Case-tailored indicated extracapsular dissection versus "one-size-fits-all" nerve dissection: Has the bet been won?

OBJECTIVE: The aim of the study was to trace the development of surgical therapy in a large cohort, examine its changes at one single institution that has been specializing in salivary gland pathologies over the last 22 years, and to determine the extent to which a possible shift in the surgical therapy of parotid benign tumors towards less radical methods was correlated with a change in the incidence of facial palsy and Frey's syndrome. STUDY DESIGN: Retrospective clinical study. METHODS: A retrospective evaluation of the records of all patients treated for benign parotid tumors at a tertiary referral center between 2000 and 2022 was carried out. Surgical methods were classified into four groups: extracapsular dissection, partial superficial parotidectomy, superficial parotidectomy and complete parotidectomy. RESULTS: A total of 4037 patients were included in the study. Our analysis demonstrated an increase in the total number of parotidectomies for benign lesions from 71 (2000) to 298 (2022), mostly due to the increase in extracapsular dissections (from 9 to 212). The increased performance of less radical surgery was associated with a significantly decreased incidence of perioperative complications. CONCLUSIONS: Our study showed that the increased performance of less radical surgery was associated with better functional outcomes over the years.

The Minor's test in Frey syndrome treated with botulinum toxin: Methodology and efficacy.

In this paper, we aimed at methodologically presenting a video-case of Frey Syndrome occurred after parotidectomy, assessed by means of Minor's Test and treated with intradermic botulinum toxin A (BoNT-A) injection. Although largely described in the literature, a detailed explanation of both the procedures has not been previously elucidated. In a more original approach, we also highlighted the role of the Minor's test in identifying the most affected skin areas and new insight on the patient-tailored approach provided by multiple injections of botulinum toxin. Six months after the procedure, the patient's symptoms were resolved, and no evident signs of Frey syndrome were detectable through the Minor's test.

Auriculotemporal Frey syndrome not associated with surgery or diabetes: systematic review.

Patients who undergo salivary gland, neck, or facelift surgery or suffer from diabetes mellitus often develop Frey syndrome (also known as auriculotemporal syndrome or gustatory sweating). Frey syndrome has been occasionally reported to occur in subjects without history of surgery or diabetes but this variant of Frey syndrome has not been systematically investigated. We searched for original articles of Frey syndrome unrelated to surgery or diabetes without date and language restriction. Article selection and data extraction were performed in duplicate. Our systematic review included 76 reports describing 121 individual cases (67 males and 54 females) of Frey syndrome not associated with surgery or diabetes. The age at onset of symptoms was ≤ 18 years in 113 (93%) cases. The time to diagnosis was 12 months or more in 55 (45%) cases. On the other hand, an allergy evaluation was performed in half of the cases. A possible cause for Frey syndrome was detected in 85 (70%) cases, most frequently history of forceps birth (N = 63; 52%). The majority of the remaining 22 cases occurred after a blunt face trauma, following an auriculotemporal nerve neuritis or in association with a neurocutaneous syndrome. The cause underlying Frey syndrome was unknown in 36 cases.   Conclusion: Frey syndrome not associated with surgery or diabetes almost exclusively affects subjects in pediatric age and is uncommon and underrecognized. Most cases occur after forceps birth. There is a need to expand awareness of this pseudo-allergic reaction among pediatricians and allergists. What is Known: • Pre-auricular reddening, sweating, and warmth in response to mastication or a salivary stimulus characterize Frey syndrome. • It usually occurs after salivary gland surgery and in diabetes. What is New: • In children, Frey syndrome is rare, and most cases occur after a forceps-assisted birth. • In childhood, this condition is often erroneously attributed to food allergy.

[Complications in the surgery of the parotid salivary glands. Causes, mechanisms of development, methods of prevention]. / Oslozhneniya v khirurgii okoloushnykh slyunnykh zhelez. Prichiny, mekhanizmy razvitiya, sposoby profilaktiki.

