Four Gland Duct Ligation with Botulinum Injections
Background:
This video visualizes the four-duct ligation surgery for chronic sialorrhea. Sialorrhea is characterized by the improper spilling of saliva, most commonly due to poor muscle coordination1. Controlling oral secretions with the perioral muscles and the act of swallowing takes precise contraction from voluntary and reflex contractions. Sialorrhea is common in newborns and children up to 5 since they have not learned to coordinate these contractions yet1. The most common etiology of persistent, or new, sialorrhea is cerebral palsy, amyotrophic lateral sclerosis, seizures, cerebrovascular accidents, facial paralysis, and dental problems1.While many neurological conditions can predispose a child to sialorrhea, cerebral palsy is most common, comprising up to 10% of cases3.The side effects of untreated sialorrhea include increased risk of infections, dental caries, and interference with speech. Aspiration pneumonia is a serious consequence from pooling of saliva in the posterior pharynx3. Patients can also become malnourished due to trouble chewing, loss of fluids/electrolytes, and loss of protein2. Non-evasive measures such as oral motor therapy, behavior modification therapy via biofeedback, and drug therapy should be considered before proceeding to surgical treatment2. Surgical treatment is preferred when the patient is at risk for aspiration pneumonia3. One of the most common surgical procedures for sialorrhea is the four-gland duct ligation. While the four-gland duct ligation is low risk for complications, facial swelling, aspiration pneumonia, oxygen desaturation, and vomiting are potential complications. Out of these, facial swelling was the most common adverse event3.
Methods:
An appropriate surgical candidate was identified in the clinic and advised about the risks and benefits of the procedure. The patient was appropriately prepped and inducted under general anesthesia. An oral side bitter was placed to visualize the oral cavity. Stensen’s duct was identified on the left with army navy retraction. A lacrimal probe was used to maintain the duct opening and an alice retractor was used to hold the duct in place. The dissection was performed bluntly and with cautery. Care was taken to prevent injury to the duct and to provide clear exposure. The probe was removed, and the proximal portion of the duct was ligated with two oppositely placed 3.0 silk sutures. The mucosa was then closed with 4.0 chromic suture in a simple interrupted stitch. The same procedure was performed on the contralateral side. The focus was then turned to whartons duct. The oral side bitter was removed, and the tongue was retracted using an army navy. The right papilla was identified and retracted with a Geralds with teeth to maintain proper visualization of the duct. Blunt and cautery dissection was performed around the duct for proper exposure. Once down to the base of the duct, tonsil clamps were used to clamp just proximal to the gland to aid with suture ligation. Two oppositely placed 3.0 silk sutures were used to ligate the duct. The mucosa was closed with a 4.0 chromic stitch. The exact same procedure was performed on the left whartons duct. Once complete the oral cavity was irrigated and cleaned. Ultrasound was then brought into the field. Under direct visual guidance 1mg/kg of botulinum toxin was injected into the parotid and submandibular glands using the hockey shaped ultrasound probe. Having tolerated the procedure well, the patient was turned back over to anesthesia, awakened and transferred to the recovery room in stable condition.
Results:
There were no complications encountered before, during, or after the procedure. The patient was followed in clinic for 1 year and the patient’s care giver reported satisfactory reduction in sialorrhea.
Discussion:
This video shows the steps of performing a 4-gland duct ligation with botulinum toxin injections. It is a commonly indicated procedure in children under 5 years of age for chronic sialorrhea refractory to other treatment options. While not first line therapy, this procedure should be heavily considered for due to post-operative success and care giver satisfaction.
References:
Jean-Paul Meningaud, Poramate Pitak-Arnnop, Luc Chikhani, Jacques-Charles Bertrand, Drooling of saliva: A review of the etiology and management options, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, Volume 101, Issue 1,2006, Pages 48-57, ISSN 1079-2104
Little, S.A., Kubba, H. and Hussain, S.S.M. (2009), An evidence-based approach to the child who drools saliva. Clinical Otolaryngology, 34: 236-239. https://doi-org.libproxy.uams.edu/10.1111/j.1749-4486.2009.01917.x
Khan WU, Islam A, Fu A, et al. Four-Duct Ligation for the Treatment of Sialorrhea in Children. JAMA Otolaryngol Head Neck Surg. 2016;142(3):278–283. doi:10.1001/jamaoto.2015.3592