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Available online at www.sciencedirect.com

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British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx

Hilotherapy for the management of perioperative pain and

swelling in facial surgery: a systematic review and
meta-analysis
G.E. Glass a,b , N. Waterhouse a , K. Shakib c,∗
a Wellington Hospital, HCA Healthcare, London, UK
b Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
c Department of Oral & Maxillofacial Surgery, Royal Free London NHS, London UK

Accepted 4 July 2016

Abstract

Hilotherapy is the application of cold compression at a regulated temperature through a face mask. Studies that have evaluated its efficacy
have focused on postoperative oedema, pain, and the patient’s comfort. However, there is no clear consensus in favour of its use, so we
have made a systematic review and meta-analysis to evaluate relevant published reports. We searched PubMed, EMBASE, MEDLINE, the
Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials to identify studies. Sixty-one records were
screened, six of which met the inclusion criteria and four of which were suitable for meta-analysis. All data suitable for meta-analysis were
derived from studies of elective and traumatic facial skeletal surgery. Hilotherapy was associated with significant reductions in facial pain on
postoperative day 2 (p < 0.00001), and facial oedema on days 2 (p = 0.0004) and 3 (p = 0.02). Patients reported more comfort and satisfaction
with hilotherapy than with cold compression (p < 0.00001). The effect of hilotherapy on ecchymosis and formation of haematomas remains
uncertain. Well-designed, randomised, controlled trials of its use after aesthetic facial surgery are required.
© 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Hilotherapy; Hilotherm®; cryotherapy; facial surgery; orthognathic surgery; oedema; facial pain; post operative cooling

Introduction been concerns that it may impair microvascular blood flow

Cryotherapy is a traditional way of minimising pain, swelling,
and discomfort after trauma or facial surgery, but the qual-
ity of evidence is poor (Collier J et al. Facial cooling
following orthognathic surgery-pilot data and recommen-
dations for a multi-centre study. Paper presented at the
annual scientific meeting of the British Association of Oral
and Maxillofacial Surgeons, 2012)1–3 and there have even
∗
Corresponding author. Tel.: +020 82164271.
E-mail address: k.shakib@nhs.net (K. Shakib).
and lymphatic drainage, and cause cold burns or nervous
injury. 4,5
Hilotherapy (Hilotherm®, Hilotherm GmbH, Lud-
wigshafen, Germany) uses a prefabricated, facially-
contoured, polyurethane mask to channel a current of cool,
sterile water adjacent to the skin to provide regulated
cryotherapy perioperatively.6 As it provides a way of stan-
dardising cryotherapy, it can be evaluated in a randomised,
controlled trial. Published studies have given conflicting
results, and to draw conclusions about its efficacy we have
evaluated the evidence systematically.