Operations for neoplasms of the parotid salivary gland require from the surgeon a deep knowledge of the anatomical and topographic features of this area and technical skill, which puts it in a number of «jewelry¼ operations that require patience and concentration. The review is devoted to the topic of specific postoperative complications after parotidectomy or subtotal resection of the gland. These include relapses of tumors, paralysis or paresis of facial muscles, Frey syndrome, salivary fistulas or sialocele, violation of skin sensitivity, soft tissue deformity. The review presents the frequency and causes of complications, mechanisms of their development, methods of prevention and elimination.

[Determining the degree of risk of postoperative complications in patients with a benign tumor of the parotid salivary gland]. / Opredelenie stepeni riska vozniknoveniya posleoperatsionnykh oslozhnenii u patsientov s dobrokachestvennoi opukhol'yu okoloushnoi slyunnoi zhelezy.

THE AIM OF THE STUDY: Determination of the risk of postoperative complications in patients after surgical treatment of benign neoplasms of the parotid salivary glands. MATERIAL AND METHODS: The results of treatment of 228 patients with benign neoplasms of the parotid salivary gland in the period from 2019 to 2021 were analyzed. A questionnaire of 7 questions was formed the answers to which allowed patients to be assigned to a certain risk group: low, medium, high or extremely high. This gradation allows choosing the optimal method and scope of surgical treatment for each patient individually. RESULTS: Patients of the first and second groups (low and medium risk) are characterized by the occurrence of temporary isolated facial nerve dysfunction with a short recovery period (up to 1 month), as well as sialocele associated with the preservation of a fragment of the gland. For the patients of the third and fourth groups (high and extremely high risk) in which parotidectomy was performed typical features included persistent paresis of facial muscles and facial soft tissue asymmetry. CONCLUSION: A personalized approach based on determining the degree of risk of postoperative complications helps surgeon in deciding on the scope of surgical treatment from subtotal resection to total parotidectomy.

Treatment approaches and outcomes associated with the use of abobotulinumtoxinA for the treatment of hyperhidrosis: A systematic review.

BACKGROUND: Botulinum neurotoxin type A has been used for the treatment of hyperhidrosis. OBJECTIVE: To perform a systematic review of the literature to identify evidence on the treatment approaches and outcomes associated with abobotulinumtoxinA (aboBoNT-A) treatment of hyperhidrosis. METHODS: EMBASE, MEDLINE, and the Cochrane Library were searched for relevant observational studies, randomized controlled trials, and nonrandomized controlled trials. There were no date or country restrictions. Bibliographies of review articles and recent congress proceedings (2017-2019) were also searched. Articles were screened using predefined eligibility criteria and relevant data were extracted. RESULTS: Of 191 unique articles identified, 23 were considered relevant (3 observational studies, 10 nonrandomized controlled trials, and 10 randomized controlled trials). These articles provided data on axillary (13), palmar (7), and forehead (1) hyperhidrosis, compensatory hyperhidrosis of the back (1), Frey syndrome (1), and diabetic gustatory sweating (1). All studies reported that aboBoNT-A reduced sweating and no serious adverse events were observed. Patient satisfaction was high and improvements to quality of life were observed after aboBoNT-A treatment. LIMITATIONS: Variability in the injection technique when data were compared across studies. CONCLUSION: This study describes a range of treatment approaches and demonstrates positive outcomes of aboBoNT-A treatment for multiple types of hyperhidrosis.

Acellular dermal matrix for prevention of Frey's syndrome after superficial parotidectomy of benign tumors.

