179 Unsuccessful submandibular duct surgery for anterior drooling: Surgical failure or parotid gland salivation? 8 parotid gland salivation.15,17-19 To investigate the reasons for persistent drooling we evaluated 10 patients who needed re-intervention because of refractory anterior drooling. Following our success criteria (a 50% reduction on DQ or VAS at 32 weeks compared to baseline), only 3 cases (bilateral PDL or SMGE as a re-intervention) could be considered successful after secondary surgery. No more than 2 (out of 11) interventions led to an objective (DQ) treatment success (Table 3). These results prove that there is limited effect of 1PDL or SMGE after 2-DL or SMDR, which strongly implies that recurrence of anterior drooling after submandibular duct surgery could not be explained by surgical failure (alternative salivary pathway formation in case of 2-DL, or inadequate relocation of the ducts in case of SMDR).19,22 Salivation of the parotid glands could be a compelling reason for recurrence of drooling, because bilateral PDL combined with SMGE seemed to be the most convincing treatment strategy. This finding corresponds with the limited previous literature about SMGE combined with bilateral PDL, in which this intervention showed very good subjective results as a primary intervention.28 Nevertheless, this intervention should be handled with care, because Stern et al did report a ‘dry mouth’ as a complication in a couple of patients. This complication could have major impact on digestion especially mastication and that in turn could have a tremendous impact on quality of life. When comparing the two patients with a DQ reduction of at least 50% with the entire group, we were unable to detect a potential source of selection bias. As displayed in Table 1, there were no major differences in characteristics. The only notable aspect was the fact that the two patients with a high therapy response, were the only patients that did not suffer from cerebral palsy and were at the lowest age at time of surgery (8 and 9 years of age at primary surgery, and respectively 8 and 10 years of age at re-intervention). This is contrary to recent literature that reported age >12 years to predict treatment success after SMDR.21
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