laskawi 1999 journal of oral and maxillofacial surgery

8/6/2019 Laskawi 1999 Journal of Oral and Maxillofacial Surgery

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J Oral Maxillofac Surg57:642-648,1999

Gustatory Sweating: Clinical Implicationsand Etiologic AspectsRainer Laskawi, MD, * Maik E&es, MD, f Ra@b Rddel, MD,+

and Claudia Schoenebeck, MDJPurpose: It was the aim of this study to provide detailed general information on the clin ica l picture ofdifferent kinds of gustatory sweating, including reevaluation of a series of patients who underwentparotidectomy, removal of the submandibular gland, or neck dissec tion.Patients and Methods : This study summarizes the statements of 548 patients questioned about theoccurrence of gustatory sweating after parotidectomy (n = 296), extirpation of the submandibular gland(n = 79), and neck dissection (n = 173).Results : After parotidectomy, 45% of the patients had noticed gustatory sweating. In most of them(70%), the symptoms began within 6 months after surgery. Gustatory sweating developed in only onepatient with submandibular extirpation (1.5%), and not at all after neck dissection. Most patients (52%)reported that the symptoms occurred independent of the kind of food ingested. These resul ts show thatthe masticatory component is an important trigger for Freys syndrome. Application of Minors testloca lized gustatory sweating mainly in the region of previous parotid lobe removal, but also in other areasderiving their sensory supply from the auriculotemporal, greater auricular, and lesser occipital nerves.The size of the area affected by the sweating was similar after latera l and total parotidectomy. Whenevaluating cliical symptoms, subjective assessment by the patients seemed to play a major role. Aftersubmandibular extirpation and neck dissec tion, some patients reported gustatory sweating that was notverified by Minors test.Conclusion: There is general agreement that the cause of gustatory sweating is sympathetic orparasympathetic innervation of previously denervated sweat glands, initiated by gustatory triggers. Thelocation of the erroneous innervation depends on the type of lesion. In cases after parotidectomy,misdirected parasympathetic regeneration is the model integrating all known factors into a rationalconcept. For didactic and systematic-pragmatic reasons, a clinically oriented classification of gustatorysweating (types I to III) seems to be useful.

The surgeon is confronted with gustatory sweatingmain ly after parotid gland surgery, most notablyparotidectomy. la2 t is widely assumed that this findingis caused by parasympathetic fibers regenerating aftera lesion and, in the process of resprouting, makingcontact with sweat glands of the skin that are normallyinnervated by sympathetic fibers.J As a consequence,

Received from the Department of Otolaryngology, Head and NeckSurgery, University of Gijttingen, GBttingen, Germany.

*Assistant Medical Director.tResident.*Resident.BDentist.Address correspondence and reprint requests to Dr Iaskawi:

UniversitW-HNO-Klinii, Robert-Koch-%, 40, D-37075 G(ittingen,Germany.o 1999 Amer ican Association of Oral and Maxi l lo facia l Surgeons0278.2391/99, 5706-0002$3.00/0

acety lcholine, the neurotransmitter active in both thesympathetic and the parasympathetic nervous sys-tems, then triggers pathologic secretion from thesweat glands. The first descriptions of unilateral focalgustatory hyperhidrosis subsequent to a parotid ab-scess were provided as early as 1757 by Duphenix3and in 1853 by Baillarger. As a separate diagnosticentity, the so-called auriculotemporal syndrome wasdescribed in detail by Frey.5 Gustatory sweating alsohas been reported to occur after extirpation of thesubmandibular gland.6Several factors may be involved in lesions to parasym-pathetic fibers during operations on salivary glands: 1)the complete or partial removal of the gland in parotidor submandibular surgery during which these fibersare injured far in the periphery; 2) surgical dissectionalong the course of the facial nerve, which is accompa-nied by parasympathetic fibers, may result in theirdisruption during parotidectomy. Both factors maybecome involved after trauma, such as in fractures