PURPOSE: To evaluate: 1) the efficacy of acellular dermal matrix (ADM) to prevent Frey's syndrome (FS) after superficial parotidectomy of benign tumors. 2) the effect of different follow-up intervals on the incidence of FS. METHODS: Fifty-five patients with benign parotid gland tumors underwent superficial parotidectomy were divided into two groups: Non-ADM group (n = 31, 56.3%) and ADM group (n = 24, 43.6%). The primary outcomes measure was the incidence of FS. The secondary outcomes were surgical site depression, infection, salivary sialocele, and salivary fistula. Subjective FS was evaluated using a clinical questionnaire submitted via WeChat at 3, 6, 12, 18, 24, and 32 months postoperatively. Objective FS was evaluated using Minor starch-iodine test at 6 and 12 months postoperatively. RESULTS: There was a statistically significant difference in the incidence of subjective and objective FS when ADM compared with Non-ADM groups (P<0.05). The respective incidence of subjective FS at 3, 6, 12, 18, 24, and 32 months was 4.2%, 8.3%,20.8%, 20.8%, 20.8%, 20.8% in ADM group and 3.2%, 9.7%, 29%, 38.7%, 45.2% in Non-ADM group. The incidence of objective FS after 6 and 12 months was 4.2%, 8.3% in ADM group and 8.3% (2/24), 38.7% (12/31) in Non-ADM group respectively. Five patients in ADM group and 1 patient in Non-ADM group developed sialocele, and all patients resolved with conservative management. Surgical site depression was significantly higher in the Non-ADM group (15/31) compared with (5/24) in ADM (P=0.049). No cases of immune rejection, infection, hematoma, or salivary fistula were observed in ADM group. CONCLUSIONS: The current study demonstrated that 1) ADM could reduce the incidence of FS in the patients undergoing superficial parotidectomy. 2) the peak onset of about 18 months appear to be acceptable follow-up for the development of FS.

The effects of residual parotid volume on symptom-specific quality of life and complications in patients undergoing parotid surgery.

PURPOSE: To measure postoperative residual parotid volumes in parotidectomy patients and to measure the effect of residual parotid volumes on the symptom-specific quality of life (SSQOL) and complications. METHODS: Between January 2010 and December 2016, 148 parotid gland surgeries were performed, and 74 patients were included in the study. Bilateral parotid gland volumes were measured by Magnetic Resonance Imaging (MRI). Parotidectomy Outcome Inventory-8 and aesthetic scale questionnaire were applied to the patients. The volumetric averages obtained were compared with the questions in the SSQOL scale, the aesthetic scale data, and complications. RESULTS: In the volumetric examination performed with MRI, the mean residual volumes of the operated parotid glands were 9.5 cm3, while the non-operated side was 28.8 cm3. The width of the surgery and the residual parotid tissue volume was inversely correlated. There was a statistically significant difference between the residual parotid gland volume and the pain related to the surgical area, depression in the surgical site, Frey's syndrome, incision scar, and numbness. As the residual parotid gland volumes decreased, the patients' cosmetic problems related to the surgical field increased significantly, and their SSQOL decreased. CONCLUSION: Postoperative residual parotid tissue volume could be an objective parameter to measure patients' SSQOL and complications. After parotidectomy, the maximum amount of disease-free tissue of the parotid gland should be left in place to increase patients' quality of life and minimize complications.

Fat transfer after parotidectomy: fat resorption rates, aesthetic and functional outcomes of en-bloc fat graft versus lipofilling technique.

PURPOSE: Reconstruction of parotidectomy involves the correction of facial contour abnormalities and prevention from Frey Syndrome. Reconstruction of parotidectomy field with autologous fat has not been popular among head and neck surgeons due to unclear predictability of fat resorption rates. The aim of this paper is to compare the fat resorption rates between different fat transfer techniques using radiologic measurements and reviewing the aesthetic and functional outcomes. METHODS: We retrospectively reviewed medical records of patients, who underwent parotidectomy in Hacettepe University Hospital between 2015 and 2018. The aesthetic and functional outcomes of en-bloc fat graft and lipofilling techniques were compared among themselves, as well as with patients who had no reconstruction, using objective parameters. Fat resorption rates were compared using calculation of fat volumes obtained by MRI scans, 1 year after surgery. RESULTS: Among 77 patients, 26 underwent reconstruction with en-bloc fat graft (P-EBFG); 21 patients reconstruction with lipofilling technique (P-LFT), whereas 30 patients had no reconstruction of parotidectomy field (P-NR). In three groups, there was no statistically significant difference in mean resected parotid tissue volumes (mean 18 ± 10.8 cm3, p = 0.754). We found a significant difference in decreased presence of Frey Syndrome and increased satisfation rates of cosmetic appearance in P-EBFG and P-LFT, in comparison to P-NR (p < 0.001). There was no significant difference in fat resorption rates between P-EBFG (50.75 + 21.20%) and P-LFT (48.59 + 17.93%) (p = 0.771). CONCLUSION: Both en-bloc fat graft and lipofilling techniques have been found to be safe and to have similar fat resorption rates for reconstruction after parotidectomy.

