Lucja Frey--historical relevance and syndrome review

A Case Report of Early-Onset Frey's Syndrome in an Infant

The appearance of flushing in the territory of the auriculotemporal nerve after ingestion of foods with a sweet, salty, or sour flavor could suggest Frey's syndrome, especially if the infant has a history of obstetric trauma. This rare and benign condition requires no diagnostic exploration or treatment. A 3-month-old male infant presented with facial flushing since he was 6 weeks' old. Episodes of flushing were stereotypical, over the zone innervated by the left auriculotemporal nerve. They started 10 to 15 seconds after the beginning of the feeding and disappeared after 15 to 20 minutes. At the time of the onset of facial erythema, the infant was exclusively bottle feeding. Diagnosis of Frey's syndrome was made on historical and clinical grounds, and no further testing was needed. Flushing gradually started to fade at the age of 5 months and completely disappeared after 8 months. Introducing solid food did not cause any deterioration of facial erythema. Early recognition of Frey's syndrome is important to avoid unnecessary investigation and therapy. On the other hand, our reported case warns that Frey's syndrome may occur in very early infancy without ingestion of solid food.

Meta-Analysis to Evaluate the Efficacy of Sternocleidomastoid Muscle Flap as a Reconstruction Modality in Prevention of Frey's Syndrome Following Parotidectomy

BACKGROUND

One of the commonest complications following parotidectomy is Frey's syndrome (FS). The use of sternocleidomastoid muscle (SCM) flap to prevent FS is controversial. Hence, this study has been designed to compare the effect of SCM flap with no reconstruction in prevention of FS following parotidectomy.

METHODOLOGY

An exhaustive literature search was conducted in July 2019. Studies focusing on sternocleidomastoid flap following parotidectomy were included in the meta-analysis. A random effects model was used to generate pooled estimates. Odds ratio with a 95% confidence interval was calculated for subjective symptoms and objective test.

RESULTS

A total of 125 studies were identified, out of which 17 studies were recruited in the meta-analysis. Sixteen studies were analyzed for the subjective symptoms, and ten were analyzed for the objective signs. There was no statistically significant difference in the occurrence of FS with the use of SCM flap on objective analysis. However, the subjective analysis showed a statistically significant reduction in FS following reconstruction with SCM flap after parotidectomy.

CONCLUSION

The present meta-analysis suggests that the use of SCM flap following parotidectomy has no effect in reducing the incidence of Frey's syndrome.

Frey's syndrome: A review of the physiology and possible role of neurotrophic factors

OBJECTIVES

Frey's syndrome (FS) describes the phenomenon of gustatory sweating and is a cause of significant social embarrassment for sufferers. It has been attributed to aberrant growth of parasympathetic salivatory fibers in the auriculotemporal nerve toward overlying sweat glands. However, the exact mechanism behind this growth is unknown. This review aims to expand and elucidate the theory of aberrant regeneration in FS.

METHODS

A review of the recent literature on nerve regeneration was conducted in order develop further insights into the etiology of both adult onset and pediatric FS.

RESULTS

Neurturin, a neurotrophic factor released by both salivary and sweat glands, was identified as a possible key player in the etiology of FS.

CONCLUSION

Further research into the role of neurturin could help to elucidate the pathogenic mechanisms underlying the condition and might reveal neurturin to be a potential target for pharmacological intervention.

LEVEL OF EVIDENCE

NA (Basic Science Review).

What is the best method for prevention of postparotidectomy Frey syndrome? Network meta-analysis

BACKGROUND

Prevention of Frey syndrome (FS) after parotidectomy using an interposition barrier has long been gaining a wide popularity; however, there is no clear evidence regarding which preventive technique is more effective. The aim of this network meta-analysis (NMA) is to answer the question: What is the best method for prevention of FS after parotidectomy?

METHODS

A comprehensive search of the PubMed, Embase, SCOPUS, and Cochrane library was conducted to identify the eligible studies. The outcome was the incidence of subjective Frey syndrome (SFS) and objective Frey syndrome (OFS). The Bayesian NMA accompanied with a random effects model and 95% credible intervals (CrIs) were calculated using GeMTC R package.