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involving the temporomandibular joint or in salivarygland infections.3,*

The area of pathologic sweating coincides in mostinstances partly or completely with the regional distri-bution of the auriculotemporal and greater auricu larnerves. Gustatory sweating has even been observed inthe external auditory meatus. Gustatory sweatingmay occur even without intraoperative excision ofsaliva ry gland tissue. Its occurrence after extirpationof cervica l lymph nodes9 and after neck dissec tionlOJ1also can be explained by innervation of cutaneoussweat glands by misdirected cholinergic parasympa-thetic nerve fibers. This happens when preganglion icparasympathetic fibers running toward the subman-dibular gland, or postganglionic parasympathetic fi-bers coursing to the sublingual gland, are damaged.The lesion is supposed to occur at the submandibularganglion, which is manipulated during dissection ofthe lingual nerve. l l

It is genera lly assumed that the newly formedconnection between the sweat glands and cholinergicparasympathetic fibers is only made possible by apreceding sympathetic denervation of the sweatglands, for instance, by surgical intervention (therebydisrupting the sympathetic fibers running in theauriculotemporal and greater auricu lar nerves) andduring preparation of the skin flap.lz After parotidec-tomy, Glais ter et all3 even found the reverse phenom-enon of pathologic saliva production caused bymisdirected sympathetic fibers in the region of parotidremnants.

It was the aim of this study to provide detailedinformation on the clinical picture of gustatory sweat-ing based on a thorough reevaluation of our ownpatients. Besides a general description of symptoms,we present data on the localization of Frey syndromeafter parotidectomy, after extirpation of the subman-

643

dibular gland, and after neck dissection. The dataderived from our patients form the basis of a discus-sion of certain etiologic aspects. To better differenti-ate between the manifold pathologic states connectedwith gustatory sweating that were described in theliterature, a classification system based on clinicalappearance is suggested.

Patients and MethodsThe 548 patients included in this study responded

to a questionnaire sent to them. Questions concernedthe time when symptoms were noticed, trigger mecha-nisms, and the nature of complain ts. One hundredeighty (60.8%) of the origina l 296 patients who had aparotidectomy, 68 (86.1%) of the 79 patients in whomthe submandibular gland had been removed, and 109(63%) of the 173 patients who had a neck dissectionreturned the questionnaire. Of the group of neckdissection patients, nine underwent radical neck dis-section and 164 underwent functional neck dissec-tion. Among the 109 patients that underwent a total of161 neck dissections who answered the question-naire, the submandibular gland had been extirpatedsimultaneously in 24 cases. Most of our investigatedpatients (85%) were treated for laryngeal, oropharyn-geal, or hypopharyngeal cancer. Based on our therapyregimen, dissection of the level I lymph nodes, includ-ing removal of the submandibular gland was not usualin these cases, in contrast to patients with cancer ofthe oral cavity (15%).

Minors tes tl* was performed in 37 patients withFreys syndrome (Fig 1). This number included 19patients after parotidectomy (22 operated sides, 14lateral and 8 total parotidectomies), seven patientsafter extirpation of the submandibular gland, and 11

F IGURE 1. Examp les of a posit ive Minor s test, in A,C, pat ients after parot idectomy who also showed sweating in regions outside the area ofprevious lobe surgery. C, Even the area suppl ied by the lesser occipi tal nerve may be involved. After man dibular fracture with concom itant dam age tothe parot id, the area of sweat product ion, 6, l ies relat ively far anter ior ly.


