Letters to the Editor

Atropine and Scopolamine For the Treatment of Sialorrhea

TO THE EDITOR: In their article, “Sialorrhea: A Management Challenge,”1 the authors advocate the use of glycopyrrolate tablets and scopolamine (Transderm Scop) topical patches for the treatment of sialorrhea. I propose that physicians also should consider two alternatives: low-dose atropine sulfate tablets and scopolamine hydrobromide tablets.

One study2 documented that oral administration of atropine reduced the amount of resting secretion, intraoral accumulation, and pharyngeal-laryngeal pooling of saliva by more than 50 percent of baseline levels, with negligible side effects. Another study3 demonstrated depression of salivation up to 80 percent in healthy adult patients taking oral atropine.

Atropine tablets reduce salivation in infants, children, and adults. The medication may be administered every four to six hours as needed. The average wholesale price of atropine tablets is approximately one third of the price of glycopyrrolate tablets.4

Scopolamine tablets may be administered every eight hours as needed. This medication warrants consideration as a substitute for the scopolamine patch because of its dosing flexibility, faster onset of action, shorter duration of action, and significantly lower cost.4,5

Craig R. Sherman, M.D.

Hope Pharmaceuticals
8260 E. Gelding Dr., Suite 104
Scottsdale, AZ 85260

REFERENCES

editor’s note: Hope Pharmaceuticals manufactures atropine sulfate and scopolamine hydrobromide tablets.

in reply: We appreciate Dr. Sherman’s insights into additional medical treatment options for sialorrhea and agree that a variety of preparations of anticholinergic medications may offer promising results. Unfortunately, study of the use of low-dose atropine sulfate tablets or scopolamine hydrobromide tablets for the treatment of sialorrhea is limited, especially in children.

Although oral anticholinergic medications are consistently reliable in their reduction of sialorrhea, side effect profiles frequently result in discontinuation of their use.1,2 A retrospective review and a prospective randomized trial of the use of transdermal scopolamine for the treatment of drooling demonstrate high efficacy and low toxicity.3,4

Dr. Sherman references a case report5 of the use of atropine to control sialorrhea in a patient with a closed head injury. The toxicities frequently associated with systemic anticholinergics may not have been apparent in this patient because of his underlying mental status. Dr. Sherman further indicates that oral atropine was demonstrated to reduce salivation by up to 80 percent in healthy adults; the applicability of this data to patients with pathologic sialorrhea has not been elucidated.6

Although there is potentially a variety of cost-effective, efficacious medications in the treatment of sialorrhea, further study is indicated.

Neil G. Hockstein, M.D.

Family Ear, Nose, and Throat
1941 Limestone Rd.
Wilmington, DE 19808

REFERENCES

Missed Subtarsal Foreign Body in Patient Presenting with Ocular Injury

TO THE EDITOR: We read with interest the article, “Management of Corneal Abrasions” by Drs. Wilson and Last1 in American Family Physician. We would like to highlight the importance of looking for subtarsal foreign bodies in relevant cases of eye injury.

A 25-year-old man attended the emergency department after molten metal splashed into his right eye. His eyes had been irrigated at his workplace. The emergency department physician examined his eyes and could not find any obvious foreign body. When the patient still had pain and foreign body sensation in his right eye, orbital radiographs were taken, which showed a small, round, radio-opaque shadow in the right orbit consistent with a metallic foreign body (Figure 1). The exact location of the foreign body could not be determined, so the patient was referred to the on-call ophthalmologist.

On ocular examination, the patient’s visual acuities were 20/20 (unaided) in both eyes. Slit lamp examination showed mild medial conjunctival congestion in the right eye. No abnormalities of the conjunctiva or cornea were seen on fluorescein staining, and there was no entry wound. Eversion of the right upper eyelid showed a subtarsal metallic foreign body. The rest of the ocular examination was unremarkable. The subtarsal foreign body (Figure 2) was removed under topical anesthesia, and the patient was discharged with a prescription for topical antibiotics.

Eye injuries from foreign bodies remain one of the most common presentations to the emergency department. Eversion of the upper eyelids to rule out subtarsal foreign bodies is an essential part of ocular examination in all patients with a history of eye injuries. In our patient, the subtarsal foreign body was overlooked because eyelid eversion was not performed. Failing to do this simple technique may result not only in performing unnecessary investigations, but, more importantly, in subtarsal foreign bodies going undetected, which can lead to complications such as persistent grittiness, corneal abrasions, recurrent traumatic keratitis,2 and granuloma formation.3

A review article4 showed that most orbital radiographs are performed needlessly. They suggested restricting radiologic investigations to patients with clinical evidence of penetrating ocular or orbital trauma, or a subconjunctival hemorrhage.

Newman5 reported that an eyelid foreign body may mimic an intraocular foreign body on plain radiography, which was the case in our patient.

This case report demonstrates the importance of examination by upper-eyelid eversion in patients who present with a history of ocular injury or grittiness and a foreign body sensation in the eye. This simple technique may prevent complications caused by missed subtarsal foreign bodies such as corneal abrasions and infections, and also avoid unnecessary imaging studies.

Krishnappa. C. MADHUSUDHANA, M.D.
Partha CHAKRABORTY, M.S.

Department of Ophthalmology
Darlington Memorial Hospital
Hollyhurst Rd.
Darlington, UK DL3 6HX

REFERENCES

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org.

Please include your complete address, telephone number, fax number, and e-mail address. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

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