Botulinum toxin treatment for symptomatic Frey's syndrome

Effects of acellular dermal matrix on the prevention of complications and esthetic outcome after parotidectomy: A propensity score matched analysis

OBJECTIVE

The present study was designed to investigate whether acellular dermal matrix (ADM) grafts could prevent Frey's syndrome (FS) and improve esthetic scores following parotidectomy.

METHODS

From January 2015 to December 2019, 175 patients underwent parotidectomy. We divided the patients into two groups: the ADM group and the control group. We included in each group 30 patients according to a propensity score matched analysis.

RESULTS

FS was subjective in 1 patient (3%) from the ADM group and 9 patients (30%) from the control group (P=0.015). Patients in the ADM group had a subjective esthetic score of 6.1 + 1.7 compared with 5.2 + 1.7 in the control group. The subjective esthetic score for patients in the ADM group was higher than that for patients in the control group (P =0.040).

CONCLUSION

The present clinical study suggests that ADM grafts are effective in preventing FS and improving esthetic scores after parotidectomy.

Efficacy and safety of botulinum toxin type A for treatment of Frey's syndrome: evidence from 22 published articles

Frey’s syndrome (FS) is an unavoidable sequela following the surgery of the parotid gland. Although several treatment methods are available, their efficacy is short term or accompanied by unacceptable complications. In the past two decades, botulinum toxin type A (BTXA) has been widely used to treat FS. Although several systematic reviews have been reported recently, they were conflicting and with obvious deficiencies. Thus, we performed an objectively systematic review to determine whether BTXA is an effective and safe treatment for FS. A literature retrieval covering PubMed, Web of Science, Ovid, Embase and Cochrane library was performed on 16 January, 2015. Proportion meta-analysis and corresponding 95% confidence interval (CI) were performed to evaluate the efficacy and safety of BXTA in treatment of FS. A total of 499 records were retrieved and 22 articles with 23 studies were included after scrutiny by two independent authors. Statistical analyses regarding the effective rate, incidence of complications were used to estimate the efficacy and safety of BTXA. Our results suggested that the effective rate of BTXA for treatment of FS is 98.5% (95% CI = 0.971–0.994) and the incidence of complication is 3.6% (95% CI = 0.017–0.061). In conclusion, our study supports that BTXA produces meaningful benefits on the treatment of patients with FS. However, owing to lack of strong evidence, future studies with well-designed inclusion criteria and multicenter randomized controlled trials are needed to give more credible evidence, if possible.

Interventions for the treatment of Frey's syndrome

BACKGROUND

Frey's syndrome is a rare disorder, the symptoms of which include sweating, flushing and warming over the preauricular and temporal areas following a gustatory stimulus. It often occurs in patients who have undergone parotidectomy, submandibular gland surgery, radical neck dissection, infection and traumatic injury in the parotid region, and is caused by the aberrant regrowth of facial autonomic nerve fibres. Currently there are several options used to treat patients with Frey's syndrome; for example, the topical application of anticholinergics and antiperspirants, and the intradermal injection of botulinum toxin. It is uncertain which treatment is most effective and safe.

OBJECTIVES

To assess the efficacy and safety of different interventions for the treatment of Frey's syndrome.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; ICTRP and additional sources for published and unpublished trials. The date of the search was 28 April 2014.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials (RCTs) in participants diagnosed with Frey's syndrome using a clinical standard such as Minor's starch-iodine test. We planned to include trials in which participants received any intervention versus no treatment (observation) or an alternative intervention, with or without a second active treatment. Our primary outcome measures were success rate (as assessed clinically by Minor's starch-iodine test, the iodine-sublimated paper histogram method, blotting paper technique or another method) and adverse events. Our secondary outcome measure was success rate as assessed by patients (disappearance or improvement of symptoms).

