JCN Open Access LETTER TO THE EDITOR

pISSN 1738-6586 / eISSN 2005-5013 / J Clin Neurol 2019;15(4):585-587 / https://doi.org/10.3988/jcn.2019.15.4.585

A Case of Frey’s Syndrome Diagnosed and Followed Up

Using the Quantitative Sudomotor Axon Reflex Test

Jaehwan Kim Dear Editor,

Minkyung Kim
YeEun Kim
Hye Lim Lee
Department of Neurology,
Korea University Guro Hospital,
Korea University College of Medicine,
Seoul, Korea
Received April 26, 2019
Revised June 18, 2019
Accepted June 26, 2019
Correspondence
Hye Lim Lee, MD
Department of Neurology,
Korea University Guro Hospital,
Korea University College of Medicine,
148 Gurodong-ro, Guro-gu,
Seoul 08308, Korea
Tel +82-2-2626-3046
Frey’s syndrome (also called focal gustatory hyperhidrosis) is a rare neurologic disorder
presenting with abnormal facial sweating when consuming meals. The syndrome had been
reported in up to 53% of parotidectomy patients, and may occur due to injury or inflamma-
tion of the parotid or submandibular glands, or the cervical sympathetic trunk.1,2 The diag-
nosis is traditionally made based on clinical symptoms and a starch iodine test.3 This test, while
sensitive to the diagnosis of focal hyperhidrosis, does not adequately quantify sweat secretion.
We report a case in which we performed the quantitative sudomotor axon reflex test (QSART)
to diagnose focal hyperhidrosis, and assessed the therapeutic effect at follow-up.
A 45-year-old man visited a department of neurology for sweating in the left auriculotem-
poral area while consuming meals or chewing. He reported that the symptom began at ap-
proximately 30 years of age and was more severe when eating hot or sour foods. A benign
branchial cleft cyst had been surgically removed from the left side of his neck in infancy. Ad-
ditionally, he underwent endoscopic submucosal dissection due to early gastric cancer 1 month
prior to admission, but was not taking any medication. During a neurologic examination he
reported experiencing hypesthesia at the operation site since childhood. Laboratory tests in-
cluding thyroid function and blood sugar, autoimmune antibody tests, electrophysiologic tests,
and brain CT revealed no abnormalities.
We performed the QSART using the Q-Sweat device (WR Medical, Maplewood, MN,
USA) in both auriculotemporal areas, as well as on the left arm and leg.4 We observed ex-
cessive sweating in the left but not the right auriculotemporal area when the patient was
chewing gum (Fig. 1A). Hyperhidrosis was also observed in the left auriculotemporal area
upon stimulation with acetylcholine (Fig. 1B).
The nightly application of aluminum chloride cream greatly reduced his symptoms. The to-
tal sweat volume in the left auriculotemporal area while chewing was significantly reduced
at a 2-month follow-up (Fig. 1C).
Our use of the QSART confirmed the presence of excessive sweat secretion in the symp-
tomatic auriculotemporal site induced both by either stimulation with acetylcholine or chew-
ing. Frey’s syndrome may be caused by aberrant innervation of sympathetically innervated
facial sweat glands by postganglionic parasympathetic nerve fibers in damaged tissue.5 There-
fore, mastication, which releases acetylcholine from parasympathetic nerve endings, results
in sweating. The mechanism underlying Frey’s syndrome in our patient was unclear, since the
patient had undergone neck surgery during infancy and the symptoms occurred only when
he reached his thirties. However, a case of delayed Frey’s syndrome occurring 40 years after
surgery has been reported.6 Our patient reported hypesthesia at the operation site, which might
indicate the presence of similar aberrant re-innervation of the postganglionic nerve fibers near
the site of his neck operation.
The QSART is a quantitative type of sudometry that is commonly used to diagnose early dia-
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JCN Frey’s Syndrome Using QSART

betic polyneuropathy or small-fiber neuropathy.7 A few studies
have assessed the effectiveness of treatments in patients with
hyperhidrosis,8,9 and found the QSART to be useful in measur-
ing the therapeutic effects. The present case has demonstrated
that the QSART may also be equally useful in Frey’s syndrome.
Focal hyperhidrosis could have a negative impact on social
interactions, resulting in a reduced quality of life.3 It is there-
fore important to diagnose focal hyperhidrosis and assess the
possible treatment effects in order to treat it satisfactorily, for
which we believe that the QSART may be helpful.

