An unusual response to eating

A patient noticed a clear discharge but was unsure of the source, explains Dr Pipin Singh.

Examination revealed normal auditory canals and tympanic membranes (SPL)
Examination revealed normal auditory canals and tympanic membranes (SPL)

A 55-year-old woman attended surgery reporting a six-month history of a clear discharge around her left cheek, which appeared only after she had eaten a meal.

The discharge was first pointed out to her by her husband. Becoming aware of it, she had attempted to clear it away with her hand.

The patient was unable to pinpoint exactly where the discharge came from, but she said that it was becoming noticeably worse.

She also reported some sharp pains in her left ear within the past month and was concerned that the two might be connected.

Key points
  • Frey's syndrome arises from damage to the auriculotemporal nerve
  • The nerve is often damaged following surgery to the parotid gland
  • Treatment options include
      - Topical antiperspirants
      - Topical anticholinergic ointments
      - Botulinum toxin injections
      - Surgery

Surgical excision

Her history consisted of a hiatus hernia and oesophagitis, for which she takes omeprazole 20mg once daily.

She had also had a left partial superficial parotidectomy via a facelift incision in 2010, about a year before the onset of the symptom. Histology revealed a pleomorphic adenoma that had been excised.

The patient takes no other regular medication and does not smoke or drink alcohol.

Examination findings revealed normal external auditory canals and normal tympanic membranes bilaterally. There was mild tenderness around her mandible, but no maxillary or frontal sinus tenderness. There were no palpable lymph nodes, nor any evidence of the reported discharge in the consultation.

After history and examination, the aetiology of this problem remained unclear and I wrote to the patient's surgeon for advice. A diagnosis of Frey's syndrome was made.

Frey's syndrome, first described in the mid-1700s, is a result of surgery or trauma to the parotid gland. It arises from damage to the auriculotemporal nerve.

Nerve damage

The auriculotemporal nerve, a branch of the trigeminal nerve, carries sympathetic fibres to the superficial temporal region, the external acoustic meatus and the outer part of the tympanic membrane. It is also responsible for carrying parasympathetic fibres to the parotid gland.

If the nerve is damaged after parotid surgery, the parasympathetic fibres attach themselves to sweat glands when regenerating, instead of the parotid gland.

On exposure to food (thinking of, smelling, or seeing it), the patient will perspire as well as salivate. This term is known as gustatory sweating. It is common after parotid surgery. Whether the patient seeks treatment depends on how troublesome the symptoms are.

The diagnosis is clinical; however, the starch iodine test may be used on exposure to a food stimulus.

Treatment options include topical antiperspirants, such as those used for hyperhidrosis, topical anticholinergic ointments (glycopyrrolate), botulinum toxin therapy or surgical removal of the nerve fibres.

Conclusion

Parotid surgery is performed for a number of reasons and Frey's syndrome is a well-documented complication that can arise.

GPs often see patients postoperatively and being aware of this condition will allow us to reassure the patient and discuss the treatment options available in primary care before considering botulinum toxin or further surgery.

  • Dr Singh is a GP in Northumberland

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