Thread by @michael_train10

🤤 DROOLING MANAGEMENT 🤤
Join me for my first #neuropalliative care Tweetorial:
1/11

But first, an anatomy refresher:

3 major glands involved: parotid, submandibular (SM), sublingual (SL)

💦 Unstimulated state: about 70% of saliva from SM + SL
💦 Stimulated state: 5x ⬆️ production, mostly via parotid

⚡CN 7 innervates SM & SL
⚡CN 9 innervates parotid

2/11

Saliva is produced via parasympathetic (muscarinic cholinergic) tone and cleared via swallowing.

Drooling = when thin saliva is present past the lip margin

Etiologies:
1. Impaired clearance (think neuromuscular dz ⬇️ swallowing)
2. Overproduction (think 💊 side effect)

3/11

Okay, but how big of a problem is this?

*Affects about 10-40% of children with cerebral palsy
*Affects about 70-80% of adults with Parkinson’s and 50% of adults with ALS
*Affects about 30-80% of patients taking clozapine (👋 #PsychTwitter)

4/11

You can use a few helpful scores in clinic:
The Oral Secretion Scale (OSS) has been validated for predicting NIV tolerance, need for hospice, and survival in ALS
Many different scales can be used in Parkinson’s disease, but a systematic review named the ROMP-Saliva superior

5/11

Now let’s review some options for management, starting with some good first steps:
1. Make sure your patient has thin secretions (management for thick secretions differs)
2. Don’t forget about the dentist 🦷 (malocclusion can worsen drooling)
3. Consider SLP for dysphagia

6/11

Oral anticholinergics are 1st line, but they are often limited by systemic effects (urinary retention, tachycardia, confusion/delirium) and nearly ⅓ of patients do not respond.
Enter: glycopyrrolate. It hardly crosses the BBB (less CNS effect), and it can be used IV at EOL

7/11

Atropine’s ophthalmic drop can be safely given sublingually (up to q4 hours) and this application mitigates many CNS effects.
Remember that scopolamine patches treat motion sickness (i.e, a “central” symptom), so they are more prone to cause AMS than atropine or glyco🔥late

8/11

Injection of botulinum toxin in the parotid and SM glands is a safe and effective management strategy for thin secretions. It does not require US or EMG (in the right hands). Tell your patients to expect relief for 2-3 months, but warn they will require repeated injections.

9/11

For refractory cases, radiation (EBRT) to the SM glands and parotids has been shown to help around 80% of patients, but ~ 40% experience toxicity. Surgery is also possible; low-quality evidence supports SM gland excision and parotid duct rerouting as preferred approaches.

10/11

CONCLUSIONS:
⭐Sialorrhea is a highly prevalent symptom in many neurologic conditions
⭐The mainstays of therapy are anticholinergic meds (while attempting to limit systemic effects)
⭐Botulinum toxin injection is an efficacious management strategy

11/11

What would you add? What would you like to see covered next? #NeuroPal @Neuropall_SIG @ContinuumAAN @Neuropalcare @AMehtaMD

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