This CPB has been updated with additional background ......Excessive drooling (sialorrhea, ptyalism)...

Prior Authorization Review Panel MCO Policy Submission

A separate copy of this form must accompany each policy submitted for review.

Policies submitted without this form will not be considered for review.

Plan: Aetna Better Health Submission Date: 09/04/2018

Policy Number: 0265 Effective Date: Revision Date:

Policy Name: Surgical Treatments to Control Drooling (Sialorrhea)

Type of Submission – Check all that apply: New Policy Revised Policy* Annual Review – No Revisions

*All revisions to the policy must be highlighted using track changes throughout the document. Please provide any clarifying information for the policy below:

CPB 265 Surgical Treatments to Control Drooling (Sialorrhea)

Clinical content was last revised on 05/12/2017. Additional non-clinical updates were made by Corporate since the last PARP submission, as documented below.

Revision and Update History since last PARP submission: 06/21/2018 - This CPB has been updated with additional background information and references. 03/14/2019 – Tentative next scheduled review date by Corporate .

Name of Authorized Individual (Please type or print):

Dr. Bernard Lewin, M.D.

Signature of Authorized Individual:

www.aetnabetterhealth.com/pennsylvania Updated 09/04/2018

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Surgical Treatments to Control Drooling (Sialorrhea) - Medical Clinical Policy Bulletins |...

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Surgical Treatments to Control Drooling (Sialorrhea)

Policy His tory

Last Review

06/21/2018

Effective: 06/18/1998

Next

Review: 03/14/2019

Review History

Definitions

A dditiona l In form at ion

Clinical Policy

Bulletin Notes

Number: 0265

*Please see amendment for Pennsylvania Medicaid at the end of this CPB.

Policy

Aetna considers surgical correction of refractory excessive

drooling medically necessary for members who meet both of

the following criteria.

1. Members must have excessive drooling that is associated

with significant morbidity such as skin maceration, poor

oral hygiene or dehydration; and

2. Members must have failed to adequately respond to

appropriate physical therapy and drug therapy.

The following surgical procedures to control excessive drooling

may be considered medically necessary for members who

meet the selection criteria listed above:

1. Excision of submandibular gland, with or without parotid

duct ligation

2. Four-duct ligation (i.e., ligation of bilateral submandibular

ducts and bilateral parotid ducts)

3. Parotid duct diversion, bilateral (Wilke type procedure)

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Surgical Treatments to Control Drooling (Sialorrhea) - Medical Clinical Policy Bulletins |... Page 2 of 19

4. Parotid duct diversion, bilateral, with excision of one

submandibular gland

5. Parotid duct diversion, bilateral, with excision of both

submandibular glands

6. Parotid duct diversion, bilateral, with ligation of both

submandibular ducts

7. Relocation of the submandibular ducts, with or without

removal of sublingual glands

8. Tympanic neurectomy or chorda tympani neurectomy.

Aetna considers surgical correction of drooling cosmetic when

criteria are not met.

Aetna considers transoral submandibular ganglion neurectomy

experimental and investigational for correction of drooling

because the effectiveness of this approach has not been

established.

See also CPB 0113 - Botulinum Toxin (../100_199/0113.html)

.

B ac kg round

Excessive drooling (sialorrhea, ptyalism) is estimated to occur

in 10 % of patients with cerebral palsy (CP), and in other

patients with neurological damage. While drooling can be

considered a cosmetic problem, excessive drooling can result

in significant hygienic problems, maceration of the skin and

dehydration. Furthermore, excessive drooling can limit any

efforts at speech therapy.

Drooling can either be related to a central neurogenic problem,

as in CP, in which there is poor coordination of the muscles of

deglutination, or be related to a peripheral nerve lesion, such

as in facial nerve or glossopharyngeal nerve palsy. All

patients should initially be treated with various physical




therapy and behavior modifications regimens. Medical therapy

has focused on the use of anti-cholinergic drugs (e.g.,

amitriptyline, atropine, glycopyrrolate, hyoscyamine, and

transdermal scopolamine), which reduce the production of

saliva. However, therapeutic doses of these drugs usually

result in unacceptable side effects such as constipation,

urinary retention, blurred vision and restlessness. When

conservative approaches fail, surgical intervention can be

considered.

