15 passage of solid foods, and intimate kissing.35, 36 Medication and interventional treatment potentially interfere with the natural function of saliva. There is, therefore, a delicate balance to be found between drooling and xerostomia.37, 38 Behavioural therapy and speech and language therapy are therefore considered first-line therapies for drooling in children with neurodisabilities. Some patients respond and maintain the treatment effect. In other patients, speech and language therapy and behavioral therapy is not effective enough as a single treatment, or it is expected to be ineffective because of the severity of the oromotor disorder or intellectual impairment.39 Anti-cholinergic agents are effective in reducing drooling. However, (systemic) adverse effects are frequently reported and do not uncommonly require cessation of therapy.40-42 Moreover, the effect of oral anticholinergics only lasts as long as the medication is used. The submandibular gland accounts for the majority of the saliva in the resting situation. Most of the invasive treatments in our institution, therefore, primarily target this gland specifically. BoNT-A injections have emerged as first-line pharmacotherapy for drooling resistant to conservative treatment. BoNT-A has proven clinically effective in 50% of children for a median of 22 weeks.15 Adverse events after BoNT-A are usually mild and transient. They primarily include temporary oro-motor paresis resulting in dysphagia. Still, severe dysphagia leading to temporary nasogastric feeding occurs in 3% of patients.43 BoNT-A is injected with ultrasound guidance under general anaesthesia. Due to the inherent temporary effect of BoNT-A, patients generally require at least yearly treatment to maintain the effect.24 Whether it is because the burden of the intervention eventually outweighs the benefits or because the effect of BoNT-A diminishes after repetitive injections, after a certain amount of repeated injections, it is common for patients and caregivers to ask for more definitive treatments. This is when surgery is advocated. In our institution, surgery
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