161 The medium to long-term effects of two-duct ligation for excessive drooling in neurodisabilities, a cross-sectional study 7 Current study confirms a certain degree of recurrence after 2-DL, which has also been mentioned in previous research.8,11,9,17 Why the recurrence happens is not entirely clear. We presume that it is caused by a combination of alternative salivary pathway formation, compensatory hypersalivation and patient characteristics. It is previously proposed that the risk of recurrence by additional salivary pathway formation is increased when using ligatures instead of clips.8,11,9 18 In our series, three out of the four patients treated with ligatures underwent additional treatment for drooling, but we feel that this number is too low to draw definitive conclusions. Submandibular saliva might also find an alternative route through the duct of Bartholin. When a clip is placed too distally, saliva could drain via this duct to the ducts of Rivinus and into the oral cavity.19 Compensatory hypersalivation from the parotid gland could be another reason for treatment failure after 2-DL. 9,18,8 However, a study on the long-term effect of 4-DL (including ligation of the parotid ducts) also showed an increase in drooling one year postintervention.9 Compensatory sublingual or minor salivary gland hypersalivation might be an alternative explanation. In recent studies age (moremature, >12 years), posture (no anteflexion), and normal speech were identified as predictors for 2-DL treatment success.13,14 Although not significantly so, there were more patients with dysarthria in the group that received a reintervention after 2-DL. We did not find significant differences between the groups in age and posture. We theorize that yet unidentified patient characteristics could also contribute to recurrence after 2-DL. The number of reinterventions was in line with reintervention rates after 4-DL in previous research, but was higher than previous studies into 2- and 3-DL.16,9 The latter differences might have occurred because of the greater number of patients included in our study compared to previous papers.16
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