Delayed Frey syndrome after closed treatment of condylar fracture

Frey syndrome is also known as auriculotemporal syndrome and gustatory sweating. It is characterized by the occurrence of hyperesthesia, flushing, and warmth or sweating over the distribution of the auriculotemporal nerve and/or greater auricular nerve while eating foods that produce a strong salivary stimulus. It is commonly seen as a complication of parotidectomy and open surgery of temporomandibular joint. It can also be caused by other forms of trauma, including blunt trauma, but rarely does it occur without trauma. The relation between fracture displacement of the condyle and Frey syndrome adds further support to the view of the intimate anatomic relationship of the auriculotemporal nerve with the capsule of the temporomandibular joint. However, despite the proximity of these structures and the high incidence of condylar fracture (25%-36% of mandibular fractures), Frey syndrome is rare after this type of fracture. Symptoms are sometimes delayed and can be very slight; often neither the patient nor the surgeon realizes their presence. The symptoms usually appear 5 weeks to 1 year after nerve damage.In this clinical report, we presented the delayed occurrence of Frey syndrome in a patient in 6 years after closed reduction of condylar fracture. One prospective study and 11 case reports describing the development of Frey syndrome after closed treatment of mandibular condyle fractures were found in the last 4 decades. Our clinical report participates to literature as a 12th case report.     

腮腺良性肿瘤切除的改良术式

目的　探讨保留腮腺嚼肌筋膜、耳大神经和胸锁乳突肌瓣整复的改良腮腺切除术对术后并发症的预防效果。方法　226例腮腺良性肿瘤患者随机分为4组。1组:94例患者采用保留腮腺嚼肌筋膜的腮腺切除术式;2组: 42例患者采用保留筋膜加胸锁乳突肌瓣整复的术式;3组:57例患者采用传统的皮下瓣(不保留腮腺嚼肌筋膜);4 组:33例患者采用不保留筋膜加胸锁乳突肌瓣整复的术式。患者术后随访2年,每2月1次。通过Minor试验和主观感受,观察术后患者味觉出汗综合征的发生,评价患者耳垂麻木和耳垂区软组织凹陷情况。结果　味觉出汗综合征的发生率1组(5·32%)或2组(4·76%)与3组(49·1%)或4组(51·5%)间在主观感受上存在统计学差异(P< 0·005)。采用胸锁乳突肌瓣与否没有统计学差异(P>0·05)。微量淀粉碘试验检测示1组与3组或4组间有统计学差异(P<0·005)。味觉出汗综合征的症状持续时间在1组与3组或4组间有统计学差异(P<0·001)。1组和2 组或3组和4组间在防止耳垂凹陷上存在统计学差异(P<0·05);未采用胸锁乳突肌瓣的2组与4组间无统计学差异(P>0·05)。保留耳大神经后术区出现麻木症状较术前无明显改变。结论　腮腺切除术时保留腮腺嚼肌筋膜对预防味觉出汗综合征有显著效果。采用胸锁乳突肌瓣整复可以防止耳垂区的凹陷,取得较好的美学效果。保留耳大神经可预防术区感觉降低。     

Nerve injury in fractures of the condylar neck.

Although fractures of the condylar neck belong to the most frequent injuries of the jaws, and various nerves are found in close proximity to the temporomandibular joints, only little mention is made in the literature of neurological complications arising from accidents. We have therefore carried out a prospective study on nerve injuries in 237 fractures of the articular process in the period 1971-1975. We found two cases of post-traumatic Frey's syndrome, whereby the syndrome developed from a post-traumatic auriculotemporal neuralgia. We also found loss of function of auriculotemporal buccal and facial nerves, and loss of taste sensation of the tongue in another case, caused by damage to the chorda tympani. This paper discusses the formal and causal origin of the individual damages, and suggests possibilities for their management.     

Auriculo-temporal nerve. Clinicopathological relevance to facial-maxillary practice.

