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Frey's syndrome: a masquerader of food allergy
  1. Nahin Hussain,
  2. Muthu Dhanarass,
  3. William Whitehouse
  1. Department of Paediatric Neurology, Queen Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
  1. Correspondence to Dr Nahin Hussain, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester LE15WW, UK; dr_nahin{at}yahoo.com

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A 6-year-old girl was referred to the paediatrician with a 5-year history of erythema on both her cheeks precipitated by eating sweets, citrus fruit, grapes, tomato sauce, fruit-flavoured ice creams and spicy foods. She was born at term by normal vaginal delivery following an uneventful pregnancy. Her mother first noticed the condition when the girl was 6 months old after she had eaten fromage frais for the first time. It regularly appeared when she ate sweets or citrus fruits but never with bland food or drink. The erythema was not associated with pain or discomfort, redness of eyes or sweating. She had no history of atopy, asthma or allergy. It did not affect her daily activities, but her teachers, who noticed it at school, raised the possibility of food allergy. Examination showed no swelling, tenderness in the face or lymphadenopathy, and the parotid gland region was normal. Erythema of the face appeared within a minute of the child chewing a citrus-flavoured sweet; there was no clinically evident hyperhidrosis (figure 1). She was diagnosed as having Frey's syndrome.

Figure 1

Before (top) and after (bottom) eating a sweet. Erythema over the cheeks.

Auriculotemporal nerve (Frey) syndrome consists of the development of facial flushing or sweating over the distribution of the nerve immediately after eating or drinking.1 It was first described by Duphenix in 1757, but rediscovered by Frey in 1923. The auriculotemporal nerve, a branch of the trigeminal nerve, carries both sensory innervations to the skin and parasympathetic and sympathetic fibres to the parotid gland. It has been recognised as a common postoperative complication of parotid-gland surgery or dorsal sympathectomy. The most widely accepted mechanism of Frey's syndrome is aberrant neuronal regeneration.1 Trauma to the parotid region during forceps delivery may be responsible for the condition in infants.2 Its incidence is not known. The syndrome is uncommon in children. Unlike adults, children do not exhibit sweating over the affected area of skin.2 3 The diagnosis of Frey's syndrome can be made clinically on the basis of reported symptoms. The most common objective tests are a lemon (which brings out the facial flushing) and starch/iodine (which demonstrates the gustatory sweating). The condition has the potential to cause great social distress and anxiety for the child and parents. Gustatory flushing in children may mimic food allergy leading to unnecessary exclusion diets.4 In this case, localised distribution along the distribution of the nerve and precipitation following ingestion of certain foods that stimulate the nerve in the absence of other hypersensitivity symptoms excluded food allergy. In adults with severe symptoms, topical antiperspirants, botulinum toxin injections and other surgical treatments have been tried with variable results. As the course of the condition with no recognisable cause in children is benign, it is important to recognise it, thus avoiding unnecessary referral and evaluation. Simple explanation and reassurance are usually adequate therapy.

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Footnotes

  • Competing interests None.

  • Patient consent Parental consent received.

  • Provenance and peer review Not commissioned; not externally peer reviewed.

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