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644 GUSTATORY SWEATING

FIGURE 2. Schem atic representat ion of the areas selected forevalua t ion based on var ious regions of sensory innervat ion of the&

reaurtcular region. Regions I and VI correspond to the area innervatedy the aur iculotem poral nerve; regions I I , I l l and IV are suppl ied by the

anter ior and poster ior branches of the greater aur icular nerve; andregion V is innervated by the lesser occipi tal and aur iculotemp oralnerves. Percentages give the frequency of postparot idectomy gustatorysweating in the var ious regions.

patients after neck dissection. For Minors test, asolution containing 15 g iodine, 100 mL castor oil, and900 mL ethanol was applied to the sk in of the tiectedside. Then this area was powdered with starch.Patients were asked to eat an apple and in positivecases about 30 seconds later the treated skin areasshowed a deep blue color, indicating the reactionbetween the two basic components (starch, iodine) ofthis test.

For an exact determination of the area of gustatorysweating, the periauricular region in the confines ofthe various regions of sensory innervation15 wasdivided into six fields (Fig 2). Because of the severityof symptoms, the previously noted 19 patients (22treated sides) who had had a parotidectomy weretreated with botulinum toxin. The crite ria for treatingwere a strong ly felt reduction of life quality and thedesire to be treated. The dosages used depended onthe extent of the sweating skin area and variedbetween 2.5 and 100 units of Botox (Allergan Inc,Irvine, CA). In all treated patients, gustatory sweatingceased completely within 2 days, and the averageduration of this positive effect was 17.3 months.16a17Before botulinum injection, the area showing gusta-tory sweating was divided into fields of 4 cm* eachthat facilitated assessment of their size. Where appli-cable. one of three different statistical tests was used

(x2 test for contingency tables, Fishers exact test,unpaired t test), as specified in the Results section.

ResultsGENERAL DATA ON SYMPTOMS AND TRIGGERSEighty-one (45%) of the 180 patients with parotidec-tomy returning questionnaires reported the occu r-

rence of Freys syndrome. The different pathologicconditions are summarized in Table 1. Among theclinical symptoms stated, 52 patients (63%) sufferedfrom dripping sweat, sometimes combined withother complaints, and sweating was reported by 41(50%) patients. Lesser symptoms of erythema andlocal hyperthermia were noticed by 30 (36%), and25 (31%) patients, respectively. Other complaintswere formication in 16 cases (19%) and a swellingsensation in 11 cases (13%). Bu rning (5 pa-tients = 6%) and yellowish discoloration of hair (3patients = 4%) were rarely mentioned.

Fift y-s ix (70%) of these 81 patients stated that thesymptoms had developed within the first 6 monthsafter surgery . Gustatory sweating noticed for the firsttime as late as 1 year postoperatively was reported byfive patients (6%). In 43 cases (52%) Freys syndromeoccurred regardless of the kind of food ingested.However, in others, the syndrome was triggered byfood of a particu lar taste or consistency. Among thetypes of food responsible for the attacks were, aloneor in combination, hard food (31 patients = 38%)food with a very sour taste (30 patients = 36%) hotfood (22 patients = 27%) and very spicy food (17patients = 21%). Sweets (11 patients = 13%) cook-ing smells (4 patients = 5%) drinking (5 pa-tients = 6%), and ice cream (3 patients = 4%) werementioned less frequently. Nineteen patients (10.6%)who stiered very greatly from the sweating symp-

Benign Lesions Number Malignant Lesions NumberPleonlorphicadenomaWarthin tumorChronic infectioncys tHistiocytolna

LymphangiomaLipomaTotalFrequency Freyssyndrome

80

4714

4

1

14

15 170 (46%)

Adenoidcystic carci-nomaMucoepidermoid car-cinomaLymphoma (non-Hodgin)Squamous cell carci-nomaMetastases (of squa-mous cell carci-noma)Acinic cell carcinoma

1174

3

3

12911(37%)


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toms were given appointments for botulinum toxintherapy.

