Mastering Sialorrhea: Advances in Surgical Management will be discussed.

Functional problems and correction of these problems are one of the main reasons for patients seeking corrective surgery. This panel especially addresses these issues and speakers will present their solutions to functional problems

Management of Nasal Valve Collapse Following Rhinoplastic Surgery

Nasal valve collapse (NVC) is a frequent, yet often overlooked, complication following rhinoplasty. It affects both the internal and external nasal valves and can lead to persistent nasal obstruction despite an otherwise successful cosmetic outcome. NVC is a significant and often underdiagnosed cause of postoperative nasal obstruction following rhinoplastic surgery. The incidence of NVC post-rhinoplasty is estimated at 10–15%, though this may be underestimated due to variability in diagnostic practices.

The nasal valve area, comprising the narrowest segment of the nasal airway, is highly susceptible to both static and dynamic collapse, particularly after structural alteration during cosmetic or functional rhinoplasty. Post-rhinoplasty NVC may result from structural weakening due to excessive cartilage resection, inadequate support of the lateral nasal wall, or failure to reinforce the internal valve. As the nasal valve area is critical to regulating airflow resistance, even minor structural changes can result in significant functional impairment.

The management strategy for NVC involves primarily prevention in the original operation. If occurs postoperatively, objective and subjective diagnostic methods, such as Visual Analog Scale (VAS) for patient-reported nasal obstruction, peak nasal inspiratory flow (PNIF) measurements, modified Cottle tests, nasal endoscopy, and digital imaging or anatomical assessment are used for definite diagnosis. Non-surgical methods are tried namely, the use of external nasal dilators strips, trial of internal nasal stents or nasal valve dilators and medical therapy (nasal corticosteroids, antihistamines) to optimize mucosal condition. These modalities, while non-invasive, are often insufficient or poorly tolerated by some patients due to comfort or cosmetic concerns.

Surgical correction methods may include the use of spreader grafts, alar batten grafts, and suspension techniques, tailored to the type and severity of the valve collapse. Alar batten grafts can improve the NVC, but cause the nose look less elegant and broad. Moreover, some patients feel uncomfortable due to graft rigidity on the nasal side walls.

Alternatively, nasal valve suspension sutures have shown promise in addressing both internal and external NVC without compromising nasal appearance. This technique does not require cartilage grafts, avoiding donor site morbidity, utilizes a minimally invasive endonasal approach, and involves placement of one or two 4-0 or 5-0 PDS sutures in a horizontal mattress configuration to support the lateral nasal wall.

This surgical technique is indicated for patients presenting with persistent nasal obstruction secondary to valve collapse following primary rhinoplasty. Exclusion criteria include unresolved septal deviation, turbinate hypertrophy unrelated to valve dysfunction, or active sinonasal disease. Patients were followed for a minimum of six months.

Postoperative outcomes were assessed using VAS scoring for subjective improvement, PNIF measurements for objective airflow assessment, modified Cottle test and nasal endoscopy, and photographic documentation to evaluate maintenance of aesthetic outcomes.

Nasal valve suspension sutures represent an effective and cosmetically favorable surgical option for managing NVC after rhinoplasty. This technique provides effective relief of nasal obstruction without compromising the external nasal appearance, making it a valuable alternative to traditional graft-based procedures in appropriately selected patients.

Course Description

This course is designed for otolaryngologists in the multidisciplinary management of pediatric sialorrhea. The curriculum provides a comprehensive overview of the pathophysiology, clinical assessment, and treatment modalities available for this challenging condition, with a particular emphasis on the novel integration of staggered botulinum toxin-A injections into the parotid and submandibular glands prior to four-duct ligation.

This approach has been shown to optimize surgical outcomes by reducing glandular secretion preoperatively, thereby minimizing patients' discomfort and postoperative complications such as gland swelling and sialadenitis. Through detailed anatomical review, evidence-based discussions, and operative video demonstrations, participants will gain the skills necessary to safely and effectively perform these interventions.

Outcome Objectives

Upon completion of this course, participants will be able to:

1. Describe the underlying pathophysiology and clinical manifestations of pediatric sialorrhea and its impact on functional swallowing and psychosocial well-being.
2. Identify appropriate candidates for botulinum toxin-A injections and four-duct ligation based on clinical evaluation and diagnostic criteria.
3. Explain the pharmacological mechanism of botulinum toxin-A and the clinical rationale for its staggered administration prior to surgical intervention.
4. Critically evaluate surgical treatment options regard to their indications, contraindications, and complication profiles.
5. Recognize potential perioperative and postoperative complications and apply strategies to prevent and manage these effectively.
6. Formulate multidisciplinary management plans incorporating surgical, medical, and rehabilitative therapies tailored to individual patient needs to improve outcomes and quality of life.

Background

Sialorrhea in the pediatric population is most commonly associated with neurological impairments such as cerebral palsy, neuromuscular disorders, and developmental delays. The pathogenesis involves disrupted coordination of the oral phase of swallowing, leading to excessive saliva pooling and drooling. Excessive drooling or sialorrhea, often resulting from impaired oral phase swallowing coordination, significantly impacts patient health and quality of life through physical complications such as skin irritation, aspiration pneumonia, and social stigmatization.

Conservative management strategies include oral motor and behavioral therapies, but their efficacy is often limited in severe or refractory cases. Pharmacological interventions, particularly botulinum toxin injections, provide transient reduction of salivary secretion but may require repeated administration. Surgical interventions aim to provide more durable solutions by altering salivary flow pathways or reducing glandular output.

Four-duct ligation has been demonstrated as an effective surgical option. Nevertheless, it carries risks such as postoperative glandular swelling and sialadenitis, which can complicate recovery. The protocol of administering staggered botulinum toxin-A injections into the parotid and submandibular glands prior to surgery serves to transiently decrease gland function, reduce secretion, and prepare the tissues for duct ligation, thereby minimizing complications.

References

1. Özturan O, Çalım ÖF. Approach to the patient with sialorrhea and treatment management. Praxis of ORL. 2018;6(1):39-47.
2. Calim OF, Hassouna HNH, Yildirim YS, Dogan R, Ozturan O. Pediatric Sialorrhea: Submandibular Duct Rerouting and Intraparotid Botulinum Toxin A Injection With Literature Review. Ann Otol Rhinol Laryngol. 2019 Feb;128(2):104-112.
3. Calim OF, Polat E, Ozturan O. Staggered botulinum toxin-a injections into parotid and submandibular glands prior to four-duct ligation for pediatric sialorrhea. Eur Arch Otorhinolaryngol. 2025 Apr;282(4):2043-2051. doi: 10.1007/s00405-024-09022-z.