What treatment options are available for persistent drooling 10 years after a tonsillectomy?

Treatment Options for Persistent Drooling 10 Years After Tonsillectomy

Glycopyrrolate oral solution is the recommended first-line treatment for persistent drooling after tonsillectomy, with a starting dose of 0.02 mg/kg three times daily and titration up to 0.1 mg/kg three times daily as needed. 1

Understanding Post-Tonsillectomy Drooling

Persistent drooling following tonsillectomy is an uncommon but distressing symptom that can significantly impact quality of life. While tonsillectomy is generally considered a safe procedure 2, some patients may experience persistent symptoms including drooling that require further management.

Potential Causes of Persistent Drooling

• Obstructive sleep-disordered breathing (oSDB) may persist or recur after tonsillectomy, potentially contributing to drooling symptoms 3
• Lingual tonsillar hypertrophy (LTH) can develop after adenotonsillectomy and may contribute to persistent symptoms 3
• Laryngopharyngeal reflux may be associated with lingual tonsillar hypertrophy and subsequent symptoms 3

Treatment Algorithm

First-Line Pharmacological Management

• Glycopyrrolate oral solution is FDA-approved for chronic severe drooling and should be initiated at 0.02 mg/kg three times daily 1
• Titrate dose in increments of 0.02 mg/kg every 5-7 days based on therapeutic response and adverse reactions 1
• Maximum recommended dose is 0.1 mg/kg three times daily, not to exceed 1.5-3 mg per dose based on weight 1
• Administer at least one hour before or two hours after meals for optimal absorption 1

Monitoring and Side Effects

• Monitor for common adverse reactions including dry mouth (most common), vomiting, constipation, flushing, and nasal congestion 1
• Assess for constipation within 4-5 days of initial dosing or after dose increases 1
• Use with caution in patients with renal impairment as glycopyrrolate is largely renally eliminated 1

Surgical Options for Refractory Cases

For patients who fail medical management, surgical interventions may be considered:

• Lingual tonsillectomy may be beneficial if lingual tonsillar hypertrophy is identified as contributing to symptoms 3

  • Can be performed transorally via direct or endoscopic access using radiofrequency ablation, suction cautery, or microdebridement 3
  • Studies show improvement in obstructive symptoms in 61% of patients 3
  • Potential complications include airway edema (19%), decreased oral intake/dysphagia, voice changes, and bleeding 3

• Transposition of Wharton's duct to the floor of the mouth has been reported as an effective surgical approach for drooling in otherwise healthy children 4

Alternative Treatments

• Botulinum toxin injection into the salivary glands has shown success in treating drooling, particularly in cases refractory to other treatments 5
• This approach may be especially beneficial for patients who have undergone radiation therapy of the head and neck region 5

Important Considerations and Caveats

• Comprehensive evaluation is essential to identify the underlying cause of persistent drooling before initiating treatment 6
• Treatment options range from conservative therapy to medication, radiation, or surgery, and often a combination is needed 6
• None of the available treatments is completely free of undesirable effects 6
• Patients with certain medical conditions (e.g., glaucoma, paralytic ileus, unstable cardiovascular status, severe ulcerative colitis, myasthenia gravis) should not receive anticholinergic therapy like glycopyrrolate 1
• Glycopyrrolate should not be used concurrently with solid oral dosage forms of potassium chloride 1

Follow-up and Monitoring

• Regular follow-up is essential to assess treatment efficacy and monitor for adverse effects 1
• If symptoms persist despite optimal medical management, consider referral for evaluation of surgical options 3, 4
• Polysomnography may be useful to evaluate for persistent obstructive sleep-disordered breathing that could be contributing to symptoms 3

Remember that chronic drooling can be difficult to manage, and a combination of approaches may be necessary to achieve optimal symptom control 6.