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Gustatory sweating is an unusual entity that may occur as an idiosyncratic reaction to certain foods, as a localized reaction to trauma or infection, or as the result of diabetic neuropathy. This report deals with a severe case of diabetic gustatory sweating, discusses the various types of gustatory sweating, and reviews the English literature dealing with the diabetic form.
Gustatory sweating is a potential manifestation of autonomic dysfunction in diabetes. This syndrome is seen in long-standing diabetes and is associated with nephropathy, peripheral neuropathy, and other signs of dysautonomia. Symptoms of profuse head and neck diaphoresis with eating may suggest this clinical diagnosis. We present a patient who had complicated diabetes with symptoms of gustatory sweating and other evidence of dysautonomia. Diagnosis and treatment possibilities are discussed, with a review of the literature and an emphasis on bedside testing.
PURPOSE: To determine whether purified botulinum toxin might be as effective in the treatment of "crocodile tears" (gustatory epiphora) as it has been in the treatment of other hypersecretion syndromes such as Frey's syndrome (gustatory sweating). METHODS: One patient with Frey's syndrome (gustatory sweating) was successfully treated with botulinum toxin. After this, two patients with chronic symptomatic crocodile tears (related to previous facial palsy) were treated with botulinum toxin injections into and around the lacrimal gland. RESULTS: Both patients reported remarkable relief from symptoms and were observed to have no tearing while eating. CONCLUSIONS: Purified botulinum toxin appears to be an effective treatment for crocodile tears.
Gustatory sweating has been only rarely reported in diabetes mellitus and is thought to be due to axonal regeneration within the autonomic nervous system. We investigated the relationship of gustatory sweating to other diabetic complications. 196 patients in four groups (diabetic nephropathy, diabetic neuropathy, diabetic controls, and non-diabetic renal failure) were questioned about gustatory sweating. Somatic and autonomic neuropathy were assessed by clinical signs, vibration perception threshold, and heart rate variability. Sixty-nine percent of patients with nephropathy and 36% of those with neuropathy reported gustatory sweating, whereas less than 5% reported it in the other two groups. Five subjects reported that gustatory sweating either disappeared or significantly improved immediately after renal transplantation. Analysis of the nephropathy and neuropathy groups separately showed a strong correlation between gustatory sweating and degree of neuropathy (p < 0.01). This study shows that gustatory sweating is much more common than previously believed and demonstrates that it is often very closely linked with diabetic nephropathy.
Gustatory sweating as a feature of autonomic neuropathy is an unusual phenomenon in diabetes mellitus. We describe a patient with type 1 diabetes mellitus complicated by retinopathy, nephropathy and neuropathy. This patient presented with bilateral diffuse facial sweating during eating. She was treated with the antimuscarine agent oxybutynine, which provided a striking relief from the gustatory sweating.
The treatment of gustatory sweating in diabetes mellitus is usually with oral anti-cholinergic drugs, but these frequently lead to unacceptable side effects. Glycopyrrolate is an anti-muscarinic agent that can be applied topically and is efficacious in gustatory sweating occurring in other conditions. In a double-blind placebo-controlled crossover study, we assessed the value of glycopyrrolate in 13 diabetic patients with gustatory sweating. Sweating was measured by a sweat challenge, and diaries recorded by the patients throughout the 2 weeks of each treatment period. Compared to placebo, glycopyrrolate reduced the sweat response to a challenge by 82% (p < 0.01). The frequency of episodes of gustatory sweating during the treatment period was also reduced by 51% (p < 0.01), with a nearly 100% reduction in the frequency of episodes of severe sweating (p < 0.01). In conclusion, topically applied glycopyrrolate is a very effective treatment in reducing both the severity and frequency of diabetic gustatory sweating.
Gustatory sweating is an autonomic disorder that frequently occurs after parotid gland surgery. We investigated the action of intracutaneous injections of botulinum toxin (BTX) (1.0-2.0 mouse units/2.25-cm2 skin area) in 45 patients (mean age, 52 years) with gustatory sweating. The area of hyperhidrosis was determined by Minor's iodine test before and up to 24 weeks after the injection. The effect of BTX was assessed by measuring the hyperhidrotic area. The maximum BTX-induced reduction of gustatory sweating was seen at 7.4 +/- 4.5 days after injection. The area of sweating decreased from 17.6 +/- 8.6 cm2 before BTX to 1.3 +/- 1.6 cm2 after BTX (p < 0.0001). Half the patients rated gustatory sweating subjectively as completely abolished, and the remainder felt pronounced improvement. No toxic effects were observed. In none of the patients did hyperhidrosis recur over a 6-month follow-up. We conclude that BTX is a safe and effective treatment that can be recommended as the therapy of choice in gustatory sweating.