Frey Syndrome, First Bite Syndrome, great auricular nerve morbidity, and quality of life following parotidectomy.

PURPOSE: Parotidectomy may be burdened by numerous complications that may worsen subjects' quality of life (QoL). These include paresis or paralysis of the facial nerve, face profile asymmetry, keloids, salivary fistula, Frey Syndrome (FS), First Bite Syndrome (FBS), and hypo-anaesthesia of the skin. This study is an effort to assess the incidence of complications following parotidectomy and their impact on subjects' QoL. METHODS: Subjects undergoing parotidectomy for benign neoplasms from 2012 to 2015 were selected and invited to attend our outpatient clinic. After a brief anamnesis, the medical examiners tested their tactile perception and performed the Minor test for FS. Depending on the complications showed, subjects were asked to complete from 1 to 4 questionnaires about their QoL. RESULTS: 76 subjects completed the medical examination. The most frequent complication was the hypo-anaesthesia of the skin (71%). 21 subjects (28%) were positive to the Minor test, while 8 subjects (11%) reported FBS-compatible symptoms. Two subjects (3%) showed a facial nerve paralysis. Free abdominal fat graft was used in 16 subjects (21%) and it was associated with a lower incidence of FS. Surgery of the deep lobe of the parotid was associated with FBS. CONCLUSIONS: FBS appears to have a greater influence on subjects' QoL than FS and hypo-anaesthesia of the skin. Moreover, this work confirms that surgery of the deep lobe of the parotid is a risk factor for developing FBS and the free abdominal fat graft is a reliable technique to prevent FS.

Frey's syndrome: diagnosis in geriatric dentistry.

Frey's syndrome, is characterized by warmth, flushing and sweating of the face, most of time in the preauricular region, initiated by any gustatory stimulus. It is frequently related to parotid surgery. A case of Frey's syndrome in a 81-year-old female whose long-delayed clinical onset post-parotidectomy is presented.

Late Prevalence of Typical and Atypical Symptoms of Frey's Syndrome after Parotidectomy for Benign Tumor.

BACKGROUND: The treatment of choice for tumors located in the parotid gland is surgery. Nevertheless, postoperative complications are not infrequent. Regardless of the type of surgical procedure, the most common complication is Frey's syndrome (FS). Traditionally, FS includes unilateral gustatory sweating and flushing of the facial skin lining the parotid compartment. Recent research describes atypical discomfort associated with FS. The aim of this study was to assess the late prevalence and severity of both usual and atypical symptoms after parotidectomy for benign tumors. METHODS: We conducted a cross-sectional study involving 86 subjects who underwent superficial parotidectomy at least one year before the study. The questionnaire included the sweating-flushing-itch-paresthesia-pain (SFIPP) Frey scale supplemented by specific questions about symptoms. RESULTS: Sixty-seven out of eighty-six (77.9%) cases reported almost one symptom. The most frequent symptom was itch (36/67-53.7%), followed by pain (35/67-52.2%), while 28/67 (41.8%) subjects complained of atypical symptoms without flushing or sweating. A desire to treat the discomfort was reported by 50/67 (74.6%) subjects. CONCLUSIONS: Late postparotidectomy local discomfort is not infrequent and includes both usual and "unusual" symptoms almost equally. Our results suggest the importance of informing patients about the occurrence of the syndrome and the available treatment options during pre- and postoperative counseling.