http://dx.doi.org/10.1016/j.bjoms.2016.07.003
0266-4356/© 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Glass GE, et al. Hilotherapy for the management of perioperative pain and swelling in facial surgery: a
systematic review and meta-analysis. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.07.003
YBJOM-4940; No. of Pages 6
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2 G.E. Glass et al. / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
Methods
Search
We searched PubMed, EMBASE (OvidSP), Medline
(OvidSP), the Cochrane Database of Systematic Reviews,
and the Cochrane Central Register of Controlled Trials, using
medical subject heading (MeSH) and free-text terms. We also
scrutinised the online trials registers ClinicalTrials.gov and
the national research register for completed, discontinued,
and ongoing trials about the use of cryotherapy and hilother-
apy in facial surgery. The search was made in accordance
with the Cochrane Highly Sensitive Search Strategy guideline
in the Cochrane handbook for systematic reviews of inter-
ventions. 7 The review is reported in line with the Preferred
Reporting Items for Systematic Reviews and Meta-analyses
(PRISMA) statement. 8
Inclusion criteria
We included randomised controlled trials that compared
facial cooling by hilotherapy with standard dressings or cold
compression after facial reconstructive or aesthetic proce-
dures in both adults and children. Where there were two or
more clinically homogeneous studies, data were pooled in a
meta-analysis.
Exclusion criteria
Prospective, comparative, and case-control studies were
mentioned in the text, but not analysed further. Published
abstracts, posters, and theses were excluded.
Outcome measures
Primary outcome measures were oedema and pain. Sec-
ondary outcome measures were tolerance, haematoma, and
ecchymoses. In three of four trials included, facial oedema
was measured using 3-dimensional volumetric morphomet-
ric imaging software. In the case of elective facial surgery a
preoperative scan was used to establish a reference volume. In
the case of emergency facial surgery for trauma a late postop-
erative scan was used to establish a reference volume. In the
remaining trial, facial oedema was evaluated from a series of
measurements made from the fixed point of the tragus.9 The
final trial qualitatively evaluated facial oedema and ecchy-
mosis at routine postoperative review and was excluded from
further analyses. 10 A visual analogue scale (VAS) of 0-10
was used to evaluate facial pain in four of the studies while
one used a scale of 1-4 where 1 indicated no pain and 4
indicated severe pain. 10
Collection and analysis of data
Studies were assessed for risk of bias. 11 For all stud-
ies included in the meta-analysis we recorded details of
Please cite this article in press as: Glass GE, et al. Hilotherapy for the management of perioperative pain and swelling in facial surgery: a
systematic review and meta-analysis. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.07.003
participants, operation, temperature of the hilotherapy, com-
parative technique, and outcomes. Continuous outcomes
were calculated using the mean difference and 95% CI for
each trial. For dichotomous outcomes we calculated risk
ratios (RR) and 95% CI for each trial. We used both random-
effect and fixed effects models in our meta-analysis: in a
fixed-effect analysis the true effect size is assumed to be the
same in all included studies, while in a random-effects model
the true effect size varies between studies. The summary
effect is the estimate of the mean of these effects. In practice,
the random-effects model gives more weight to smaller stud-
ies than the fixed-effects model does. Our rationale was to
use the random-effects model a priori as we assumed there
to be variance between studies, but we calculated the vari-
ance within each study and if it was low we used the fixed
effects model. For more details please refer to Introduction to
meta-analysis by Borenstein et al., 12 Variance (statistical het-
erogeneity) was calculated both with the chi square test and
the I2 statistic. A chi square test with p <0.10 or an I2 > 50%
were taken to indicate significant heterogeneity. Heteroge-
neous data were pooled using the random-effects model while
homogeneous data were pooled using the fixed-effect model.
As all studies of oedema, pain, and patients’ satisfaction
that we included used the same scales, the forest plots were
calculated using mean difference, not standardised mean dif-
ference. In accordance with the limited number of trials
included for each outcome, we did not construct a funnel
plot to investigate reporting bias. For statistical analysis we
used Review Manager (RevMan) (version 5.3, Copenhagen:
the Nordic Cochrane Centre, the Cochrane Collaboration,
2014).
Results
General
Sixty-one abstracts and seven full texts were assessed for eli-
gibility. Six trials involving 286 patients met the inclusion
criteria 9,10,13–16 and four were suitable for meta-analysis
(Fig. 1). 13–16 Men accounted for around half of all study
participants and for 62 of 74 (84%) of participants in the
two studies of facial trauma. All trials used Hilotherm® at
14-15 ◦ C. In all but one the hilotherapy mask covered the mid-
dle and lower thirds of the face, and in the remaining case it
covered the upper and middle thirds. 13 In each case hilother-
apy was started immediately postoperatively, but the regimen
varied thereafter from a single application of 45 minutes
after third molar extractions 15 to a continuous period of
48 hours, or 48 -72 hours after orthognathic surgery. 9,14 The
Hilotherm® masks are shown in Fig. 2.
The control arm comprised cool compresses in four stud-
ies and dressings alone in only one.10 In the remaining study,
both controls were incorporated into the study design.9 Four
of the six trials evaluated facial oedema objectively, using
the same 3-dimensional volumetric morphometric imaging
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Fig. 1. Search of databases and selection of publications for study.