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LOCALIZATION AND EXTENSION OF GUSTATORYSWEATING AFTERPAROTIDECTOMYMinor s test was performed in all 19 patients (22

operated facia l sides) before receiving botulinumtoxin therapy. Close inspect ion showed that the areashowing discoloration after provocation by gustatorystimulants was predominantly localized where a pa-rotid lobe dissec tion had been carried out (Fig 2). Thehirsute area of the head (reg ion N, Fig 1) and theupper, middle, and lower retroauricu lar regions (re-gions III to V), areas where the sweat gland-equippedskin had not been touched, also showed the typicalbluish color in some instances (Fig 2).

Table 2 shows the data indicating the color develop-ment in the various areas and their combinations. AreaVI was involved significantly more often in patientsafter total parotidectomy (P = .039, Fisher s exacttest). No such difference could be found for the otherareas or their combinations. Area sizes were onlyslightly different between patients with a lateral (mean:49.4 mm*; min, 16; max, 96 mm2) and a total parotidec-tomy (mean: 52.4 mm2; min, 28; max, 84 mm*).

INCIDENCE OF GUSTATORYSWEATING AFTEREXTIRPATIONOF THE SUBMANDIBULAR GLANDSeven (10%) of 68 patients in whom the entire

submandibular gland had been extirpated had noticedgustatory sweating. However, the Minors test wasposit ive in only one patient (1.5%, Fig 3). The area ofpathologic sweating corresponded exactly to the skinoverlying the previous site of the extirpated gland.The patient had noticed abnormal sweat productionfor the first time 1 month after surgery. There was adiscrepancy between the results of the Minors testand the subjective compla ints in the other patients.

F IGURE 3. Minor s test in a pat ient a fter subm andibular glandext irpat ion A, before and B, after gustatory st imulat ion . The discolorat ion of the subm andibular region is clear ly visible.

teen neck dissections had been performed in these11 patients. They all belonged to the group of func-tional neck dissection.* In two of them, the sub-mandibular gland had also been removed. Thestarch-iodine test was negative in all patients studied.Here too, a discrepancy existed between subjective(patients complaints) and objective data (Minorstest). Also, both neck d issections that included thesubmandibular gland had failed to produce Freyssyndrome.

INCIDENCE OF GUSTATORYSWEATING AFTERNECK DISSECTIONOf the 109 patients availab le for follow-up, 11 (10%)indicated the occurrence of gustatory sweating. Fif-

DiscussionArea n % Combination of Areas n %

I 17 77.3 IA1II 20 91.0 I/II/IIIIII 15 68.2 IAIAmvlv 2 9 IAIAIIMV 1 4.5 IAIMVI 5 22.7 IMII / I I I

3 13.67 31.82 9.12 9.12 9.14.518.2

Our results concerning the time after which Freyssyndrome develops after surgery and the frequency ofvascular symptoms are in good agreement withthose of other authors.9 Table 1 summarizes thefrequency of the different pathologic conditions . Theanalysis showed that there was no significant differ-ence in the incidence of Freys syndrome in surgica llytreated benign and malignant lesions. However, in thisseries of patients, an increased incidence of Freys


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646 GUSTATORY SWECATING

syndrome was noticed compared with our previousinvestigationzO

Most patients reported an independence of theoccurrence of gustatory sweating from the quality ofthe taste of the food. The most frequent statementmade with regard to food consistency was that hardfood elicited sweating. This contirms that, as notedby others, 21,22he mast icatory component seems toplay a major role as a trigger. Ice cream or beverageshardly ever elicited the syndrome in our patients.