Factors influencing Frey syndrome after parotidectomy with acellular dermal matrix.

BACKGROUND: Frey syndrome, also known as ototemporal nerve syndrome or gustatory sweating syndrome, is one of the most common complications of parotid gland surgery. This condition is characterized by abnormal sensations in the facial skin accompanied by episodes of flushing and sweating triggered by cognitive processes, visual stimuli, or eating. AIM: To investigate the preventive effect of acellular dermal matrix (ADM) on Frey syndrome after parotid tumor resection and analyzed the effects of Frey syndrome across various surgical methods and other factors involved in parotid tumor resection. METHODS: Retrospective data from 82 patients were analyzed to assess the correlation between sex, age, resection sample size, operation time, operation mode, ADM usage, and occurrence of postoperative Frey syndrome. RESULTS: Among the 82 patients, the incidence of Frey syndrome was 56.1%. There were no significant differences in sex, age, or operation time between the two groups (P > 0.05). However, there was a significant difference between ADM implantation and occurrence of Frey syndrome (P < 0.05). ADM application could reduce the variation in the incidence of Frey syndrome across different operation modes. CONCLUSION: ADM can effectively prevent Frey syndrome and delay its onset.

An Extremely Delayed Onset of Frey Syndrome: A Case Report and Literature Review.

We report the case of an 80-year-old man with Frey syndrome that developed 30 years postoperatively, which is an exceptionally long period before its occurrence. Sweating and flushing occurred on only the side of his face where the surgery was performed, and he had no other causative abnormalities. Following treatment with botulinum toxin, the patient's symptoms resolved. Extremely early- and late-onset cases do not fit the conventional paradigm of this pathology. Various surgical methods to prevent this syndrome have been explored, but complete prevention has not yet been achieved. These findings suggest that the underlying pathophysiology of Frey syndrome may be more complex than previously recognized.

SMAS flap for extracapsular dissection of parotid gland tumors: is it necessary?

OBJECTIVE: The aim of this retrospective article is to evaluate postoperative outcomes after extracapsular dissection for small benign superficial parotid neoplasms (<3 cm) in patients who received Superficial Musculoaponeurotic System (SMAS) flap and in patients who did not receive it. METHODS: Two groups were created and statistically compared regarding Frey's syndrome and aesthetic satisfaction by data collected through the POI-8 validated questionnaire and through an aesthetic satisfaction scale ranging from 1 to 10. The difference between these two groups was the utilization of SMAS flap. SMAS flap was harvested in one of these two group, meanwhile was not used in the other. RESULTS: The p-value analysis between group 1 and group 2 on these complications, resulted statistically not significant. Also, the aesthetic satisfaction resulted not statistically significant between group 1 and group 2. Gender, localization, and facial palsy resulted statistically correlated with the aesthetic satisfaction (p-value < 0.05). CONCLUSION: In conclusion, there is no statistical difference in the use of SMAS flap for benign parotid neoformations of the superficial lobe, with a diameter of less than 3 cm for which extracapsular dissection is adopted as a surgical technique.

Treatment of Frey Syndrome with Botulinum Toxin-A: A Practical Approach from Minor's Test to Injection.