Surgical management of sialorrhea includes rerouting the

parotid or submandibular ducts, excision of the submandibular

glands or transection of the nerves innervating the parotid

gland (tympanic neurectomy) or submandibular gland (chorda

tympani neurectomy). Although none of the procedures has

been studied in large series of patients, all seem to be

associated with a success rate of greater than 82 %. Selection

of the procedure seems to be largely a physician/patient

preference issue, balancing the increased morbidity of the

gland excision or duct relocation procedures against the threat

of recurrence and the loss of taste associated with the

neurectomy procedures.

Glynn and O'Dwyer (2007) stated that submandibular duct

relocation plus or minus excision of the sublingual glands are

relatively simple procedures with low morbidity. In a

prospective study, these researchers compared both

procedures including operative time, length of hospital stay,

post-operative complications, drooling scores and parental

satisfaction. A total of 71 submandibular duct relocation and

29 submandibular duct relocation plus excision of the

sublingual glands procedures were performed. Exclusion

criteria were patients with recurrent aspiration pneumonias or

dental caries. Two patients were lost to follow-up and

excluded from the study. Operative time and length of hospital

stay were increased in the submandibular duct relocation plus

sublingual gland excision group. Drooling scores and parental

satisfaction results were excellent, 93 % of parents in the




submandibular duct relocation group and 89 % of parents in

the duct relocation plus sublingual glands excision were

satisfied and would recommend the procedure. There was no

statistical difference (p = 0.643) in drooling scores between

the 2 procedures. Post-operative morbidity was higher with

the addition of sublingual gland excision, with post-operative

hemorrhage occurring in 13.7 % and 36 % of parents

expressing concern over post-operative pain, compared with 3

% post-operative hemorrhage rate with submandibular duct

relocation and only 12 % of parents expressing the same

concerns. The authors concluded that both procedures are

effective in drooling control, but the addition of sublingual

gland excision increases morbidity. These researchers no

longer excise sublingual glands with submandibular duct

relocation.

Celet Ozden et al (2012) noted that drooling complicates many

neurologic disorders including CP. Surgical treatment consists

mainly of ablative (excision/ligation) or physiological (diversion)

methods; combined techniques have also been proposed.

These investigators have applied bilateral diversion of both

submandibular and parotid ducts in 12 CP patients (age range

of 7 to 15 years). Pre-operative drooling severity was grade

4/5 in 10 cases and grade 5/5 in 2 of the cases. All patients

underwent physiotherapy for a minimum of 6 months and were

consulted with a dentist, otolaryngologist, and a speech

therapist before surgery. No bleeding, hematoma, or infection

has been observed in any of the patients. Two patients had

early post-operative tongue edema that regressed with

conservative treatment. All patients except 1 regressed to

grade 2/5 drooling by the first post-operative month. In 1

patient who had previously been classified as grade 5/5,

surgery provided limited improvement with only 1 grade of step-

down. Satisfactory results for the patients and their families

could be achieved and sustained for a median 18 months (7 to

20 months) of follow-up. The authors concluded that the

quadruple duct diversion method is an effective physiological

surgical method in the control of drooling in CP.




