16 GENERAL INTRODUCTION is generally considered when the child is older than eight years or when there is a low expectation of “outgrowing” the drooling. Submandibular duct relocation (SMDR) has been the surgical technique of choice for anterior drooling since the 1980s. It is successful in approximately 80% of patients.44-47 SMDR is, in our opinion, still the most effective treatment for drooling, and we believe that this is primarily explained by the relocation of saliva to the base of the tongue, which leads to more frequent swallowing. SMDR is only performed in patients with safe swallowing, adequate posture, and non-progressive neurological disease. When compared to BoNT-A, SMDR is time-consuming and invasive and requires multiple days of admission. Postoperatively we prefer to observe patients one night, intubated and sedated on the pediatric intensive care unit due to the risk of swelling of the floor of the mouth, which can potentially cause upper airway obstruction. Other adverse events include postoperative bleeding, ranulas, nerve damage, sialoadenitis, and transient submandibular gland swelling.48 Briefly, although very effective, SMDR is undoubtedly the more invasive treatment option. Also, SMDR is contraindicated in posterior drooling, unsafe oral intake, and progressive neurodisabilities.48-50 In these cases, submandibular gland excision (SMGE) is commonly advised. SMGE has demonstrated slightly poorer results compared to SMDR but requires just one night postoperative admission. Disadvantages compared to SMDR include risk for adverse events and visible scars near the jawline.51 Severe adverse events after SMDR and SMGE are reported in 8% of our patients and include prolonged intensive care admission and surgical re-intervention.48, 50, 51 The operative time, adverse events, and the necessity for postoperative admission have led us (and others) to consider less invasive alternatives to SMDR and SMGE. A procedure utilizing ligation of the salivary duct, first reported by Klem and Mair in 1999, has slowly gained popularity. Initially, parotid and submandibular duct ligation (four-duct ligation, 4DL) was reported for severe aspiration. Soon
RkJQdWJsaXNoZXIy MjY0ODMw