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)
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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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
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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
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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.
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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
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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.
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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.
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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.
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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
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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
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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.
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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
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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
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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
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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.
http://aetnet.aetna.com/mpa/cpb/200_299/0265.html 09/02/2018
Surgical Treatments to Control Drooling (Sialorrhea) - Medical Clinical Policy Bulletin... Page 16 of 19
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
gland excision and parotid duct ligation. Adv
Otorhinolaryngol. 2012;73:70-75.
25. Celet Ozden B, Aydin A, Kuvat SV, et al. Quadruple
salivary duct diversion for drooling in cerebral palsy. J
Craniofac Surg. 2012;23(3):738-741.
http://aetnet.aetna.com/mpa/cpb/200_299/0265.html 09/02/2018
Surgical Treatments to Control Drooling (Sialorrhea) - Medical Clinical Policy Bulletin... Page 17 of 19
26. Chanu NP, Sahni JK, Aneja S, Naglot S. Four-duct
ligation in children with drooling. Am J Otolaryngol.
2012;33(5):604-607.
27. Noonan K, Prunty S, Ha JF, Vijayasekaran S. Surgical
management of chronic salivary aspiration. Int J
Pediatr Otorhinolaryngol. 2014;78(12):2079-2082.
28. Formeister EJ, Dahl JP, Rose AS. Surgical management
of chronic sialorrhea in pediatric patients: 10-year
experience from one tertiary care institution. Int J
Pediatr Otorhinolaryngol. 2014;78(8):1387-1392.
29. Spock T, Hoffman HT, Joshi AS. Transoral
submandibular ganglion neurectomy: An anatomical
feasibility study. Ann Otol Rhinol Laryngol. 2015;124
(5):341-344.
30. Banfi P, Ticozzi N, Lax A, et al. A review of options for
treating sialorrhea in amyotrophic lateral sclerosis.
Respir Care. 2015;60(3):446-454.
31. Klem C, Mair EA. Four-duct ligation: A simple and
effective treatment for chronic aspiration from
sialorrhea. Arch Otolaryngol Head Neck Surg. 1999;125
(7):796-800.
32. Shirley WP, Hill JS, Woolley AL, Wiatrak BJ. Success and
complications of four-duct ligation for sialorrhea. Int J
Pediatr Otorhinolaryngol. 2003;67(1):1-6.
33. Chanu NP, Sahni JK, Aneja S, Naglot S. Four-duct
ligation in children with drooling. Am J Otolaryngol.
2012;33(5):604-607.
34. Khan WU, Islam A, Fu A, et al. Four-duct ligation for the
treatment of sialorrhea in children. JAMA Otolaryngol
Head Neck Surg. 2016;142(3):278-283.
35. Sagar P, Handa KK, Gulati S, Kumar R. Submandibular
duct re-routing for drooling in neurologically impaired
children. Indian J Otolaryngol Head Neck Surg. 2016;68
(1):75-79.
36. Kok SE, van der Burg JJ, van Hulst K, et al. The impact of
submandibular duct relocation on drooling and the
well-being of children with neurodevelopmental
http://aetnet.aetna.com/mpa/cpb/200_299/0265.html 09/02/2018
Surgical Treatments to Control Drooling (Sialorrhea) - Medical Clinical Policy Bulletin... Page 18 of 19
disabilities. Int J Pediatr Otorhinolaryngol.
2016;88:173-178.
37. Hernandez-Palestina MS, Cisneros-Lesser JC, Arellano-
Saldana ME, Plascencia-Nieto SE. Submandibular gland
resection for the management of sialorrhea in
paediatric patients with cerebral palsy and
unresponsive to type A botullinum toxin. Pilot study.
Cir Cir. 2016;84(6):459-468.
38. Hughes CA, Brown J. Pediatric trans-oral
submandibular gland excision: A safe and effective
technique. Int J Pediatr Otorhinolaryngol. 2017;93:13-
16.
39. Ozturk K, Erdur O, Gul O, Olmez A. Feasibility of
endoscopic submandibular ganglion neurectomy for
drooling. Laryngoscope. 2017;127(7):1604-1607.
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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.
http://aetnet.aetna.com/mpa/cpb/200_299/0265.html 09/02/2018
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
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