Introduction: Frey's syndrome, described by Lucy Frey in 1923, is a unique condition characterized by sweating, flushing, and reddening as a direct response to mastication. This phenomenon results from the aberrant regeneration of postganglionic parasympathetic neurons originating from the auriculotemporal nerve and the subsequent acetylcholine secretion induced by masticatory stimuli. Although rare, this syndrome can have multiple underlying causes and is frequently observed, occurring in up to 65% of cases following lateral parotid resections. Additionally, it can less commonly manifest after neck dissection, facelift procedures, or be associated with diabetes mellitus. Method: This article outlines a comprehensive diagnostic algorithm for Frey's syndrome, which includes the utilization of the Minor-Starch-Iodine Test. This test is a key component in diagnosing the syndrome and is discussed in detail, providing insights into its procedure and interpretation. Additionally, the gold standard of treatment for established Frey's syndrome, botulinum toxin A, is thoroughly described, including its mechanism of action, administration, and potential side effects. Discussion: Finally, the article underscores the need for further research to enhance our understanding of Frey's syndrome, leading to better diagnostic methods and more tailored treatment options for patients.

Perplexing First Branchialcleft Anomalies-A Case Series with Review of Literature.

Incomplete obliteration of the branchial apparatus results in the formation of branchial cleft anomalies. First branchial cleft anomalies may persist anywhere in the first branchial arch, from the external auditory canal at the level of the bony cartilaginous junction to the submandibular triangle. The majority of cases present in childhood as an opening in the skin though they may present as cysts or neck masses, mostly mistaken for neck abscesses which leads to inadequate treatment and complications. Here different cases of first branchial cleft anomalies with variable presentation and treatment are illustrated. The need for proper diagnosis and adequate treatment cannot be overemphasized to avoid mismanagement and complications.

Frey syndrome after conservative parotidectomy: Importance of closing the remnant parotid parenchyma.

BACKGROUND: Frey syndrome (FS) is a typical late complication following parotidectomy. Parotid surgery without proper coverage or reconstruction of exposed parotid parenchyma may contribute to the development of FS. Therefore, this study compared the closure versus the non-closure of exposed parotid parenchyma in the occurrence of FS. METHODS: This study included 195 patients with parotid lesions who underwent partial or superficial parotidectomy plus closure or non-closure of exposed parotid parenchyma, both with the application of fibrin glue. Two surgical methods of closure and non-closure were allocated to patients without randomization and blinding processes. The primary outcome was FS, and the second outcome was other complication rates. RESULTS: The closure and non-closure of exposed parotid parenchyma were performed in 102 and 93 patients, respectively. Early postoperative complications occurred with temporary events: transient facial weakness, 32 (16.4%); hematoma, 13 (6.7%); and wound infection, 2 (1.0%), without statistical difference between the two groups (P > 0.1). However, sialocele occurred in the non-closure group (n = 19) more than in the closure group (n = 7) (P = 0.005). In the first postoperative year, decreased sensation and local pain were found in 16 patients (8.2%) and 9 patients (4.6%), respectively, with no statistical difference between the two groups (P > 0.1). FS was found more in the non-closure group (n = 19, 20.4%) than in the closure group (n = 4, 3.9%) (P < 0.001). CONCLUSION: The closure of exposed parotid parenchyma and covering fascia is preferred over the non-closure to prevent FS.

Prevalence of Frey syndrome following extraoral surgical treatment for mandibular fractures: a systematic review and meta-analysis.

Our study aims to estimate the prevalence of Frey syndrome following open reduction and internal fixation (ORIF) for mandibular fractures. Two reviewers independently conducted a systematic literature search in the Medline and Scopus databases. The pooled prevalence with 95% confidence intervals (CI) was estimated, and quality assessment, outlier analysis, and influential analysis were performed. In total, fifteen eligible studies were included in this meta-analysis. One study was identified as critically influential. The overall prevalence of Frey syndrome following extraoral surgical treatment for mandibular fractures was estimated as 0.01% (95%CI 0%-0.7%) with moderate heterogeneity observed between studies. In the meta-regression analysis with continuous variables, no statistically significant association was observed. Despite the relatively low prevalence, the impact of Frey syndrome on affected individuals should not be underestimated. Additional research will provide a more comprehensive understanding of the underlying factors contributing to Frey syndrome, leading to improved preventive measures and treatment strategies. A better grasp of the prevalence and associated risk factors will aid in the development of guidelines to minimize the occurrence of this syndrome.