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In recent years we treated 53 patients suffering from Frey's syndrome with an antihidrotic gel. The active ingredient we used was aluminiumtrichloridhexahydrate. In addition to presenting a historic review we will also demonstrate and discuss our results. The study concludes, that this gel is effective in treating Frey's syndrome.
OBJECTIVE: To compare the duration of effect of two dosage regimes of botulinum toxin A to treat patients with Frey's syndrome. STUDY DESIGN: Prospective study of two unselected cohorts of 20 patients each. METHODS: The dimension of the affected skin area was determined with Minors iodine-starch test. The skin was infiltrated with botulinum toxin type A (Dysport, Ipsen Pharma, Ettlingen, Germany) using an interinjection distance of 1 cm. In the first group, a concentration of 10 mount units (MU)/0.1 mL and in the second group a concentration of 20 MU/0.1 mL was used. At each injection site, 0.1 mL of the respective solution was injected. The outcome measures were the time of reappearance of gustatory sweating, and the results of an iodine-starch test 10 and 20 months after treatment. RESULTS: Using the lower concentration, the mean duration of effectiveness was 8.3 +/- 2 months (mean +/- standard deviation). Using the higher concentration, the effect was much longer at 16.5 +/- 6 months. Eighty-five percent of the first group but only 5% of the second had a positive Minor's iodine-starch test 10 months after treatment. After 20 months four patients in the second group still had a negative iodine-starch test. In both groups, the amount of required botulinum toxin for the second treatment after recurrence of Frey's syndrome was the same as for the first treatment. CONCLUSIONS: Using a higher concentration of botulinum toxin type A (20 MU Dysport/0.1 mL) is more effective than a lower concentration (10 MU Dysport/0.1 mL) in the treatment of Frey's syndrome.
Gustatory sweating and flushing, or Frey's syndrome, is a fairly common complication following surgery or injury to the parotid gland and is thought to be caused by aberrant nerve regeneration. A similar condition has been reported in the literature following surgery to the submandibular region. Since this was first described in 1934, only 7 subsequent cases of submandibular sweating and flushing have been reported. We present a case of a 52-year-old female who underwent excision of the left submandibular gland as a result of chronic sialadenitis. Twelve months following surgery, symptoms indicative of Frey's syndrome were experienced in the operative region. A review of the aetiology and treatment of the condition is described.
A case of Frey's syndrome of the external auditory canal is reported. The patient presented with unilateral gustatory otorrhea and thickened external auditory canal skin. Histopathologic examination of the canal skin showed sudomotor gland hyperplasia. Symptoms were relieved with canal skin excision and skin graft.
A new suggestion for treating marked sweating with Frey's syndrome namely, sweat suppression by aluminium chloride, is presented, together with a survey of the different attempts to suppress the hyperhidrosis. The mechanism of sweat suppression, the form of application and the results in 28 patients suffering from marked gustatory sweating, are outlined. After a single application, an interval of several weeks free of symptoms can be expected.
The benefit of using a sternocleidomastoid flap following parotidectomy to reduce the incidence of symptomatic gustatory sweating (Frey's syndrome) was reviewed. A retrospective study was undertaken to review subjective and objective symptoms of Frey's syndrome in two groups of patients, one of whom had undergone superficial parotidectomy with a sternocleidomastoid flap rotated at the time of surgery and a second group of patients who had undergone a standard superficial parotidectomy. A total of 22 patients, randomly sampled and willing to attend, were evaluated postoperatively, at a median time from surgery of 42 months (range 23-82 months) in the non-flap group and 44 months (range 14-66 months) in the flap group, by Minor's starch iodine test. In the 11 patients who had a sternocleidomastoid flap rotated, two had evidence of gustatory sweating. Of the 11 that had not undergone sternocleidomastoid flap rotation, nine patients showed evidence of gustatory sweating (P < 0.05, chi 2 test). There were two patients in total who had clinical symptoms of Frey's syndrome and both of these had not undergone flap rotation at the time of parotidectomy.
