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THE AURICULOTEMPORAL SYNDROME A CLINICAL AND PHARMACOLOGIC STUDY A. S. Freedberg, … , Robert S. Shaw, M. J. McManus J Clin Invest. 1948;27(5):669-676. https://doi.org/10.1172/JCI102015. Research Article Find the latest version: https://jci.me/102015/pdf THE AURICULOTEMPORAL SYNDROME A CLINICAL AND PHARMACOLOGIC STUDY By A. S. FREEDBERG, ROBERT S. SHAW AND M. J. McMANUS (From the Department of Medicine, Harvard Medical School, and the Medical Service and Research Laboratories, Beth Israel Hospital, Boston) (Received for publication May 26, 1948) The auriculotemporal syndrome which develops temporal nerve. There was a right facial weakness and after injury to the parotid gland, consists of ptosis of the right upper eyelid; the latter was said to flushing and profuse sweating, upon eating, over have been present since the patient's recent cerebral vas- cular accident. The cranial nerves were otherwise normal. the cutaneous distribution of the auriculotemporal Case 2: T. H., a 63 year old man, MGH No. 484270, nerve on the injured side. Although there have with a history of recent sinusitis, had had bilateral sup- been few cases reported since the original descrip- purative parotitis, of unknown etiology, twenty-five years tion by Frey (1) in 1923, the syndrome is not previously; this had been drained through incisions over rare, having been noted repeatedly, for-example, the glands on both sides. Several weeks after operation the patient noted the occurrence of profuse sweating and in clinics observing patients after operation on a a feeling of warmth on the left side of his face when eat- parotid gland (2, 3). The syndrome is of interest ing. The phenomenon had continued until admission. It to the physiologist because it affords an oppor- was brought on by eating any food, especially apples. At tunity to study the consequences of denervation of no time had the patient noticed any numbness or paralysis cholinergic end organs. It is our purpose to pre- of his face. Physical examination was not remarkable sent three instances of this syndrome with except for the old drainage scars over both parotid glands. some The parotid glands were normal to palpation and saliva observations relating to its mechanism. was easily expressed from both ducts. Sensation over the face was normal and the function of other cranial nerves CASE HISTORIES was apparently intact. Case 3: D. E. S., a 49 year old married woman 1: a (re- Case J. B., 68 year old man, BIH No. 78777, ferred entered the on of by Dr. I. T. Nathanson), had had a tumor of the hospital 9/29/44 complaining transient right parotid gland removed in 1942. weakness and dysarthria. These symptoms were believed Approximately onc. to be consequent to a recent cerebrovascular accident. year later she noted the onset of sweating following the Forty-one years ago, while in the Russian army, the eating of various foods. The sweating involved the right patient had had typhoid fever, complicated by right paro- side of the face in the region of the incision. Rarely a titis. Two attempts to drain the parotid gland by vertical sense of heat was noted but visible flushing was never incisions were unsuccessful. Two incisions, 2 cm. lateral observed. No specific food was noted to be particularly to the right upper border of the thyroid gland, resulted effective in producing the sweating reaction. Although in drainage for approximately 50 days. Approximately on rare occasions a whole meal did not produce sweating, one month after the successful drainage, and two months hot tea by itself occasionally produced profuse perspira- after the onset of the parotitis, the patient noticed the de- tion. She had had mumps as a child, but with no sequelae. velopment of profuse sweating over the right side of the face while eating. Although ingestion of many foods was OBSERVATIONS followed by sweating, the phenomenon was particularly marked when apples were eaten. On each occasion just Observations in Case 1: The observations on prior to the onset of sweating the patient experienced a sweating were made by means of the Minor sensation of warmth over the involved area. Redness, starch-iodine test (4) which consists of applying a swelling and pain, however, were absent; at no time was solution of iodine (15 cc. 1 per cent iodine, 5 cc. numbness noted over the involved area. The amount of sweating had become less pronounced during the previous of castor oil and 80 cc. 95 per cent alcohol) and three years. after drying, lightly dusting the skin with starch On physical examination, scars on the face and neck and noting the onset of sweating which is signal- were noted. The opening of the right Stenson's duct was ized as black spots. Ten seconds after taking a protuberant; saliva could not be expressed from it. The bite of apple and while chewing, the