What is the workup for a patient with hypersalivation?

From the Guidelines

The workup for a patient with hypersalivation should begin with a thorough history and physical examination to identify potential causes, and may involve laboratory tests, imaging studies, and specialist consultation to determine the underlying etiology and develop an effective treatment plan. When evaluating a patient with hypersalivation, clinicians should consider various potential causes, including medication use, neurological conditions, oral infections, and exposure to toxins or heavy metals 1. The initial assessment should include:

• A detailed medical history to identify potential contributing factors, such as medication use (e.g., clozapine, pilocarpine, and cholinergic agents) or neurological conditions (e.g., Parkinson's disease, cerebral palsy, ALS)
• A physical examination focusing on the oral cavity, neurological assessment, and evaluation of swallowing function
• Laboratory tests, such as complete blood count, metabolic panel, thyroid function tests, and heavy metal screening if toxin exposure is suspected
• Imaging studies, including MRI or CT of the head and neck, to rule out structural abnormalities, tumors, or neurological conditions Additionally, sialometry (measurement of salivary flow rate) and sialography may be useful in quantifying the degree of hypersalivation and visualizing salivary gland structure. In cases where anticholinergic therapy is ineffective or not tolerated, botulinum toxin (BT) therapy to salivary glands may be considered as an alternative treatment option 1. Specialist consultation, including neurologists, otolaryngologists, or speech pathologists, may be necessary to further evaluate and manage the underlying cause of hypersalivation. By taking a comprehensive approach, clinicians can develop an effective treatment plan tailored to the specific etiology of the patient's hypersalivation.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Workup for Hypersalivation

The workup for a patient with hypersalivation involves a comprehensive evaluation to determine the underlying cause of the condition. The following steps can be taken:

• Evaluate the patient's medical history to identify any underlying conditions that may be contributing to the hypersalivation, such as neurological disorders or medication side effects 2, 3.
• Perform a physical examination to assess the patient's overall health and identify any signs of underlying conditions that may be contributing to the hypersalivation.
• Use transnasal swallowing endoscopy to evaluate dysphagia and assess the patient's swallowing function 2.
• Consider additional radiologic assessments to complete the diagnostic workup 2.
• Assess the patient's quality of life and the impact of hypersalivation on their daily activities.

Diagnostic Considerations

The diagnosis of hypersalivation can be challenging, and a thorough evaluation is necessary to determine the underlying cause. The following diagnostic considerations should be taken into account:

• Sialorrhea, or drooling, is a common problem in patients with amyotrophic lateral sclerosis (ALS) and can be treated with anticholinergic drugs, botulinum toxin injections, or radiation therapy 3.
• Xerostomia, or dry mouth, can be a debilitating condition that affects the middle-aged and elderly population, and can be caused by medications with anticholinergic properties, dehydration, diabetes, or radiotherapy for head and neck cancer 4.
• Glycopyrrolate has been shown to be effective in treating sialorrhea in developmentally disabled children and in patients with Parkinson's disease 5, 6.

Treatment Options

The treatment of hypersalivation depends on the underlying cause and may involve the following options:

• Swallowing therapy as a first-line approach to overcome the syndrome 2.
• Glycopyrrolate, which has been approved for children and adolescents and has been shown to reduce saliva flow with limited risk 2, 5, 6.
• Botulinum toxin injections, which are an established treatment option for chronic hypersalivation in adults 2.
• Surgical approaches, such as salivary duct relocation, which are recommended less often due to invasiveness and failure 2.
• Radiotherapy, which is reserved mainly for neurodegenerative diseases and shows good response, but carries cancer induction risks 2, 3.