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Original Investigation
March 2016

Four-Duct Ligation for the Treatment of Sialorrhea in Children

Author Affiliations
  • 1Faculty of Health Sciences, School of Medicine, Trinity College Dublin, Dublin, Ireland
  • 2Department of Pharmacology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 3Department of Occupational Therapy, School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada
  • 4Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 5Faculty of Arts and Science, University of Toronto, Toronto, Ontario, Canada
  • 6Cleft Lip and Palate/Craniofacial Service, Child Development Program, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
  • 7Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 8Department of Otolaryngology–Head and Neck Surgery, The Hospital for Sick Children (SickKids), University of Toronto, Toronto, Ontario, Canada
JAMA Otolaryngol Head Neck Surg. 2016;142(3):278-283. doi:10.1001/jamaoto.2015.3592

Importance  The 4-duct ligation procedure has appeal for its surgical simplicity and limited invasiveness in the management of pediatric sialorrhea. However, more information is required to understand the benefits, risks, success rates, and long-term effects of this intervention.

Objectives  To report the clinical outcomes of the 4-duct ligation procedure in pediatric patients diagnosed as having sialorrhea and the associated complication rates and to characterize patient and caregiver satisfaction in a consecutive series.

Design, Setting, and Participants  This investigation was a retrospective cohort study at an academic tertiary pediatric center and pediatric rehabilitation hospital. Patients included 38 children with neurological impairment who underwent a 4-duct salivary gland ligation (parotid and submandibular glands) between January 1, 2004, and July 31, 2012. The dates of the analysis were August 2013 through February 2015.

Main Outcomes and Measures  Posttreatment assessments included duration of effect, severity and frequency of drooling before and after the procedure, patient complications, caregiver satisfaction, caregiver recommendation of the procedure, and caregiver overall assessment of the child’s quality of life. Clinical and outcome measures were collected before the procedure, 1 month after the procedure, 1 year after the procedure, and at the most recent follow-up (range, 3-8 years).

Results  The study cohort comprised 38 participants. Their median age was 11 years (age range, 5-17 years), and 37% (14 of 38) were female. The mean (SD) duration of effect was 52.6 (20.4) months. Patients with previous sialorrhea management were more likely to demonstrate an improvement in their drooling frequency score at 1 year. Thirteen complications were documented in 12 patients. The most common complications were persistent facial swelling and aspiration pneumonia. Eighty percent (28 of 35) of caregivers reported an improvement in their child’s drooling at 1 month, while 69% (25 of 36) and 71% (24 of 34) stated that there was an improvement at the 1-year follow-up and the most recent follow-up, respectively.

Conclusions and Relevance  The 4-duct ligation procedure offers a simple, effective, and minimally invasive approach to the management of sialorrhea in children.