Síndrome de frey: revisión de literatura / Frey syndrome: review of the literature

El síndrome de Frey descrito inicialmente en 1923, es también conocido como Síndrome de la sudoración gustativa o Síndrome del Nervio aurículotemporal (N.auriculotemporalis), ya que las lesiones cutáneas asociadas a éste aparecen en la zona inervada por esta rama del nervio maxilar inferior (N. Mandibulares). Se caracteriza por sudoración gustativa y eritema en la región cervico-facial como respuesta a estímulos gustativos y excepcionalmente táctiles, pudiendo surgir como una complicación tras cirugía de la glándula parótida (parotidectomía), traumatismos o infección supurativa de esta glándula, como consecuencia de un daño ocasionado en las fibras parasimpáticas del nervio aurículotempora (N.auriculotemporalis). Los síntomas de sudoración y enrojecimiento de la piel suelen desarrollarse lentamente y resultan muy molestos. El tratamiento consiste en la colocación de anticolinérgicos locales o sistémicos, interposición de diversos materiales como colgajos regionales, tal como el músculo esternocleidomastoideo o la fascia temporoparietal

Frey's syndrome described initially in 1923, is also known as gustatory sweating syndrome or Auriculotemporal nerve Syndrome, since the cutaneous injuries associated with this one appear in the area supplied by this branch of the mandibularis nerve. It is characterized by gustatory perspiration and erythema in the cervico-facial region as response to gustatory and exceptionally tactile stimulation, being able to arise as a complication after surgery of the parotid gland (parotidectomy), traumatism or supurative infection of this gland, as consequence of a damage caused in the parasympathetic fibers from the auriculotemporal nerve. The symptoms of perspiration and reddening of the skin use to develop slowly and turn out to be very troublesome. The treatment consists of the placement of local or systemic anticolinergics, interposition of diverse materials as regional muscle flaps, such as the esternocleidomastoid muscle or the fascia temporoparietal

Síndrome de Frey por submaxilectomía y tratamiento con toxina botulínica / Frey syndrome secondary to submaxillectomy and botulinic treatment

El síndrome de Frey (SF) se caracteriza por rubor, calor y sudación en la región maseterina y geniana durante las comidas. El SF se observa en el 20-60% de los pacientes sometidos a parotidectomía. Presentamos un caso con SF secundario a la ablación de la glándula submaxilar en un varón de 30 años de edad, sin antecedentes patológicos, que consultó en el año 2000 por adenopatía cervical izquierda. La misma fue biopsiada y la anatomía patológica informó carcinoma medular de tiroides. El paciente presentaba múltiples metástasis hepáticas y pulmonares, motivo por el cual recibió tratamiento quimioterápico con cisplatino plus doxorrubicina (seis ciclos) con respuesta completa, finalizando dicho esquema en marzo del 2002. En julio del 2002 se realizó tiroidectomía total más vaciamiento ganglionar izquierdo con resección de la glándula submaxilar. Durante la cirugía se lesionó la rama mentoniana del nervio cervicofacial, rama del VII par craneal. En septiembre del 2004 consultó por episodios de sudación durante las comidas en la región submaxilar izquierda. Se realizó prueba de Minor y luego se procedió a aplicar toxina botulínica tipo A en la región afectada, a razón de 2.5 UI por punto (cm2), a un total de 17 puntos. El control a los 21 días demostró más de un 95% de efectividad en la resolución del SF. El efecto duró un año, y una segunda reinfiltración mostró similar respuesta. No hallamos descripciones anteriores de SF en región submaxilar; se presenta su tratamiento satisfactorio con toxina botulínica tipo A.