In a prospective, non-randomized interventional study, Chanu

et al (2012) evaluated the improvement in drooling in children

undergoing 4-duct ligation procedure for excessive drooling

and studied its effect on their quality of life. A total of 30

drooling children of both sexes aged 4 to 15 years underwent

4-duct ligation (i.e., ligation of bilateral submandibular ducts

and bilateral parotid ducts). Comparison of pre-operative and

post-operative drooling scores using Thomas-Stonell and

Greenberg classification was done. Glasgow Children's

Benefit Inventory Score was used to assess the improvement

in the quality of life. Success rate in terms of improvement in

drooling was 93.33 %. A complication rate of 16.67 % was

found. The mean improvement in total drooling score after 12

months was 4.43. The paired t-test applied on pre-operative

and post-operative combined drooling scores showed p <

0.001. The mean Glasgow Children's Benefit Inventory score

was 36.15. In the post-operative period, transient swelling of

cheeks, transient swelling of submandibular glands, change in

the consistency of saliva, cheek abscess, collection of saliva in

the cheek, and parotid duct fistula were observed. The

authors concluded that the 4-duct ligation resulted in marked

improvement in drooling and significantly increased the quality

of life in drooling children. It has few complications, which can

be managed effectively.

Stern et al (2002) evaluated the safety of bilateral

submandibular gland excision (SGE) with parotid duct ligation

(PDL) and assessed its long-term complications and

effectiveness in the treatment of chronic sialorrhea in children.

A total of 93 patients with chronic sialorrhea who underwent

bilateral SGE with PDL from 1988 to 1997 were included in

this study. Main outcome measures included operative and

post-operative complications, length of post-operative

hospitalization, post-operative drooling, care requirements,

xerostomia, dental caries, and overall satisfaction. The mean

post-operative stay was 2.4 days. There were 3 post-

operative complications. Seventy-two families were

interviewed (follow-up time, 1 to 10 years): 62 (87 %) reported




no further drooling or significant improvement; 7 reported the

occurrence of dry mouth; and 2 reported an increase in dental

caries. The authors concluded that bilateral SGE with PDL is

a safe and consistently efficient procedure for the treatment of

chronic sialorrhea in children.

Noonan et al (2014) noted that sialorrhea and chronic salivary

aspiration are a major problem in many neurologically

impaired children causing embarrassment, skin issues and

recurrent lower respiratory tract infections (LRTI). These

researchers evaluated the effectiveness of salivary gland

surgery in the treatment of chronic salivary aspiration in such

children. They compared admission rates for LRTI per annum

before and after surgical intervention. These investigators

performed a retrospective review of all patients who underwent

salivary management surgery for chronic aspiration under

Princess Margaret Hospital's (PMH) Otolaryngology

department from 2006 until 2013. A total of 12 patients were

included in this review. Their ages ranged from 3 to 21 years

(mean of 11.4). Their genders were equally distributed. Two

patients had underlying congenital disorders; 1 had an

acquired brain injury, while the majority (n = 9, 75 %) had

cerebral palsy secondary to a sustained perinatal injury. Most

patients (n = 11, 91.7 %) had bilateral SGE and PDL as a

primary procedure. One patient had a laryngo-tracheal

separation. Two patients went on to have a second

procedure. The mean follow-up time was 5 years. Using

Wilcoxon Signed-Rank test, these researchers showed that

the median rate of admission per annum for LRTI pre-

operatively was 1.0. This was reduced to 0.5 post-operatively,

which was statistically significant (p ≤ 0.05). The authors

hypothesized that the combination of bilateral SGE and

bilateral PDL is effective in reducing admissions with aspiration

pneumonia in neurologically impaired children, and therefore

improves the quality of life in these patients.




Naghavi and Jalali (2010) assessed the results following

submandibular duct relocation and sublingual resection for the

treatment of drooling. These researchers presented the

results of the surgical protocol used between 1994 and 2007

at the Drooling Clinic of Amiralmomenin Hospital in Rasht, Iran

(n = 32). The pre-operative and post-operative levels of

drooling were measured. The parents of the patients were

contacted by telephone at least 1 year after operation. Of all

the patients, 18 were males and 14 were females; and were

aged 6 to 26 years. Of 30 patients with complete patients'

chart, the mean drooling score fell from 7.59 to 2.71 after

surgery (p < 0.0001). In 30 patients, results of operation were

ascertained by telephone at average of 5.6 years after

operation. In 78.1 % of patients, long-term result was

successful and none was considered worse after the

procedure. There were few complications, none of which had

any long-term adverse effects. Swelling of submandibular

glands was frequently observed in the immediate post-

operative period. Only 1 ranula was seen as delayed

complication. The authors concluded that submandibular duct

relocation with simultaneous sublingual gland excision is a

safe and consistently efficient procedure for the treatment of

chronic sialorrhea.