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We identified no RCTs or quasi-RCTs that fulfilled the inclusion criteria. Our searches retrieved eight potentially relevant studies, but after assessment of the full-text reports we excluded all of them due to the absence of randomisation or because the patients did not have Frey's syndrome. We excluded one randomised controlled trial that compared two different doses of botulinum toxin in patients with Frey's syndrome because the comparator was not an alternative treatment.

AUTHORS' CONCLUSIONS

We are unable to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome.RCTs are urgently needed to assess the effectiveness of interventions for the treatment of Frey's syndrome. Future RCTs should include patients with Frey's syndrome of different ranges of severity and report these patients separately. Studies should investigate all possibly effective treatments (such as anticholinergics, antiperspirants and botulinum toxin) compared to control groups using different treatments or placebo. Subjective assessment of Frey's syndrome should be considered as one of the outcome measures.

Autologous fat transfer: an aesthetic and functional refinement for parotidectomy

Parotidectomy is a surgical procedure associated to functional (Frey's syndrome) as well as aesthetic (facial asymmetry) complications that can be very disturbing for the patient. Several procedures have been described to primarily avoid or secondarily reconstruct the facial defect and treat the neurological iatrogenic syndrome. Autologous fat transfer was primarily used in 10 cases to avoid such complications. It is an easy technique widely used in cosmetic and reconstructive surgery. This technique gives very satisfying long-term results on the cosmetic as well as on the physiological point of view.

Parotid carcinoma: Current diagnostic workup and treatment

In this review we present recent progress in diagnostic workup, prognostic evaluation, treatment options and resulting outcomes. Whenever possible, complete resection remains the mainstay of treatment. Sacrifice of facial nerve branches is reserved for the clinically or electromyographically dysfunctioning facial nerve. Clinical or radiological neck disease demands combined surgery and radiotherapy. Treatment of the N0 neck is indicated for advanced stage-high grade tumors but the question remains unanswered whether this should be surgical or radiotherapeutic elective treatment. Surgery alone will cure low stage, low grade tumors, that show no additional negative prognostic factors following adequate resection. In all other tumors postoperative radiotherapy will improve locoregional control. This approach results in good locoregional control, in a way that distant metastasis remains the typical presentation of treatment failure. In this setting, the results of systemic treatment today remain limited, but a huge effort in the molecular biology field has been done to introduce targeted therapy into this domain of head and neck cancer. Disease control remains variable within the patient population. This variation can increasingly be predicted by systems that incorporate the combined information of multivariately identified and quantified prognostic factors into an individualized prognosis for the parotid carcinoma patient.

Effectiveness of repeated treatment with botulinum toxin type A across different conditions

This review assessed the overall effectiveness of repeated treatments with botulinum toxin type A (BoNTA) across different conditions, as documented in the published literature. Forty-four original research articles reporting on 16 different conditions were identified that included data on the duration or efficacy of multiple treatments with BoNTA. All of the 44 studies found sustained or enhanced improvement in efficacy and/or duration over the follow-up period, which ranged from a few treatments to more than 10 years. Dosages did not change over time in 22 of the studies, increased in 4 studies, were not reported over time in 17 studies, and tended to increase then decrease in one study. Seven studies reported a statistically significant increase in the efficacy or duration of BoNTA over time. Results suggest that continued benefit with repeated BoNTA treatment is widely reported in the literature.

Novel cutaneous uses for botulinum toxin type A

Botulinum toxin type A is a neurotoxin produced by the bacterium Clostridium botulinum which causes a flaccid muscle paralysis. It has been used extensively in the field of dermatology for the treatment of dynamic rhytides and in the treatment of hyperhidrosis. Botulinum toxin has an excellent safety profile and few side effects when used for these purposes. Recently, botulinum toxin has also been used experimentally in a number of other dermatologic conditions with good results. These conditions include: persistent facial flushing, gustatory sweating and epiphora, anal fissures, familial benign pemphigus (Hailey-Hailey disease), dyshidrotic eczema, and following surgical wound closures. While randomized, controlled prospective trials are still needed to further understand the efficacy and safety of botulinum toxin in these conditions, anecdotal and case report data suggest that botulinum toxin is both safe and efficacious in these and many other procedures.