patient noticed orifice of the left duct appeared normal and saliva was easily expressed. Perception of heat and cold was normal a feeling of warmth over the right face, and a and equal on both sides of the face. There was cutaneous slight flush was noted on this side. Five seconds hypaesthesia in the distribution of the right auriculo- later, sweating appeared in part of the area in- 669 670 A. S. VREDIBERG, ROBERT S. SHAW AND M. J. MCMANUS sive during the whole period of injection and for a short time afterward. A series of experiments was performed to de- termine whether there was hypersensitivity of the sweating mechanism in the involved area. In normal controls, local sweating was observed over and around intradermal wheals made by the in- jection of 0.1 cc. of various concentrations of acetylcholine bromide dissolved in isotonic saline solution. By using increasing dilutions, a meas- ure of the sensitivity of the local sweating appa- ratus to acetylcholine might be obtained. While sensitivity was found to vary in different individu- als and in different regions of the body, the end FIG. 1. THE DISTRIBUTION OF SWEATING OBSERVED IN points were consistent. In this patient, intra- CASE 1, REPRESENTED BY THE CROSS-HATCHED AREA dermal wheals in the involved area on the right side of the face produced with 0.1 cc. of isotonic cluded in the distribution of the auriculotemporal saline solution containing 0.0001-0.1 'gamma of nerve (Figure 1). The sweating could be induced acetylcholine bromide resulted in local sweating. by chewing any food, but was absent or slight Similar concentrations of acetylcholine in sym- when the patient chewed paraffin. The applica- metrical positions on the left face of the patient did tion of ice to the right face before chewing food not produce sweating. A wheal on the left side resulted in a decreased amount of sweating in the of the face which contained 0.5 gamma acetylcho- chilled area. Sweating was absent when the pa- line per 0.1 cc. produced sweating. tient held but did not chew food placed in his Iontophoresis (3.4 milliamperes for ten minutes mouth. When the tongue was swabbed with through a 1 sq. cm. pad) of a 1: 12,500 solution vinegar, a small amount of sweating appeared. of acetylcholine bromide in isotonic saline solu- The response was independent of the region of the tion, produced sweating on the involved right side tongue swabbed. When the patient chewed a of the face and no sweating on the uninvolved left pledget of cotton soaked in vinegar, the amount side on two attempts, with no sweating on either of sweating, as judged by the extent and depth of side on the third attempt. Ten mgm. of acetylcho- the starch-iodine reaction, was more marked. line bromide injected subcutaneously did not re- Psychic salivation and sweating could not be in- sult in facial sweating. duced. Sweating induced by the general appli- The possibility was examined that disturbances cation of heat to the body was irregularly dimin- in vasomotor nervous function are present in the ished over the right side of the face. auriculotemporal syndrome. The variation in skin Procainization of the right auriculotemporal temperature of the involved areas in response to was nerve resulted in anesthesia over part of the dis- cooling and heating the body and extremities measured and to unin- tribution of the nerve. In the area of anesthesia compared symmetrical volved areas. To determine the time of occur- sweating failed to appear after the usual stimula- tion. Novocaine injection 1 of the right superior rence of the maximal response to heating and cool- ing, measurements of the skin temperature of a cervical ganglion resulted in a Horner's syndrome, The measurements of skin suffusion of the conjunctiva, increased warmth, finger tip were made. temperature were made at frequent intervals with and dilation of the right hand veins. While the a thermocouple. The experiment was performed cervical sympathetics were blocked, eating an apple in a constant temperature room, 200 C. The pa- induced sweating in 45 seconds and 20 seconds in tient was seated and the legs, arms and chest were two successive trials. The patient was apprehen- uncovered. Within 20 minutes a distinct fall' in 1 The authors are indebted to Dr. Reginald Smithwick finger tip temperature was observed (Figure 2) for the procaine blocks in Cases 1 and 2. which 'reached a maximum in 70 minutes. The THE AURICULOTEMPORAL SYNDROME 671 right ear skin temperature fell from 29.50 C to served to sweat, although this had never been 25.50 C in this interval of time. At the arrow noted by the patient. Psychic salivation was eas- (70 minutes) one leg and one arm were immersed ily induced, but the syndrome of flushing and in running warm water (T 420); the patient was sweating did not occur.

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