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31Aesthetic Medicine • April 2016

CASE FILES www.aestheticmed.co.uk

Dr Patrick Treacy shares some of his most challenging cases. This month he talks about treating post endoscopic thoracic sympathectomy “gustatory sweating” with botulinum toxin A

Dr Treacy’sCASEBOOK

A47-year-old English patient presented with redness and sweating on the forehead and temporal area and in the lateral neck and décolletage area bilaterally. The symptoms appeared whenever he ate, saw or thought about

certain foods, especially spicy foods such as chorizo. He also had mild discharge from the nose when smelling certain food. The symptoms started after the patient underwent an endoscopic thoracic sympathectomy 16 years before. This is a surgical procedure wherein part of the sympathetic trunk is cut or clamped to treat sweating of the hands or blushing. As a result of severance and inappropriate regeneration, the parasympathetic nerve fibres may switch course, resulting in “gustatory sweating” or sweating in the anticipation of eating, instead of the normal salivatory response.

Frey’s syndrome is a rare disorder, the symptoms of which include sweating, flushing and warming over the frontalis, preauricular, temporal areas and neck area following a gustatory stimulus. It often occurs in patients who have undergone parotidectomy, submandibular gland surgery, radical neck dissection or endoscopic thoracic sympathectomy. It is caused by the aberrant regrowth of facial autonomic nerve fibres.

TREATMENTCurrently there are several options used to treat patients with Frey’s syndrome; for example, the topical application of anticholinergics and anti-perspirants, and the intradermal injection of botulinum toxin. The options include:

Topical anti-perspirant (20% aluminum chloride solution) Application of an ointment containing an anti-cholinergic drug such as 3% scopolamine, 2% glycopyrolate or diphemanil methylsulphate

Topical application of an adrenoceptor agonist (clonidine) Blockage of parasympathetic outflow by way of alcohol injection or 2% lignocaine injections at various sites such as the otic ganglion & the auriculotemporal nerve

Botox (patients who are unresponsive to topical therapy may want to consider a trial of botox before

considering surgical options)Many publications say it is uncertain which

treatment is most effective and safe.1 However, the author like many other

physicians has found that Botox A injection is a safe and effective treatment with long-lasting effects for patients with extensive gustatory sweating.2,3

DIAGNOSIS Diagnosis is made based on clinical

signs and symptoms and a test, called the Minor Iodine-Starch test. The

affected area of the face is painted with iodine which is allowed to dry, then dry corn

starch is applied to the face. The starch turns blue on exposure to iodine in the presence of sweat.4

METHODInjection dosage of 3 MU/cm2 of botulinum toxin A into the areas testing positive as a result of the Minor Iodine-Starch test.

CONCLUSION Frey’s syndrome or gustatory sweating was first described by Baillarger in 1853. Lucie Frey had described a patient as “auriculotemporal syndrome” in 1923. The explanation >

Frey’s syndrome is a rare disorder, the symptoms

of which include sweating, flushing and warming over the frontalis, preauricular, temporal areas and neck area following

a gustatory stimulus

32 Aesthetic Medicine • April 2016

CASE FILES www.aestheticmed.co.uk

S K I N / D E R M AT O L O G Y

Please advise on captions

>> Dr Patrick Treacy is CEO Ailesbury Clinics, chairman of the Irish Association of Cosmetic Doctors and Irish regional representative of the British College of Aesthetic Medicine (BCAM). He is also president of the World Trichology Association. Dr Treacy has won a number of awards for his contributions to facial aesthetics and hair transplants including the AMEC Award in Paris in 2014. Dr Treacy also sits on the editorial boards of three international journals and features regularly on international television and radio programmes. He is on the scientific committee for AMWC Monaco 2015, AMWC Eastern Europe 2015, AMWC Latin America 2015, RSM ICG7 (London) and Faculty IMCAS Paris 2015 and IMCAS China 2015.

REFERENCES 1. Cochrane Database Syst Rev. 2015 Mar 17;3:CD009959. doi: 10.1002/14651858.

CD009959.pub2. Interventions for the treatment of Frey’s syndrome. Li C1, Wu F, Zhang Q, Gao Q, Shi Z, Li L.

2. Mund Kiefer Gesichtschir. 2004 Nov;8(6):369-75. Epub 2004 Oct 29. [Botulinum toxin for treatment of gustatory sweating. A prospective randomized study].

3. Head Neck. 2003 Aug;25(8):624-8. Treatment of gustatory sweating (Frey’s syndrome) with botulinum toxin A. Eckardt A1, Kuettner C.

4. Choi, Hyo Geun; Kwon, Sae Young; Won, Jung Youn; Yoo, Seung Woo; Lee, Min Gu; Kim, Si Whan; Park, Bumjung (2013). “Comparisons of Three Indicators for Frey’s Syndrome: Subjective Symptoms, Minor’s Starch Iodine Test, and Infrared Thermography”. Clinical and Experimental Otorhinolaryngology 6 (4): 249. doi:10.3342/ceo.2013.6.4.249. ISSN 1976-8710. Ann Vasc Surg. 2013 May;27(4):447-53. doi: 10.1016/j.avsg.2012.05.026. Epub 2013 Feb 11.

5. Clin Auton Res. 2008 Apr;18(2):80-3. doi: 10.1007/s10286-008-0460-5. Results, side effects and complications after thoracoscopic sympathetic block by clamping. The monza clinical experience. Sciuchetti JF1, Corti F, Ballabio D, Angeli MC.

6. Technical difficulties and complications of sympathectomy in the treatment of hyperhidrosis: an analysis of 1731 cases. de Andrade Filho LO1, Kuzniec S, Wolosker N, Yazbek G, Kauffman P, Milanez de Campos JR.

7. J Med Assoc Thai. 2007 Nov;90(11):2397-402. Treatment of Frey’s syndrome with botulinum toxin. Pomprasit M1, Chintrakarn C.

for this symptom has been an aberrant regeneration of cholinergic parasympathetic fibres, which regenerate and anastomosis with postganglionic sympathetic fibres that supply vessels and sweat glands of the skin. However, the symptom is being seen more commonly post endoscopic thoracic sympathectomy used for blushing or hyperhidrosis.5 This has led to a modified technique using endoclips where major complications are compensatory sweating (22%) Horner’s syndrome (1%) pneumothorax (3%) and no cases of gustatory sweating were reported.6

This patient had a complete resolution and confirms intracutaneous injection of botulinum toxin A represents a highly effective and minimally invasive procedure for the treatment of Frey’s syndrome. Studies show that a dosage of 3 MU/cm2 of botulinum toxin A achieves a complete and reliable blockade of gustatory sweating lasting for at least 12 months.7 AM

Proposed mechanism of Frey syndrome.

Treatment Algorithm for Frey’s Syndrome

Gustatory Hyperhidrosis (Frey’s Syndrome)

Topical anti-perspirant therapy )aluminum chloride hexahydrate) Pay special attention to correct application time/technique and education re. avoiding side effects.

Good response: repeat p.r.n.

No response or patient requests

botullinum toxin A injections

Consider systemic meds:1. Anticholinergics (propantheline, oxybutynin, glycopyrronium, benztropine) 2. Benzodiazepines (short course, as needed) 3. Diltiazem 4. Clonidine 5.Others

No response or patient requests