Hornibrook and Cochrane (2012) reviewed the causes of

severe sialorrhea, and in particular in children in whom it can

become a life-long disability. These investigators also

discussed history of medical and surgical treatments. A major

advance has been the surgical relocation of the submandibular

gland ducts with removal of sublingual glands. The results of

this operation, technical considerations, and its outcomes in 16

children were presented. There were no significant

complications. Caregivers judged the effectiveness with a

median score of "75 %" improvement. The technique has

become the most logical and reliable surgical treatment for

drooling, with very good control in most cases. In contrast to

"Botox", its effects are permanent.




Formeister et al (2014) stated that chronic sialorrhea is a

common problem for pediatric patients with disorders that

affect swallowing. While many patients are successfully

treated with medical therapies such as Robinul

(glycopyrrolate) and scopolamine, a number of such children

are not able to tolerate the side effects of these medications.

In these cases, surgical treatments can include botulinum toxin

A (Botox) injections into the major salivary glands, sublingual

or submandibular gland excision (SMGE), submandibular duct

ligation, PDL, or any combination of the above procedures.

These investigators reported on the 10-year experience with

the surgical management of chronic sialorrhea at 1 tertiary

care institution, and compared the efficacy of open surgical

procedures versus Botox injections for reduction in salivary

flow. A retrospective chart review identified 27 pediatric

patients with chronic sialorrhea; 21 of whom underwent Botox

injections and 15 of whom underwent surgical procedures.

Pre-operative and follow-up clinic notes were reviewed to

determine the level and severity of drooling as well as the

effectiveness of sialorrhea reduction, as assessed by the

Teacher Drooling Scale (TDS). A total of 42% of those

receiving Botox injections reported a reduction in drooling, with

the average pre- and post-Botox TDS of 4.3 and 3.9,

respectively (p = 0.02 by the Wilcoxon signed rank test); 9 of

the patients receiving Botox injections (43 %) required multiple

injections, with an average duration of effect of 3.9 months,

and 7 patients (33 %) eventually required surgery. All of the

children who underwent surgery (7 bilateral SMGE with PDL, 6

SMGE only, and 2 PDL only) experienced a reduction in

drooling, with average pre- and post-operative TDS of 4.5 and

2.2, respectively. This reduction was significant by the

Wilcoxon signed rank test (p = 0.001). The authors concluded

that the 10-year experience at their institution demonstrated

the safety, effectiveness and long-term control of drooling in

the patients undergoing surgery for intractable sialorrhea.




Four-Duct Ligation (i.e., Ligation of Bilateral Submandibular Ducts and Bilateral Parotid Ducts):

In a case-series study, Klem and Mair (1999) examined the

effectiveness of bilateral submandibular and parotid duct

ligation on children with severe neuromuscular impairment and

chronic aspiration of salivary secretions and identified any

predictable anatomical connections between the

submandibular duct and sublingual glands. A total of 5

children with severe neuromuscular impairment and recurrent

aspiration pneumonitis were included in this study. Subjects

underwent bilateral submandibular and parotid duct ligation.

The oral cavities of 8 cadavers were dissected to identify

anatomical connections between the submandibular duct and

sublingual glands. Main outcome measures were incidence of

post-operative aspiration pneumonitis; gross anatomical

connections between the submandibular duct and sublingual

gland in cadaveric specimens. No post-operative airway

obstruction, infection, or xerostomia was noted, and

technetium scanning confirmed control of salivary secretions

from major salivary glands. Caregivers noted diminished

salivary secretions and no aspiration pneumonia. The authors

concluded that this new, simple intra-oral procedure controlled

aspiration pneumonitis with minimal surgical dissection and

had less morbidity than procedures involving major salivary

gland excision. Ranula formation, a common complication of

submandibular duct transposition, is unlikely in this procedure

because the sublingual ducts are not interrupted.