Between 1980 and 1990, 35 patients underwent conservative parotidectomy combining a rhytidectomy incision and a superficial musculoaponeurotic system preservation technique to reduce the postoperative incidence of Frey's syndrome. All patients were evaluated by questionnaire for subjective symptoms of gustatory sweating and flushing as well as satisfaction with the aesthetic appearance of their cheek. Six percent of patients (2 of 35) complained of symptoms of Frey's syndrome. Ninety-four percent of patients (33 of 35) noticed minimal or no contour deformity of the surgical area. Twenty patients underwent Minor's starch iodine testing to identify objective evidence of aberrant nerve regeneration at the postoperative site. Fifteen percent of these patients (3 of 20) demonstrated a positive starch iodine test; however, one of these three patients was unaware of symptoms of Frey's syndrome. Symptoms of gustatory sweating are a reliable indicator of aberrant nerve regeneration. Conservative parotidectomy with superficial musculoaponeurotic system preservation for benign parotid disease produces a low incidence of Frey's syndrome and satisfactory cosmetic results.
The effectiveness of botulinum toxin injections for the management of Frey's syndrome was studied. Botulinum toxin A (approximately 0.5 Units/cm2) was injected intracutaneously into the affected skin area as determined by Minor's starch iodine test. Gustatory sweating in the treated skin area ceased completely within 1 week and has not reappeared (12 months follow up until now in the first treated case). There have been no side effects. It is concluded that local botulinum toxin injections are a highly effective and safe treatment for Frey's syndrome. Additional study is required to evaluate the duration of the therapeutic effect.
Dermis-fat grafts were performed on 7 patients at the time of parotidectomy to prevent Frey's syndrome and the characteristic concave deformity. Only 1 patient demonstrated postoperative Frey's syndrome, and 1 demonstrated a slightly concave deformity due to fat absorption. Although other barrier materials have been reported to achieve success in preventing gustatory sweating, our method simultaneously corrects the associated deformity of facial contour as well.
We studied the incidence of Frey's syndrome and facial contour deformity in two groups of patients who had undergone superficial parotidectomy. One group was made up of 12 patients who were randomized to undergo reconstruction of the surgical defect with a sternocleidomastoid muscle flap; the other 12 patients did not receive a flap. All 24 patients were evaluated via a short questionnaire, the starch-iodine test, and a visual examination. On the questionnaire, none of the 24 patients said they experienced abnormal facial sweating, flushing, or warmth while eating, although 6 of the 12 patients in the nonflap group had a mildly positive starch-iodine test. No patient in the flap group had a positive test. The difference between the two groups was statistically significant (p < 0.05). No statistically significant difference was seen between the two groups with respect to cosmetic results.
An expanded polytef (polytetrafluoroethylene [ePTFE]) soft-tissue patch was used in nine patients to reconstruct postparotidectomy defects and prevent Frey's syndrome. All nine cases were constructed primarily using either a 1- or 2-mm-thick patch depending on the depth of the defect. All nine patients achieved excellent, nearly normal contour that approximates the uninvolved side. None complained of Frey's syndrome. Average follow-up to date is 12 months.
For a long period the therapeutic modalities to treat focal hyperhidrosis (HH) were very limited. Due to this the problem of focal HH was delt with stepmotherly. Nowadays we can consider BTX as the therapy of choice for axillary HH after topical treatment with aluminium salts have failed. The amount of successful reports on botulinum toxin (BTX) in the treatment of focal HH brought a change and the interest for this specific disorder grew. This article gives details on anatomy and physiology of sweating and mechanism of BTX. Further distinctive syndromes associated with HH, which all can be treated with BTX like localized unilateral hyperhidrosis (LUH), Ross' Syndrome and Frey' Syndrome are presented. A diagnosis of primary HH is usually based on the patients's history, typical younger age and visible signs of excessive sweating. Before treatment it is important to objectify focal HH with performing sweat tests such like Minor starch test and/or gravimetry. The total number of sweat glands is somewhere between 2 and 4 million and only about 5% are active at the same time, indicating the enormous potential for sweat production. The eccrine sweat gland is a long-branched tubular structure with highly coiled secretory portion and a straight ductular portion. Sweat is produced by clear and dark cells and is a clear hypotonic, odorless fluid. In response to nerve impulses, Acetylcholine (ACh) is released from the presynaptic nerve endings and then binds to postsynaptic cholinergic receptors presumably present in the basolateral membrane of the clear cells. This activates a complex in- and efflux of electrolytes creating the hypotonic sweat. Injection of BTX leads to temporary chemodenervation with the loss or reduction of activity of the target organ. BTX is consisted of a heavy and a light chain. The structural architecture of BTX comprises three domains-L, H(N) and H(C)-each with a specific function in the mechanism of cell intoxication. The heavy chain is responsible for binding to the nerve cell, whereas the light chain catalyzes the proteolysis of one of the three SNARE proteins (Snap-25, Vamp or Syntaxin) depending to the serotype of BTX (7 serotypes A-G). Once cleaved by BTX, the SNARE proteins cannot become part of the complex capable of mediating the vesicle membrane fusion and therefore prevents the release of ACh and hence transmission of the nerve impulse.