Botulinum toxin-physiology and applications in head and neck disorders

This article is structured around a literature review that was carried out using Ovid and Medline with the key words "botulinum," "toxin," and "ENT." Botulinum toxin has been used safely in humans for more than 20 years. The effects are transient, such that treatments are required to be repeated at intervals. Its application to ENT provides a useful tool to treat dystonia, autonomic dysfunction, facial nerve paresis, and hyperfunctional lines. It may also be of benefit in laryngeal rebalancing and the treatment of headaches. Further research is being carried out and new indications for treatment with botulinum toxin may include sialorrhea and rhinorrhea.

Preliminary experience with botulinum toxin type A intracutaneous injection for Frey's syndrome

BACKGROUND

Gustatory sweating, the main symptom of Frey's syndrome, usually occurs after parotid gland surgery. Numerous medical and surgical treatments have been proposed to treat this condition, but there are various drawbacks. Botulinum toxin type A intracutaneous injection is a relatively new treatment modality; its use has never been reported in Taiwan. Here, we present our preliminary experience with this technique and review the literature.

METHODS

Between March 2002 and June 2005, 10 consecutive patients with severe gustatory sweating were managed with intracutaneous injection of botulinum toxin type A for a total of 16 times. The affected skin was visualized by Minor's starch-iodine test and then recorded. The interinjection distance was 1 cm and a mean dose of 46.4 U (at a concentration of 2.5 U/0.1 mL) was used.

RESULTS

In all 10 cases, gustatory sweating improved within 2 days after injection, with no side effects. Patients in whom the first 13 injections were performed experienced recurrence of gustatory sweating. Mean duration of effectiveness was 9.3 months; the shortest duration of effectiveness was 2 months and the longest was 28 months. One patient also had gustatory flushing, but this symptom did not improve even after 3 treatments.

CONCLUSION

Intracutaneous injection of botulinum toxin type A is a highly reliable, effective, safe, and minimally invasive treatment for gustatory sweating. Some patients had long-lasting therapeutic results. We recommend it as a valuable treatment option for severe cases of gustatory sweating. However, in our experience, it had no effect on facial skin flushing. Therefore, in addition to acetylcholine, there might be other neurotransmitters that are responsible for skin vasodilatation.

Botulinumtoxin zur Behandlung des gustatorischen Schwitzens

BACKGROUND

Botulinum toxin A has meanwhile become a proven method for treatment of gustatory sweating (focal hyperhidrosis, Frey's syndrome). Clear-cut recommendations regarding dosage of botulinum toxin A in Frey's syndrome are currently not available. The aim of this prospective randomized study therefore was to investigate botulinum toxin A with respect to its efficacy in Frey's syndrome, the ideal dose yielding maximal duration of the effect, and patient contentedness as well as unwanted side effects in patients of the Clinic of OMF Surgery at the Ruhr-University of Bochum.

PATIENTS AND METHOD

Twenty patients suffering from severe Frey's syndrome as a result of operations of the parotid gland were examined with the starch iodine test according to Minor. The gustatory skin areas were re-examined after intracutaneous injection of botulinum toxin A for up to 1 year. The patients ( n=20) were randomly assigned to two different treatment groups (group I: 2 MU/cm(2), n=10; group II: 3 MU/cm(2), n=10).

RESULTS

Mean sweating skin areas in the two treatment groups ranged between 39+/-9 and 32+/-12 cm(2), respectively. A single injection of 3 MU botulinum toxin A resulted in a nearly complete blockade of gustatory sweating for the observation period of 1 year. In the group treated with 2 MU botulinum toxin A, 44% of the total gustatory skin areas were still sweating, thus necessitating a second injection of botulinum toxin A in these patients.