software.13–16 Five of the six studies also evaluated facial
pain using semiquantitative scales. 10,13–16 In four, the doc-
umentation of results was sufficiently detailed to permit a
meta-analysis.13–16 The studies included are summarised in
the table (supplemental data, online only), and a risk of bias
assessment in Fig. 3.
Facial oedema
Five trials quantitatively evaluated the influence of hilother-
apy on facial oedema. The risk of selection bias was not clear
because details about the methods of randomisation were
inadequate, but as the risk of other forms of bias was low
in four of the five, these four were included in the meta-
analysis. By contrast, the description of the study’s design
was not sufficiently detailed in the paper by Moro et al to
permit numerical or demographic comparison of the three
arms,9 and while the design stated that measurements were
Fig. 2. The Hilotherm® face masks. A = Upper and mid face; B = middle
and lower face.
was analysed statistically and compared with the baseline
measurements.
The studies suitable for meta-analysis reported heteroge-
neous data on day 2 (chi square p < 0.00001, I2 = 89%) and
day 3 (chi square p < 0.0001, I2 = 96%) so a random effects
model was used. By contrast, data reported on day 28 were
homogeneous (chi square p = 0.7, I2 = 0%) so a fixed effect
model was used. As shown in Fig. 4, hilotherapy (applied
immediately postoperatively) was associated with a signifi-
cant reduction in facial oedema on day 2 (Fig. 4A; p = 0.0004)
and day 3 (Fig. 4B; p = 0.02); an effect which had normalised
by day 28 (Fig. 4 C; p = 0.39).
Facial pain
Of the five trials that evaluated the effect of hilotherapy on
postoperative facial pain, four used the VAS of 0-10 while one
10 used a scale of 1-4, where 1 indicated no pain and 4 severe

made at three intervals postoperatively, only one (24 hours) pain. However, this trial did not report the data in sufficient

Risk of bias assessment

First author and Random Allocation Blinding of Incomplete Blinding of Incomplete Free from Free from
reference Sequence Concealment? outcome outcome outcome outcome selective other bias?
Generation? assessment data 1 assessment data 2 reporting?
1? addressed? 2? addressed?
Oedema Oedema Pain Pain
Reconstructive
Rana (14) Unclear Unclear Yes Yes No Yes Unclear Yes
Rana (15) Unclear Unclear Yes Yes No Yes Unclear Yes
Rana (16) Unclear Unclear Yes Yes No Yes Unclear Yes
Modabber (13) Unclear Unclear Yes Yes No Yes Unclear Yes
Moro (9) Unclear Unclear No Unclear N/A N/A No Unclear

Aesthetic
Jones (10) Yes Unclear No No No No Unclear Yes

Fig. 3. Risk of bias assessment.

Please cite this article in press as: Glass GE, et al. Hilotherapy for the management of perioperative pain and swelling in facial surgery: a
systematic review and meta-analysis. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.07.003
YBJOM-4940; No. of Pages 6
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Fig. 4. Facial oedema: a forest plot showing a meta-analysis of hilotherapy compared with cold compression on postoperative day 2 (A), day 3 (B), and day
28 (C).

Fig. 5. Facial pain: a forest plot showing a meta-analysis of hilotherapy compared with cold compression on postoperative day 2.

