Frey syndrome, also known as an auriculotemporal syndrome and gustatory sweating, is a neurological condition characterised by flushing sweating, pain, and sometimes itching in the region of the face below the ear in response to chewing. Psychological distress can accompany these signs and symptoms as they can make day-to-day activities, like eating, more difficult and sometimes embarrassing. Frey syndrome is typically a complication of surgery in the head and neck region, though the condition can rarely be caused by something non-surgical, such as physical trauma, infections, and diabetes. Depending on the severity of signs and symptoms, management and treatment for Frey syndrome can vary, possibly involving counselling, botulinum toxin injections, and surgery.¹ ² ³
Causes of frey syndrome
Frey syndrome is commonly caused by surgery in the head and neck region, including salivary gland surgery and facelifts. Frey syndrome typically presents within weeks to months following surgery, though sometimes takes many years to manifest.² ³
Rarely, Frey syndrome can be caused by something non-surgical, such as physical trauma, including jaw dislocations, jaw fractures, burns, infections, and diabetes.²
The cause of Frey syndrome, whether it be surgical or non-surgical, leads to the auriculotemporal nerve being damaged. As the auriculotemporal nerve is involved in chewing, damage to this nerve causes problems such as flushing, sweating, itching, and pain in the region of the face below the ear when patients with Frey syndrome chew.² ⁴
Signs and symptoms of frey syndrome
Signs and symptoms of Frey syndrome, as well as how long they last and their severity, can vary depending on the person. Physically, they occur in the region of the face below the ear in response to chewing and can include:¹
Frey syndrome’s signs and symptoms can cause psychological distress as they can make day-to-day activities, like eating, more difficult and sometimes embarrassing. As a result, social situations can become distressing for some patients.²
Diagnosis of frey syndrome
A medical history is taken by your doctor during a consultation. This provides an opportunity for your doctor to understand you more, such as your conditions, medications, lifestyle, and any signs and symptoms you’re experiencing. Here, a doctor can determine whether these signs and symptoms are in line with that of Frey syndrome, as well as if there is a past event that may have caused them.⁵ ⁶
The starch-iodine test can allow for a diagnosis of Frey syndrome before signs and symptoms present. The starch-iodine test involves the region of the face below the ear being painted with iodine. Once this iodine has dried, starch is applied on top of the iodine. This starch will typically turn blue or brown when those with Frey syndrome chew or engage in something else that stimulates saliva due to their sweating.¹,⁶
Thermography is another tool that can be used to diagnose Frey syndrome before signs and symptoms show up. Thermography uses a camera to display temperature differences throughout the body. As the region of the face below the ear increases in temperature when someone with Frey syndrome chews, Frey syndrome can be detected through thermography displaying this temperature increase.⁶ ⁷
Management and treatment of frey syndrome
Management and treatment of Frey syndrome is not one-size-fits-all, with management and treatment varying depending on the severity of your signs and symptoms, preferences, and availability. Frey syndrome sometimes resolves on its own, without the involvement of management and treatment.²
Antiperspirants and anticholinergics
Antiperspirants and anticholinergics can be applied to the area of skin affected by Frey syndrome as a cream formula. To be effective in stopping the sweating caused by Frey syndrome, they need to be applied daily around the time of eating.²
Botulinum toxin injections
Botulinum toxin, also known as botox, can be injected into the area of skin affected by Frey syndrome. Botulinum toxin injections provide effects that last much longer than antiperspirants and anticholinergics, not requiring daily administration but can instead be administered at year-long intervals.² ⁸
Botulinum toxin injections do present with several potential non-serious side effects:⁸
- Flu-like signs and symptoms occurred one day after the botulinum toxin injection.
- Bruising, swelling, and redness at the site of the botulinum toxin injection
- Difficulty moving the face
- Temporary drooping and weakness in the face
Sometimes, surgery is considered an option in the management and treatment of Frey syndrome. Surgery can involve a range of techniques, such as removing the damaged structures causing Frey syndrome or placing a barrier between said damaged structures and the skin.²
Unfortunately, the recurrence of Frey syndrome’s signs and symptoms is common after surgery, though they often are not as severe as they were pre-surgery. Furthermore, surgery also carries a risk of facial nerve injury.²
Can Frey syndrome be cured?
