A Little Boy’s Cheek Turns Red When He Eats!

Image Source: The New England Journal of Medicine©

With a brief glance at the image and the title, what is the spot diagnosis?

A 2-year-old boy was referred to the otolaryngology clinic with complaints of recurrent right cheek’s redness/flushing during eating for the past 18 months. His mother first noticed this when he started weaning at the age of 6 months (Panel B). The redness is not associated with pain, itching, sweating, fever, or any other symptoms. The boy was born at full term, via forceps-assisted vaginal delivery.

Panel C of the attached image shows the child after eating at 18 months of age, whereas panel D shows the picture of the child when he is not eating. Note that the flushing is only during eating.

Past surgical and medical history were unremarkable. There were no notable allergies to food or nuts, and the skin allergen testing was also negative.

To clinically confirm the suspected diagnosis, the child was given strawberries to eat in the clinic, the flushing reappeared.

A diagnosis of Frey’s syndrome was made.

Frey’s syndrome is also known as ‘Auriculotemporal nerve syndrome.’ It is damage to the parasympathetic nerve fibers within the parotid gland followed by aberrant reinnervation manifested by gustatory flushing and/or sweating.

  In simpler words, it is aberrant reinnervation of the parasympathetic and sympathetic nerves after any injury/trauma to the nerves. To make it even simpler, the responses, such as flushing and sweating, previously controlled by sympathetic nerves, now respond to parasympathetic stimulation such as eating (mastication and swallowing).

Image Source: Osborne Head & Neck Institute©

This aberrant regeneration of the nerves is responsible for flushing whenever the boy eats.

Damage to the nerve fibers can occur during parotid gland surgery, facial trauma, infections such as herpes zoster, and forceps-assisted vaginal delivery.

Diagnosis of Frey’s syndrome is clinical; usually, no fancy tests are required!

Frey’s syndrome usually doesn’t require treatment. The child in the discussion here was provided no specific treatment, his condition persisted even at the age of three.

There is no recommended treatment for it. However, spontaneous remission has been reported in children as they grew older. If the patient’s symptoms are excessive and uncomfortable, then medical treatments, such as topical anticholinergic ointments (scopolamine, glycopyrrolate), topical αlpha agonist (clonidine), and botulinum toxin injections can be offered to the patient. None of these medical management approaches is a definitive cure. These may subside or dampen the symptoms for a temporary period.

Is Frey’s syndrome dangerous or fatal?

The answer is no!
Undeniably, it is uncomfortable and embarrassing for the affected individual, which may affect the suffer’s self-confidence in the long run, but it has no known associated medical adversities.


Alexander Smith, M. C. (2020, April 09). Frey’s Syndrome. Retrieved from The New England Journal of Medicine: https://www.nejm.org/doi/full/10.1056/NEJMicm1809117

Caulley, L., & Hong, P. (2013). Pediatric auriculotemporal nerve (Frey) syndrome. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne,185(6), 504.

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Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.


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