Management of Frey Syndrome: Treatment Options and Strategies for Managing Frey Syndrome

It can be confusing to experience unusual facial flushing and sweating when you smell, think, or simply talk about food. The condition could be Frey syndrome if you recently had a Parotidectomy, Submandibular Gland Surgery, or facial trauma (penetrative injuries, blunt force, burns, infection, diabetic neuropathy, or mandibular fracture).^1,2

While many with Frey syndrome manage without treatment, others, embarrassed by noticeable facial sweating and flushing when eating, may seek treatment and management strategies. Currently, doctors manage Frey syndrome with topical antiperspirants, anticholinergics, Botox, or a secondary surgery.^1,3

This article discusses what it is like to live with Frey syndrome, its treatment options, and management strategies.

Frey Syndrome: Is it something to be concerned about?

What is Frey Syndrome?

Frey syndrome is mainly associated with the parotid glands, organs on both sides of your face that produce most of your saliva. Through the auriculotemporal nerves, the brain directs saliva production by the parotid glands. 

A parotid gland might be removed surgically for various reasons, including inflammation.⁴ The auriculotemporal nerves that connect the parotid glands with the brain, however, are left behind. If damaged during the surgery, the nerves may regenerate. 

Occasionally, the regenerated auriculotemporal nerve fibres search for and connect to new vessels or glands.⁵

In Frey syndrome, the stray auriculotemporal nerve fibres connect to the skin's vessels and sweat glands. 

Hence, the response to the stimulus (food thoughts or eating spicy and sour food) is flushing and sweating, not salivation, due to misdirected nerve fibres.⁶

Read more on the causes, symptoms, and diagnosis of Frey syndrome. 

Should you be concerned about Frey Syndrome?

The common symptoms of Frey syndrome are gustatory sweating (profuse sweating triggered by food and its ingestion) and flushing.⁷ The intensity of these symptoms can vary. 

Symptoms like gustatory sweating (GS) and flushing could have a psychological impact stemming from embarrassment and social isolation.^7,8 However, GS is harmless. 

Additionally, people with Frey syndrome have been reported to exhibit pain and itching in the affected area (between the jaw and ear).⁷

Frey syndrome does not progress and remains mild once established. Most people with Frey syndrome go about their lives without treatment. Others with discomfort (burning sensation, pain, and itch) and affected quality of life can manage the symptoms with an appropriate treatment plan after consulting a doctor.⁶

How can Frey Syndrome be managed? A guide to interventions

More than half of the people who underwent Parotidectomy reported Frey syndrome.^6,7 Medical and surgical measures are currently available to manage the symptoms of Frey syndrome. 

How is Frey Syndrome managed through medical therapies?

Topical treatment as a medical therapy for Frey Syndrome

The main advantage of topical treatment is that it is non-invasive.

Topical antiperspirants

Antiperspirants function by blocking the sweat glands, thereby reducing sweat.⁹ Topical applications of aluminium chloride hexahydrate or commercial antiperspirants to the affected area can help manage GS.^1,5 

However, there is no standardised regime, and the effect lasts for a few hours.¹ Also, there is a chance of skin inflammation and irritability.^3,9 

Topical anticholinergics

Acetylcholine is essential for the secretion of sweat, saliva, and mucus. Thus, anticholinergics that block acetylcholine control sweating. Topical applications of scopolamine (0.25 to 3 % dosage) or glycopyrrolate provide temporary relief.^1,10 

Like antiperspirants, there is no standardised, effective regime.¹ Due to the functional mechanism, dry mouth, affected vision, and constipation are the possible side effects.^1,10 However, the side effects are less frequent with glycopyrrolate and can be managed.¹⁰ 

Combining topical anticholinergics and antiperspirants at low doses can help manage the sweating better. Under medical supervision, this approach could be helpful, especially for people with mild symptoms.

Botox: An effective and safe treatment for Frey Syndrome?

Botulinum toxin type A (BoNT-A), a neurotoxin, acts as an anticholinergic when injected into the skin.⁶ Since 1994, research has proven BoNT-A, or Botox, as an effective treatment for GS and flushing with minimal, temporary side effects.^1,7

Recent research indicates BoNT-A as a safe treatment for improving atypical Frey syndrome symptoms like heat, itch, and pain.⁷ Intradermal injection of BoNT-A is considered effective because:^1,7,10

• Effect seen within 15 days
• Maximum effect observed between 3 and 6 months of administration
• Long-lasting effect (3 to 20 months)
• Minimal side effects (reversible dry mouth, pain, local muscular weakness) 
• Minimally invasive 

GS is treated effectively with BoNT-A. Unlike topical antiperspirants and anticholinergics, the BoNT-A effect lasts more than 6 months.¹⁰ Depletion of the BoNT-A effect requires repeat injections to avoid symptom recurrence and prolong the symptom-free duration.

How is Frey Syndrome managed through surgical procedures?

Surgical procedures are rare in Frey syndrome management. Surgery is opted for when medical treatments fail.⁶ The following surgical procedures are initiated in unmanageable cases:¹

• Neurectomy
• Placing an interposition barrier

Is neurectomy an efficient treatment option for Frey Syndrome?