Gustatory sweating results from a disruption of the auriculotemporal nerve pathways. Damage to the nerve may cause a misdirected re-growth that results in parasympathetic innervation of sympathetic receptors and, therefore, facial sweating and flushing with gustatory stimulation. Over the past 300 years, the history of gustatory sweating has included observations of typhus-induced parotiditis, war injuries, and occupational accidents. Despite religious and personal persecution, Lucja Frey (1889-1943) systematically investigated gustatory sweating. Following the discovery of a German World War II document regarding Lucja Frey, an international committee was organized to research the history of gustatory sweating and of Dr. Frey's contributions to the understanding of the syndrome. Twenty original scientific publications from 1700 to 1950 on gustatory sweating were reviewed. Frey was the first to describe gustatory sweating as a disorder of both sympathetic and parasympathetic innervation. She proposed novel pathologic and pharmacologic mechanisms to explain the syndrome. Subsequent discoveries, including the work of André-Thomas in 1927, have provided a more complete understanding of gustatory sweating and the pathologic mechanism of aberrant neuronal regeneration.
Gustatory sweating is a reflex, localized production of sweat associated with sight, smell, or ingestion of food. It involves most commonly the area of the auriculo-temporal nerve where it produces the well known Frey's syndrome. The pathophysiology of the syndrome is described with the aid of diagrams. Anatomically related syndromes are explained, namely the chorda tympani syndrome, crocodile tears, xerophthalmia of the suprageniculate facial nerve palsy, and the partial (otogenic) Horner's syndrome.
Three patients suffering from gustatory sweating following trauma to the preauricular region from a bullet wound or parotid gland surgery were treated by intracutaneous injection of botulinum toxin A. Within 2 weeks, gustatory sweating in the area injected completely ceased in all patients with no side-effects. The efficacy of treatment was confirmed by repeated Minor's iodine starch tests. So far, sweating has not recurred during a follow-up period of up to 8 months. Botulinum toxin appears to be a promising new drug for the treatment of this autonomic disorder.
OBJECTIVE: To evaluate the duration of effectiveness of intracutaneous injection of botulinum toxin type A for gustatory sweating as well as the incidence, severity, management, and outcome of recurrent gustatory sweating. DESIGN: An inception cohort with a minimum of 18 months of follow-up. SETTING: A tertiary care center and university teaching hospital. PATIENTS: Thirty-three patients with severe gustatory sweating. INTERVENTION: Intracutaneous injection of 25 to 175 IU (mean, 86 IU) of botulinum toxin type A. MAIN OUTCOME MEASURES: Analysis of the effectiveness of the intracutaneous injection of botulinum toxin type A using the Kaplan-Meier actuarial life-table method; completion of the Minor starch-iodine test in patients without symptomatic recurrent gustatory sweating; and the patients' self-assessment of the severity of the recurrent gustatory sweating. RESULTS: The 1-, 2-, and 3-year actuarial estimate for symptomatic recurrent gustatory sweating was 27%, 63%, and 92%, respectively. In the 7 patients without symptomatic recurrent gustatory sweating, the Minor starch-iodine test revealed persistent gustatory sweating in 6, resulting in an overall 97% rate (32 of 33 patients) for recurrent gustatory sweating. No statistical relationship could be demonstrated between the duration of effectiveness, the incidence of recurrent gustatory sweating, the severity of recurrent gustatory sweating, and the following variables: age, sex, cause of gustatory sweating, skin surface involved, and dose of botulinum toxin type A injection. Within the group of 26 patients with symptomatic recurrent gustatory sweating, (1) the severity of the recurrent gustatory sweating was always reduced when compared with the severity of the initial gustatory sweating, and (2) the recurrent gustatory sweating always remained amenable to reinjection of botulinum toxin type A. CONCLUSIONS: The present series demonstrated a linear regression in the effectiveness of the intracutaneous injection of botulinum toxin type A in patients with gustatory sweating, while no factors appeared to be statistically related to the duration of effectiveness and/or the incidence of recurrent gustatory sweating. However, because the severity of recurrent gustatory sweating is reduced when compared with the severity of the initial gustatory sweating and because recurrent gustatory sweating remains amenable to reinjection of botulinum toxin type A, we believe that the intracutaneous injection of botulinum toxin type A should become the first-line treatment option in patients with gustatory sweating.
