Management of Sialorrhea

Stuart Isaacson, MD: When you decide that treatment is indicated, do you ever take a step first trying to encourage the patient to swallow more, using mechanical ways of trying to induce swallowing? Or do you go straight to pharmacologic treatment?

Richard M. Trosch, MD: You can’t tell someone to swallow more. It’s sort of like telling them to breathe more deeply. If I told you to breathe deeply, you would do it for about 15 seconds, and then your mind would go somewhere else and you’d breathe the way you breathe. We’re not going to change the rate of swallowing. I’m not convinced that speech therapy training to help them helps with Parkinson disease. It may be effective in other types of sialorrhea, but for Parkinson there’s really a problem that you can’t fix with speech pathology training. Some people find that chewing gum helps. If someone has very mild, excessive salvia in their mouth where they’re not actually having anterior drooling or spillage, then maybe chewing gum would be a good solution.

Stuart Isaacson, MD: To try and stimulate the swallowing from chewing the gum?

Richard M. Trosch, MD: Right.

Stuart Isaacson, MD: I’ve used a lollipop also on a stick so they don’t choke on it, but it’s something to stimulate swallowing as well. How about behavioral modification?

Richard M. Trosch, MD: I’ve not really found it to be effective for Parkinson. It may be for other maybe developmental disorders in children, but I’ve not found it to be effective for PD [Parkinson disease], so I’ve not been using it in my population.

Stuart Isaacson, MD: When would you turn to things like surgery, ductal ligations, and radiation? Those seem extreme, but are there places when you’d go there?

Richard M. Trosch, MD: Lately I haven’t needed to, but I’ve used surgery in the past. Many years ago, perhaps over 2 decades ago, before I was using botulinum toxic substances, I had several patients for whom we did surgery. There are a few procedures out there. There’s mostly moving around the ducts, a translocation of either the submandibular duct or the parotid duct. There’s resection of the submandibular gland as well.

But there is a variety of surgeries that have been employed, either resecting the gland or repositioning the duct. The problem I found with surgeries is dosing. This is 1 of those conditions where there’s a sweet spot—like other things that we study, we like to see the condition go away. We don’t want to see saliva go away. People need saliva. You need it to swallow. You need it to taste. It has bacteriostatic properties. So we’d like to reduce the amount of saliva but not eliminate the amount. And we want to reduce it in a controlled fashion. And the problem I have with surgery is that it’s easy to overshoot, and then people end up with xerostomia and dry mouth, and they have a problem with dental caries and other problems. Or you undershoot, and then you have to do another procedure and go back. Some of the surgeries where they relocate the duct, you get more posterior drooling. You get rid of the anterior drooling, but you have more posterior drooling.

Stuart Isaacson, MD: That’s problematic.

Richard M. Trosch, MD: You need something that you can dose, that can get you the right amount, and for which surgery is difficult to do. Most of these require general anesthesia, and this tends to be an older population. So I’ve not used surgery. I know people still do radiation. Radiation has its own problems, so that’s for a very old person who has a limited life span who perhaps hasn’t responded to botulinum toxic injections. You could consider radiating the parotid or submandibular glands.

Stuart Isaacson, MD: Do you ever look at the medications patients are taking to see if there could be medications on the list that might increase saliva production?

Richard M. Trosch, MD: There are a few. The prototypical one, I think, is clozapine. You see it in the psychiatric population, where you have increased production or patients outside Parkinson disease who are on other neuroleptics who became Parkinsonian may develop sialorrhea as well.

Stuart Isaacson, MD: Let’s turn to treatment using oral therapies. There’s a number of different oral therapies that patients can swallow, or drops and different things. How do you approach that? Do you use these regularly? Is this something you use first line, or do you use botulinum toxin first line? Where do you place these oral therapies? How do you think about them?

Richard M. Trosch, MD: Right now I think the botulinum toxic substances are really the first-line therapy that I go to. The anticholinergic drugs like the atropine sublingual drops or the scopolamine patch.

Stuart Isaacson, MD: Glycopyrrolate.

Richard M. Trosch, MD: Glycopyrrolate of the 3 is probably the 1 with the least CNS [central nervous system] penetration. So we’re less likely to have worsening of cognitive impairment or the appearance of psychosis with that 1.

Stuart Isaacson, MD: Is that your biggest concern, the systemic adverse effects of anticholinergic therapies?

Richard M. Trosch, MD: Yeah. I mean, we already have problems in Parkinson disease. They tend to have gastric atony. They tend to have constipation. Orthostatic hypotension is very common.

Stuart Isaacson, MD: Memory problems.

Richard M. Trosch, MD: Memory problems as well, the CNS problems. Even in a drug like glycopyrrolate that doesn’t have much CNS penetration, it still is acting peripherally if we have other problems it’s likely to exacerbate. So I don’t tend to reach for those too often, and maybe that would be something when used in someone who wasn’t a candidate, for some reason, for botulinum toxic injection.

Stuart Isaacson, MD: It’s interesting that we’ve shied away as a field for many patients from anticholinergics for things like tremors, unless we have to use them. Yet for sialorrhea the anticholinergics were still being used. But these systemic adverse effects can pose a real

problem.

Richard M. Trosch, MD: Right, and we have safer therapies that I find more effective.