Anatomically, the auriculo-temporal nerve (ATN), a peripheral branch of the trigeminal nerve is in close relation to the parotid gland, neck of the mandible, temporal vessels, and sphenomandibular ligament. Fine branches of the ATN are at risk of division during surgical intervention of the parotid gland or condyle of the mandible. "Frey's syndrome", or abnormal gustatory sweating, may be a consequence of injury to the branches of the auriculo-temporal nerve. This uncommon syndrome can also occur with fractures of the temporo-mandibular joint (TMJ), due to the anatomic proximity of the nerve to the bone.     

脱细胞异体真皮基质预防腮腺切除术后味觉出汗综合征和面部凹陷的临床研究

目的评价脱细胞异体真皮基质(ADM)组织补片预防腮腺切除术后味觉出汗综合征和面部凹陷畸形的临床效果。方法将50例腮腺切除术的患者随机分成组织补片组和对照组,每组各25例。组织补片组腮腺切除术后在腮腺切除创面置入ADM组织补片,对照组行常规腮腺浅叶切除术。术后1年统计2组味觉出汗综合征的主观症状及客观测定阳性例数和患者对面部外形的满意例数。结果术后1年复查时组织补片组和对照组出现味觉出汗综合征主观症状的例数分别为1例和10例,客观测定阳性的例数分别为2例和16例,2组差异均有统计学意义(P<0.01);2组患者对面部外形的满意例数分别为22例和8例;差异有统计学意义(P<0.01)。结论ADM局部应用对预防腮腺术后味觉出汗综合征及面部凹陷畸形的发生有较好的作用。     

Fat injections for the management of post-parotidectomy Frey syndrome: A technical note

PurposeFrey syndrome (profuse sweating and cutaneous flushing in the area innervated by the auriculotemporal nerve) is a frequent and unpleasant complication of parotidectomy. Fat injections may be useful in preventing the abnormal nerve neo-anastomoses sprouting to the sweat glands that are responsible for gustatory sweating, but have never been used before.Material and methodsWe describe the use of fat injections into the parotid gland of four patients with post-parotidectomy Frey syndrome.ResultsAll of the patients experienced a clinical and subjective improvement, although slight sweating persisted. There were no untoward effects during the procedure and, in particular, no facial nerve impairment.ConclusionOn the basis of our experience minimally invasive fat injections can be considered in the case of post-parotidectomy Frey syndrome, but patients should be informed that subsequent procedures may be needed to achieve a definitive result.     

An assessment for auriculotemporal syndrome following temporomandibular joint surgery through the preauricular approach

Twenty temporomandibular joints (TMJs) were operated on for the correction of arthrographically confirmed internal derangements using a modified preauricular approach. Postoperatively, three of the 20 patients tested exhibited auriculotemporal syndrome as deduced from a starch-iodine test. The manifestation was subclinical and consisted of sweating only over the distribution of the auriculotemporal and great auricular nerves in response to a gustatory stimulus. The response was variable from patient to patient.     

Treatment of gustatory sweating with low-dose botulinum toxin A: a case report

Frey's syndrome, gustatory sweating in the preauricular area, is an unpleasant phenomenon occurring during meals after surgery on the parotid gland. Recently, botulinum toxin A (BTX) has been shown to reduce the symptoms, but the variation in the reported doses is large. OBJECTIVE: To quantify the effect of treatment with low-dose BTX in a case of Frey's syndrome over a period of 6 months. MATERIAL AND METHODS: A 56-year-old woman was treated with 10 U Botox given as 20 single, intracutaneous injections of 0.5 U, one for each cm(2), 3 years after resection of the parotid gland. Before treatment and repeatedly during the 6-month period, the sweating was rated subjectively on a 100-mm visual analog scale (VAS) and by a severity index, and objectively by assessment of the extent of the involved skin area using Minor's iodine-starch test, staining the area of sweating dark. RESULTS: The treatment decreased the involved area from 20 to 5 cm(2) and the VAS ratings from 98 to 8 mm. The index showed that treatment affected the sweating intensity, not the frequency. After the 6-month period the patient was still satisfied, but the involved skin area had increased; however, not entirely to pretreatment values. CONCLUSIONS: The effect of BTX injections for gustatory sweating obtained in this case was comparable to results reported using higher doses. Low doses of BTX can therefore be used in the treatment of Frey's syndrome, but studies to clarify the dose-response relationship, in terms of both time-course and obtained effect, are needed.     