The size of the area of gustatory sweating afterparotidectomy varied greatly, but even relatively small,circumscribed, areas caused discomfort in the affectedpersons. Neither field size nor amount of sweatproduction seemed to determine the degree of suffer-ing, and the subjective feeling was the determiningfactor. This pronounced subjectivity was substanti-ated by the patients impression of having developedgustatory sweating after submandibular gland extirpa-tion or neck dissection, when the objective measure-ment by Minors test failed to confirm actual sweating.Conversely, gustatory sweating nearly always devel-oped after parotidectomy* but was not noticed by allpatients as a problem needing treatment, a fact thatalso points to a strong subjective component. Like-wise, when the symptoms recur after treatment ofgustatory sweating by botulinum toxin injection, itgoes unnoticed by some patients.l

Not all regions affected by sweating coincided withthe regional distribution of the auriculotemporal nerve.It receives its parasympathetic fibers from branchesconnected with the facia l nerve and provides thetemporal skin anterior to and above the ear throughthe superficia l temporal branches. The other regions(areas II to V) receive their sensory supply through theanterior and posterior branches of the greater auricu-lar nerve and partly through the lesser occipital nerve,representing the dorsal portion of area V. In princip le,although very rare according to our results , thesenerves may serve as guiding structures along whichregenerating parasympathetic fibers find their waytoward the skin . This phenomenon was described byLaage-Hellmann12 for the auriculotemporal and greaterauricular nerves. The area supplied by the lesseroccipital nerve was not involved. As far as we know,we are the first to descr ibe such an involvement. Themechanism denervating the sweat glands in this re-gion is unknown because the lesser occipital nerve isnot damaged. It might be speculated that innervat ionis maintained or reestablished by competing parasym-pathetic and sympathetic fibers, but two other mecha-nisms seem much more likely. Either there exists anexpanded area of representation of the auriculotem-poral nerve that would also permit sensory supply tomore cranial-dorsal skin areas or, most likely, sympa-thetic fibers accompanying blood vessels nourishing

the relevant regions of the skin were injured intraop-eratively. Such vesse ls could be the occipital arteryand its branches, and a lesion of sympathetic fibersclose to their branching off from the external carotidartery seems possible during parotidectomy.

The significant difference between involvement ofarea VI after total and lateral parotidectomy may beexplained by the more extended lesion of the auricu lo-temporal nerve and its branches after total parotidec-tomy, with subsequent sympathetic denervation oflarger portions of the skin.12 However, resprouting ofparasympathetic axons without guiding strncturesalso could permit the regenerating fibers to reach skinareas outside the normal field innervated by theauriculotemporal nerve.

Berini and Gafl and McEwen and Sanchez,23 as wellas this study, found gustatory sweating after extirpa-tion of the submandibular gland, although this seemsto be a very rare occurrence. Only a single case ofgustatory sweating was found after 206 operations byBerini and GaF and after 6s operations by us. Ofcourse, these resu lts have to be interpreted withcaution because gustatory sweating may be presentwithout being noticed by the patients. It is not clearwhy it is so rare after submandibular gland extirpa-tion. This operation certainly damages the integrity ofthe parasympathetic innervation, but regenerationdoes not e lici t the same effects as parotidectomy.Several reasons may be responsible for this phenom-enon: the submandibular gland lies deeper under theskin than does the parotid; undermining the skinduring surgical dissection is much less rigorous than inparotidectomy, which reduces the degree of sweatgland denervation, and the platysma may act as anatural barrier. This assumption is substantiated bythe finding that, after parotidectomy, barr iers againstparasympathetic fibers such as the superficial mus-culo-aponeurotic system24,25 or others were success-fully introduced to prevent gustatory sweating.26 Lastly ,a guiding structure such as the auriculotemporalnerve is missing in the vic inity of the submandibulargland, making it much more difficult for resproutingparasympathetic fibers to find their way to the skin .

The absence of gustatory sweating after neck dissec-tion in our patients can be explained by the techniqueused.18 The lingual nerve, as a rule, was not dissected,and thus the danger of injuring the submandibularganglion was avoided. For the reasons previouslystated, simultaneous extirpation of the submandibulargland does not enhance the chances for developmentof Freys syndrome.

