The role of radiation therapy in the management of sialorrhea

doi:10.1016/S0360-3016(98)00153-9

International Journal of Radiation OncologyBiologyPhysics

Volume 41, Issue 5, 15 July 1998, Pages 1113-1119

https://doi.org/10.1016/S0360-3016(98)00153-9 Get rights and content

Abstract

Purpose: Sialorrhea is the unintentional loss of saliva and other contents from the mouth. Most patients with this condition are elderly, requiring palliative treatment. These patients have neuropathology with associated poor performance status. Treatment prescribed for this disabling and distressing condition has often been of a surgical nature and described in young patients. It would be inapplicable to the elderly. The aim of this study was to review the role of radiation therapy in the management of sialorrhea. Previous reports are few in number and are cautionary because of adverse effects which have been described, including dryness of the mouth.

Methods and Materials: A total of 34 patients were referred to the Department of Radiation Oncology, Palmerston North Hospital, between 1966 and August 1994, of whom only 1 patient received treatment prior to 1985. Three patients declined treatment and were, therefore, excluded from this review. Thirty-one patients, including 14 males and 17 females, of median age 72 years received 1 or more radiation treatments for sialorrhea. The patients were followed up for a median of 12 months, ranging from 6 months to 27 years.

Results: Initially, 82% (28/34) of treatments were associated with a satisfactory response. Six patients relapsed, of whom five experienced relapse within 6 months of initial treatment. Two patients were re-treated, one of whom achieved a complete response. Up to the time of review 64% (23/36) of treatments maintained a satisfactory response. The varied fractionation regimens used were not shown to affect the response rate; low doses were shown to be as effective as higher doses, and were not associated with any significant acute or late side effects. Only 4 patients developed long-term side effects. However, response rates were superior for patients treated with electrons, as opposed to orthovoltage therapy, and in particular when electron energies greater than 7 megavolts were used (76% vs. 38% maintained response, p < 0.05). Responses were also superior for patients treated with radiation fields which encompassed both parotid and submandibular glands (74% vs. 33% maintained response, p < 0.01).

Conclusions: Radiation therapy has proven to be a safe and effective treatment in this group of patients, thereby avoiding the adverse effects of anticholinergic medication and invasive surgical procedures.

Introduction

Sialorrhea (excessive salivation or chronic drooling) is defined as the unintentional loss of saliva and other contents from the mouth. The term implies excessive secretion of saliva, which may be considered an antisocial behavior, the expression of which can impede successful integration into the community 1, 2, 3. The treatment of sialorrhea varies, depending on its etiology, and involves a number of professionals including speech therapists, plastic surgeons, geriatricians, and neurologists 3, 4. More than 75% of the 1.5 liters per day of salivary secretion is produced by the major paired salivary glands 5, 6. Radiotherapy to the posterior oral cavity encompassing the major salivary glands generally induces dryness of the mouth as a result of its effect on the secretion of the parotid and submandibular glands 7, 8. There are very few reports in the literature describing the use of radiation therapy in the treatment of sialorrhea secondary to nonmalignant causes (9). This study aimed to evaluate the role and effectiveness of radiation therapy in the management of sialorrhea in nonmalignant disease.

Section snippets

Materials and methods

The records of all patients referred to the Radiotherapy Department at Palmerston North Hospital, New Zealand, between 1966 and August 1994, with a diagnosis of sialorrhea, were reviewed retrospectively. Only 1 of these patients received treatment prior to 1985. Thirty-four patients were referred, of whom 3 declined treatment and were, therefore, excluded from this review. The 31 patients in the study comprised 14 males and 17 females, of median age 72 years (range 24–88 years, Fig. 1), whose

Results

Initially, 34 treatments were delivered resulting in 18 complete responses and 10 partial responses. Four patients did not respond to treatment. The responses in the remaining 2 cases were recorded as unknown as these 2 patients were lost to follow-up. For the purposes of statistical analysis these were recorded as nonresponders. Therefore, initially 28 treatments achieved a satisfactory response (82%, 28/34). Six patients relapsed of whom two were re-treated, one achieving a complete response

Discussion

Several nonmalignant conditions lead to the development of sialorrhea, some of which are listed in Table 1. These conditions are usually associated with poor oral motor control which causes an open-mouth posture, impaired eating ability, problems with communication, and constant drooling of saliva 2, 3. Some authors suggest that sialorrhea develops as a result of impaired swallowing and lip closure (2). However, it is also believed that a component of sialorrhea is due to excessive salivation,

Conclusion

This review confirms that radiation therapy has a role in the management of patients suffering from sialorrhea, particularly in patients who are elderly and of poor performance status. Radiation therapy has been shown to be both safe and effective. It avoids the potential adverse effects associated with anticholinergic medication and/or surgery, which are not well tolerated in the elderly, or those with intellectual disability or neuropathology. A treatment schedule such as 5 fractions of 4 Gy

Acknowledgements

We are indebted to colleagues (past and present) at Palmerston North Hospital for allowing us to include their patients in this review.

