humano botulinica termografia

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British Journal of Oral and Maxillofacial Surgery 52 (2014) 90–92
Available online at www.sciencedirect.com
hort communication
ole of medical thermography in treatment of Frey’s
yndrome with botulinum toxin A
ichard James Green ∗, Simon Endersby, John Allen, James Adams
axillofacial Department, Queen Victoria Road, Newcastle, Tyne and Wear NE1 4LP, United Kingdom
ccepted 24 September 2013
vailable online 13 November 2013
bstract
rey syndrome classically causes gustatory sweating and facial flushing. We describe 2 cases in which medical thermography was used to
nvestigate the symptoms. Images were taken after patients chewed a sialagogue and 2 weeks later they were given injections of botulinum
oxin A. Images taken 4 weeks after treatment showed a considerable reduction in sweating and facial flushing, which was supported by the
esults of quality of life questionnaires completed before and after treatment. Medical thermography is much cleaner than the Minor’s starch
odine test. It identifies areas of gustatory sweating, changes in temperature, and vascular changes, which potentially enable treatment to be
argeted accurately.
2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
eywords: Frey’s syndrome; Medical thermography; Parotidectomy; Botulinum toxin A
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ntroduction
arotidectomy is commonly done for malignant and benign
arotid disease, and Frey syndrome has been reported as a
omplication in 6–96% of cases.1–4
Many methods have been used to identify areas of gusta-
ory sweating, the most common of which is Minor’s starch
odine test. However, we have found it cumbersome, partic-
larly in hair bearing regions, and although it can isolate the
rea that sweats, the area of facial flushing is often not iden-
ified. Many other methods have been trialled but none has
ained widespread acceptance.4–6
Medical infrared thermography produces images that
how surface temperature and it also can assess responses
7
o physiological challenges. Isogai and Kamiishi used
t to produce a qualitative assessment of sweating and to
ssess the degree of vascular change,8 but we know of no
∗ Corresponding author. Tel.: +44 191 233 6161.
E-mail address: Richardgreen81@hotmail.co.uk (R.J. Green).
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266-4356/$ – see front matter © 2013 The British Association of Oral and Maxillofacia
http://dx.doi.org/10.1016/j.bjoms.2013.09.013
urther published reports of it being used to investigate Frey
yndrome. We aimed to explore and develop a robust local
easurement protocol, and to undertake pilot assessments
o explore its clinical effectiveness.
ethod
e used medical thermography to show areas of sweating
nd vascular change in 2 female patients aged 61 and 46
ears. Both had had superficial parotidectomy for benign
isease and had developed chronic Frey syndrome as a
esult.
A protocol was produced, which included a period of
cclimatisation in a normothermic temperature and humidity-
ontrolled suite for 20 min. The relative humidity was
etween 30% and 40%. Images were collected using a ther-
al camera. The camera and humidity-controlled room were
lready available and were being used by the medical physics
epartment to investigate vascular conditions. The patients
ompleted a quality of life Frey questionnaire (graded in 13
l Surgeons. Published by Elsevier Ltd. All rights reserved.
dx.doi.org/10.1016/j.bjoms.2013.09.013
http://www.sciencedirect.com/science/journal/02664356
mailto:Richardgreen81@hotmail.co.uk
dx.doi.org/10.1016/j.bjoms.2013.09.013
R.J. Green et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 90–92 91
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Fig. 3. After treatment (case 1). Compared with Figs. 1 and 2 there is no
facial flushing or reduction in temperature at the symptomatic areas 6 min
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ig. 1. Before treatment (case 1). Increase in temperature over the parotid
egion 2 min after chewing the sialagogue (published with the patient’s
onsent).
easures giving a maximum score of 39) then chewed a sial-
gogue. Thermal images were taken at 1, 2, 6, 10, 15, and
0 min, and were assessed using dedicated thermal imaging
isualisation software (FLIR ThermaCAM Researcher, FLIR
ystems UK, West Malling, UK).
After 2 weeks, injections of botulinum toxin A (Dysport)
.5 U/0.1 ml were given intradermally to the areas of sweat-
ng and facial flushing in a 1 cm grid pattern. A total of
0 units were used.9 Patients were imaged again 4 weeks
ater.
esults
he first symptom to manifest was facial flushing. Before
reatment there was an obvious rise in temperature with facial
ushing in the preauricular and submandibular areas 2 min
fter chewing the sialagogue (white areas Fig. 1).
Gustatory sweating seemed to be worst 6 min after chew-
ng the sialagogue. Fig. 2 shows a reduction in temperature
round the preauricular and submandibular areas (dark
olouration) before treatment because of the evaporation of
weat. Fig. 3 shows excellent results after treatment with an
ig. 2. Before treatment (case 1). Cool areas anterior to the ear lobule
nd submandibular area, which indicate sweating 6 min after chewing the
ialagogue (published with the patient’s consent).
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fter chewing the sialagogue (published with the patient’s consent).
ppreciable reduction in facial flushing at 6 min and no evi-
ence of a reduction in temperature around the previously
ffected areas. Imaging of the second patient showed identical
esults.
Clinical findings were supported by the results of the qual-
ty of life questionnaires. Before treatment the scores were
7 and 9; after treatment both scored 4.
iscussion
lthough the numbers are small, we have shown a clear rela-
ion between clinical outcome measures and thermal imaging
easurements of flushing and sweating after stimulus. Since
he equipment is already in place in many medical physics
epartments, we prefer to investigate Frey syndrome with
edical thermography as it is fast and objective, and is less
nvasive and cumbersome than the standard Minor’s test. It
dentifies the vascular changes and changes in temperature,
hich so often trouble the patient, and enables more accurate
reatment with injections of botulinum toxin A.
onflict of interest
one declared.
eferences
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	Role of medical thermography in treatment of Freys syndrome with botulinum toxin A
	Introduction
	Method
	Results
	Discussion
	Conflict of interest
	References