Drooling
Drooling—the flow of saliva from the mouth—results from a failure to swallow or retain saliva or from excess salivation. It may stem from facial muscle paralysis or weakness that prevents mouth closure, from neuromuscular disorders or local pain that causes dysphagia or, less commonly, from the effects of drugs or toxins that induce salivation. Drooling may be scant or copious (up to 1 L daily) and may cause circumoral irritation. Because it signals an inability to handle secretions, drooling warns of potential aspiration.
History and physical examination
If you observe the patient drooling, first determine the amount. Is it scant or copious? When did it begin? Ask the patient if his pillow is wet in the morning. Also, inspect for circumoral irritation.
Then explore associated signs and symptoms. Ask about sore throat and difficulty swallowing, chewing, speaking, or breathing. Have the patient describe any pain or stiffness in the face and neck and any muscle weakness in the face and extremities. Has he noticed any mental status changes, such as drowsiness or agitation? Ask about changes in vision, hearing, and sense of taste. Also ask about anorexia, weight loss, fatigue, nausea, vomiting, and altered elimination habits. Has the patient recently had a cold or other infection? Was he recently bitten by an animal or exposed to pesticides? Finally, obtain a complete drug history.
Next, perform a physical examination, starting with vital signs. Inspect the face for signs of paralysis or an abnormal expression. Examine the mouth and neck for swelling, the throat for edema and redness, and the tonsils for exudate. Note halitosis. Examine the tongue for bilateral furrowing (trident tongue). Look for pallor, skin lesions, and frontal baldness. Carefully assess any bite or puncture marks.
Assess cranial nerves II through VII, IX, and X. Then check pupillary size and response to light. Assess the patient’s speech. Evaluate muscle strength and palpate for tenderness or atrophy. Also palpate for lymphadenopathy, especially in the cervical area. Observe the patient’s ability to swallow. Test for poor balance, hyperreflexia, and a positive Babinski’s reflex. Also, assess sensory function for paresthesia.
Medical causes
Achalasia
Progressively severe dysphagia may cause copious drooling late in this disorder. When the patient lies down, food and saliva in the dilated esophagus flow back to the pharynx and mouth, resulting in drooling. Coughing or choking and aspiration may follow regurgitation. Other findings include weight loss and, possibly, spasms or substernal pain after eating.
Acoustic neuroma
When this malignant tumor involves the facial nerve, it produces facial weakness or paralysis with scant to copious drooling. The drooling is followed by tinnitus, unilateral hearing loss, and vertigo. Other symptoms include dysphagia, poor balance, and ear or eye pain.
Amyotrophic lateral sclerosis
Brain stem involvement in this degenerative disorder weakens muscles of the face and tongue, resulting in constant scant to copious drooling. The drooling is accompanied by dysarthria and difficulty chewing, swallowing, and breathing. Fasciculations are common along with muscle atrophy and weakness, especially in the forearms and hands, and hyperreflexia and spasticity in the legs.
Bell’s palsy
Drooling accompanies the gradual onset of facial hemiplegia in Bell’s palsy. The affected side of the face sags and is expressionless, the nasolabial fold flattens, and the palpebral fissure (distance between upper and lower eyelids) widens. The patient usually complains of pain in or behind the ear. Other cardinal signs and symptoms include a unilateral diminished or absent corneal reflex, decreased lacrimation, Bell’s phenomenon (upward deviation of the eye with attempt at eyelid closure), and partial loss of taste or abnormal taste sensation.
Diphtheria
In this infection, moderate drooling results from dysphagia associated with sore throat. The hallmark of diphtheria, however, is a bluish white, gray, or black membrane over the mucous membranes of the tonsils, pharynx, larynx, soft palate, and nose. This membrane causes pooling of saliva, which aggravates drooling. Other signs and symptoms include fever, pallor, tachycardia, halitosis, noisy respirations, cervical lymphadenopathy, purpuric skin lesions, drowsiness, and delirium.
