Dealing with Drooling (Neurology Now article)

[Guest guest]

There's a good article in the latest issue of Neurology Now magazine on the

treatment of drooling in neurological disorders. Dr. (a

neurologist at Stanford and at the ALS center at CPMC San Francisco) is quoted

in the article as saying: " We tend to think that since some of these

[neurologic] conditions are incurable, they're also untreatable. That's a big

mistake. We have many treatments—for the breathing issues, the nutritional

issues, treatments that slow the progression of disease, and yes, treatments for

drooling. "

The article mentions the medication glycopyrrolate (brand name=Robinul).

Generally speaking, caution should be exercised when giving an anticholinergic

medication such as Robinul to someone to dementia (as there may already be a

lack of acetylcholine in the brain of someone with dementia).

Neurology Now is a magazine written for laypeople. Subscriptions to the

bimonthly publication are available at no charge; see:

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Robin

http://journals.lww.com/neurologynow/Fulltext/2011/07010/EYE_ON_THERAPY__Dealing\

_with_Drooling__Getting_rid.15.aspx

EYE ON THERAPY

Dealing with Drooling

Getting rid of excess saliva goes high-tech.

by Amy Paturel, MS, MPH

Neurology Now

February/March 2011; Volume 7(1); Pp 38,40

When 61-year-old Deborah first experienced trouble swallowing, she didn't

think much of it. But six months later, when she began having symptoms like

slurred speech and difficulty projecting her voice, she visited a neurologist.

Diagnosed with amyotrophic lateral sclerosis (ALS, also called Lou Gehrig's

disease) in February 2008, quickly discovered how integral the muscles in

her mouth were to her quality of life. Not only did she have difficulty

speaking, but she also experienced excess saliva pooling in her mouth. At its

worst, found herself changing clothes up to four times a day because she

had drooled down the front of her shirt.

" I was reluctant to be in public or around strangers—especially when a meal was

involved, " says . " People were always offering me tissues to control the

drooling. It was embarrassing. "

Drooling, or sialorrhea, can be a major problem for people with neurologic

conditions ranging from Parkinson's disease and cerebral palsy to certain types

of stroke and ALS. People with these conditions may not have the brain control

to coordinate muscle movements in the face and mouth.

" Any condition that affects the muscles and nerves of the bulbar area (the

swallowing mechanism) could cause increased drooling, " says Bachrach,

M.D., co-director of the Cerebral Palsy Program for Alfred I. duPont Hospital

for Children in Wilmington, DE. And if you're not swallowing your saliva, it

tends to pool and accumulate in the mouth, and then it starts overflowing.

Beyond the obvious social implications of incessant drooling, the overflow of

saliva in the mouth can irritate tissues around the lips and even cause

aspiration pneumonia, a serious condition where people breathe fluid (or other

foreign materials) from the mouth into the lungs. But with recent advances in

everything from oral medication to botulinum toxin injections, people have more

options than ever to control sialorrhea.

SWALLOWING THERAPY

Speech and swallowing therapy is a great option for people who are mildly

impaired and highly motivated to control their drooling. Most neurologists will

advise patients to investigate this approach before considering invasive

procedures. Through a series of sessions, therapists teach patients a variety of

techniques to improve the safety of swallowing and minimize the risks of

aspiration.

" There's a lot that a swallowing therapist can do in this area, " says

, M.D., professor of neurology at Stanford University and director of the

Forbes Norris ALS Research Center at the California Pacific Medical Center in

San Francisco. " If you tuck in your chin when you're swallowing, for example,

you'll open up the airway, making it easier for fluid and food to go down. "

Even just becoming more aware of when and how you swallow can be effective. With

regular training, people can learn to swallow more efficiently and get rid of

excess saliva. Unfortunately, none of these techniques actually dries up the

spit. If that's your goal, medications or surgery are your best bets.

MEDICATION

When less invasive methods have failed, the next approach is medication, usually

anti-cholinergic medications. This class of drugs is used for everything from

seasickness to overactive bladder. But with dry mouth as one of the main side

effects, anti-cholinergics have become a useful tool to control drooling. In

fact, studies investigating glycopyrrolate (the most commonly prescribed

medication for drooling) consistently find the drug reduces drooling for up to

95 percent of patients who try it.

" One of the biggest challenges was that glycopyrrolate was only available in

tablet form, so it was hard to adjust the dose to very small amounts, " says Dr.