Shirley and co-workers (2003) compared results in their first 21

patients undergoing four-duct (4-duct) ligation (i.e., ligation of

bilateral submandibular ducts and bilateral parotid ducts) with

results reported in the literature for other procedures to treat

sialorrhea. These investigators retrospectively reviewed

medical records of all 21 children who were treated with 4-duct

ligation, a relatively simple intra-oral procedure to control

sialorrhea, between August 1999 and September 2000 and

contacted primary caregivers by telephone to answer a



Surgical Treatments to Control Drooling (Sialorrhea) - Medical Clinical Policy Bulletin... Page 10 of 19

questionnaire regarding objective and subjective results of

surgery. Surgery was considered successful when caregivers

rated patients as “much better” or “better” after surgery.

Follow-up was completed in all 21 of the patients 1 to 14

months after surgery. The success rate of 4-duct ligation

(“much better” or “better” after surgery) was 81 %, and no

patient's sialorrhea problem was worse after surgery. Major

complications occurred in 2 (10 %) of the patients (1 ranula

and 1 case of sialoadenitis), which were both successfully

treated surgically. Minor complications occurred in 4 (19 %) of

the patients, tongue swelling that prolonged hospitalization, a

ranula that resolved, and prolonged submandibular gland

swelling that resolved (2 cases). More than 50 % of patients

were discharged the day of or the day after surgery. The

authors concluded that 4-duct ligation should be considered

when surgery is indicated to treat sialorrhea.

In a prospective, non-randomized, interventional study, Chanu

and colleagues (2012) evaluated the improvement in drooling

in children undergoing 4-duct ligation procedure for excessive

drooling and examined its effect on their quality of life (QOL).

The study was carried out between November 2009 and

September 2011. A total of 30 drooling children of both sexes

aged 4 to 15 years underwent 4-duct ligation. Comparison of

pre-operative and post-operative drooling scores using

Thomas-Stonell and Greenberg classification was performed.

Glasgow Children's Benefit Inventory Score was used to

assess the improvement in the QOL. Success rate in terms of

improvement in drooling was 93.33 %. A complication rate of

16.67 % was found. The mean improvement in total drooling

score after 12 months was 4.43. The paired t-test applied on

pre-operative and post-operative combined drooling scores

showed p < 0.001. The mean Glasgow Children's Benefit

Inventory score was 36.15. In the post-operative period,

transient swelling of cheeks, transient swelling of

submandibular glands, change in the consistency of saliva,

cheek abscess, collection of saliva in the cheek, and parotid

duct fistula were observed. The authors concluded that 4-duct




ligation resulted in marked improvement in drooling and

significantly increased the QOL in drooling children. It had few

complications, which can be managed effectively.

In a consecutive series study, Khan and associates (2016)

reported the clinical outcomes of the 4-duct ligation procedure

in pediatric patients diagnosed as having sialorrhea and the

associated complication rates and characterized patient and

caregiver satisfaction. 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 between January 1, 2004, and July 31, 2012.

The dates of the analysis were August 2013 through February

2015. Post-treatment 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 QOL. 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 of 3 to 8 years). The study cohort

comprised 38 participants; their median age was 11 years

(range of 5 to 17), 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; 13 complications were documented in 12 patients.

The most common complications were persistent facial

swelling and aspiration pneumonia; 80 % (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. The authors concluded

that the 4-duct ligation procedure offered a simple, effective,

and minimally invasive approach to the management of

sialorrhea in children.