RESULTS

Thirty-four studies (n = 2987 patients) with five interventions, namely Alloderm (ADM), temporoparietal fascia (TPF), sternocleidomastoid muscle (SCM), superficial musculoaponeurotic system (SMAS), and free fat graft (FFG), were compared together and with no interposition barrier (NB). The results of NMA showed a statistically significant reduction in both SFS and OFS when ADM, TPF, SMAS, FFG, and SCM were compared with NB. No statistical differences were observed when comparing ADM, SCM, SMAS, FFG, and TPF. TPF ranked the best of all treatments (59.4%) and was associated with the least incidence of SFS; whereas ADM ranked the best of all treatments (61.1%) and was associated with the least incidence of OFS.

CONCLUSIONS

All interventions (TPF flap, ADM, FFG, SMAS, and SCM) were associated with a significant reduction in the incidence of FS when compared with NB. TPF and ADM showed the best outcome with the least incidence of SFS and OFS, respectively.

Prospective outcomes following drainless superficial parotidectomy with sternocleidomastoid flap reconstruction

Background

Patients undergoing superficial parotidectomy for benign parotid lesions are at risk of postoperative complications, most notably cosmetic complications such as facial paralysis and contour defects, and functional complications including Frey’s syndrome. Traditionally, surgical drains have been placed at the end of surgery to prevent hematoma and sialocele formation. However, this can increase the risk of postoperative complications and contribute to a prolonged course in hospital. To try and prevent these risks and complications, we introduced a novel technique of a drainless parotidectomy by reconstructing the resulting parotid bed defect with a superiorly based sternocleidomastoid (SCM) rotational flap and by placement of gelfoam into the wound bed and a facelift dressing postoperatively to provide additional hemostasis and avoid drain placement.

Methods

All patients with benign parotid disease undergoing a drainless superficial parotidectomy and reconstruction with a superiorly based SCM rotational flap at our center were identified within a prospective cohort database between July 2010–2018. Primary outcomes included postoperative cosmetic and functional outcomes, complications and length of hospital stay. A secondary cost analysis was done to compare this novel technique to traditional superficial parotidectomy with surgical drain placement.

Results

Fifty patients were identified within the database and were included in the final analysis. The average length of hospital stay was 1.02 days. All patients were satisfied with their aesthetic outcome at 1 year. During long term follow-up, 63% of patients reported normal appearance of the operated side. Seven patient’s (14%) developed temporary facial paresis following surgery. All patients had resultant normal facial function at follow-up in 1 year. No patients developed subjective Frey’s Syndrome. Two patients (4%) developed a postoperative sialocele requiring drainage and one patient (2%) developed a hematoma on extubation requiring evacuation and drain placement. Cost analysis demonstrated a cost savings of approximately $975 per person following surgery.

Conclusion

In the current study, we introduced a novel approach of a drainless superficial parotidectomy using a superiorly based SCM flap, gelfoam and placement of a post-operative facelift dressing. This drainless approach was associated with good long-term cosmetic and functional outcomes with few postoperative complications. This new technique may also offer the potential for long-term savings to the health care system.

Autonomic Cross-Innervation in Patients With Neurofibromatosis Type 2: Frey Syndrome and Unilateral Epiphora With Rhinorrhea

The authors present 2 cases of cross-innervation in patients with neurofibromatosis type 2. In the first case, an iodine test was performed to demonstrate Frey syndrome in a 28-year-old female with neurofibromatosis type 2 who developed symptoms at age 10 years. The second patient is an 18-year-old female with neurofibromatosis type 2, 2 years status post left vestibular schwannoma subtotal resection who presented with paradoxical unilateral lacrimation and rhinorrhea triggered by heat stress and exercise. The pathophysiology of these cases is discussed.