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Cited by (71)

Whole-brain Irradiation Field Design: A Comparison of Parotid Dose
2017, Medical Dosimetry
Citation Excerpt :
A wide range of fractionation schemes were used; however, in patients who received 30 Gy in 10 fractions, 60% had either a complete or a partial response. Two patients received 10 Gy in 12 fractions and both had a complete response.13 Anecdotally, patients have reported evidence of xerostomia after WBRT.
Whole-brain radiation therapy (WBRT) plays an important role in patients with diffusely metastatic intracranial disease. Whether the extent of the radiation field design to C1 or C2 affects parotid dose and risk for developing xerostomia is unknown. The goal of this study is to examine the parotid dose based off of the inferior extent of WBRT field to either C1 or C2. Patients treated with WBRT with either 30 Gy or 37.5 Gy from 2011 to 2014 at a single institution were examined. Parotid dose constraints were compared with Radiation Therapy Oncology Group (RTOG) 0615 nasopharyngeal carcinoma for a 33-fraction treatment: mean <26 Gy, volume constraint at 20 Gy (V20) < 20 cc, and dose at 50% of the parotid volume (D50) < 30 Gy. Biologically effective dose (BED) conversions with an α/β of 3 for normal parotid were performed to compare with 10-fraction and 15-fraction treatments of WBRT. The constraints are as follows: mean < BED 32.83 Gy, V15.76 (for 10-fraction WBRT) or V17.35 (for 15-fraction WBRT) < 20 cc, and D50 < BED 39.09 Gy. Nineteen patients treated to C1 and 26 patients treated to C2 were analyzed. Comparing WBRT to C1 with WBRT to C2, the mean left, right, and both parotids' doses were lower when treated to C1. Converting mean dose to BED₃, the parotid doses were lower than BED₃ constraint of 32.83 Gy: left (30.12 Gy), right (30.69 Gy), and both parotids (30.32 Gy). V20 to combined parotids was lower in patients treated to C1. When accounting for fractionation of WBRT received, the mean corrected V20 volume was less than 20 cc when treating to C1. D50 for C1 was lower than C2 for the left parotid, right parotid, and both parotids. BED₃ conversion for the mean D50 of the left, right, and both parotids was less than 39.09 Gy. In conclusion, WBRT to C1 limits parotid dose, and parotid dose constraints are achievable compared with inferior border at C2. A possible mean parotid dose constraint with BED₃ should be less than 32.83 Gy.
Radiation therapy for hypersalivation: A prospective study in 50 amyotrophic lateral sclerosis patients
2014, International Journal of Radiation Oncology Biology Physics
Citation Excerpt :
Various schedules of RT have been reported, ranging from 4 to 48 Gy (4-8, 16, 17). A single low-dose (7-Gy) fraction was suggested to be as effective as higher total dosage in drooling reduction (5-7). On the other hand, Bourry et al reported more common positive responses with a higher total dose (≥16 Gy; 78.6%) than a lower dose (<16 Gy; 33%; P=.07) (19).
This study aimed to evaluate the efficiency and the tolerance of radiation therapy (RT) on salivary glands in a large series of amyotrophic lateral sclerosis (ALS) patients with hypersalivation.
Fifty ALS patients that had medically failure pretreatment were included in this prospective study. RT was delivered through a conventional linear accelerator with 6-MV photons and 2 opposed beams fields including both submandibular glands and two-thirds of both parotid glands. Total RT dose was 10 Gy in 2 fractions (n=30) or 20 Gy in 4 fractions (n=20). RT efficacy was assessed with the 9-grade Sialorrhea Scoring Scale (SSS), recently prospectively validated as the most effective and sensitive tool to measure sialorrhea in ALS patients.
At the end of RT, all patients had improved: 46 had a complete response (92% CR, SSS 1-3) and 4 had a partial response (8% PR, SSS 4-5). A significant lasting salivary reduction was observed 6 months after RT completion: there was 71% CR and 26% PR, and there was a significant SSS reduction versus baseline (P<10⁻⁶). There was no grade 3 to 4 toxicity, and most side effects (34%) occurred during RT. Nine patients (18%) underwent a second salivary gland RT course, with a 3-months mean delay from the first RT, resulting in a SSS decrease (−77%). Both RT dose regimens induced a significant SSS decrease with no significant toxicity. There were, however, more patients with CR/PR in the 20-Gy protocol (P=.02), and 8 of 9 patients (89%) receiving a second RT course had previously been treated within the 10-Gy protocol.
Radiation therapy of 20 Gy in 4 fractions is an efficient and safe treatment for ALS patients with sialorrhea. A shorter RT course (10 Gy in 2 fractions) may be proposed in patients in poor medical condition.
Salivary glands radiotherapy to reduce sialorrhea in amyotrophic lateral sclerosis: Dose and energy
