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.