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Hypersalivation Ptyalism Sialorrhea

last modified on: Mon, 11/20/2023 - 15:12


return to: Sialorrhea assessment and intervention in Speech Pathology (drooling)Botox injection to salivary glands for hypersalivationBotulinum neurotoxin treatment of salivary gland disorders 

see also: Transdermal scopolamine and glycopyrrolate for sialorrhea and salivary fistula or Facial Dystonia with Sialorrhea (Loss of Saliva or Drooling)

Intraductal approach to botox infusion: https://onlinelibrary.wiley.com/doi/full/10.1002/lio2.306


Excessive accumulation of saliva may be due to increased amount of salivary production (hypersalivation)

  1. ptyalism - 'excessive flow of saliva' (Merriam Webster on-line dictionary 2014).
  2. sialorrhea - 'excessive salivation' (Merriam Webster on-line dictionary 2014)
  3. drooling - 'unintentional loss of saliva from the mouth' (Moller et al 2014)

Excessive accumulation of salivary can also result from decreased clearance of saliva.

Etiologies by definition

A. Hypersalivation (salivary overproduction)

  1. Gastroesophageal reflux disease / Dysphagia / Pregnancy / Rabies / Pancreatitis / Liver Disease / Serotonin Syndrome / Mouth ulcers / Oral Infections
  2. Medications: clozapine, pilocarpine, ketamine, potassium chlorate, risperidone
  3. Toxins: mercury, copper, organophosphates (insecticides), arsenic

B. Decreased clearance or inability to retain saliva within the oral cavity 

  1. Infections: tonsillitis, mumps, epiglottitis
  2. Neurologic disorders: cerebral palsy, stroke, jaw opening dystonia, facial nerve paralysis, Parkinson's disease, ALS  
  3. Jaw mobility abnormalities (dislocation, fracture)


Parkinsons Disease and Sialorrhea

Suggested Algorithm from NICE (United Kingdom information service - see references) as of 2017:

  1. Only consider pharmacologic management of drooling in patients with Parkinsons disease if other methods (such as work with a speech pathologist) fail
  2. Consider use of glycopyrrolate
  3. If treatment of glycopyrrolate not effective or otherwise contraindicated - consider botulinum toxin injection


Moller E, Daugaard D, Holm O et al: Repeated Treatments of Drooling with Botulinum Toxin B in Neurology  Acta Neurol Scand: 2014   

Reddihough D, Erasmus CE, Johnson H, McKellar GM, Jongerius PH: Botulinum toxin assessment, interventionand aftercare for paediatric and adult drooling: international consensus statement. Eur J Neurol 2010 Aug;17 Suppl2:109-21

Adam T. Schwalje MD, DMA, Henry T. Hoffman MD, MS: Intraductal Salivary Gland Infusion With Botulinum Toxin 
First published: 03 September 2019 https://doi.org/10.1002/lio2.306
Laryngoscope Investigative Otolaryngology Original Research Open Access https://onlinelibrary.wiley.com/doi/full/10.1002/lio2.306

Ribeiro LB, Xerez DR, Maliska C, de Souza SAL, Costa MMB. Qualitative and quantitative scintigraphy in sialorrhea before and after botulinum toxin injection. Laryngoscope. 2019 Nov;129(11):2521-2526. doi: 10.1002/lary.27826. Epub 2019 Jan 28. PMID: 30693525.

Hobson EV, McGeachan A, Al-Chalabi A, Chandran S, Crawley F, Dick D, Donaghy C, Ealing J, Ellis CM, Gorrie G, Hanemann CO, Harrower T, Jung A, Majeed T, Malaspina A, Morrison K, Orrell RW, Pall H, Pinto A, Talbot K, Turner MR, Williams TL, Young CA, Shaw PJ, McDermott CJ. Management of sialorrhoea in motor neuron disease: a survey of current UK practice. Amyotroph Lateral Scler Frontotemporal Degener. 2013 Dec;14(7-8):521-7. doi: 10.3109/21678421.2013.790452. Epub 2013 May 7. PMID: 23647474.

McGeachan AJ, Hobson EV, Al-Chalabi A, Stephenson J, Chandran S, Crawley F, Dick D, Donaghy C, Ellis CM, Gorrie G, Hanemann CO, Harrower T, Jung A, Malaspina A, Morrison KE, Orrell RW, Talbot K, Turner MR, Williams TL, Young CA, Shaw PJ, McDermott CJ. A multicentre evaluation of oropharyngeal secretion management practices in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener. 2017 Feb;18(1-2):1-9. doi: 10.1080/21678421.2016.1221433. Epub 2016 Aug 31. Erratum in: Amyotroph Lateral Scler Frontotemporal Degener. 2017 Feb;18(1-2):152. PMID: 27579520.

Andersen PM, Abrahams S, Borasio GD, et al. EFNS guidelines on the clinical management of amyotrophic lateral sclerosis (MALS)-revised report of an EFNS task force. Eur J Neurol 2011;19(3):360-375

NICE (National Institute for Health and Care Excellence) Guidelines  Parkinsons's Disease in Adults published 19 July 2017  section 1.5 Pharmacologic management of non-motor symptoms  <accessed 12-28-2021 on line: Recommendations | Parkinson’s disease in adults | Guidance | NICE >  NICE is an executive non-departmental public body, sponsored by the Department of Health and Social Care in the United Kingdom (www.gov.uk)

Hughes A, Lambert EM. Drooling and Aspiration of Saliva. Otolaryngol Clin North Am. 2022 Dec;55(6):1181-1194. doi: 10.1016/j.otc.2022.07.007. PMID: 36371134.

Zhang HL, Zhu JE, Li JX, Li XL, Sun LP, Xu HX, Yu SY. US-guided percutaneous microwave ablation (MWA) of submandibular gland: A new minimal invasive and effective treatment for refractory sialorrhea and treatment response evaluation with contrast-enhanced imaging techniques. Clin Hemorheol Microcirc. 2021;78(2):215-226. doi: 10.3233/CH-211115. PMID: 33682703.