1,500

Test site: Lt. cheek

Sweat rate (nL/min)

Total volume (μL): 9.784 1,000
Totalized time: 10:00

Chewing start

Chewing stop
Response latency: 0:20
Baseline rate (nL/min): 98.8
500
Ending offset (nL/min): 416.1

0
00:00 05:00 10:00
500

400
Test site: Rt. cheek
Sweat rate (nL/min)

Total volume (μL): 0.051 300

Totalized time: 10:00
Chewing start

Chewing stop
Response latency: 0:15
200
Baseline rate (nL/min): 57.5
Ending offset (nL/min): 3.6
100

0
A   00:00 05:00 10:00

1,200

1,000
Sweat rate (nL/min)

Test site: Lt. cheek 800

Ach injection

Total volume (μL): 4.697

Totalized time: 10:00 600
Response latency: 0:12
Baseline rate (nL/min): 328.5 400
Ending offset (nL/min): 366.1
200

0
00:00 05:00 10:00
500

400
Sweat rate (nL/min)

Test site: Rt. cheek

Total volume (μL): 0.225 300
Totalized time: 10:00
Ach injection

Response latency: 1:12

200
Baseline rate (nL/min): 62.7
Ending offset (nL/min): 0.9
100

0
B 00:00 05:00 10:00

Fig. 1. The results of QSART. A: QSART findings in both auriculotemporal areas. Excessive sweating was observed on the left side after chewing gum.
B: The sweat volume was larger in the left than the right auriculotemporal area. C: Sweating was significantly reduced on the left side after treatment
with aluminum chloride cream at a 2-month follow-up. QSART: quantitative sudomotor axon reflex test.

586 J Clin Neurol 2019;15(4):585-587

 Kim J et al. JCN
500

400
Test site: Lt. cheek

Sweat rate (nL/min)

Total volume (μL): 1.055 300

Chewing start
Totalized time: 10:00

Chewing stop
Response latency: 0:21
200
Baseline rate (nL/min): 81.2
Ending offset (nL/min): 21.2
100

0
00:00 05:00 10:00
500

400
Test site: Rt. cheek Sweat rate (nL/min)
Total volume (μL): 0.323 300
Totalized time: 10:00

Chewing start

Chewing stop
Response latency: 1:06 200
Baseline rate (nL/min): 59.6
Ending offset (nL/min): 11.5
100

0
C 00:00 05:00 10:00

Fig. 1. The results of QSART. A: QSART findings in both auriculotemporal areas. Excessive sweating was observed on the left side after chewing
gum. B: The sweat volume was larger in the left than the right auriculotemporal area. C: Sweating was significantly reduced on the left side after
treatment with aluminum chloride cream at a 2-month follow-up. QSART: quantitative sudomotor axon reflex test (continued).

Author Contributions
Conceptualization: Hye Lim Lee. Investigation: Jaehwan Kim, YeEun Kim,
Minkyung Kim. Methodology: Jaehwan Kim, YeEun Kim, Minkyung Kim.
Supervision: Hye Lim Lee. Writing—original draft: Jaehwan Kim. Writ-
ing—review & editing: Hye Lim Lee.
ORCID iDs
Jaehwan Kim https://orcid.org/0000-0002-3415-6877
Minkyung Kim https://orcid.org/0000-0003-0694-9906
YeEun Kim https://orcid.org/0000-0002-9790-123X
Hye Lim Lee https://orcid.org/0000-0002-9800-3263
Conflicts of Interest
The authors have no potential conflicts of interest to disclose.
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