A case of Frey syndrome (FS) secondary to submaxillar gland exeresis is presented and the results of the treatment with botulinum toxin (BTX) type A. FS is a condition of sweating cheek and preauricular area during mealtime as a sequel detected in about 20-60% of patients after parotidectomy. The clinical symptoms include swelling, flushing and hyperhidrosis. The treatment choice for this condition is intracutaneous injection of BTX type A which blocks acetylcholine release at the sweat glands. A 30-year-old man, with thyroid medullar carcinoma diagnosed in 2002 received 6 cicles of cisplatin plus doxorubicin previous to the thyroidectomy with anterolateral neck dissection. During surgery the left ramus marginalis mandibulae was damaged. Two years later the patient referred sweating in submaxillar region during meals. CT scan demonstrated the absence of left submaxillar gland. Minor's test disclosed the affected area and BTX type A was injected (2.5 U/cm2/17 points). A twenty-one-day control showed a 95% reduction of the affected skin area. Persistent efficacy was observed up to one year followup time when he was reinjected. The FS, also known as "gustatory hyperhidrosis", was probably first reported by M. Duphenix in 1757. Lucja Frey considered its physiopathology as a disorder of both sympathetic and parasympathetic innervation. In our case the FS was caused by a misdirected regeneration of postganglionic parasympathetic nerve fibers that arrised from the nervus lingualis rami ganglionares of the nervus trigeminus. After nerve injury the colinergic parasympathetic fibers seek out colinergic receptors -sympathetic receptors of the skin- innervating sweat glands and small skin vessels. All previous cases were located at masseter region post-parotidectomy. We have not found any description of FS in the submaxillary region. The self-assessed efficacy of the treatment with a hyperhidrosis disease severity scale revealed a very satisfied patient at 20 months follow-up after being injected twice with BTX type A.

Prevalência da Síndrome de Frey após parotidectomia parcial / Frey syndrome prevalence after partial parotidectomy

INTRODUÇÃO: síndrome de Frey é uma seqüela observada após parotidectomia com incidência que varia muito na literatura. O diagnóstico é avaliado pela presença da tríade clássica - sudorese, calor e hiperemia na face, durante a alimentação - e documentado pelo teste com amido e iodo de Minor. OBJETIVO: Avaliar a incidência desta síndrome nos pacientes submetidos à parotidectomia parcial, no Centro de Otorrinolaringologia de Limeira, no período de 1994-2004 e correlacioná-la com os achados clínicos e com a técnica cirúrgica utilizada. MATERIAL E MÉTODO: Quatorze pacientes foram submetidos à parotidectomia parcial com rotação de retalho pediculado do músculo esternocleidomastóideo e responderam a questionário e a seguir foi realizado o teste do iodo, classificando-se os pacientes em positivos e negativos para o teste em um estudo clínico retrospectivo. RESULTADO: Nesta casuística, observamos que 21 por cento dos pacientes após parotidectomia parcial apresentaram positividade para o teste, sendo os mesmos pacientes que apresentaram queixas clínicas ao responderem o questionário. CONCLUSÃO: Somente os pacientes que apresentaram sintomatologia clínica tiveram positividade no teste do iodo, e a técnica cirúrgica empregada foi eficiente no tratamento da patologia da glândula, pois apresentou baixa incidência de acordo com a literatura pesquisada.

INTRODUCTION: Frey syndrome is a sequela observed after parotidectomy and the reported incidence varies enormously in the literature. Diagnosis is evaluated by presence of the classic triad of gustatory sweating, heating and flushing while feeding and documented by Minor starch-iodine test. AIM: to evaluate the incidence of this syndrome in patients submitted to partial parotidectomy at Centro Otorrinolaringológico de Limeira, from 1994 to 2004, including presence of signs and symptoms and the surgical technique. MATERIAL AND METHOD: fourteen patients undergoing partial parotidectomy with sternocleidomastoid muscle flap answered a questionnaire and were classified as positive or negative by Minor starch-iodine test in a clinical retrospective study. RESULTS: 21 percent of the patients presented symptoms and positive iodine test. CONCLUSION: only the patients presenting clinical symptoms had a positive test and the adopted surgical technique was efficient due to low incidence of the syndrome.