2013, Cancer/Radiotherapie
This retrospective study evaluated the effectiveness of salivary gland radiotherapy for reducing sialorrhea in patients with amyotrophic lateral sclerosis (ALS).
From August 2001 to February 2008, 21 patients with amyotrophic lateral sclerosis (six men, 15 women; mean age 61.2 years, range 39–81) received external beam radiotherapy for sialorrhea (evaluation by the ALS Functional Rating Scale). All patients had previously received pharmacological treatments with unsatisfactory results or side effects. The mean dose was 19.1 Gy (range 3–48), delivered in five fractions (range 1–16) on 17 days (range 1–77). Eight patients received 3D-conformal and 13 received 2D-conformal radiotherapy. Clinical target volumes included the parotids and submandibular glands (18 patients), submandibular glands and one parotid (one patient), or parotids (two patients). Thirteen patients were treated with 5.5–6 MV photons and eight were treated with 6–15 MeV electrons. A satisfactory salivary response was defined as complete or partial improvement. The median follow up was 10.4 months (range 0.4–26). One patient was lost to follow up.
A positive response was observed in 65% of patients during a mean of 7 months (range 1–23). Four patients (20%) treated with photons and no patients treated with electrons experienced acute toxicity. Half (50%) the patients treated with photons and 87.5% of patients treated with electrons responded positively (P = 0.09). Positive responses were more common with a high total dose (≥ 16 Gy; 78.6%) than a low total dose (< 16 Gy; 33%; P = 0.07). No differences were observed in tolerance (P = 0.27). Age and sex did not impact the response.
Salivary gland radiotherapy effectively reduced sialorrhea in patients with amyotrophic lateral sclerosis. An adequate compromise between toxicity and efficiency was achieved with 3D-conformal radiotherapy delivered with electrons to parotids and submandibular glands in a total dose of 16 Gy or more (mean: 20 Gy in five fractions).
L’objectif de cette étude rétrospective était d’évaluer l’efficacité de la radiothérapie des glandes salivaires pour réduire l’hypersialorrhée chez les patients atteints de sclérose latérale amyotrophique.
Entre août 2001 et février 2008, six hommes et 15 femmes âgés en moyenne de 61,2 ans et atteints de sclérose latérale amyotrophique ont été irradiés pour une hypersialorrhée (évaluée par l’ALS Functional Rating Scale). Tous les patients avaient auparavant reçu des traitements pharmacologiques avec un résultat insuffisant ou des effets secondaires. Une dose moyenne de 19,1 Gy (3–48) a été délivrée en cinq fractions (1–16) sur 17 jours (1–77). La radiothérapie était conformationnelle tridimensionnelle pour huit patients et bidimensionnelle pour 13. Les volumes cibles cliniques comprenaient les parotides et les glandes sous-maxillaires (18 patients), les glandes sous-maxillaires et une parotide (un patient), ou les deux parotides (deux patients). Treize patients ont été irradiés avec des photons de 5,5 à 6 MV et huit des électrons de 6 à 15 MeV. Une réponse salivaire satisfaisante a été définie comme une amélioration complète ou partielle. Le suivi médian était de 10,4 mois (0,4–26). Un patient a été perdu de vue.
Une réponse a été observée chez 65 % des patients durant en moyenne sept mois (1–23). Une toxicité aiguë a été observée chez quatre patients (20 %) irradiés par photons, et chez aucun des patients irradiés par électrons. La moitié (50 %) des patients irradiés par photons et 87,5 % des patients irradiés par électrons ont bénéficié d’une réponse (p = 0,09). Les réponses ont été plus fréquentes avec une dose de 16 Gy ou plus (78,6 % contre 33 % ; p = 0,07). Il n’a pas été observé de différence de tolérance (p = 0,27). L’âge et le sexe n’ont pas eu d’incidence sur la réponse.
La radiothérapie des glandes salivaires réduit efficacement l’hypersialorrhée chez les patients atteints de sclérose latérale amyotrophique. Un compromis adéquat entre la toxicité et l’efficacité a été obtenu avec la radiothérapie conformationnelle tridimensionnelle, délivrée par électrons dans un volume incluant les glandes parotides et sous-mandibulaire à une dose totale d’au moins 16 Gy (20 Gy en cinq fractions en moyenne).
Rehabilitation of motor neuron disease
2013, Handbook of Clinical Neurology
Citation Excerpt :
Uncommonly, bulbar dysfunction may result (Meijer et al., 2008). Radiation therapy to the parotid glands or the submandibular and sublingual glands has been shown to be effective and safe in uncontrolled studies of patients with ALS and other disorders (Borg and Hirst, 1998; Harriman et al., 2001; Stalpers and Moser, 2002; Neppelberg et al., 2007). Side-effects are transient, and include pain in the parotid area, dryness of the mouth, burning of the skin, sore throat, and nausea (Harriman et al., 2001).