The sternocleidomastoid muscle flap may play a significant role in reducing the incidence of Frey's syndrome and maintaining facial contour after parotidectomy. Patients who underwent superficial parotidectomy from August 1992 to March 1999 were divided into two groups (N = 26). One group had sternocleidomastoid muscle flap reconstruction. A historical cohort study was designed with the two groups being matched for sex, age, pathology, postoperative radiation, date of surgery, and extent of dissection. The starch iodine test was used to evaluate for gustatory sweating, and the Observer Rated Disfigurement Scale was used to assess facial contour and aesthetics. The results of our study suggest that the sternocleidomastoid flap reconstruction following parotidectomy surgery does not alter the incidence of Frey's syndrome and does not significantly improve facial contour and aesthetics.
Between 1992 and 2002, 46 patients who underwent standard superficial parotidectomy with a superficial muscoloaponeurotic system (SMAS) preservation technique were included in a retrospective study. Twenty-six patients were evaluated by questionnaire for subjective symptoms of gustatory sweating and flushing as well as satisfaction with the aesthetic appearance of their cheek. Six of twenty-six patients (23.1%) complained of symptoms of Frey's syndrome. Seven of twenty-six patients (26.9%) demonstrated a positive Minor's starch iodine test. By this technique the incidence of Frey's syndrome is substantially reduced from 48% by subjective review and 72% by objective measurement reported in the previous study by the same group of surgeons without using the SMAS preservation technique. This study supports the role of the SMAS flap in preventing Frey's syndrome following standard superficial parotidectomy.
Botulinum toxin has been successfully used to treat Frey's syndrome occurring in a 31-year-old patient following superficial parotidectomy for pleomorphic adenoma. An initial injection of 7.5 U (0.3 ml over 6 cm2 of cheek) resulted in 3 months' resolution of gustatory sweating and flushing and a second injection 12 months' symptomatic improvement. The symptoms recurred after further facial surgery.
Nine patients suffering from gustatory sweating (Frey's syndrome) following parotidectomy have been treated by topical applications of aluminium chloride hexahydrate. Treatment has successfully controlled gustatory sweating using application intervals varying from 1 to 50 days.
398 out of 700 patients (= 56.8%), who underwent parotidectomy in the years 1969-1982 at the ENT-Clinic, University of Münster, answered a follow-up study on the postoperative onset of the auriculotemporal syndrome. We investigated the relations between marked sweating and different surgeons, surgical techniques, histology, lesions of the facial nerve, first appearance and mechanisms to elicit the sweating. The results are discussed with regard to the different hypotheses on the development of Frey's syndrome. No unequivocal indications regarding the cause of Frey's syndrome could be established.
BACKGROUND: Gustatory sweating is a common complication of parotid surgery. Injection of botulinum toxin A has been reported as a safe and effective treatment option for patients with Frey's syndrome. PATIENTS AND METHODS: A total of 69 patients who had undergone superficial parotidectomy because of adenoma were evaluated with respect to the incidence of Frey's syndrome and treatment interest. Minor's iodine starch test was used to detect the affected skin area. Affected skin areas were documented using a digital camera; skin areas were evaluated morphometrically. A single injection of Botox per 1 cm(2) skin field was administered to those patients interested in treatment. RESULTS: Of 43 patients (62%) with gustatory sweating, 33 patients requested treatment. The affected skin area varied from 16 cm(2) to 81 cm(2). The individual Botox dosage ranged from 16 to 80 IU. All relevant clinical symptoms of sweating disappeared within 1 week after a single injection. Treatment was well tolerated with no side effects. CONCLUSION: Botox A injection is a safe and effective treatment with long-lasting effects for patients with extensive gustatory sweating.