Endoscopic Transoral Submandibular Ganglion Neurectomy:

Spock et al (2015) explored the feasibility of transoral

submandibular ganglion neurectomy for the management of

sialorrhea. A total of 10 human cadaver dissections of the

floor of mouth were performed bilaterally, for a total of 20

separate cases. A transoral submandibular ganglion

neurectomy was performed in 10 cadavers (20 neurectomies)

easily and reliably, without injury to the submandibular duct or

the main trunk of the lingual nerve. The authors concluded

that transoral submandibular ganglion neurectomy is an

attractive addition to the armamentarium of surgical options for

the treatment of medically intractable sialorrhea. They stated

that further study in selected patients is needed to

demonstrate clinical feasibility.

Hughes and Brown (2017) carried out a retrospective review of

10 pediatric patients who underwent transoral submandibular

gland excision; the series was analyzed for age, gender,

indication for procedure, complications, length of

hospitalization, and post-operative pathology. Patients were

followed for a minimum of 12 months. A total of 7 females and

3 males aged 9 to 17 underwent the procedure. Recurrent

sialoadenitis, and sialolithiasis, accounted for 6 cases while

salivary neoplasms (pleomorphic adenoma) accounted for 4

cases. No patient suffered vessel or nerve injury; and no

patient showed recurrent disease at 12 months follow-up. All

glands were completely removed and no patient required

conversion to the transcervical approach. The authors

concluded that transoral submandibular gland excision was

safe and effective in the pediatric population. This method

avoided a cervical scar, avoided injury to the marginal

mandibular branch of the facial nerve, and completely

removed the duct, eliminating the potentiality of remnant duct

disease. The authors have performed 10 transoral




submandibular gland excisions in pediatric patients without

complications. This was a small (n = 2) retrospective study; its

findings need to be validated by well-designed studies.

Ozturk and colleagues (2017) performed endoscopic transoral

neurectomy of the submandibular and sublingual glands to

treat drooling. These researchers bilaterally operated 2 adult

cases with treatment-resistant drooling. In these patients,

conventional treatment had failed. Repeated botulinum toxin

type A injections had been effective but were becoming less

so. The patients benefited from surgery in that their saliva

scores decreased. No issue emerged over 6 months of follow-

up. The authors concluded that endoscopic transoral

neurectomy of the submandibular and sublingual glands

reduced saliva production and allowed management of

drooling in treatment-resistant patients. This was a small

case-series study (n = 2); its findings need to be validated by

well-designed studies.

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

Code Code Description

CPT codes covered if selection criteria are met:

42440 Excision of submandibular (submaxillary) gland

42507 Parotid duct diversion, bilateral (Wilke type

procedure)

42509 with excision of both submandibular glands

42510 with ligation of both submandibular

(Wharton's) ducts

42665 Ligation salivary duct, intraoral [four- duct

ligation]

69676 Tympanic neurectomy




Code Code Description

Other CPT codes related to the CPB:

42500 Plastic repair of salivary duct, sialodochoplasty;

primary or simple

42505 secondary or complicated

42550 Injection procedure for sialography

70390 Sialography, radiological supervision and

interpretation

HCPCS codes covered if selection criteria are met:

D7981 Excision of salivary gland, by report

Other HCPCS codes related to the CPB:

D0310 Sialography

ICD-10 codes covered if selection criteria are met:

K11.1 Hypertrophy of salivary gland

K11.7 Disturbances of salivary secretion

The above polic y is bas ed on the following referenc es:

1. Myer CM. Sialorrhea. Ped Clin N Amer. 1989;36:1495-

1500.

2. Wilkie TF, Brody GS. The surgical treatment of

drooling: A ten-year review. Plas Reconstruc Surg.

1977;59(6):791-797.

3. Crysdale WS. The drooling patients: Evaluation and

current surgical option. Laryngoscope. 1980;90:775-

783.

4. Dundas DF, Peterson RA. Surgical treatment of

drooling by bilateral parotid duct ligation and




submandibular resection. Plas Reconstruc Surg.

1979;64:47-51.

5. Glass LW, Nobel GL, Vecchione TR. Treatment of

uncontrolled drooling by bilateral excision of

submandibular glands and parotid duct ligations. Plas

Reconstruc Surg. 1978;62(4):523-526.