detail to permit inclusion in the meta-analysis. All four stud- Discussion

ies included reported data on pain from postoperative day 2,
and because they were statistically heterogeneous (chi square
p = 0.005, I2 = 77%) a random effects model was used. Fig. 5
shows that there was a significant reduction in pain associated
with hilotherapy on postoperative day 2 (p < 0.00001).
Subjective satisfaction
Four trials evaluated the patients’ satisfaction with hilother-
apy or cool compression, using an ordinal scale from 1 to
4 where 1 was very “satisfied” and 4 was “not satisfied”. In
each case patients were asked to report their experience at the
time of discharge. The remaining trial, which simply reported
that eight of 15 patients found hilotherapy soothing, was
excluded from the meta-analysis.10 Studies included were
statistically homogeneous (chi square p = 0.39, I2 = 0%), so
a fixed effect model was used. As shown in Fig. 6, patients
were significantly more satisfied with hilotherapy than with
cold compression (p < 0.00001).
We have systematically evaluated the evidence for the use of
perioperative hilotherapy after facial surgery. Meta-analysis
showed that when it was used in the immediate postopera-
tive period it significantly reduced swelling within the first
72 hours. Patients reported that pain was significantly less
on postoperative day 2 and they were more satisfied with
dressings at the time of discharge. In most cases hilotherapy
was compared with cold compression, although two studies
(excluded from the meta-analysis) compared it with standard
facial dressings alone.
If patients who had both elective facial surgery and oper-
ations for trauma experience significantly less postoperative
pain and swelling after hilotherapy, then the recovery period
might be shortened, with implications for the resumption of
preoperative activities. This may also have implications for
the development and subsequent resolution of ecchymoses
which, although not assessed objectively in any of the stud-
ies, also contribute to the duration of recovery. As we seek to
make our patients as comfortable as possible, it is useful to
know that the hilotherapy facemask was well-tolerated and