Graft interposition for preventing Frey's syndrome in patients undergoing parotidectomy

BACKGROUND

Frey's syndrome is characterised by transient flushing and sometimes facial sweating in the area of the auriculotemporal nerve. It most commonly occurs after parotidectomy, but other causes may include submandibular gland surgery, mandibular condylar fracture, obstetric (forceps) trauma, sympathectomy and metabolic disease. Although the pathophysiology of Frey's syndrome remains controversial, the generally accepted hypothesis is that it occurs as the result of injury to the auriculotemporal nerve.There is currently no clear evidence to establish the efficacy and safety of the different methods used for the treatment of Frey's syndrome, therefore the prevention of this symptom during surgery is important. The main method used for prevention is the interposition of a graft between the skin flap and the parotid bed during surgery. Biomaterials, allograft or autograft can be used for this purpose.

OBJECTIVES

To evaluate the effects and safety of biomaterial, allograft or autograft interposition for the prevention of Frey's syndrome in patients undergoing parotidectomy, and to identify its effect on prevention and delayed occurrence.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Cochrane Register of Controlled Trials (CENTRAL; 2019, Issue 2); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 5 February 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in patients with parotid disease (including tumours, inflammation, trauma etc.) undergoing parotidectomy with a minimal follow-up period of six months. We planned to include trials with interventions including biomaterial, allograft or autograft interposition alone or in combination with other surgical techniques. We included trials that compared any graft interposition and no graft interposition, or different graft interpositions.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcome measures were incidence rate of Frey's syndrome assessed clinically (Minor's starch-iodine test) and other complications (postoperative infection, subjective painful or restricted cervical movement, scar spread, rejection of the graft, complications related to the donor site such as accessory nerve injury and haematoma). Our secondary outcome measures were incidence rate of Frey's syndrome assessed by participants (by questionnaire) and sweating area assessed by Minor's starch-iodine test. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included three RCTs (124 participants), two of which we assessed as at high risk of bias and one at unclear risk of bias. All studies were hospital-based and recruited participants undergoing superficial parotidectomy. Most participants were diagnosed with benign lesions of the parotid gland. Participants were followed up for more than six months. The studies evaluated the two comparisons shown below:Sternocleidomastoid muscle flap versus no flapTwo studies assessed this comparison. Both assessed the effects of the sternocleidomastoid muscle flap procedure on the incidence rate of Frey's syndrome assessed clinically but neither showed a significant difference between groups (risk ratio (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.23; 24 participants and RR 1.23, 95% CI 0.88 to 1.73; 36 participants; very low-certainty evidence). We did not pool the data due to the high heterogeneity (I² = 87%).One study found that the sternocleidomastoid muscle flap may result in little or no difference in other complications including haematoma (RR 2.18, 95% CI 0.09 to 50.16; 36 participants; low-certainty evidence), subjective painful or restricted cervical movement (RR 0.54, 95% CI 0.14 to 2.05; 36 participants; low-certainty evidence) and scar spread in the cervical region (RR 0.71, 95% CI 0.05 to 10.54; 36 participants; low-certainty evidence). Both studies reported the incidence rate of Frey's syndrome assessed by participants, with one reporting no events in either group and the other finding no evidence of a difference (RR 0.63, 95% CI 0.32 to 1.26; 36 participants; low-certainty evidence).Acellular dermal matrix versus no graftOnly one study assessed this comparison. Use of an acellular dermal matrix graft may result in little or no difference to the incidence rate of Frey's syndrome (assessed clinically) in comparison with the no graft group, but the evidence is very uncertain (RR 0.08, 95% CI 0.00 to 1.25; 30 participants; very low-certainty evidence).Acellular dermal matrix may slightly increase the wound infection rate compared with control (RR 17.00, 95% CI 1.02 to 282.67; 64 participants; low-certainty evidence). Acellular dermal matrix may result in little or no difference to the incidence of seromas or sialoceles (RR 2.33, 95% CI 0.66 to 8.23; 64 participants; low-certainty evidence). Acellular dermal matrix may result in little or no difference to the incidence rate of Frey's syndrome (assessed by participants) in comparison with the no graft group (RR 0.33, 95% CI 0.04 to 3.04; 64 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

The evidence for the effectiveness of graft interposition in preventing Frey's syndrome is of low or very low certainty. The use of acellular dermal matrix may be associated with an increase in the wound infection rate, and little or no difference in the incidence of seromas or sialoceles. Further studies are needed to draw reliable conclusions.