The theoretica l concept of the cause of gustatorysweating after operations with combined sympathetic-parasympathetic lesions was presented in the introduc-tion. However, gustatory sweating has also beendescribed as a consequence of sympathetic-sympa-


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thetic lesions in the cervical region, such as aftersympathectomy.27s28 In trauma or after resection ofsympathetic ganglia containing axons controlled bythermal or gustatory stimuli, preganglionic and post-ganglionic fibers are damaged. Pregang lionic sympa-thetic fibers that are controlled by gustatory stimulicontain acetylcholine as a neurotransmitter; aberrantregeneration after disruption therefore may lead toatypical sympathetic innervation of sweat glands result-ing in Freys syndrome when these fibers are excitedby stimulants. Because our technique of neck dissec-tion does not involve resection of the cervical sympa-thetic ganglia, the lack of gustatory sweating in ourpatients is not surprising. Another cause for Freyssyndrome has been suggested to be an exclusivelysympathetic efference of a preformed reflex arc.29This would exclude parasympathetic involvementafter parotidectomy. The model leaves open a numberof anatomic questions pertaining to gustatory control;acetylcholine is supposed to be secreted in increasedamounts in the parotid remnants left behind aftersurgery9J8 and to subsequently stimulate the dener-vated, and thus supersensitive, sweat glands. In ouropinion, this explanation is not valid because it leavesthe contact of neurotransmitter with the effector tochance by implying simple diffusion.

A further point frequently discussed in the literatureis the possible existence of a preformed reflex arc.29This surmise is supported by the occurrence ofgustatory sweating in normal persons, and the degreeis supposed to depend on the excitatory leve l of thereflex arc. Such a model would help to explain whyFreys syndrome develops after lesions of the centralnervous system, for instance, in encephalitisz7 andthe nature of the changes involved. In this context, ashift of the reflex threshold could play a role. Otherhypothetical central nervous system mechanisms mightbe the formation of new connections between bothfunctional systems (the thermoregulatory and thegustatory) during regeneration, and the induction ofplastic processes in more distant brain centers afterperipheral lesions (eg, after parotidectomy). Findingsderived from study of the motor system30-32 how thata number of cort ical changes, for instance afterdamage to the facial nerve, can be demonstrated.

Because of the multitude of possible pathologicstates that may be instrumenta l in causing gustatorysweating, we believe that the introduction of a classi fi-cation based on and characterizing the different clini-cal situations encountered is advisable (Table 3). Anadvantage of such a classification system would be thepossibi lity to use the aforementioned pathologic andanatomic models as a basis for a simplified, yetunequivocal, discussion of the subject. In other words,we need some kind of standardizat ion of assessmentwhen communicating about gustatory sweating.

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Twe Pathologic State Pathologic BasisType1 Salivaty glan d surgery, Lesion of tbermoregu-Sympathetic/ salivaty gland dis- lated sympathetic

Para- eases, neck dissec- fibers + a lesio n ofsympathetic tion gustatorycontrolledparasympatheticfibers

?lypen Sympathectomy, neck Lesion of thermoregu-Sympathetic surgery with sympa- lated sympatheticthetic (trunk) fibers + a lesion oflesions, cervical and preganglionic (cho-cephalic trauma liner&) gustatory-

controlled sympa-thetic fibersType ICI Normal persons, feeble Central nervous lesion

Central persons,central ner- of tbermoregulatedvous diseases, eg, or (?) gustatory regu-encephalotrophy, lation centers, lowencephalitis, spinal reflex threshold ofprocesses such as gustatory sweat ingsyringomyelia, emo-tional stress

In conclusion, there is some general agreement onthe cause of gustatory sweating. Its symptoms arecaused by sympathetic or parasympathetic innerva-tion of prev iously denervated sweat glands, initiatedby gustatory triggers and stimulated by the neurotrans-mitter acety lcholine. The location of the erroneousinnervation depends on the type of lesion. A numberof hypotheses have been offered to explain gustatorysweating after parotidectomy, but none of them hasbeen proved. In our opinion, misdirec ted parasympa-thetic regeneration is the model that best integrates allknown factors into a rational concept.