6. Toremalm NG, Bjerre I. Surgical elimination of

drooling. Laryngoscope. 1976;86:104-112.

7. Becmeur F, Horta-Geraud P, Brunot B, et al. Diversion

of salivary flow to treat drooling in patients with

cerebral palsy. J Pediatr Surg. 1996;31(12):1629-1633.

8. O'Dwyer TP, Conlon BJ. The surgical management of

drooling - a 15 years follow-up. Clin Otolaryngol.

1997;22(3):284-287.

9. Ethunandan M, MacPherson DW. Persistent drooling:

Treatment by bilateral submandibular duct

transposition and simultaneous sublingual gland

excision. Ann R Coll Surg Engl. 1998;80(4):279-282.

10. Wilson SW, Henderson HP. The surgical treatment of

drooling in Leicester: 12 years experience. Br J Plast

Surg. 1999;52(5):335-338.

11. Panarese A, Ghosh S, Hodgson D, et al. Outcomes of

submandibular duct re-implantation for sialorrhoea.

Clin Otolaryngol. 2001;26(2):143-146.

12. Stern Y, Feinmesser R, Collins M, et al. Bilateral

submandibular gland excision with parotid duct

ligation for treatment of sialorrhea in children: Long-

term results. Arch Otolaryngol Head Neck Surg.

2002;128(7):801-803.

13. De M, Adair R, Golchin K, Cinnamond MJ. Outcomes of

submandibular duct relocation: a 15-year experience. J

Laryngol Otol. 2003;117(10):821-823.

14. Uppal HS, De R, D'Souza AR, Pearman K, Proops DW.

Bilateral submandibular duct relocation for drooling:

an evaluation of results for the Birmingham Children's

Hospital. Eur Arch Otorhinolaryngol. 2003;260(1):48-

51.




15. Hockstein NG, Samadi DS, Gendron K, Handler SD.

Sialorrhea: A management challenge. Am Fam

Physician. 2004;69(11):2628-2634.

16. Meningaud JP, Pitak-Arnnop P, Chikhani L, Bertrand JC.

Drooling of saliva: A review of the etiology and

management options. Oral Surg Oral Med Oral Pathol

Oral Radiol Endod. 2006;101(1):48-57.

17. Jongerius PH, van Tiel P, van Limbeek J, et al. A

systematic review for evidence of efficacy of

anticholinergic drugs to treat drooling. Arch Dis

Childhood. 2003;88(10):911-914.

18. Glynn F, O'Dwyer TP. Does the addition of sublingual

gland excision to submandibular duct relocation give

better overall results in drooling control? Clin

Otolaryngol. 2007;32(2):103-107.

19. Heywood RL, Cochrane LA, Hartley BE. Parotid duct

ligation for treatment of drooling in children with

neurological impairment. J Laryngol Otol. 2009;123

(9):997-1001.

20. Little SA, Kubba H, Hussain SS. An evidence-based

approach to the child who drools saliva. Clin

Otolaryngol. 2009;34(3):236-239.

21. Reed J, Mans CK, Brietzke SE. Surgical management of

drooling: A meta-analysis. Arch Otolaryngol Head Neck

Surg. 2009;135(9):924-931.

22. Naghavi SE, Jalali MM. Management of drooling for

patients in the north of Iran: Analysis of the surgical

management. J Res Med Sci. 2010;15(1):1-5.

23. Hornibrook J, Cochrane N. Contemporary surgical

management of severe sialorrhea in children. ISRN

Pediatr. 2012;2012:364875.

24. Gallagher TQ, Hartnick CJ. Bilateral submandibular

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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan

benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,

general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care

services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors

in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely

responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is

subject to change.

Copyright © 2001-2018 Aetna Inc.



AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number:

0265 Surgical Treatments to Control Drooling (Sialorrhea) There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania Updated 09/04/2018

http://www.aetnabetterhealth.com/pennsylvania

This CPB has been updated with additional background ......Excessive drooling (sialorrhea, ptyalism)...

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