The incidence of Frey's syndrome.

AIMS: The incidence of Frey's syndrome after parotidectomy greatly varies in the literature. The aim of this study was to analyse the incidence with the help of a new series of patients and to discuss and review the results. PATIENTS: 372 patients (age: 50.7+/-11.6 yrs) underwent unilateral parotidectomy. In 203 subjects the insertion of a sternocleidomastoideus flap in the parotid area was performed intraoperatively. METHODS: Patients were followed-up concerning the clinical presence of gustatory sweating and flushing after secretory stimulation, and were questioned about suffering in everyday life. RESULTS: 86 patients (23.5%) developed Frey's syndrome after an average of 12 months (12.3+/-9.9 months) following parotidectomy. Only 44% of the patients with Frey's syndrome were symptomatic. No benefit concerning Frey's syndrome following application of a sternocleidomastoideus flap was seen. CONCLUSION: Gustatory sweating after parotidectomy must still be regarded as an unpleasant and common complication. Nevertheless, it is more the subjective suffering of the patients than the incidence that makes prevention important.     

Atypical Frey syndrome as a complication of Obwegeser osteotomy

A patient with Frey syndrome on the left cheek area as a complication of an Obwegeser osteotomy is reported. Flushing, sweating of skin, and hypoesthesia of buccal mucosae were present 6 months after surgery. An injury to the auriculotemporal nerve during desperiostization of the posterior border of the mandibular ramus is believed to be the principal cause. The physiopathologic mechanism is thought to occur in relation to aberrant regeneration of the postganglionic secretomotor parasympathetic nerve fibers carried in this nerve. These regenerated fibers erroneously reach the sweat glands of the cheek skin through anastomosis with the buccal nerve and temporofacial ramus of the facial nerve. Direct injury of the buccal nerve may be another cause, because of its close anatomic course with the external pterygoid muscle and the mandibular ramus. An extensive literature review revealed no cases of this syndrome as a complication of Obwegeser osteotomy.     

Facial flushing in children: a variant of the auriculo-temporal syndrome.

Duphenix in 1757 has been credited with describing the first case of gustatory sweating which occurred after drainage of a parotid abscess. Later, Baillarger reported a case in which the sweating occurred on both sides because of bilateral parotitis. In 1923, Frey reported a case of gustatory sweating caused by an infected bullet wound of the parotid. She noted that the sweating coincided with the skin distribution of the auriculo-temporal nerve. Since her report, gustatory sweating has also been known as the "Auriculo-temporal Syndrome" or "Frey's Syndrome."     

Morbidity associated with removal of the submandibular gland.

Postoperative complications in 206 submandibular gland excisions, excluding those resulting from benign or malignant tumours, carried out during a 15-year period were reviewed. Most patients (62%) had sialolithiasis. Coexistence of sialolithiasis and nephrolithiasis was documented in 5.5% of cases. Early postoperative complications (particularly infection) developed in 14.6% of the cases, whereas late complications appeared in 25.3% of the cases (residual inflammation in Wharton's duct 7.3%). Neurological complications were observed in 16% of the cases. In 7 cases (3.4%) several nerves were involved and almost always the hypoglossal nerve. In 37.4% of the cases, these lesions resolved spontaneously in a mean period of 4 months. In those cases with a permanent neurological deficit, the facial nerve was the most often affected (7.7%) followed by the hypoglossal (2.9%) and the lingual nerve (1.4%). A single case of gustatory sweating (Frey's) syndrome was observed.     

