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/ 13 SEPTEMBER 1989 ~ NEW ZEALAND MEDICAL JOURNAL 10 s`, v 7-5)- Treetment of Frey's syndrome (gustatory sweating) with topicall glycopyrrolate: case report Treatment' of Frey's syndrome with topical glycopytrolate is well iescribed in the speciali3t literature but is generally not well -nown. lt is likely there are a number of people in New Zealand that have thle problem, but who are unaware of this potentially' effective and Jaimple treatment. However when I saw my first patient with Frey's syndrome a few, years ago. 1 soon discovered that topical glycopyrTolau was not something that was readily available. Frey s syndrome or loealised faciali gusutory sweating and'' flushing is a rare ¢ondition which is most commonly seen as a sequelae of superficial parotidectomy. The patient. a 45 year old female. had~ had a left superfiaal parotidectomy five years before for recurrent parotitii. Following the operation, she developed sweating on tbe lelt side of her face whenever she ate and this caused sigaificant socia1 embarrassment. When the problem first occurred her surgeon had told her nothing could be done. ln fact a number of treatments 'Rre available and include commercial antiperspiranta, tupical2Q°k ahlminium ch1oridein alcohol.' stellate ganglion bloc3is, tympanic neurectomy: and subdermal insertion of fascia lata grafts. I believe none of these treatments are as simple and generally as effeotive as topical glycopyrrolate. Glycopysrolate is a quarteraary amonium antichoiiaergic agent which does not cross the blood brain barrier. unlike scopolamine, and is associated with a very lo.v, incidence of side effects. It has been shown to be an effective treatment for Frey's syndrome 11.2~ The gl'ycopyrrolate (Bomar]c I.aboratories) was formulated in two strengths.l % and 2% and in two formulations, gel and a cream. The cream was prepared by dissolving the glycopyrrolate in a minimum amount of water and incorporating into oetomaaogol eream. The cream was adjusted to *H! 3.D3.5. The gel was prepared by incorporating the powder.into Sonigel'in which it rapidly dissolved. ~ The patient commenced'treatment wit~,1% formulations and as these controlled symptoms for up to five days with the only adverse effect being an occasional dry throaL treatment was maintained at this strength. The gel' was it,, cosmetically more acceptable formulation as the affected area estended~ into the aairline. The main preQntion is to avoid use in pa " ts with~nsrrew angle glaucoma. The following instructions were supplied to the patient: (1) Avoid applying to nose, mouth and eyes. (2) 1vevkr apply to cut or infected skin. (3) Effectiveness may increase by applying twice in the same day. or by rubbing into the akia after•,applicatioa. /41 Always wash hands well after.vards with soap ani water. Do not wash the treated part of the face for 3 to 4 hours. Avoid contact between the eyelids and the wash cloth uW on the treatment area. 151 Keep well away from childre.n. 16)'lCaep in a cool! place. (7d if a significant side effect such as bl visibn or dry mouth oenus aad'penists, temporarily diswati e and contact your doaor. tBI Do not reapply until sweating o~cnrs. Thanl[s to J u6e 1[a4rht tntwn PharmaOrt wLo 6LelOpad the /a"r>s1Lk;i001 H R Stegebuis, ENT Departmdat, B Ellis, PharmaCyPalmenton North Hospitsl, Palmerston North: 1! . K.,n Cd LL ho..~ AJ. V.u.lm JC:7fa Prq y.brc a aa0ia W.mw v.=ast. Ocdu.yolop.)i-dl:.e} SWj ]fa2 aP. 42ft6. 2 K•31ar.. Yi. Tlaapee P. th.. Rumda Drye NvrNet ~alra ~+~ia. AaecYdd.pc qr:au n ETy r.r.6ama. IhYt bt.tlVe Cs Hscr 1N{: f? IiWO Passive smoking In New Zealand Mr l.e's letter to tbe NZ M'.diril Journal (NZ Msd J 1989; 102: 4481',ooatains mne3~ the same arguments u in his previous dforta on bebelf of the tobacco iadustry in New Zaaland and other countries f1.41. e.ch of which have previously beea rebutted ltTl. Mr Lee need not have pointed out to us that aeveral'studies of passive smolomg and ischaemic heart disease involved small numbers of casea. Indeed be does not appear to have grasped'tbat lthis is precisely the reason why we chose to nse the restilts of r'a meu aaalysi+ in our estimates. What is important is the owrall numbers in the meta analysis, not the numbers in selected subgroups in specific studies. We fail to see the point that Mr Lee is trying to make in his comment