All participants had no known history of diabetes mellitus, hypertension, thyroid dysfunction or chronic alcoholism. And, we excluded the subjects who take the anticholinergics, beta-agonist or steroid. Salivary pH and flow rate were compared between the TBI groups and the control group. We also measured Korean mini-mental state examination (K-MMSE) and disability rating scale (DRS) and compared mean values between TBI groups. RESULTS: There was no statistical difference in the mean salivary pH and flow rate between the tested groups. The drooling severity and frequency showed no correlation with salivary flow rate in all groups. The drooling severity and frequency showed significant correlations with K-MMSE, but not with DRS in TBI groups. CONCLUSION: The results of this study suggested that the cause of drooling in patients with TBI may not be the hypersalivation and functional disability, but cognitive dysfunction.