DROOL procedure for refractory sialorrhoea improves pulmonary inflammation and reduces hospitalizations after surgery in kids: JAMA

In the case series of 112 patients with refractory sialorrhea, there was a significant reduction in the median polymorphonuclear neutrophil percentage in bronchoalveolar lavage samples from 65.0% preoperatively to 32.5% postoperatively over 10 years. Patient caregivers also reported reduced annual hospitalizations and improved global function after surgery.

Refractory sialorrhea in children can lead to irreversible lung damage and pulmonary aspiration. There is a lack of data on objective outcome measures, especially about pulmonary health, despite many studies devoted to surgical treatment of sialorrhea. Ashley L. Miller, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, and colleagues aimed to determine whether bilateral submandibular gland excision and bilateral parotid duct ligation (“DROOL” procedure) reduces pulmonary inflammation in bronchoalveolar lavage (BAL) samples after surgery. They also evaluated patient factors associated with improvement after surgery in a retrospective case series.

The study included 112 patients undergoing the DROOL procedure at a single tertiary care pediatric children’s hospital from 2012 to 2021. The main outcomes included the degree of pulmonary inflammation (neutrophil percentage) according to BAL cytologic findings and overall bronchoscopy findings up to 12 months before and after the DROOL procedure. Secondary outcomes included caregiver reports of function before and after the procedure, several annual hospitalizations, and the need for additional operations and/or revision procedures for secretion management.

The study led to the following findings:

• 112 patients (median age, 3.4 years; 58.0% boys) underwent DROOL procedures and had both preoperative and postoperative BAL samples during the study period.
• Patients demonstrated objective improvement in pulmonary inflammation after surgery, with the median polymorphonuclear neutrophil percentage decreasing from 65.0% before the surgery to 32.5% after the surgery.
• Before the DROOL procedure, 30.4% of patients were hospitalized 2 or more times annually for respiratory illness, which decreased to 10.1% after surgery (3 patients did not have hospitalization data available following surgery).
• Most caretakers (65.2%) reported improved secretion management after the procedure.

"Overall, the findings of the case series suggest that the DROOL procedure is an effective and safe surgical therapy for refractory sialorrhea, which results in both subjective improvement in quality of life and secretion management as well as objective improvement in inflammation and pulmonary health for most patients," the researchers wrote.

"Our findings may help to inform preoperative counselling of sialorrhea patients and concern for pulmonary aspiration," they concluded. "Additional research is necessary to guide patient selection and optimal timing for this procedure."

Reference:

Miller AL, Hysinger EB, Tabangin ME, Torres-Silva C, de Alarcon A, Hart CK. Pulmonary and Clinical Outcomes After Bilateral Submandibular Gland Excision and Parotid Duct Ligation for Refractory Sialorrhea. JAMA Otolaryngol Head Neck Surg. Published online November 22, 2023. doi:10.1001/jamaoto.2023.3670