Prospective randomised trial of the benefits of a sternocleidomastoid flap after superficial parotidectomy

Parotid surgery can cause postoperative facial nerve dysfunction, cosmetic impairment, and Frey's syndrome. Thirty-six patients listed for superficial parotidectomy were entered into a prospective randomised trial to find out if the use of a sternocleidomastoid flap could reduce the incidence of these complications. Partial facial nerve paresis was seen at 3 months in five patients in whom flaps were raised compared with six among those who did not have flaps (P=0.025). There was no difference between the two groups at 1 year. The flap was not associated with an improvement in either subjective (P=0.13) or objective (P=0.12) appearance measured on visual analogue scales. Eight patients in whom flaps were raised described symptoms suggestive of Frey's syndrome, compared with nine patients in whom a flap was not raised (P=0.31). Overall 19 of those who had a flap and 11 of those who did not had a positive starch-iodine test (P=0.21).     

改良腮腺良性肿瘤切除术21例报道

目的：对常规腮腺良性肿瘤切除术进行改进，使切口更加隐蔽，保护耳大神经，减少Frey’s综合征的发生，同时纠正术区凹陷。方法：采取改良除皱术切口，清晰显露解剖耳大神经；转移带蒂颞肌筋膜瓣充填术区缺损，并作为屏障阻断副交感神经与节后交感神经纤维互相吻合的途径。结果：21例接受改良手术的病人，皮肤切口隐藏良好，20例伤口一期愈合，随访6月—2年，无1例发生Frey’s综合征，术侧耳垂感觉完全恢复。结论：改良腮腺肿瘤手术既能彻底摘除肿瘤，又可防止术后局部凹陷畸形和Frey’s综合征的发生，值得推广应用。     

Use of a porcine dermal collagen graft (Permacol) in parotid surgery

Our aim was to present the results of the use of porcine dermal collagen graft (Permacol) in the prevention of Frey's syndrome and face-contouring aesthetic deformities after operations on the parotid. We treated 19 patients with parotid tumours. After resection, a Permacol sheet was applied to the perimeter of the tissue deficit so that it was fully covered, and was sutured firmly. This technique produced satisfactory aesthetic results with good facial contouring in all patients. It also protected the exposed parotid nerve plexus, and none of the patients developed Frey's syndrome. Permacol produced good results in both postoperative facial contouring and prevention of Frey's syndrome.     

Temporoparietal fascia flaps and superficial musculoaponeurotic system plication in parotid surgery reduces Frey's syndrome.

PURPOSE: The purpose of this retrospective study was to evaluate the incidence of Frey's syndrome after parotid gland surgery with elevation of a skin flap versus the interposition of musculoaponeurotic tissue between the skin and the facial nerve. MATERIALS AND METHODS: The standard skin flap was used in 122 patients (1981 to 1989), whereas interposition of temporoparietal galea or superficial musculoaponeurotic system was performed in 146 consecutive patients (1989 to 1998). RESULTS: The incidence of Frey's syndrome was reduced from 33% to 4% with the use of a musculoaponeurotic layer, and the mean duration of postoperative facial nerve paresis decreased from 3 months to 6 weeks. CONCLUSIONS: Consideration should be given to the use of an interpositional layer of tissue between the facial nerve and the skin flap to reduce the incidence of Frey's syndrome after parotid gland surgery.     

Parotidectomy: assessment of a surgical technique including facelift incision and SMAS advancement.