Please cite this article in press as: Glass GE, et al. Hilotherapy for the management of perioperative pain and swelling in facial surgery: a
systematic review and meta-analysis. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.07.003
YBJOM-4940; No. of Pages 6
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Fig. 6. Subjective comfort and satisfaction: a forest plot showing a meta-analysis of hilotherapy compared with cold compression on semiquantitative scale at
discharge.
significantly more comfortable than cold compression dress-
ings during the early postoperative period, and it supports our
own observations.
One important caveat is that hilotherapy with Hilotherm®
is more expensive both in terms of hardware and nursing
than simple dressings. The cooling unit costs about £4500
(November 2015), and the cost:benefit ratio is for each prac-
titioner to consider.
The finding that hilotherapy was more effective than cold
compression may simply result from differences in surface
contact, with the contoured hilotherapy mask applied across
a wider area. Alternatively, standard cryotherapy is likely to
vary in temperature (becoming warmer over time), which
hilotherapy does not. Finally, the gauze dressing is likely
to exert a tangible, but poorly-defined, influence on thermal
conduction. Jones at al attempted to explain this, although
with only 15 patients and the lack of a standard, measurable
outcome they could draw no definite conclusions.10
Facial cooling exerts physiological influences that depend
on the temperature of the skin, so a system that applies
a regulated temperature for a given time yields a more
consistent physiological response than one with no such
regulation. For example, physiological cooling exerts an
autonomic-mediated vasoconstrictive effect which, in theory,
minimises oedema and ecchymosis. 17,18 At low temperatures
the activity of neutrophils, which synthesise proinflammatory
cytokines to mediate pain and swelling, is impaired. When
the local temperature falls below about 14 ◦ C the propaga-
tion of action potentials along autonomic and sensory nerves
is impaired (cold-induced neuropraxia), 19 resulting in para-
doxical vasodilatation and paraesthesia. Facial cooling also
results in bradycardia, and increases blood pressure and cere-
bral blood flow.20 Transient apnoea increases this bradycardic
response, which may have implications for postoperative
sedation with hilotherapy.21
Patients’ satisfaction with hilotherapy may have several
explanations. For example, once applied, the hilotherapy
mask does not have to be manipulated, unlike standard cold
compression gel packs, which required replacement. Naka-
mura et al found that during mild exposure to heat, thermal
comfort varied according to which area of the body was
cooled topically, with facial cooling inducing the greatest
comfort.22 These data suggest that facial cooling is inherently
soothing.
Our findings are at odds with those of Jones et al,
who randomised 50 consecutive patients who were having
Please cite this article in press as: Glass GE, et al. Hilotherapy for the management of perioperative pain and swelling in facial surgery: a
systematic review and meta-analysis. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.07.003
5
a superficial muscular aponeurotic system (SMAS)-based
rhytidectomy to Hilotherm® or standard dressings.10 They
reported no difference in facial oedema noted by a doctor on
day 1 and, in a subsequent arm of the study that involved
15 patients, reported greater subjective swelling at days 6-8
on the hemifaces randomised to perioperative Hilotherm®.
Martin et al described a study of 54 patients randomised to
have Hilotherm®, Hilotherm® dressings (not circulating), or
no dressings, after sagittal split osteotomy.23 They found no
differences in reported pain from days 1-7 in either group,
but the study lacked sufficient power to answer the question.
This systematic review was limited because of the paucity
of high-quality, randomised, controlled trials on the use
of hilotherapy in facial surgery. Those that we included
used the same methods in their approach, which supports
the need for standardisation. The meta-analysis is based on
146 patients, with the control intervention being cold com-
pression. While this control was probably adopted to satisfy
clinical equipoise, the reality is that often no topical treatment
is given in the perioperative period, so a further control arm
is advisable in future studies, as adopted by Moro et al.9 As
our systematic review has yielded analysable data from only
146 patients, it is clear that many surgeons use this technique
pragmatically rather than scientifically.
As the studies included all evaluated hilotherapy after elec-
tive and traumatic oral and maxillofacial surgery, the extent
to which our findings are relevant to aesthetic surgery may be
debated. However, extrapolation of the data about postopera-
tive swelling, pain, and patients’ satisfaction is reasonable.
None of the studies were designed to address specific con-
cerns related to aesthetic surgery such as ecchymosis and
haematoma that arise as a consequence of the creation of sur-
gical planes dissimilar to those used in these studies. Given
the paucity of data, it seems reasonable to call for well-
designed, randomised, controlled trials of hilotherapy in the
postoperative management of facial aesthetic surgery.
The second limitation of this review is that all the studies
suitable for meta-analysis were done by the same investiga-
tors. The addition of further studies by different groups using
robust techniques and standard data would be welcome.
Further research on the use of hilotherapy would be
improved if the features that define successful treatment
were clarified, and standard methods were used to obtain the
data. Volumetric data should be obtained using 3-dimensional
imaging, while subjective outcomes should use validated
scoring systems such as the VAS for pain. Studies would
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be further improved by specifying beforehand the times
for collection of data, rather than gathering them ad hoc
during follow up. Additionally, while hilotherapy was invari-
ably used perioperatively, the duration of application differed
among studies, and was governed by the nature of the pro-
cedure and whether the patient was treated as a day case or
an inpatient. The status of the patient is an important distinc-
tion as it remains the primary determinant of the potential
duration of hilotherapy.
Another variable is the type of mask used. One study used
a mask designed to cover the upper and middle third of the
face. While we felt that inclusion of this study was justified
as the volumetric data for both the intervention and con-
trol arms were equal and appropriate, our inclusion of third
molar extraction may be debated, but the fact remains that it
causes facial swelling and pain, and so enables an objective
comparison between hilotherapy and a control intervention.
In conclusion, when applied after bony facial surgery,
hilotherapy is well tolerated by patients and it reduces
swelling and pain in the early postoperative period. There are
insufficient data at present to support the use of hilotherapy to
reduce ecchymosis and haematoma formation, features that
also reflect surgical technique, tumescent infiltration, and the
use of drains. Well-designed randomised controlled trials of
the use of hilotherapy after aesthetic and soft tissue facial
surgery are required.
Conflict of Interest
We have no conflicts of interest. Specifically, we have been
given no incentive by Hilotherm GmbH.
Ethics statement/confirmation of patients’ permission
This meta-analysis does not identify any patients and does
not require any permission.
Appendix A. Supplementary data
Supplementary material related to this article can be
found, in the online version, at http://dx.doi.org/10.1016/
j.bjoms.2016.07.003.
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systematic review and meta-analysis. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.07.003
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