References1.2.

3.

8.

9.

Seifert G, Miehlke A, Haubrich J, et al: Speicheldriisen-krankheiten. Thieme, Stuttgart, 1984Hiittenbrink KB, Hiittenbrink B: Das gustatorische Schwitzennach Parotidektomie. Laryngol Rhino1 Otol (Stuttg) 65:130,1986Duphenix M: Observations sur les fistules du canal salivaire deStenon: Sur une plaque compliqute a la joue oti le canal futd&hire. Mem Acad R Chir 3:431, 1757Baillarger JGF: Memoire sur lobliter ation du canal de Stenon.Gaz Med (Faris) 23:194, 1853Frey L: Le syndrome du nerf auriculo-temporal. Rev Neurol2197, 1923Berini AL, Gay EC: Morbidity associated with removal of thesubmandibular gland. J Craniomaxillofac Surg 20:216, 1992Herrmamr A, Zoller J, Maier H: Freysches Syndrom (gustato-risches Schwitzen) nach Kiefergelenksfraktur. Laryngorhinoot-ologie 70:196, 1991Redleaf MI, McCabe BF: Gustatory otorrhea: Freys syndrome ofthe external auditory canal. Ann Otol Rhino1 Laryngol 102:438,1993Langenskiiild A: Gustatory local hyperhidrosis followi ng inju-ries in parotid region. Acta Chi r Stand 93:294, 1946


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648 DISCUSSION10. Spiro RH, Martin H: Gustatory sweating followin g parotid

surgery and radical neck dissection. Ann Surg 165:118, 196711. Myers E, ConIey J: Gustatory sweating after radical neck

dissection, Arch Otolaryngol91:534, 197012. Laage-Hellm ann JE: Gustatory sweating and flushing after con-

servative parotidectomy. Acta Otolaryngol (Stockh) 48234,195713. Glaister DH , Hearnshaw JR , Heftron PF, et al: The mecha nism ofpost-parotidectomy gustatory sweating (The auriculo-temporalsyndrome). Br Med J 5102:942,1958

14. Minor V: Em neues Verfahren zu der klinischen Untersuchungder Schwei8absonderung. Dtsch 2 NervenheiIk 101:302, 1928

15. Feneis H: Anatomisch es BiIdworterbuch. Thieme, Stuttgart,197416. Drobik C, Laskawi R, Schwab S: Die Therapie des Frey

Syndroms mit Botulinum-toxin A. Erfahrungen mit einer neuenBehandhmgsm ethode. HNO 43:644,1995

17. Laskawi R, Drobik C, Schijnebeck C: Up-to-date report ofbotulinum toxin type A treatment in patients with gus tatorysweating (Freys syndrome). Laryngoscope 108:381,199818. Ambrosch P, Freudenberg L, Kron M, et al: Selective neck

dissection in the managem ent of squamous cell carcinoma of theupper digestive tract. Eur Arch Otorhinolat yngol253:329,1996

19. Schmelzer A, Rosin V, Steinbach E: Zur Therapie des FreyschenSyndroms durch em antihidrotisches Gel. Laryngorhmotologie71:59,199220. Laskawi R , Schott T, Mirzaie-Petri M, et al: Surgical managemen tof pleomorphic adenomas of the parotid gland: A follow-upstudy of three methods . J Oral MaxilIofac Surg 54:1176,1996

2 1. Uprus V , Gaylor JB, Carmichael EA: Localized abnormal flushingand sweating on eating. Brain 57:443,1934

22. Freedberg AS, Shaw RS, McManus MJ: The auriculotemporalsyndrome: A clinical and phenomenologic study. J CIin Invest27:669, 194823. McEwen DR, Sanchez MM : Compl ications assoc iated withexcision of a submandibular salivary gland tumor. AORN J64:109, 199624 . A&on GR, Rappaport I: Prevention of Freys syndrome withsuperficial muscuioaponeurotic system interposition. Am J Surg166:407, 199325 . Moulton BR, Allison G, Rappaport I: Variations in the use ofSMAS (superfic ial musculoaponeurotic syste m) to prevent Freyssyndrome after parotidectomy. Int Surg 81:174, 1996

