Drooling and Aspiration in Children

Drooling and Aspiration in Children: ENT Causes and Clinical Management

Introduction

Drooling and aspiration are common paediatric symptoms often overlooked or misattributed to developmental delay alone. While some drooling is physiological in infants, persistent or excessive drooling beyond 4 years of age, or signs of aspiration (such as coughing during feeding or recurrent pneumonia), demand a thorough ENT evaluation. These conditions can affect a child’s nutrition, airway safety, and social integration. ENT specialists play a central role in identifying structural, neurological, and functional causes and guiding multidisciplinary care.

Drooling is distinct from hypersalivation, which is the excessive production of saliva. The majority of children who drool do not hypersalivate, so the terms are not interchangeable.

Impact of Drooling on Children and Families

Drooling isn’t just a medical issue—it affects quality of life:

• Social embarrassment (peer rejection, bullying, isolation).
• Skin irritation (constant wetness).
• Increased care burden (frequent clothing changes).

What Is Drooling?

Drooling, or sialorrhea, is the involuntary leakage of saliva from the mouth. While normal in infants, persistent drooling beyond age 4 may indicate an underlying issue. It can be classified as:

• Anterior drooling – Saliva spills out of the mouth.
• Posterior drooling – Saliva flows into the throat, increasing aspiration risk (saliva entering the lungs).

Linked Topics: Salivary Glands Anatomy

Causes of Drooling in Children

Drooling usually results from swallowing difficulties. Most children with drooling have normal saliva production—the issue is swallowing control rather than excess saliva production. Common causes include:

1. Developmental and Neurological Factors

• Cerebral palsy (the most common cause – drooling present in 26–58% of children).
• Oromotor dyspraxia (difficulty coordinating mouth movements – Poor lip closure, weak oral muscles, or uncoordinated tongue movements reduce swallowing efficiency).
• Autism spectrum disorder (Children with autism or intellectual disabilities may lack awareness of saliva pooling, leading to drooling).

2. Structural and Medical Conditions

• Nasal obstruction (adenoid hypertrophy) forces mouth breathing, leading to drooling and allergies.
• Dental issues(malocclusion, cavities).
• Infections (tonsillitis, peritonsillar abscess)
• Gastroesophageal reflux (GERD).
• Medications (anticonvulsants, antipsychotics)

What Is Aspiration?

Aspiration is the inhalation of food, liquids, or saliva into the lungs, often occurring during feeding. It may be silent or accompanied by coughing, choking, or cyanosis. Chronic aspiration can lead to coughing, choking, and recurrent pneumonia.

Symptoms of Aspiration:

• Recurrent lower respiratory tract infections
• A wet voice or cough during feeding
• Feeding refusal or failure to thrive

Diagnosis of Drooling and Aspiration

1. History Taking: Look for coughing, choking (especially at night), or recurrent pneumonias, indicating aspiration.
2. Clinical Swallow Assessment: A speech therapist evaluates swallowing safety, checking for aspiration risks.
3. Investigations: Videofluoroscopic swallowing study (VFSS) or fibre-optic endoscopic evaluation of swallow (FEES) confirms aspiration. Microlaryngobronchoscopy rules out structural causes like laryngeal cleft in non-neurological cases.
4. Severity Scales: The Drooling Severity and Frequency Scale (DSFS) rates drooling on a 1–9 scale, offering a practical measure for treatment planning.

Management

It follows a stepwise approach, starting with non-invasive methods and progressing to surgical options when needed. Here’s how it works:

Step 1: Speech Therapy. It improves oral motor control.

Step 2: Pharmacological Treatments. Antimuscarinic drugs reduce saliva production but thicken secretions, causing side effects like constipation or blurred vision. Common options include:

• Hyoscine Hydrobromide: Transdermal patches are effective but have a 45% discontinuation rate due to side effects.
• Glycopyrronium Bromide: Oral solution with fewer central side effects, stopped by only 6% of users.
• Trihexyphenidyl: Syrup form allows easy dose adjustments.

Families need clear guidance on side effect management, as 50% may switch to invasive treatments.

Step 3: Botulinum Toxin Injections. Botulinum toxin (e.g., Botox) paralyses salivary gland nerves and temporarily blocks the glands, reducing saliva production. It is effective in 50–80% of cases, lasting 4–6 months. There can be transient dysphagia or severe swallowing issues, which may require tube feeding.

Step 4: Surgical Interventions. Surgery offers long-term results but requires careful patient selection. Children over age 6 with no improvement from other treatments, especially for aspiration. Options include:

• Submandibular Duct Transfer: Redirects ducts to the tonsil fossa, effective in 80–88% of non-aspirating children. Risks include ranula formation (4–20%).
• Submandibular Gland Excision: Combined with parotid duct ligation, it’s safe for aspirating children, reducing pneumonia rates.
• Laryngotracheal Separation: A last resort for intractable aspiration, separating air and food tracts, often allowing oral feeding resumption.

 

FAQs About Drooling and Aspiration

Q: When should I worry about my child’s drooling?

A: If drooling persists past age 4, causes skin irritation, or leads to choking, see a doctor.

Q: Can drooling be cured without surgery?

A: Yes! Speech therapy, medications, and Botox help many children.

Q: Is drooling linked to autism?

A: Sometimes, children with autism or sensory issues may not notice saliva pooling.

Q: What’s the safest surgery for drooling?

A: Submandibular duct relocation has high success rates (80-88%).

———— End of the chapter ————

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Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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