Selective Sympathicotomy Stops Sweaty Palms

Abstract & Commentary

Source: Yoon SH, Rim DC. The selective T3 sympathicotomy in patients with essential palmar hyperhidrosis. Acta Neurochir. 2003;145:467-471.

Among 54 patients with essential hyperhidrosis, 24 underwent T2/T3 sympathicotomy and were compared to 30 subsequent patients treated by selective T3 sympathicotomy. General anesthesia was used in all cases, and surgery, bilateral in all and lasting about an hour, was performed using a thoracoscope inserted into the midaxillary line at T6. T2/T3 sympathicotomy was accomplished by transecting the sympathetic chain above the second and third ribs, while for T3 sympathicotomy the sympathetic chain was cut only above the third rib. Patients were followed for a mean of approximately 17 months postoperatively, and statistical analysis was performed using the Mann-Whitney test and Fisher’s exact test.

Palmar hyperhidrosis was relieved in all patients, without recurrence, during the observation period. Compensatory hyperhidrosis, involving the chest, back, abdomen, legs, or multiple sites, was reported in 11 (45.8%) of T2/T3 sympathicotomized patients but in only 5 (16.7%) of T3 sympathicotomized cases. Overall, 66% of the former but 88% of the latter reported "full satisfaction" with their procedure, while 25% and 13%, respectively, reported "satisfaction." Eight percent of the former, but none of the latter, were dissatisfied. Complications included chest pain (n = 6, n = 4, respectively), pneumothorax (n = 1 in each group), and Horner’s syndrome (n = 4, n = 0, respectively). Length of hospitalization (mean, 2.4 days) was similar in both groups. T3 selective thoracoscopic sympathicotomy appears superior to T2/T3 sympathicotomy for the treatment of essential hyperhidrosis.

Commentary

Favorable findings for an analogous procedure were reported earlier this year from the Mayo Clinic.1 Ten consecutive patients with essential palmar hyperhidrosis who failed medical therapy underwent bilateral sympathotomy (simple disconnection) of the second thoracic ganglion input into the brachial plexus. All 20 hands improved, with near-complete cessation or marked reduction in sweating documented by thermoregulatory sweat testing, in 11 and 8 hands, respectively. Neither pneumothorax, Horner’s syndrome, nor moderate or severe postoperative hyperhidrosis occurred in any patient. Sympathotomy of the T2 ganglion input into the brachial plexus may be superior to T3 selective thoracoscopic sympathicotomy for the treatment of primary palmar hyperhidrosis, but longer-term follow-up for both procedures is needed for confirmation.

Open-label treatment of palmar and plantar hyperhidrosis using Botulinum toxin-A injection into the palms and sole was also found to be safe and effective.2 Local side effects including hand weakness are not uncommon, but systemic side-effects, lasting up to 1 month, can also occur, including blurred vision, indigestion, and dysphagia with severe dry throat as reported with Botulinum toxin-B.3 Preliminary controlled trials for the treatment of palmar hyperhidrosis using Botulinum toxin are under way but have yet to be reported.

Axillary hyperhidrosis, as well, appears to respond to Botulinum toxin-A.4 Among 207 patients with primary bilateral axillary hyperhidrosis, 174 enrolled and completed a multicenter, double-blind study comparing placebo vs 50 U of Botulinum toxin-A injected per axilla. Blinded injections were given at study entry and followed by open-label injection every 4 months for a maximum of 12 months. Gravimetric assessment, 4 weeks following each treatment, of spontaneous sweat production of > 50 mg/axilla was the main outcome measure. Compared to placebo, Botulinum toxin-A was significantly more effective with response rates of 96.1%, 91.1%, and 83.3% following a first, second, and third treatment, respectively. Placebo response was 34.7%. Overall, 13.5% experienced side effects, compared to 4.1% in the placebo group, with increased nonaxillary sweating being most common (4.3%), followed by pain in the injection site (1.9%), hot flushes (1.4%), and muscle weakness (1%). No serious side effects (n = 11), including a single death from myocardial infarction, were felt related to study drug. Botulinum toxin-A is safe and effective for ongoing treatment of axillary hyperhidrosis. — Michael Rubin, MD. Dr. Rubin, Professor of Clinical Neurology, New York Presbyterian Hospital-Cornell Campus, is Assistant Editor of Neurology Alert.

References

1. Atkinson JL, Fealey RD. Mayo Clin Proc. 2003;78:167-172.

2. Sevim S, et al. Acta Neurol Belg. 2002;102:167-170.

3. Baumann LS, Halem ML. Arch Dermatol. 2003;139:226-227.

4. Naumann M, et al. Arch Dermatol. 2003;139:731-736.