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We searched in PubMed for relevant articles using the following key words: (hyper)salivation, sialorrhea, drooling, spitting, insular, opercular, epilepsy, seizure, ictal, EEG, and surgery. We evaluated the risk of bias and the diagnostic accuracy quality of each publication using the Quality of Diagnostic Accuracy Studies (QUADAS)\u20102\u2010adapted tool. We assessed the level of confidence (very high, high, moderate, and low) in the reported epileptogenic zone (EZ) based on the availability of findings from MRI, intracerebral EEG, and postoperative outcomes.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>We reviewed the full text of 65 articles that fulfilled the criteria for evidence synthesis. Thirty\u2010two studies and 11 case reports (173 patients) on ictal hypersalivation and 15 studies and 13 case reports (54 patients) on ictal spitting were eligible. Ictal hypersalivation was reported in approximately 11% of (mesio)\u2010temporal and approximately 23% of insular, opercular, and insulo\u2010opercular epilepsies with &gt;70% high\u2010confidence cases due to seizure\u2010free postsurgical outcomes. Ictal spitting was very rarely observed in focal epilepsies, including mesio\u2010temporal epilepsies (incidence of 1% and 1.6%, respectively), but was significantly associated with a nondominant mesio\u2010temporal EZ.<\/jats:p><\/jats:sec><jats:sec><jats:title>Significance<\/jats:title><jats:p>There is strong evidence that ictal hypersalivation is more common in insular, opercular, and insulo\u2010opercular seizures than in temporal lobe seizures, with the mid\u2010insula and central operculum most consistently identified as symptomatogenic zones. Ictal spitting is a rare complex motor automatism pointing to seizures originating in nondominant mesio\u2010temporal structures.<\/jats:p><\/jats:sec>","DOI":"10.1002\/epd2.70030","type":"journal-article","created":{"date-parts":[[2025,5,7]],"date-time":"2025-05-07T14:59:08Z","timestamp":1746629948000},"page":"550-567","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Localizing value of ictal hypersalivation\/sialorrhea and ictal spitting: A systematic review"],"prefix":"10.1002","volume":"27","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4443-5140","authenticated-orcid":false,"given":"Petia S.","family":"Dimova","sequence":"first","affiliation":[{"name":"Clinical Epileptology, Functional and Epilepsy Surgery Unit, Department of Neurosurgery St. Ivan Rilski University Hospital  Sofia 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