Frey’s Syndrome Treatment

What is Frey’s Syndrome?

Frey’s Syndrome is a syndrome that includes sweating while eating (gustatory sweating) and facial flushing. It is caused by injury to a nerve, called the auriculotemporal nerve, typically after surgical trauma to the parotid gland. This nerve, when it heals, reattaches to sweat glands instead of the original salivary gland (which had been removed during surgery).

This means that when you are supposed to salivate, you sweat instead. Redness and sweating appear when the affected person eats, sees, dreams, thinks about, or talks about foods which produce strong salivation. The patient has flushing and sweating over the temple, cheek, and upper neck areas.

How common is Frey’s Syndrome after surgery?

Frey’s Syndrome is thought to occur in all patients who have parotid surgery without reconstructive surgery. Symptoms may vary in severity and usually only patients with severe symptoms seek treatment.

Is Frey’s Syndrome dangerous?

Although Frey’s Syndrome does not cause significant harm, it can be very uncomfortable and embarrassing for the sufferer.

How is Frey’s Syndrome diagnosed?

The diagnosis of Frey’s Syndrome is usually as simple as talking to and examining the patient. An additional test that can be used to outlined the facial area is called the minor iodine and starch test.

In this test, iodine is applied to the symptomatic side of the face. After it dries, cornstarch is applied. When the patient sweats (with food stimulus), the affected area gets dark.

Will I get Frey’s Syndrome after my parotid surgery?

All patients who have salivary gland surgery without reconstruction will have gustatory sweating to some degree. The severity of symptoms depends on:

• tumor size
• amount of parotid tissue removed (e.g. superficial parotidectomy, deep-lobe parotidectomy, total parotidectomy, submandibular gland removal)
• length of the incision
• extent of the dissection area
• reconstruction after tumor removal

Simply put, the more dissection, the increased likelihood and severity of Frey’s syndrome postoperatively. Limiting the dissection is the first step to a successful surgery.

However, the most important factor is the reconstruction. If your surgeon is not experienced with preventative reconstruction of a parotidectomy, your risk of Frey’s syndrome increases significantly.

What are my treatment options?

For patients with more severe and bothersome symptoms, there are several options for treatment.

Medical treatments include:

• Topical anticholinergic ointments (scopolamine, glycopyrolate)
• Topical anti-perspirants (deodorant)
• Topical α agonist (clonidine)
• Botulinum toxin injections

Botulinum toxin appears to be the easiest and safest method. It provides the longest period of symptom relief with the lowest complications. However, none of these treatments allow a definitive cure; relief is only temporary.

For permanent treatment, reconstructive surgery is the only option. In experienced hands, surgery has the added benefit of being able to reduce facial scars from incisions and correct facial deformities from the initial surgery. However, most surgeons are not capable of performing a true reconstruction that both prevents Frey’s syndrome and treats the facial deformity from parotidectomy.

How is the surgery performed?

(1) Skin elevation

The surgery begins with careful elevation of the skin. This is the most critical part, because care must be taken to avoid any exposed facial nerve branches. The facial nerve is responsible for all movement of the face. Inadvertent injury to this nerve risks permanent paralysis.

To make this a safe procedure, we have developed custom instrumentation that increases the safety of the elevating the skin over the previous surgery site.

(2) Cover the defect

Tissue is then harvested and sized appropriately to cover the defective area. It is a dermal-fascial graft. The graft is meticulously sutured to the facial muscles, which reconstructs the natural facial muscular support. The graft accomplishes two goals: it seals off the sweat glands, curing the patient of Frey’s syndrome, and it supports the soft tissues of the cheek.

(3) Finally any further reconstruction to correct any cosmetic deformity is completed and procedure is concluded.

How can I avoid Frey’s Syndrome if I am having salivary gland surgery?

The most effective way to avoid Frey’s Syndrome is to minimize surgical trauma. The only way to do this is to have a minimally invasive surgery. Minimally invasive surgery only involves the parotid gland. It does not extend into the cheek, temple and neck, as traditional parotid surgery does.

Minimally invasive surgery can be accomplished with:

• transoral parotidectomy
• endoscopic surgery
• Parotidectomy Mini-Incision (pioneered by Dr. Ryan Osborne and Dr. Jason Hamilton)

After parotidectomy, a barrier needs to be reconstructed to prevent the salivary nerves and sweat glands from making contact with one another. If this barrier is created, the risk of Frey’s Syndrome is virtually eliminated. However, this is not a part of most traditional parotid surgery.

Keywords:

Gustatory – taste and/or related to tasting

Gustatory Sweating – excessive sweating in response to eating

Lucja Frey – one of the first female academic Neurologist in Europe who classified gustatory sweating

Auriculotemporal Nerve – a branch of the trigeminal nerve that carries both sweat (sympathetic) fibers to the sweat glands of the scalp and salivation (parasympathetic) fibers to the parotid gland