26. Sheme n LJ: Expanded polytef for reconstructing postparotidec-tomy defects and preventing Freys syndrome. Arch Otolaryn-golHeadNeckSurg 121:1307,199527. Haxton HA: Gustatory s weating. Brain 71:16, 194828. List CF , Peet MM : Sweat secretion in man . Arch NeuralPsychiatry 39:1228, 1938

29. Schiffter R, Schliack H: Das sogenannte Geschmacksschwitzen.Forts&r Neurol Psychiatry 36:261,1968

30. Toldi J, Laskawi R, Landgrebe M, et al: Biphasic reorganizationof soma totopy in the primary motor cortex follows facial nervelesion in adult rats. Neurosci Lett 203:179, 1996

31. Laskawi R, Landgrebe M, Wolff JR: Electron microscopicalevidence of synaptic reorganization in the contralateral motorcortex of adult rats following facial nerve lesion. ORL JOtorhinolatyngol Relat Spec 58:266, 1996

32. Laskawi R, Rohlma nn A, Landgrebe M, et al: Rapid astroglialreactions in the motorcortex of adult rats followi ng peripheralfacial nerve lesion. Eur Arch Otorhinolaryngol254:81, 1997

J Oral Maxi l lofac Surg57648-649, 1999

DiscussionGustatory Sweating: ClinicalImplications and Etiologic Aspects

Robert S.Julian, DDS, MDPrivate Pract ice, Fresno Oral and Max i l lofacial Surgery Group,Fresno, Cal i fornia

The authors present a vast amount of information anddiscussion related to the pathophysiology of Frey syndrome .Their conclusions regarding the mecha nisms responsible forthe clinical aspec ts of this syndrome , although complete,lack supportive scientif ic evidence based on their study. Thestated aim of the study is to discuss the clinical aspec ts ofgustatory sweating, and through a questionnaire they wereable to gather information regarding the general co mpla intsof patients, mainly after parotidectomy. To this reader it isevident that many of the patients complaints are not relatedto the comm only understood underly ing neurophysiologicmecha nisms of gustatory sweating. Complaints such aserythema, local hyperthermia, swelling sensations, burning,flushing, buz zing, shooting pain, etc, would more likelyhave a pathologic neurosensory or vasomo tor mech anism,and should not necessarily be included as being relateddirectly to gustatory sweating. The validity of their question-naire related to the incidence of Frey syndrome is suspe ct

given that 45% of those questioned were thought to havegustatory sweating. The general l iterature would suggest anoverall incidence of around 30%, which is about whatthis study demons trates if you only include patients withcomplaints of sweating. Howe ver, the information gainedthrough this questiomaire does help to delineate the na-ture of long-term morbidity after parotidectomy, even ifnot all of these symp toms can be related directly to Freysyndrome. ls2The authors showed strong evidence that botulinumtoxin is an effective treatment for gustatory sweating, eventhough this was not an actual stated goal of their stu dy.Numerous recent studies c onlirm the succ ess of this treat-ment, many of which have much longer follow-up intervalsand patient numbers. This study can be added to the body ofinformation that supports botulinum toxin as a safe andeffective treatment for gustatory sweating. This simple andefficacious treatment of gustatory sweating may well de-crease the relative importance of preventing, understand-ing, and contemplating this surgical complication from aclinical standpoint.3The authors nicely map out the involved areas of gusta-tory sweating through standard starch-iodine testing (Mi-nors test). This is useful information in determining whatareas might be involved, and in which areas to concentratetreatment and preventative measures. Such localization

laskawi 1999 journal of oral and maxillofacial surgery

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