CONCLUSION

Intracutaneous injection of botulinum toxin A represents a highly effective and minimally invasive procedure for the treatment of Frey's syndrome. This study shows for the first time that a dosage of 3 MU/cm(2) of botulinum toxin A achieves a complete and reliable blockade of gustatory sweating lasting for at least 12 months. This dose may therefore be recommended for treatment of this syndrome.

The use of botulinum toxin type A in the treatment of Frey and crocodile tears syndromes

PURPOSE

We sought to investigate the efficacy of botulinum toxin type A in the treatment of Frey and crocodile tears syndromes. Frey syndrome is a common complication after surgical intervention or injury in the region of the parotid gland. Crocodile tears syndrome is unusual and manifests after facial nerve paralysis and other causes such as head trauma.

PATIENTS AND METHODS

This was a prospective nonrandomized, nonblinded study. We used botulinum toxin type A for the treatment of 11 patients with gustatory sweating and 2 patients with crocodile tears syndrome.

RESULTS

The follow-up (6 to 23 months) of patients with gustatory sweating syndrome showed complete absence of sweating in the affected regions. One patient had recurrence after 16 months and was retreated successfully. At 1 and 24 weeks after treatment of the patients with the crocodile tears syndrome, the Schirmer test showed a reduction of stimulated lacrimation on the impaired side approaching the normal values of the unaffected side.

CONCLUSIONS

Our study supports the widely accepted aspect that botulinum toxin type A could be the treatment of choice for gustatory sweating syndrome. We also propose the toxin as a valuable treatment for crocodile tears syndrome.

Noncosmetic uses of botulinum toxin

In conclusion, botulinum toxin usage over the past 2 to 3 decades has expanded exponentially. Almost every discipline in medicine has found some therapeutic use for this toxin. Botulinum toxin has been shown to be safe, effective, and relatively easy to administer with proper training.

Botulinum Toxin for the Treatment of Facial Flushing

BACKGROUND

Facial flushing is a common problem that is encountered by fair-skinned patients of Celtic and Northern European descent. Although usually transient in nature, some patients display a persistent reddened skin tone, with periods of increased erythema. Treatment of this condition is limited.

OBJECTIVE

To describe a novel method for the treatment of persistent facial flushing.

METHOD

We report a case of persistent facial flushing that was resistant to multiple pulsed dye laser treatments and was successfully treated with botulinum toxin A.

RESULTS

The posttreatment appearance was dramatic, and the patient was highly satisfied with the cosmetic outcome.

CONCLUSION

Botulinum toxin A can be used in small quantities to decrease persistent facial flushing temporarily.

Noncosmetic uses of botulinum toxin

Since the introduction of botulinum toxin (BTX) as a therapeutic tool in the 1970s, the number of uses for this substance has increased exponentially. BTX's mechanism of action involves degrading the SNARE proteins blockading the release of acetylcholine into the neuromuscular junction. In many body systems, decrease of contractility, strength, and tension of certain muscle groups result in improved clinical outcomes. Applications now include cosmetic, gastroenterologic, otolaryngologic, genitourinary, neurologic, and dermatologic uses. In fact, BTX can be considered as a potential treatment in any situation involving inappropriate or exaggerated muscle contraction. Currently, the FDA has approved BTX-A (Botox) for treating glabellar lines, blepharospasm, strabismus, hemifacial spasm, cervical dystonia, and spasticity. With the addition of cosmetic applications to the FDA's approval list, the use of BTX has increased dramatically.

Management of Frey's syndrome and hypersialorrhea with botulinum toxin

Botulinum toxin (BTX) is a safe and reliable drug for the treatment of Frey's syndrome and hypersialorrhea. Currently, the intradermal injection of BTX is the standard treatment of Frey's syndrome. A disappearance of Frey's syndrome for 1 to 1.5 year could almost be promised. Recently, BTX was introduced for the treatment of hypersialorrhea. Although some questions exist about the optimal dosage and the type of major salivary glands that should be treated, hypersialorrhea was reduced in almost all affected children and adults for up to 6 months by using ultrasound-guided intraglandular BTX injections.

