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Letters to the Editor |

Statistics or Ethics? Decision to Treat Drooling

Poramate Pitak-Arnnop, DDS, MSc
Arch Otolaryngol Head Neck Surg. 2010;136(3):315-316. doi:10.1001/archoto.2010.3.
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I read the meta-analysis on surgical treatments of drooling by Reed et al1 with considerable interest. I would like to comment on that article regarding ethical considerations.

  • The article concluded that the success rate of bilateral submandibular gland excision and parotid duct relocation was the highest in sialorrhea surgical management. Yet, it is worth noting that drooling is not hypersalivation but results from failure of the neuromuscular coordination of the swallowing mechanism.2 It therefore seems unethical to sacrifice salivary glands, although a statistical analysis shows more effective outcomes. Adverse outcomes such as poor oral hygiene and rampant dental caries may arise thereafter.2 Moreover, sialorrhea commonly occurs in pediatric or neurologically impaired patients. Routine oral care and fluoride supplementation become crucial in the long run.2 In my experience, I have found that it is best to reroute submandibular gland ducts because this procedure is physiological and less invasive; saliva in contact with the tongue base initiates the swallowing reflex. Furthermore, it produces relatively low complications and causes no scar outside the oral cavity. Salivary gland excision is usually reserved for patients with a history of aspiration pneumonia. Details on therapies for drooling are described in a systematic review that was previously published by my colleagues and me.2

  • Because some patients are physically or mentally incapable of giving consent, seeking a legally authorized representative is necessary. As with other innovative surgical procedures, caregivers or patients themselves may form an “innovative alliance” by encouraging their surgeons to try any new thing to enhance the quality of life. Meanwhile, surgeons may apply the innovation for the same reasons, and their decision may be biased by career self-interest and financial gains.3 Also, the patients may take in information only on potential benefits and filter out information on potential risks (known as selective hearing).3 Long-term adverse effects of salivary gland excision may be ignored, while its success rates may be overemphasized. As a general rule, a patient's permission given under “unfair” or “undue” pressure is not consent.4

  • The Declaration of Helsinki states that a new intervention must be tested against the “best current proven intervention.”5 Unfortunately, there has been no universally accepted treatment for drooling hitherto.1,2 The Helsinki declaration also states that patients must be informed of all potential risks.5 Therefore, further investigations have to be carefully designed and conducted.


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