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Letters to the Editor
March 15, 2010

Statistics or Ethics? Decision to Treat Drooling—Reply

Author Affiliations

Author Affiliations: Department of Otolaryngology, Walter Reed Army Medical Center, Washington, DC.

Arch Otolaryngol Head Neck Surg. 2010;136(3):315-316. doi:10.1001/archoto.2010.4

In reply

We appreciate Dr Pitak-Arnnop's thoughtful comments. We certainly agree with the second point that appropriate preoperative counseling is critical for all surgical procedures and that in the case of drooling patients, who are often pediatric patients and/or neurologically impaired, completing this counseling with an appropriate caregiver is essential and expected in every case.

In regard to the first point, we would like to clarify the role of meta-analysis within the context of evidence-based medicine, which represents a synthesis of the best available evidence (perhaps best provided by meta-analysis), the training and experience of the provider, and the desires and qualities of the patient.1 It was our goal to compile and analyze the data concerning the surgical management of drooling to allow caregivers to use these data as a component for the decision-making process for the individual component along with the other above-mentioned factors. We do not agree with Dr Pitak-Arnnop that removal of salivary glands is unethical or inappropriate in the case of socially problematic drooling in the absence of aspiration. Indeed, if removal of the submandibular glands along with parotid duct rerouting is the most efficacious approach to manage drooling (by no means is that 100% conclusive based on the current evidence) and it is presented within the context of a complete and suitable preoperative counseling session (which may be difficult to achieve [see below]), with full discussion of risks (to include dental hygiene problems) and benefits, then, in our opinion, it is a perfectly acceptable approach to manage drooling. Although we almost always take a “least invasive procedure first” approach for most surgical problems, including drooling, we do not believe that it is consistent with the role of a physician to withhold a safe and effective procedure from a patient if the appropriately informed decision maker elects to proceed with it with the goal of enjoying a higher reported success rate and potentially avoiding revision surgery.

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