Use of AlloDerm implant to prevent frey syndrome after parotidectomy

OBJECTIVE

To evaluate the effectiveness of AlloDerm, an acellular human dermal matrix graft, as an interpositional physical barrier to prevent the development of Frey syndrome after parotidectomy.

METHODS

The 30 patients included in the study were divided into 3 groups of 10. In group 1 (study group), patients underwent superficial parotidectomy with placement of an AlloDerm graft (LifeCell Corp, Branchburg, NJ). In group 2 (control) patients had superficial parotidectomy without placement of an interpositional barrier. In group 3 (control), patients underwent deep-plane rhytidectomy without disruption of the parotid fascia. All were evaluated after 1 year and questioned about gustatory sweating. Subjective assessment of Frey syndrome was documented when patients experienced gustatory sweating, even if they were not perturbed by the symptom. The Minor starch-iodine test was performed in each patient for objective assessment.

RESULTS

The incidence of subjective Frey syndrome was observed in 1 patient in group 1 and 5 patients in group 2. The incidence of objective Frey syndrome was noted in 2 patients in group 1 and 8 patients in group 2. Both subjective and objective differences in incidence of Frey syndrome were statistically significant. None of the group 3 patients had subjective or objective Frey syndrome. Two patients in group 1 and 3 patients in group 2 developed a transient seroma or sialocele that resolved with conservative management.

CONCLUSION

The use of AlloDerm graft as an interpositional barrier improves parotidectomy outcome by reducing the incidence of Frey syndrome.

The significance of the margin in parotid surgery for pleomorphic adenoma

OBJECTIVES/HYPOTHESIS

Superficial parotidectomy dramatically reduced the high rates of tumor recurrence that occurred with simple enucleation of parotid pleomorphic adenoma (PPA). However, there is not agreement in the medical literature confirming the exact margin of parotid tissue to be resected to avoid recurrence. Worldwide, SP and/or partial superficial parotidectomy (PSP) is commonly practiced for the treatment of PPA. In Europe and Asia, reports covering a spectrum from total parotidectomy (TP) to extracapsular dissection (ECD) are common. The outcomes (capsular exposure, tumor-facial nerve interface, capsular rupture, recurrence, facial nerve dysfunction, and Frey syndrome) from surgical treatment of mobile, superficial PPA smaller than 4 cm are not significantly altered by surgical approach (TP, PSP, or ECD).

STUDY DESIGN

Retrospective series of pathological specimens were correlated with their clinical outcomes to compare TP, PSP, and ECD. Historical data review and meta-analysis were also performed.

METHODS

Matched pairs of 60 pathological specimens of PPA (20 cases treated by TP, PSP, and ECD, respectively) were compared for capsular exposure and the degree of cellularity of tumors. Statistical analysis of the respective rates of tumor-facial nerve interface, capsular rupture, recurrence, permanent and transient facial nerve dysfunction, and Frey syndrome was performed.

RESULTS

Focal capsular exposure occurs in virtually all parotid surgery for PPA, regardless of the type of operation (margin). Dissecting PPA from the facial nerve led to a positive margin in 25% of cases. Capsular rupture does result in a significantly higher rate of recurrence and did not vary among surgical approaches (TP, PSP, and ECD). Tumor-facial nerve interface did not vary significantly by surgical approach. A less complete parotidectomy did not result in a higher rate of recurrence. Less parotid tissue sacrifice did not result in a lower rate of permanent facial nerve dysfunction, although it did result in significantly less transient facial nerve dysfunction and Frey syndrome. Hypocellular tumors did not have a higher incidence of capsular rupture or recurrence. Multicentric PPA was not identified in the clinically negative deep lobe for TP specimens. The most common cause of recurrence for PPA today is enucleation.