abouttbe Japaneae prospective study:,t5ere is nothing ~ 479 statistically implausible about a signihcant relationship between passive smoking and IHD failing to show up on 14 years' follow up Isl, but appearing on 17 year follow up 191. Perhaps Mr Lee is unaware that the risk of IHD is related to duration of exposure Ipack-yearst to cigarette smoke. and that extending the duration of follow up increases the statistical power of the study? We cannot specifically comment on Mr Lee's references to his own writings on misclassification bias. Two of his citations on this subject are references to papers given by Mr Lee himself at overseas eonferenctsf which~ were therefore inaccessible to us.. Nev-rthelsiss his claim that misclassification of a proportion of smokers as nonsmokers has led to an artefactual association of lung canoa with passive smoking appears most unlikely. It is just as Iikely that misclassification of passive smokers as nonezposed'nonamokers has led to an underestimate of the risks of passive smoking, ie. correcting this source of bias is likely to raise the relative risks of lung cancer and iv1,a.m;r• beart disease. Finally, we would like to acknowledge Mr Lee's comment that the evidence relating lung cancer to passive smoking is based on 27, not merely 13 studies., As Bradford Hill remarked 11oh consistency of an observation across different studies increases our eonf5dence in the belief that the association is causal. Ichiro Kawachil Department of Community Health: Nefl Pearee. Wellington School!of Medicine, Wellington. 1. 7d..®.leauture d Ts2 1adq.eeet aa.nih ~ol tlr M.Y I/1e9 Tamc S.Ir.nna BoudRep~ JuIY'796D 2 L'ae P\. P.m- .®o*aatI3-Uri ..Br J Cw. H116: S'. Io142tl 3. 1- Pl:. DaufA. mCaaaaa tromWy oeor aue ro Nraluar+*9~+a[ eLurt Caa M.d A.aoc J 1991. 137 , 77L. 4 . 11- P9:. Prr.. a:yo.ure ro La6.® aakr (Lau.n ~ Br Y.dJ 1fe5: 291: 1M6 b. P.an J. Ddi R. Pun..v - • IRvplyi..Br J C.wQr I P66.. 6M . l o2D 1. 6 %, ,ay, Dr. D.atb. rn.C.n.aa tram 4uK uea e.r ro m.oWasvy mbna ca.pt.L . Gaa M.d Aa.a J 1%7: 137 . 373 7. Janv. MJ. Rra.d! 1.7.AK. Parr..eEpe.u+w m uala® amk. IRapy1. Br M.d J 1M5: .. 291. 1646 6. Hrrryam. T. I:mmabej ~ .( W..y mek:.n Nwa h4irrvk d Iseg esD*. A aw& frnas J apan Br M.d'J l a61: .332 ~ 163-5. i. Bndlac. KBJ A. A ahatr raaiBaaY d aadrol sutrno. l1tb d Ie.6m 1iad6r Mdr.ws.m Ise. fs empathy unhealthy? I have read withh some amusement and interest the description off various occupational or hobby rel.ted~ syndrromes, eg. space invaden' wrist. and~ triathlon tip, which surface in the medical literatur: from~ time to time. Each has described the hazarde unwitting)y encountered in one of a wide range of activities.. H'aving beelq a recent sufferer from another such unexpected condition. and.F.hus considerably less amused. I felt it appropriate to add to this mounting literature of cautionary talts. C.ourses in intei~ie.ving skilll stress the importance of nonvertial i eommunieation. It'l~ not sufficient to use the right words, or right tnzle. The positlonutgdf patient, doctor and desk affecv the power balance between patient and doctor. We have been encouraged~ to move out from be " our desks, to sit vose to the patient, and when appropriate to touch in our oommunication. Body language including body ture must be congruent with the message we are attempting communicate. A forward laaning body posture denotes a readi.nFss to Yuten,,a backward l.aning lor, , for most chairs. the at tralght up) iposition denow a negative attitude (t~ The literature on this subject~ W~y knowledge has cr.ncentrated on the effectiveness of the e*munication, and patiaat satisfaction: However, are there dazards that acoompany this improved communication? sp e dysfunction laading I report one case (myselil of aervica7 to paraestbesia in the brachial pkzus dis 'bution, in a patimt with frequent thoracic facet probkms in past The nuae appears to be an oecupational dissase- of 'empatb.tic bacdc'-too much body language of the 'I am ning' variety. (An alternative label would be that of poor posture!1 Have other medical practitioners and those in other listening add to tbe professions noted the same problem: Do we need literature yet another occupational disease? Alex Thomson, Au ~Y. la. To~ lA 1. PwsiP 1:ae vw4a) mma.rasatim e tLw ro.v 1+omw l.a~ .ae -.__._., .- ~ s..«. 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