Esophageal tumor
In this type of tumor, copious and persistent drooling is typically preceded by weight loss and progressively severe dysphagia. Other signs and symptoms include substernal, back, or neck pain and blood-flecked regurgitation.
Glossopharyngeal neuralgia
Drooling may accompany the sharp paroxysms of pain that characterize this rare disorder. The pain may be precipitated by swallowing, talking, chewing, or coughing or by external pressure on the ear; it may affect the posterior pharynx, the ear, or the base of the tongue or jaw. Associated findings include hoarseness, soft palate deviation to the unaffected side, absent gag reflex, partial loss of taste, and trapezius and sternocleidomastoid muscle weakness.
Guillain-Barré syndrome
The hallmark of this polyneuritis is ascending muscle weakness that typically starts in the legs and extends to the arms and face within 24 to 72 hours. Facial diplegia and dysphagia set the stage for scant to copious drooling, which is accompanied by dysarthria, nasal voice tone, and a diminished or absent corneal reflex. Other signs and symptoms include paresthesia, signs of respiratory distress, and signs of sympathetic dysfunction, such as orthostatic hypotension, loss of bowel and bladder control, diaphoresis, and tachycardia.
Hypocalcemia
The chief feature of hypocalcemia is tetany, characterized by muscle twitching, cramps, and seizures; carpopedal spasm; and positive Chvostek’s and Trousseau’s signs. Moderate to copious drooling may accompany the resultant dysphagia. In severe hypocalcemia, the patient may have laryngeal spasm with stridor, cyanosis, and generalized tonic-clonic seizures.
Ludwig’s angina
In this disorder, moderate to copious drooling stems from dysphagia and local swelling of the floor of the mouth, causing tongue displacement. Submandibular swelling of the neck and signs of respiratory distress may also occur.
Myasthenia gravis
Facial and pharyngeal muscle weakness causes scant to copious drooling that’s accompanied by difficulty swallowing, chewing, and speaking. Typically, drooling is preceded by diplopia and ptosis. The patient displays a masklike face and myasthenia snarl (smile with lips elevated but not retracted). Other features include a weak tongue with bilateral furrowing (trident tongue) and a sagging jaw if masseter muscles are affected. Skeletal muscle weakness is characteristic; muscles typically weaken throughout the day, especially after exercise.
Myotonic dystrophy
Facial weakness and a sagging jaw account for constant drooling in this disorder. Other characteristic findings include myotonia (inability to relax a muscle after its contraction), muscle wasting, cataracts, testicular atrophy, frontal baldness, ptosis, and a nasal, monotone voice.
Paralytic poliomyelitis
When this infection involves the brain stem, it may produce facial paralysis and dysphagia, resulting in scant to copious drooling. Typically, the drooling is preceded by fever, headache, nuchal rigidity, and intense muscle aches. The patient then develops fasciculations and usually asymmetrical paralysis in the lower legs and trunk that’s associated with transient urine retention.
Parkinson’s disease
In this degenerative disorder, the neck is flexed forward, so saliva isn’t directed to the back of the mouth; the result is drooling. Other cardinal features include a pill-rolling tremor, rigidity, bradykinesia, a shuffling gait, stooped posture, masklike facies, dysarthria, and a high-pitched, monotone voice.
Peritonsillar abscess
A severe sore throat causes dysphagia with moderate to copious drooling in this type of abscess. Accompanying signs and symptoms are high fever, rancid breath, and enlarged, reddened, edematous tonsils that may be covered by a soft gray exudate. Palpation may reveal cervical lymphadenopathy.
Rabies
When this acute central nervous system infection advances to the brain stem, it produces drooling (commonly referred to as “foaming at the mouth”) from excessive salivation, facial palsy, or extremely painful pharyngeal spasms that prohibit swallowing. It’s accompanied by hydrophobia in about 50% of patients. Seizures and hyperactive deep tendon reflexes (DTRs) may also occur before the patient develops generalized flaccid paralysis and a coma.