CONCLUSIONS

The major outcomes of surgical treatment for small PPA (capsular exposure, tumor-facial nerve interface, capsular rupture, recurrence, and permanent facial nerve dysfunction) are not significantly altered by the amount of parotid tissue sacrifice (TP, PSP, or ECD). More complete parotidectomy results in higher rates of transient facial nerve dysfunction and Frey syndrome. Focal capsular exposure occurs in virtually all cases of parotid surgery for PPA. Dissecting PPA from the facial nerve results in cases with positive margins because of incomplete capsule or perforating pseudopodia. Few separations of pseudopodia from the main tumor occur with expertly performed contemporary parotid surgery because most of the PPA has a margin of normal parotid tissue. Minimal margin surgery in ECD is not recommended.

Increased botulinum toxin type A dosage is more effective in patients with 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.

The use of acellular dermis in the prevention of Frey's syndrome

EDUCATIONAL OBJECTIVE

At the conclusion of this presentation, the participant should be able to discuss the indications and advantages of using acellular dermis in the prevention of post-parotidectomy gustatory sweating (Frey's Syndrome).

INTRODUCTION

Gustatory sweating is a common postoperative problem and a challenge to treat. The purpose of this study was to evaluate the role of acellular dermis in preventing post-parotidectomy gustatory sweating.

METHODS

Sixty-four patients were randomly assigned to two groups. Group I consisted of 32 patients who underwent a superficial lobe parotidectomy. Group II consisted of 32 patients who underwent a superficial lobe parotidectomy and underwent intraoperative placement of acellular dermis within the parotid bed, between the skin flap and the remaining parotid tissue. The implanted volume of acellular dermis was determined by the amount required to aesthetically restore lateral facial contour. All 64 patients were evaluated for gustatory sweating by identical phone and mail questionnaires. Thirty randomly chosen patients (group I = 15, group II = 15) were evaluated using a modified Minor's Starch-Iodine Test (MSIT). In all 30 patients, the MSIT was administered to both sides of the face.

RESULTS

The responses to questionnaires (N = 64) demonstrated the subjective presence of gustatory sweating in 3 of 32 patients (9.3%) in group I, whereas group II demonstrated a subjective incidence in 1 of 32 patients (3.1%). The objective incidence determined by those who underwent the MSIT (n = 30) revealed a 40% (6) and 0% incidence of Frey's Syndrome in groups I and II, respectively. The complication rate in group I was 9% (3 seromas) and in group II it was 25% (7 seromas and 1 wound infection).

CONCLUSIONS

Acellular dermis appears to be an effective method for preventing post-parotidectomy gustatory sweating, despite its higher complication rate.

Botulinum toxin: basic science and clinical uses in otolaryngology

The role of botulinum toxin as a therapeutic agent is expanding rapidly in otolaryngology. Botulinum toxin is a protease that blocks the release of acetylcholine from nerve terminals. Its effects are transient and nondestructive, and largely limited to the area in which it is administered. These effects are also graded according to dose, allowing for individualized treatment of patients and disorders. Botulinum toxin has been used primarily to treat disorders of excessive or inappropriate muscle contraction. In the field of otolaryngology, these include spasmodic dysphonia, oromandibular dystonia, and blepharospasm; vocal tics and stuttering; cricopharyngeal achalasia; various tremors and tics; hemifacial spasm; temporomandibular joint disorders; and a number of cosmetic applications. Botulinum toxin treatment has recently begun to show some benefit in the control of pain from migraine and tension headache. It may also prove useful in the control of autonomic dysfunction, as in Frey syndrome, sialorrhea, and rhinorrhea. In over 20 years of use in humans, botulinum toxin has accumulated a considerable safety record, and in many cases represents relief for thousands of patients unaided by other therapy.