How to manage post-tonsillectomy sialorrhea (excessive drooling)?

Managing Post-Tonsillectomy Drooling (Sialorrhea)

Glycopyrrolate oral solution is the most effective treatment for managing excessive drooling after tonsillectomy, with a recommended starting dose of 0.02 mg/kg three times daily, titrated as needed. 1

Understanding Post-Tonsillectomy Drooling

• Post-tonsillectomy drooling (sialorrhea) is a common temporary issue that occurs due to pain, inflammation, and difficulty swallowing after surgery 2
• Drooling typically resolves as healing progresses and pain decreases, usually within 1-2 weeks after surgery 3
• Excessive drooling can lead to perioral chapping, dehydration, odor, and social discomfort 4

First-Line Management Approaches

Pain Management (Reduces Drooling)

• Implement a multimodal analgesic regimen with scheduled paracetamol (acetaminophen) and NSAIDs as baseline therapy 5, 2
• Administer medications on a regular schedule rather than as-needed to maintain consistent pain control 5
• A single dose of intravenous dexamethasone should be given intraoperatively for both analgesic and anti-emetic effects 5, 2
• Use opioids only as rescue medication when other measures are insufficient 2

Hydration and Oral Intake

• Adequate hydration is essential for reducing thick secretions and promoting healing 2
• Ice popsicles/lollies can provide temporary pain relief and encourage swallowing 2
• Honey can be used as an analgesic adjunct with no reported side effects 5, 2

Pharmacological Management of Persistent Drooling

Anticholinergic Medications

• Glycopyrrolate oral solution is the most effective medication for controlling excessive drooling 1
  • Starting dose: 0.02 mg/kg three times daily
  • Can be titrated in increments of 0.02 mg/kg every 5-7 days
  • Maximum recommended dose: 0.1 mg/kg three times daily (not to exceed 3 mg per dose)
  • Administer at least one hour before or two hours after meals 1

Important Considerations for Glycopyrrolate Use

• Monitor for common side effects including dry mouth, constipation, flushing, and urinary retention 1
• Constipation is the most common side effect and may require discontinuation if severe 1
• Use with caution in patients with renal impairment as glycopyrrolate is largely renally eliminated 1
• Contraindicated in patients with glaucoma, paralytic ileus, unstable cardiovascular status, severe ulcerative colitis, or myasthenia gravis 1

Alternative Approaches for Persistent Drooling

• Sublingual ipratropium spray can provide more localized anticholinergic effects with fewer systemic side effects 6
• Postural adjustments (keeping head elevated) can help minimize pooling of saliva 4
• For cases of drooling that persist beyond the expected healing period (2 weeks), consider evaluation for other underlying causes 4

Monitoring and Follow-up

• Assess for signs of inadequate pain control, which may worsen drooling by limiting the patient's ability to swallow 5
• Ensure adequate oral intake to prevent dehydration, which can worsen pain and delay healing 2
• If drooling persists beyond 2 weeks post-surgery, consider follow-up with the surgeon to rule out complications 3

Special Considerations

• In children with pre-existing neurological conditions who had drooling before surgery, adenotonsillectomy may actually improve their baseline drooling 3
• Sucralfate (as a swish and swallow solution) may help reduce post-tonsillectomy pain and indirectly reduce drooling by promoting healing 7
• For most patients, drooling is self-limiting and will resolve as the surgical site heals and pain decreases 3