Management of Frey's syndrome and hypersialorrhea with botulinum toxin

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of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; ICTRP and additional sources for published and unpublished trials.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.

Stensen's duct injuries: the role of sialendoscopy and adjuvant botulinum toxin injection

INTRODUCTION

Stensen's duct injuries are uncommon but troublesome sequelae of facial surgery or other external traumas.

AIM

To investigate the feasibility of sialendoscopic control of Stensen's duct in iatrogenic injuries and the efficiency of botulinum toxin adjuvant therapy.

MATERIAL AND METHODS

In 2008 and 2010, 5 patients with parotid sialoceles or fistulas, infrequent complications after plastic surgery or trauma, were treated in a single institution, Poznan University of Medical Sciences ENT Department. The group consisted of 5 patients with diagnosed Stensen's duct injuries, which were post-surgery and post-traumatic sequelae. All were treated by means of open surgery. Botulinum toxin injection was administered during the procedure to decrease the saliva secretion and to improve the healing process. A sialendoscopy was performed to control the lumen of the junction after the duct injury was repaired.

RESULTS

Complete healing of the fistulas and sialoceles after the reparative surgery followed by a single botulinum toxin application was observed in all patients within 10-14 days. No side effects were noticed.

CONCLUSIONS

Our findings suggest that sialendoscopy is a valuable tool and an important step of control in the surgery of parotid duct injuries and the injection of botulinum toxin is an effective and safe second-line treatment.

Treatment of Frey's syndrome with botulinum toxin type B

OBJECTIVE

Frey's syndrome is a frequent sequela of parotidectomy, causing facial sweating and flushing because of gustatory stimuli. Although botulinum toxin type A has become first-line therapy for Frey's syndrome, some patients become resistant. In this study, we investigated whether another serotype, botulinum toxin type B, might be an effective alternative.

STUDY DESIGN

Case series with planned data collection.

SETTING

Otolaryngology department in a university hospital.

SUBJECTS AND METHODS

Seven patients aged 30 to 68 years, with severe Frey's syndrome, underwent the Minor test and had 80 U of botulinum toxin type B per cm(2) (mean total dose, 2354 U) injected intracutaneously in the mapped area of gustatory sweating. All patients were followed up for 12 months.

RESULTS

One month after treatment, six of the seven patients reported that gustatory sweating and flushing had resolved, and, in the remaining patient, these symptoms had decreased. The Minor test confirmed a significant improvement. The subjective benefits remained stable for six months in four patients and for nine months in the remaining three patients; 12 months after treatment, all patients still reported some improvement.

CONCLUSION

Botulinum toxin type B afforded symptomatic relief in a small sample of patients with Frey's syndrome and might be considered a potential alternative to botulinum toxin type A.

Zur Diagnostik und Behandlung von Parotistumoren

BACKGROUND

It seems that the choice of the treatment modalities for parotid gland tumors frequently depends on personal experience more than on evidence-based criteria. A nationwide survey was conducted to obtain an overview of current practice in German ENT hospitals.

METHODS

A standardised questionnaire comprising 19 questions on the treatment and diagnostic methods for parotid gland tumors was sent to all ENT hospitals in Germany.

RESULTS

The overall return rate of the questionnaires was 128 of 170 (75%). The results confirmed highly variable strategies for the treatment of parotid gland tumors in Germany.

CONCLUSION

On the basis of our survey and the upcoming establishment of a German database for salivary gland cancer in Erlangen, Germany, we hope to be able to clarify controversial topics on the treatment of parotid gland tumors in the near future.