Frey's syndrome after superficial parotidectomy: role of the sternocleidomastoid muscle flap: a prospective nonrandomized controlled trial

BACKGROUND

The prevalence of Frey's syndrome (FS) after superficial parotidectomy in correlation to the sternocleidomastoid muscle flap (SCMMF) interposition is analyzed.

METHODS

A prospective nonrandomized controlled multicenter trial included 130 patients. During superficial parotidectomy, SCMMF was dissected, if excised specimens' volume exceeded 25 mL (SCMMF group). Follow-up examinations took place after 6, 12, and 24 months and included a Minor's test.

RESULTS

SCMMF was dissected in 30 (23.1%) patients. A total of 104, 80, and 68 patients completed the 1st, 2nd, and the 3rd follow-up, respectively. FS was detectable with nonvarying prevalence (46.3%, 45.6%, and 43.4%, respectively) during follow-up. The prevalence was higher in the SCMMF group (59.9%) than in the non-SCMMF group (41.8%; P = .92). The sweating area increased during follow-up (P = .12). Overall, 89.5% of patients characterized FS as not disturbing after 2 years.

CONCLUSIONS

FS occurred with a steady and high prevalence after superficial parotidectomy. In particular, SCMMF did not lower the risk of FS.

Lucja Frey (1889–1942): life destroyed by the Holocaust--on the 70th anniversary of her death

Lucja Frey was the first to explain the pathogenesis of the auriculotemporal syndrome, and the syndrome is recognized today as the Frey syndrome. Patients with this disease are subjected to paroxysmal paraesthesia of half of the face combined with sweating and redness. This syndrome can be found in the differential diagnosis of contemporary dermatology. Among others, it is differentiated from food allergies. The life and scientific career of Lucja Frey was brutally interrupted by the tragic times of the Holocaust.

Frey syndrome in neurofibromatosis 1

A healthy 18-month-old girl presented with a history of intermittent hemifacial flushing when eating. Her symptom seemed to be exclusively triggered by chewing. Examination revealed cutaneous features of neurofibromatosis type 1 (NF1) and mild facial asymmetry. Imaging confirmed cerebral vacuolisation changes seen in NF1 and a left facial plexiform neurofibroma involving the parotid gland. This is the first reported case of Frey syndrome complicating NF1.

Gustatory itching: an unusual complication following superficial parotidectomy

OBJECTIVE

We report the previously undocumented complication of gustatory itching following superficial parotidectomy.

METHOD

Case report and review of the English literature concerning Frey's syndrome, complications of superficial parotidectomy and the pathophysiology of itching.

RESULTS

A 49-year-old woman developed gustatory itching following a superficial parotidectomy. Her symptoms were satisfactorily managed with topical and oral antihistamine preparations. We propose a neurophysiological pathway involving acetylcholine and histamine to explain this phenomenon.

CONCLUSION

To our knowledge, this is the first documented case of gustatory itching following superficial parotidectomy. The use of antihistamine preparations appears to effectively manage this symptom, without the need for invasive procedures.

Marathon of eponyms: 6 Frey syndrome (Gustatory sweating)

The use of eponyms has long been contentious, but many remain in common use, as discussed elsewhere (Editorial: Oral Diseases. 2009: 15; 185). The use of eponyms in diseases of the head and neck is found mainly in specialties dealing with medically compromised individuals (paediatric dentistry, special care dentistry, oral and maxillofacial medicine, oral and maxillofacial pathology, oral and maxillofacial radiology and oral and maxillofacial surgery) and particularly by hospital-centred practitioners. This series has selected some of the more recognized relevant eponymous conditions and presents them alphabetically. The information is based largely on data available from MEDLINE and a number of internet websites as noted below: the authors would welcome any corrections. This document summarizes data about Frey' syndrome.