ClinicalChallenges Q&A

Professor
Crispian Scully

Dr Dimitrios
Malamos

Clinical Challenges Q&A

2. A Sweaty Face
A 77-year-old female complained of
sweating from her face anterio-inferiorly to
her right ear for 5 years. One year previously,
the patient developed transient anosmia,
but ENT and MRI examinations revealed no
pathology, and the anosmia cleared, though
the sweating increased. The history revealed
a right partial parotidectomy for a mixed
salivary tumour 14 years previously.
Examination revealed no fluid,
nor signs of fistula or cutaneous infection but,
when the patient drank citrus juices, her right
auricular and parotid area became sweaty
(Figure 1a). Fluid was also appearing at the
pre-auricular area during mastication.
Q1. What is the cause?
(a) Parotid fistula;
(b) Frey syndrome;
(c) Cystic fibrosis;
(d) Hyperhidrosis;
(e) Eccrine angiomatous hamartoma.
A1. The answer to what is the cause?
(b) Frey syndrome: this is characterized by
Professor Crispian Scully, CBE, MD,
PhD, MDS, MRCS, BSc, FDS RCS, FDS
RCPS, FFD RCSI, FDS RCSE, FRCPath,
FMedSci, FHEA, FUCL, DSc, DChD,
DMed(HC), Dr HC, Emeritus Professor,
University College London, Hon
Consultant UCLH and HCA, London,
UK and Dr Dimitrios Malamos, DDS,
MSc, PhD, DipOM, Oral Medicine Clinic,
National Organization for the Provision
of Health Services (IKA), Athens, Greece.

556 DentalUpdate

increased sweating in excess of that required

unilateral sweating and flushing of facial
for regulation of body temperature. It can be
skin in the area of the parotid gland during
diffuse or focal and mainly affects parts of the
mastication. Frey syndrome (Baillarger, Dupuy,
body with a high content of sweat glands,
Gustatory or Auriculotemporal syndrome)
such as palms, soles, groins and face. It can
arises after parotidectomy or sympathectomy,
appear after eating spicy foods, strong spirits,
as a result of severance and inappropriate
caffeine or during stressful events, or be a
nerve regeneration, the parasympathetic
manifestation of various diseases of thyroid
fibres switching to severed postganglionic
or pancreas, tumours or mercury poisoning.
sympathetic fibres which innervate facial sweat
(e) Eccrine angiomatous hamartoma is a
glands, causing gustatory sweating (sweating
rare benign condition arising in young
in anticipation of food), instead of the normal
people, characterized by an increased
salivatory response. The starch-iodine test
number of eccrine elements as well as
detects hyperhidrosis (Figure 1b). Tincture of
numerous vascular channels and appears
iodine is applied and left for 10 minutes to dry
as a solitary enlarging nodule at birth or
out, and then a layer of starch is applied. The
during childhood and is associated with
patient is given lemon juice and the area that
hyperhidrosis or pain.
sweats turns blue or violet, as a result of the
interaction of starch and iodine catalysed by
the moisture. Frey syndrome was suspected
and confirmed by the starch iodine test. It may a
respond to hyoscine therapy.
(a) Parotid fistula is a common complication
of parotid surgery for removal of a benign
or malignant tumour. It is characterized by
a communication between the skin and
salivary duct or gland through which saliva is
discharged into the skin during mastication.
High amylase content helps to distinguish this b
fluid from sweat.
(c) Cystic fibrosis is a multisystem autosomal
recessive disease caused by a defect in
expression of CFTR protein, which is present
in the apical membrane of the digestive,
respiratory and sweat glands. Patients suffer
from an early age with severe respiratory,
digestive and reproductive disorders and
Figure 1. (a) Sweaty right auricular area. (b)
often dehydration due to excessive sweating.
Starch-iodine test detecting hyperhidrosis.
(d) Hyperhidrosis is the condition of abnormal
July/August 2014