Several therapeutic approaches exist to treat gustatory sweating (Frey's syndrome) following parotidectomy. Because of the lack of effective treatment, a new therapeutic modality using botulinum toxin injections was presented previously by our group. The duration of the demonstrated positive effect was essentially unknown so far. Based on our experiences using this technique since December 1993, the purpose of this clinical investigation was to make an up-to-date report and demonstrate the duration of effect of BOTOX injections in patients with severe gustatory sweating. Nineteen patients with severe gustatory sweating have been treated with BOTOX by intracutaneous injections into the affected skin areas. The maximal follow-up time was 33 months. The results were obtained by interviews and controls using Minor's starch iodine test. In all treated cases (n = 19 patients, 22 treated sides) gustatory sweating ceased completely within 2 days. Side effects were absent. In 12 patients gustatory sweating reappeared. The mean duration of effect was 17.3 months (subjective personal communication of 18 patients). Findings show that intracutaneous injection of BOTOX is a highly effective, safe, and minimally invasive treatment of Frey's syndrome with long-lasting therapeutic effect.
Mechanisms of physiological gustatory sweating and flushing were investigated in 21 patients with a facial nerve lesion compromising parasympathetic outflow to the lacrimal gland, and in 13 patients undergoing diagnostic blockade of the stellate ganglion. Vascular responses and electrodermal activity (which reflects sweating) were monitored on each side of the forehead before and during gustatory stimulation with chillies or Tabasco sauce (derived from chillies). Vascular responses in the cheeks were also monitored in 14 patients with a facial nerve lesion. Sympathetic blockade increased gustatory vasodilatation but prevented gustatory sweating on the blocked side of the forehead. A facial nerve lesion did not affect gustatory sweating in the forehead or vasodilatation in the cheeks. However, a facial nerve lesion impaired vasodilatation in the forehead in all six patients who ate chillies, and also in four of five patients whose blood vessels dilated extensively on the normally-innervated side of the forehead when the patients tasted Tabasco sauce. These findings suggest that sympathetic sudomotor activity mediates physiological gustatory sweating in the forehead, whereas sympathetic vasoconstrictor tone inhibits gustatory vasodilatation in the forehead. A parasympathetic vasodilator reflex in the facial nerve contributes actively to gustatory flushing in the forehead, but some other unidentified mechanism influences vascular responses in the cheeks.
Frey's syndrome is present in almost all patients after parotidectomy. Gustatory sweating reduces quality of life. Injections of botulinum toxin A have recently been described as effective. This study was designed to evaluate the efficacy of this new treatment. Nineteen patients with severe gustatory sweating following superficial parotidectomy were treated. One unit/cm2 botulinum toxin A was injected intracutaneously into the affected area once. Minor's starch iodine test was performed to prove the outcome of therapy 4 weeks later. Eight patients lost their sweating. However, another seven patients had some blue spots on their cheeks. In four patients whose sweating had extended beyond the hairline, remnants of gustatory sweating showed up. Overall, the affected area of gustatory sweating could be reduced by botulinum toxin A from an average of 31 cm2 before treatment to 4 cm2 after treatment. Although there were some remnants of sweating in a few patients, Frey's syndrome was gone in all cases. No side effects could be observed. Intracutaneous injections of botulinum toxin A are highly effective and safe in treatment of gustatory sweating.
BACKGROUND: Gustatory sweating is a common complication of parotid surgery. Injection of botulinum toxin A has been reported as a safe and effective treatment option for patients with Frey's syndrome. PATIENTS AND METHODS: A total of 69 patients who had undergone superficial parotidectomy because of adenoma were evaluated with respect to the incidence of Frey's syndrome and treatment interest. Minor's iodine starch test was used to detect the affected skin area. Affected skin areas were documented using a digital camera; skin areas were evaluated morphometrically. A single injection of Botox per 1 cm(2) skin field was administered to those patients interested in treatment. RESULTS: Of 43 patients (62%) with gustatory sweating, 33 patients requested treatment. The affected skin area varied from 16 cm(2) to 81 cm(2). The individual Botox dosage ranged from 16 to 80 IU. All relevant clinical symptoms of sweating disappeared within 1 week after a single injection. Treatment was well tolerated with no side effects. CONCLUSION: Botox A injection is a safe and effective treatment with long-lasting effects for patients with extensive gustatory sweating.
Gustatory sweating is a relatively common sequela to parotidectomy and is almost always unilateral in nature. This article presents a case of bilateral gustatory sweating in a patient with no history of facial trauma or surgery who was undergoing periodontal therapy. A thorough examination determined the cause of diaphoresis to be autonomic neuropathy as a result of a 26-year history of Type II diabetes mellitus. Few cases of this rare complication of diabetes have been described, and the current case represents the first report in the dental literature.
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