Retropharyngeal abscess
This disorder causes painful swallowing, resulting in moderate to copious drooling. The patient complains of a lump in his throat that he can’t swallow and of dyspnea in the sitting position that disappears when he lies down. Other cardinal signs and symptoms include coughing, snoring, choking, noisy breathing, and a “cry of a duck” voice tone. Cervical lymphadenopathy, pharyngeal edema and redness, and a high fever may also occur.
Seizures (generalized)
This tonic-clonic muscular reaction causes excessive salivation and frothing at the mouth accompanied by loss of consciousness and cyanosis. In the unresponsive postictal state, the patient may also drool.
Stroke
Facial paralysis associated with stroke results in scant to copious drooling. Other signs and symptoms include diplopia, visual field deficits, dysarthria, hearing loss, paresthesia, paralysis, ataxia, headache, dizziness, confusion, nausea, vomiting, unilateral or bilateral hyperactive DTRs, and a positive Babinski’s reflex.
Tetanus
This acute infection may produce scant to copious drooling associated with dysphagia. Typically, drooling is preceded by restlessness and pain and stiffness in the jaw, abdomen, and back that progress to tonic spasms. A locked jaw and a grotesque grinning expression (risus sardonicus) are characteristic signs. Profuse sweating, low-grade fever, and tachycardia are also common.
Other causes
Drugs
Such drugs as clonazepam, ethionamide, and haloperidol can all cause excessive salivation, which may result in drooling.
Envenomation
Some snakebites trigger excess salivation, resulting in drooling. The drooling is accompanied by other neurotoxic effects, such as diaphoresis, chills, weakness, dizziness, nausea, vomiting, paresthesia, fasciculations, and tender lymphadenopathy. Local swelling, pain, and ecchymoses may occur.
Pesticide poisoning
Toxic effects of pesticides may include excess salivation with drooling, diaphoresis, nausea and vomiting, involuntary urination and defecation, blurred vision, miosis, increased lacrimation, fasciculations, weakness, flaccid paralysis, signs of respiratory distress, and coma.
Special considerations
Be alert for aspiration in the drooling patient. Position him upright or on his side. Provide frequent mouth care, and suction as necessary to control drooling. Be prepared to perform a tracheostomy and intubation, to administer oxygen, or to execute an abdominal thrust.
Help the patient cope with drooling by providing a covered, opaque collecting jar to decrease odor and prevent transmission of infection. Keep tissues handy and drape a towel across the patient’s chest at mealtime. Encourage oral hygiene. Also, teach the patient exercises to help strengthen facial muscles, if appropriate. Assist the patient with meticulous skin care, especially around the mouth and in the neck area, to prevent skin breakdown. Cornstarch may be placed on the neck to reduce the risk of maceration.
Pediatric pointers
Normally, an infant can’t control saliva flow until about age 1, when muscular reflexes that initiate swallowing and lip closure mature. Salivation and drooling typically increase with teething, which begins at about the fifth month and continues until about age 2. Excessive salivation and drooling may also occur in response to hunger or anticipation of feeding, and in association with nausea.
Common causes of drooling in children include epiglottiditis, retropharyngeal abscess, severe tonsillitis, stomatitis, herpetic lesions, esophageal atresia, cerebral palsy, mental deficiency, and drug withdrawal in neonates of addicted mothers. It may also result from a foreign body in the esophagus, causing dysphagia.
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Mouth symptoms
Read excerpts from these other book chapters related to Mouth symptoms:
Medical Books Excerpts
- HALITOSIS
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- Drooling
- "In A Page: Pediatric Signs and Symptoms" (2007)
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- Halitosis
- "In A Page: Pediatric Signs and Symptoms" (2007)
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- Drooling
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Drooling
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Halitosis
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Mouth lesions
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Throat pain
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Halitosis
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- Halitosis
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- Throat pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Sore Throat
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
- Drooling
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Mouth symptoms
» Next page: Halitosis (Professional Guide to Signs & Symptoms (Fifth Edition))
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