Amyotrophic lateral sclerosis (ALS), the most common adult motor neuron disease, is an acquired disorder that results in loss of function in multiple domains. Although there is no treatment that can halt or reverse this progressive condition, there are many opportunities for interventions that can lead to improved quality of life for the patient and caregiver. Physical and occupational therapy can assist with mobility and activities of daily living. Interventions by speech pathology can optimize nutrition and communication. Respiratory function can be managed noninvasively or invasively. Depression, hopelessness, anxiety, and other mental health issues can and should be aggressively addressed and treated. Many symptoms such as pseudobulbar affect, sialorrhea, constipation, spasticity, and cramps can be treated effectively with medications. Spirituality and religion are important issues to address, as are end-of-life concerns, including advance directives, hospice, and the dying process. In contrast to the discouraging view that “there is nothing we can do,” a broad approach to management, through collaboration with a multidisciplinary team, will permit the ALS physician to make a meaningful difference in the lives of individuals living with ALS.
Whole brain radiotherapy for brain metastases: The technique of irradiation influences the dose to parotid glands
2012, Cancer/Radiotherapie
Deux méthodes d’irradiation panencéphalique pour des métastases cérébrales sont utilisées en routine : l’une utilisant le collimateur multilames pour protéger les globes oculaires et le massif facial, et l’autre une rotation de collimateur sans cache épargnant les organes à risques appelée mise en place directe. L’objectif de l’étude était de comparer les résultats dosimétriques dans les volumes des deux méthodes chez dix patients recevant une irradiation délivrant 30 Gy en dix fractions. Les doses délivrées aux volumes cibles prévisionnels et aux organes à risques étaient identiques, sauf les doses moyennes délivrées aux parotides. Pour l’irradiation de l’encéphale excluant la grande citerne méningée, la dose moyenne délivrée aux parotides était de 9,63 Gy avec le collimateur multilames contre 12,32 Gy avec la technique sans cache (p = 0,04). Pour l’irradiation de l’encéphale incluant la grande citerne méningée (avec une limite inférieure en regard de l’interligne C2-C3), la dose moyenne délivrée aux parotides était de 11,12 Gy avec le collimateur multilames contre 20,06 Gy avec la technique sans cache (p < 0,001). Lors d’une irradiation panencéphalique pour des métastases cérébrales, il semble donc préférable d’utiliser le collimateur multilames pour protéger les parotides.
In the treatment of brain metastases, whole brain radiotherapy can be carried out according two distinct methods: one using multileaf collimator for field shaping and protection of organs at risk, and a second one is to make a rotation of the field to avoid the eyes. The aim of the study was to compare for 10 patients the dose distributions at organs at risk for each method. Patients received 30 Gy in 10 fractions. Except for parotid glands, the dose received by organs at risk and the planning target volume was the same with each method. For whole brain radiotherapy, excluding the cisterna cerebellomedullaris, the mean parotid dose was 9.63 Gy using the multileaf collimator versus 12.32 Gy using the field rotation (P = 0.04). For whole brain radiotherapy including the cisterna cerebellomedullaris, the mean parotid dose was 11.12 Gy using the multileaf collimator versus 20.06 Gy using field rotation (P < 0.001). Using the multileaf collimator seems recommended for whole brain radiotherapy, to reduce the dose to the parotids.
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Clinical InvestigationsThe role of radiation therapy in the management of sialorrhea

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Acknowledgements

International Journal of Radiation Oncology, Biology and Physics

Archives of Oral Biology

Oral Surgery, Oral Medicine, Oral Pathology

Journal of American Dental Associaton

Roentgen. Treatment of Salivary Fistula

Policlinico (Sezione Pratica)

Estimation and Comparison of Proportions

Editorial. Drooling

Developmental Medicine and Child Neurology

Drooling in the developmentally disabledManagement practices and recommendations

Dev. Med. Child Neurol.

Saliva

Management Options for the Drooling Patient

Ear, Nose and Throat, Journal

Submandibular Duct Relocation for DroolingA 10-year Experience with 194 Patients

Otolaryngology, Head and Neck Surgery

The Chemistry and Physiolgoy of Saliva

Histologic Effect of Fractionated Doses of Selectively Applied Megavoltage Irradiation on the Major Salivary Glands of the Albino Rat

Radiology

Clinical Investigations
The role of radiation therapy in the management of sialorrhea