As the misdirected nerve fibres cause Frey syndrome, neurectomy or surgical removal of the nerves could be mulled over to alleviate the symptoms. However, the procedure is not suggested immediately for the following reasons:^1,6

• Surgery in an already-operated area could be challenging
• Secondary surgery can have unacceptable cosmetic effects
• Risk to other salivary glands and facial nerves
• Chance of dry mouth or loss of taste sensation 
• Possibility of nerve regeneration and symptom recurrence after secondary surgery

Therefore, many surgeons believe that the risks of an invasive neurectomy are not justified for a relatively benign condition like Frey syndrome.⁶

Is the interposition barrier an efficient treatment option for Frey Syndrome?

The interposition barrier is a physical barrier placed between the parotid bed and the overlying cheek skin.¹ 

The strategy aims at treating Frey syndrome by disrupting the misdirected nervation (nerve supply) to the sweat glands and the skin blood vessels through a barrier.^1,6,11

The following barriers help treat an already established Frey syndrome:^1,6,11,12,13

Dermis grafts

A dermis graft consists only of the middle layer of the skin, or dermis. The graft from an individual’s own skin is an ideal barrier with a cosmetic effect (contouring). The barrier is applied when the post-parotidectomy symptoms are minimal.

Dermal collagen implants

Dermal collagen implants, made from bovine or porcine proteins, are a safe, practical, and effective barrier with a cosmetic result, especially when a large amount of glandular tissue is removed during Parotidectomy. 

Autologous fat implantation

Fat removed from one’s abdomen is injected and layered into the parotid bed. This technique creates an effective bulk barrier while correcting the post-surgical contour defect.

Dermofat graft 

A layer of fat with an overlying dermis from one’s buttock (donor site) provides the bulk to restructure the parotid bed while acting as a barrier with a contouring effect.

Temporoparietal fascia flap (TPF)

A thin layer of flexible tissue from the scalp with intact blood supply is placed between the skin and the operated site area as a barrier and a structural support. Studies have shown that TPF reduces contour deformity and Frey syndrome symptoms. 

Sternomastoid fascial flaps

A thin layer of tissue from the neck with an intact blood supply provides a durable flap that covers the parotid wound. The flap (a barrier) disrupts misdirected nervation.

Research reports no recurrence of Frey syndrome with interposition barriers.¹¹ However, a less invasive autologous fat injection improved Frey syndrome with recurrent symptoms.^1,11 

Though the Frey syndrome treatment with an interposition barrier seems promising, it is not a safe approach. There is always a risk of a failed flap, an unfavourable cosmetic outcome, and facial nerve injury.^1,11

Currently, the interposition of a barrier between the parotid wound and the cheek skin is done during Parotidectomy to prevent Frey syndrome. 

During Parotidectomy, the intra-operative preventive techniques create a barrier between the skin and the underlying nerves. The barrier (free tissue grafts, or flaps) prevents or obstructs abnormal nerve regeneration.^1,6,12,13 Thus, minimising the risk of Frey syndrome post-surgery.

FAQs

Can Frey Syndrome get worse if left untreated?

Frey syndrome does not progress or spread to other facial areas once established. Most people with Frey syndrome go about their lives without treatment. If your symptoms are mild and you are unaffected, live your life. However, the symptoms will persist and may not diminish without treatment. 

Can I manage Frey Syndrome with a strict diet?

Lifestyle changes alone cannot effectively manage Frey syndrome symptoms. Eating certain foods that are acidic, sour, or spicy may trigger the symptoms. However, avoiding them can only reduce the severity of the symptoms.

If the symptoms of Frey syndrome have affected your quality of life, consider consulting a professional who can provide you with treatment options and strategies for managing Frey syndrome. 

How can I prevent Frey Syndrome?

Your diet or lifestyle choices do not cause Frey syndrome. Instead, it originates from misdirected nerve fibres, often due to damage during surgeries like Parotidectomy or facial trauma. While you cannot prevent Frey syndrome, it's important to stay informed. 

If you experience any symptoms after facial trauma, don't hesitate to consult your healthcare provider. Additionally, if you're scheduled for surgery near your jaw or involving salivary glands, enquire about preventive techniques with your surgeon. 

Could my baby have Frey Syndrome?

Frey syndrome in infants is rare but possible. The facial flushing could be associated with Frey syndrome if your baby was born normally but delivered with an instrument, including forceps, or non-assisted delivery with prolonged labour.^14,15

The symptoms present when the baby is around 5 months of age and introduced to solid food. Hence, facial flushing is often misdiagnosed as a food allergy.¹⁵ If you think your child has Frey syndrome, consult a Paediatrician or a specialist to discuss potential management options and monitor the condition.

Paediatric Frey syndrome is a harmless condition. Studies have indicated the possibility of condition resolution, improvement, or a decrease in symptom severity without intervention as the child grows.¹⁵

Summary

• Currently, medical and surgical measures can manage the symptoms of Frey syndrome
• Non-invasive, topical antiperspirants and anticholinergics on the affected area provide temporary relief
• Minimally invasive Botulinum Toxin A (BoNT-A) injection is a long-lasting, efficient, and well-tolerated treatment for Frey syndrome
• Interposition barrier surgery with temporoparietal fascia flap is a successful treatment for unmanageable symptoms and failed BoNT-A treatment