Frey syndrome cannot be cured. However, there are management and treatment options to stop signs and symptoms, though they typically need to be given at regular intervals to succeed. Antiperspirant and anticholinergic creams can be applied daily to affected parts of the face, at around the time of eating,, to stop signs and symptoms. Furthermore, botulinum toxin can be injected once a year to prevent signs and symptoms. There have also been reported cases of Frey syndrome resolving on its own.²
Is Frey syndrome a serious condition?
Frey syndrome is not a life-threatening condition. However, signs and symptoms can persist for a long time. Furthermore, Frey syndrome can cause psychological distress as it can make eating embarrassing, potentially making you not want to engage in social situations. However, with the right help, this psychological distress can be overcome.²
Can Frey syndrome go away on its own?
Frey syndrome can go away on its own. However, this isn’t necessarily common. Establishing a management and treatment regime can help you potentially live free from Frey syndrome’s signs and symptoms.²
Are there any lifestyle changes that can be made for Frey syndrome?
Depending on the management and treatment plan you are undergoing, you may have to make changes to your lifestyle. For example, if using antiperspirant and anticholinergic creams, it would be important to always have these on hand when going out to prevent sweating when eating. You may have to start paying more attention to when and where you eat to ensure that you’re in an environment where you feel comfortable eating and perhaps applying those antiperspirant and anticholinergic creams.²
As Frey syndrome can sometimes be psychologically distressing, it can cause social situations to become more stressful. These social situations can take some time to get used to, though integrating coping strategies into your lifestyle, perhaps with help from your doctor, can potentially help with this.²
Can Frey syndrome recur after treatment?
Frey syndrome can recur after treatment. Some treatments have longer-lasting effects than others. Antiperspirant and anticholinergic creams have to be applied around the time a patient eats to prevent signs and symptoms from recurring. Botulinum toxin injections, on the other hand, can be given annually to prevent the recurrence of these signs and symptoms. These s also commonly recur after surgery, though they typically are less severe than what they were pre-surgery.²
Frey syndrome results from a nerve in the region of the face below the ear being damaged, often because of surgery in the head and neck region, commonly causing flushing, sweating, pain, and sometimes itching in this region as one chews. As a result, Frey syndrome can cause psychological distress, such as embarrassment and avoidance of social situations. Consulting with a doctor, a starch-iodine test, and thermography can be conducted to diagnose the condition. Management and treatment can vary, often depending on how severe your signs and symptoms are, and can involve antiperspirant and anticholinergic creams, botulinum toxin injections, and sometimes surgery, though surgery commonly causes signs and symptoms to recur and can cause facial nerve injury. A doctor can help you determine which management and treatment options would be best suited for you.
- Motz KM, Kim YJ. Auriculotemporal syndrome (frey syndrome). Otolaryngologic Clinics of North America. 2016; 49(2): 501-509. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5457802/
- Mantelakis A, et al. Frey’s syndrome: a review of aetiology and treatment. Cureus. 2021; 13(12): e20107. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8638782/
- Chamisa I. Frey’s syndrome: unusually long delayed clinical onset post-parotidectomy. The Pan African Medical Journal. 2010; 5: 1. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2984316/
- Komarnitki I, Andrzejczak-Sobocińska A, Tomczyk J, Deszczyńska K, Ciszek B. Clinical anatomy of the auriculotemporal nerve in the area of the infratemporal fossa. Folia Morphologica. 2012; 71(3): 187-193. Available from: https://pubmed.ncbi.nlm.nih.gov/22936556/
- Flugelman MY. History-taking revisited: simple techniques to foster patient collaboration, improve data attainment, and establish trust with the patient. GMS Journal for Medical Education. 2021; 38(6): 109. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8493840/
- Choi HG, et al. Comparisons of three indicators for Frey’s syndrome: subjective symptoms, minor’s starch iodine test, and infrared thermography. Clinical and Experimental Otorhinolaryngology. 2013; 6(4): 249-253. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863675/
- Rakhunde MB, Gotarkar S, Choudhari SG. Thermography as a breast cancer screening technique: a review article. Cureus. 2022; 14(11): e31251. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9731505/
- NHS. Botulinum toxin injections, such as Botox. 2019. Available from: https://www.nhs.uk/conditions/cosmetic-procedures/non-surgical-cosmetic-procedures/botox-injections/