BACKGROUND: Despite its proven safety and its relevance regarding the cosmetic outcome, the SMAS-lifting technique is not a routine procedure for many surgeons. AIM: To compare the classical (subcutaneous flap and neck incision) with the SMAS-lifting techniques for parotidectomies from the patient's perspective. PATIENTS AND METHODS: Both procedures are described, tricks are pointed out. In both procedures the posterior branch of the great auricular nerve was not preserved, hence the two procedures were not evaluated regarding sensitivity of the auricle and preauricular area. Forty consecutive patients were asked to classify their concerns before (1-4 months) and 1 year after surgery (10 classical technique and 30 SMAS-lifting technique). RESULT: Before parotidectomy, patients were concerned in a decreasing order with the facial nerve function, the scar, the soft-tissue defect in the dorsal part of the cheek and Frey's syndrome. Following use of the classical technique, patients were concerned in decreasing order with the soft-tissue defect, the scar and Frey's syndrome. Following the SMAS technique, no one was concerned with the scar, Frey's syndrome, or the soft tissue defect although a slight asymmetry could still be noticed. CONCLUSION: The SMAS-lifting technique might possibly appear to offer a new standard procedure for parotidectomy, except for malignant tumours or in obese patients.     

腮腺良性肿瘤改良术式的临床探讨

目的:探讨腮腺良性肿瘤改良术式的临床效果及其合理性.方法:110例患者随机分为2组,一组行保留腮腺咬肌筋膜、保留耳大神经分支和腮腺部分切除术的腮腺良性肿瘤改良术式,另一组行传统腮腺浅叶或全叶切除术;术后随访2a.记录手术出血量、手术时间,临床检查暂时性面瘫和术后肿瘤复发,行Minor试验,问卷调查味觉出汗综合征发生率、耳垂区感觉及面部畸形情况.采用SPSS10.0软件包对数据进行t检验或X2检验.结果:2组对比,腮腺良性肿瘤改良术式的出血量和手术时间显著低于传统腮腺浅叶切除术,术后暂时性面瘫、涎瘘和术后肿瘤复发率2组无显著差异.2组味觉出汗综合征的发生率,问卷调查和微量淀粉碘试验结果,均有统计学差异(P<0.05);保留耳大神经后支,耳垂区麻木症状发生率明显降低.结论:腮腺良性肿瘤改良术式可以减少手术出血量,缩短手术时间,显著减少味觉出汗综合征、耳垂区感觉障碍的发生率,患者术后面部畸形也获得良好改善.     

腮腺区良性肿瘤术后并发症发生的相关因素分析

目的： 探讨腮腺良性肿瘤术后各类并发症发生的相关因素。方法：搜集并整理我院2010—2015年手术治疗的215例腮腺良性肿瘤患者的病例资料,回顾分析一般资料、手术治疗中不同因素及术后并发症的发生情况。采用SPSS17.0软件包对资料进行χ2检验。结果：术后积涎或涎瘘、面神经功能障碍及Frey综合征的发生与手术治疗中不同因素（手术切口、术中是否缝扎腺体残端、面神经解剖方式、手术切除范围及是否行胸锁乳突肌瓣转移修复等）之间具有显著相关性（P＜0.05）。结论：“N”形切口在解剖形态上不利于术后常规引流渗出液,需配合负压引流管,以减少术后积涎的发生。缝扎腺体残端能有效避免术后积涎及涎瘘的发生。顺行法解剖面神经及腮腺肿瘤区域性切除能加快手术速度,减少面神经的解剖量及暴露时间,从而减轻术后面神经功能障碍的发生。胸锁乳突肌瓣的转移修复能很好避免术后Frey综合征的发生。     

SMAS及胸锁乳突肌瓣在腮腺肿瘤外科中的应用

目的评价面部表浅肌肉筋膜系统(Superficial Musculoaponeurotic System,SMAS)及胸锁乳突肌瓣在腮腺肿瘤外科中应用的临床价值。方法 43例腮腺肿瘤患者,随机分为2组,术中均采用保留面神经和耳大神经,实验组肿瘤切除后以SMAS及胸锁乳突肌瓣覆盖填塞缺损术区,对照组直接关闭创口。结果两组患者均达临床Ⅰ期愈合,无涎瘘发生。实验组Frey's综合征发生率及面部凹陷畸形满意度均低于对照组(P<0.05)。结论将SMAS及胸锁乳突肌瓣应用于腮腺肿瘤外科中,有效抑制了Frey's综合征发生率,且远期美容效果较好,具有较高临床应用价值。