Bachrach. But in January 2011, the Food and Drug Administration approved a

liquid form of the drug, which will make it easier to take and easier to dose.

When started taking glycopyrrolate, her drooling improved within a matter

of days. Initially she took one tablet three times a day, but eventually she

needed four tablets daily to experience the same effects. Over time, even four

tablets didn't reduce her drooling to an acceptable level.

" Even if the drugs do work initially, receptors on the cells and within the

salivary glands change, so patients may end up requiring higher and higher doses

to get the same result—and then they get side effects, " says Brietzke,

M.D., M.P.H., director of pediatric otolaryngology at the Walter Army

Medical Center in Washington D.C. While dry mouth is the most common side

effect, some people also experience constipation, urinary retention, and

cognitive side effects such as confusion and memory impairment.

If the anti-cholinergics stop working—or the side effects are intolerable—some

physicians prescribe amitriptyline, an anti-depressant that dries up saliva. A

bonus: amitriptyline improves sleep, which is often disrupted in patients with

ALS, multiple sclerosis, and other neurologic disorders.

INJECTIONS

If meds can't control drooling, botulinum toxin is another option. Using an

ultrasound-guided approach, the physician injects the drug into the major

salivary glands to paralyze the muscles that normally squeeze out saliva. In one

study of 131 patients, published in the medical journal Archives of

Otolaryngology Head and Neck Surgery in 2010, botulinum toxin injections in the

submandibular glands (the two glands located in the lower jaw that produce most

of the saliva) reduced drooling and improved quality of life among patients who

received injections. Two months after the injections, nearly 50 percent of

patients experienced significant improvement, with effects beginning to taper

off at the eight-month mark.

started with just two shots into the salivary glands on either side of her

face. Within a week, her drooling had dissipated more than it had with

glycopyrrolate alone, and the effects lasted for three months. On the heels of

this success, 's physician gradually increased her dose to a total of six

shots (three on each side).

" With six shots, the results were much more dramatic, " says . " I have very

little drooling and the only side effect is dry mouth, which is easier to deal

with than drooling. " After the last round of botulinum toxin, discontinued

the glycopyrrolate without any noticeable difference.

Studies suggest that combined injections in both the parotid glands (which are

located in the cheeks) and submandibular glands are slightly more effective than

injections into the submandibular glands alone. And after repeated injections,

there have been some reports that the salivary glands actually stop working,

resulting in a permanent reduction in drooling. " You can't count on that, " says

Dr. Bachrach, " but it does happen in some patients. "

For other people, though, botulinum toxin is just a trial procedure to determine

whether surgery will be effective. " Botulinum toxin deactivates those major

glands, so we can see if that helps the patient with either the social problem

or aspiration, " says Dr. Brietzke. " If there's significant improvement, then we

can consider a potentially irreversible procedure, such as tying off the ducts

or removing the glands. "

SURGERY

Surgical treatment for drooling may be even more effective than injections,

without subjecting people to recurrent treatments. Studies show that people who

have surgery are generally happy with the results. Unfortunately, there are a

variety of approaches and little consensus about which ones work best. The most

straightforward procedure involves the submandibular glands: Rerouting the ducts

from these glands to the back of the mouth makes it easier to swallow saliva.

Alternatively, surgeons can reroute the ducts from the parotid glands or remove

the submandibular glands altogether.

" The evidence we have suggests that intra-oral procedures (like tying off the

four ducts in the mouth) may not be as successful, " says Dr. Brietzke. According

to a study he co-authored in Archives of Otolaryngology Head and Neck Surgery in

2009, removal of the submandibular glands and parotid duct rerouting appear to

have the highest success rates at 87.8 percent while the success rates for tying

off the four ducts varied wildly from 31 to 100 percent.

" The biggest downside is that surgery is not reversible, " says Dr. Bachrach.

" Once you've tied off the ducts, or removed the glands altogether, you can't

undo that. " So while you can go from drooling to dry, you can't go back. And dry

mouth has its own set of complications.

Even so, treating symptoms like drooling still gets short shrift from some

health care providers.

" We tend to think that since some of these [neurologic] conditions are

incurable, they're also untreatable, " says Dr. . " That's a big mistake. We

have many treatments—for the breathing issues, the nutritional issues,

treatments that slow the progression of disease, and yes, treatments for

drooling. "

For , that treatment has been invaluable. Today, she no longer carries a

napkin with her at all times, she doesn't shy away from social events, even with

strangers, and her shirt stays dry throughout the day. " I'm very happy with the

results, " she says.