Treatment of Hypersialorrhea
For patients with hypersialorrhea, a stepwise approach starting with anticholinergic medications as first-line therapy, followed by botulinum toxin injections to salivary glands for inadequate response or intolerance, is recommended. 1, 2
First-Line Treatment: Anticholinergic Medications
Oral Anticholinergics
Glycopyrrolate oral solution:
- FDA-approved for chronic severe drooling in patients aged 3-16 years with neurologic conditions 3
- Initial dosing: 0.02 mg/kg orally three times daily
- Titrate in increments of 0.02 mg/kg every 5-7 days based on response and side effects
- Maximum recommended dose: 0.1 mg/kg three times daily (not to exceed 1.5-3 mg per dose based on weight) 3
- Administration: At least one hour before or two hours after meals (high-fat meals reduce bioavailability by ~74%) 3
Other anticholinergic options:
- Atropine
- Scopolamine (can be used as transdermal patch)
- Amitriptyline
- Hyoscyamine 4
Monitoring and Side Effects
- Common anticholinergic side effects: dry mouth (most common), constipation, urinary retention, blurred vision, confusion, and flushing 1, 3
- Monitor for constipation within 4-5 days of initial dosing or after dose increases 3
- Use with caution in patients with renal impairment 3
- Continue only if benefits outweigh side effects 1
Second-Line Treatment: Botulinum Toxin Injections
When anticholinergic medications fail or are not tolerated:
- Botulinum toxin injections to salivary glands 1, 2
- IncobotulinumtoxinA (Xeomin) 100 Units is FDA-approved for this indication 2
- Administered into parotid and submandibular salivary glands in a 3:2 dose ratio
- Benefits: inexpensive, simple injections, lasting effects (weeks to months) 1
- Side effects: mild to moderate dry mouth (2.7-11.1%) and dysphagia (0-4.2%) 2
- May need to be repeated as effects wear off 1
Third-Line Treatment: Radiation Therapy
For patients with significant debility from sialorrhea who fail previous treatments:
- Salivary gland radiation therapy 1
- Provides long-lasting relief but causes irreversible dryness
- Balance of benefits and risks is unclear; harm may outweigh benefits in some patients
- Should be reserved for use in experienced centers 1
- Consider only for patients with severe, debilitating sialorrhea unresponsive to other treatments
Fourth-Line Treatment: Surgical Options
When other treatments fail and permanent solution is desired:
- Surgical interventions may include:
- Salivary gland excision
- Salivary duct ligation
- Duct rerouting 5
- These provide the most permanent treatment but are the most invasive options
Special Considerations
Causes of Hypersialorrhea
- Most commonly caused by poor oral and facial muscle control in neurologically impaired patients 5, 6
- Common in patients with:
- Neuromuscular disorders (particularly ALS)
- Cerebral palsy
- Parkinson's disease
- Post-stroke
- Drug-induced (particularly from antipsychotics like clozapine) 7
Complications of Untreated Hypersialorrhea
- Perioral chapping
- Dehydration
- Odor
- Social stigmatization
- Increased risk of aspiration and pneumonia 1, 5
Treatment Approach for Drug-Induced Sialorrhea
For medication-induced hypersialorrhea (e.g., from clozapine):
- Patient education and non-drug management (increasing swallowing frequency, chewing gum)
- Adjust dosage of the causative medication if possible
- Add anticholinergic therapy (glycopyrrolate has shown effectiveness) 7, 8
Clinical Pearls
- A multidisciplinary approach involving primary care providers, speech pathologists, occupational therapists, dentists, neurologists, and otolaryngologists often yields the best outcomes 5, 6
- Treatment selection should consider the severity of drooling, patient's quality of life, and risk of aspiration
- Anticholinergic medications should be used cautiously in elderly patients due to increased risk of cognitive side effects
- For patients with neuromuscular disorders, addressing sialorrhea is crucial for improving quality of life and reducing aspiration risk 1