Efficacy

There are many reports of series of patients treated by ETS for palmar hyperhidrosis. Results are generally excellent, with dry palms achieved 95% to 100% of the time.[112,137,151] Satisfaction with the procedure was usually not as high, with 72% of patients satisfied and 23% partially satisfied in one large series.[151] This relatively low satisfaction when dryness is almost always achieved may be due to patients being bothered by side effects such as compensatory sweating.[46] Recurrence rates were generally low (1.2% to 3%).[35,72,137]

Axillary hyperhidrosis

Small numbers of patients treated with ETS for axillary hyperhidrosis have been reported as part of the large series in which most patients had palmar or palmar-axillary sweating. In one series, 83% with axillary sweating were dry postoperatively, compared to 95% of those with palmar symptoms; over a median follow-up of 16 years, there was no change for the palmar group, but only 68% of the axillary sweaters remained dry.[150]

A study of 171 patients with axillary hyperhidrosis evaluated the effect of more-selective sympathectomy on outcome.[60] Sympathectomies at T3-T4 were performed in 40 patients, at T4 alone in 56 patients, and at T4-T5 in 75 patients. Outcome was rated as excellent if there was significant or complete disappearance of symptoms, good if at least a 50% improvement resulted, and poor if less than a 50% improvement resulted. Excellent results were found in 56%, 52%, and 71% of the T3-T4, T4, and T4-T5 groups, respectively. Poor results were twice as likely for the T3-T4 and T4 groups (30%, 32%) than for the T4-T5 group (15%). Patients in the T3-T4 group had more than double the incidence of compensatory hyperhidrosis that the other groups had. It was concluded that T4-T5 sympathectomy is the ETS treatment of choice.

Facial hyperhidrosis

Small numbers of patients with facial hyperhidrosis treated with ETS were included in several large series. In one such report, 97% of those with facial sweating had effective relief of symptoms, with an overall satisfaction rate of 76%.[112]

Reports of selective sympathectomy for craniofacial patients suggest that several different approaches can relieve symptoms. All 30 patients treated with T2 sympathectomy had a good response, and over a mean follow-up of 15 months, all remained satisfied with the results.[69] T2-T3 sympathectomy decreased sweating in 23 of 25 patients, but only 15 had good results (that is, no further need for a handkerchief) and 60% had compensatory sweating.[26] In another approach, the lower third of the stellate ganglion was clipped rather than ablated so patients could opt for a reversal procedure should severe compensatory sweating or Horner’s syndrome develop.[89] Twenty-eight patients underwent clipping, with a 100% response rate for facial sweating. Of the 25 (86%) who had compensatory sweating, only 1 patient opted for a reversal, which was successful.[89]

Treating children

Since hyperhidrosis in children and adolescents can have negative effects on daily life and social interactions similar to those experienced by adults, they should be offered effective treatment as well, starting with the least invasive approach. When all other treatments have failed ETS may be viewed by some physicians as an option--but always as a last resort. As with adults, compensatory sweating continues to be a major problem about which patients and parents need to be well informed before considering ETS. In a study published in the Journal of Pediatric Surgery, twenty-six children aged 11 to 17 years, almost all with palmar hyperhidrosis, were treated with ETS in one series, and 19 were followed for a median period of 16 years after surgery.[64] Over a 32-year period, 19 children had bilateral sympathectomies, done in 2 sessions, and 7 had unilateral sympathectomy for symptoms on the dominant side. There were no significant perioperative complications reported, and all patients went home the next day. According to the study, all had successful control of sweating in the specific, affected area but 63% had compensatory sweating and 63% reported gustatory sweating at follow-up, with 47% reporting both. At long-term follow-up, 58% were fully satisfied with the procedure and 37% were only partially satisfied. It’s important to note that as recently as 2005, the Taiwanese Department of Health began to prohibit surgeons from performing ETS on patients under 20 years old. This new age limit aims to ensure that patients choosing to undergo ETS are mature enough to fully investigate other less drastic options, and fully understand the potential risks and side effects of this procedure.

Variation: Stereotactic percutaneous thermoablation

Using stereotactic guidance based on a 3-dimensional system of coordinates derived from cadaveric studies, a Taiwanese group has treated over 1700 patients with palmar and facial hyperhidrosis using percutaneous thermocoagulation.[27] After a lateral x-ray to provide reference points for the stereotactic location of the T2 and T3 ganglia, a spinal needle is placed under fluoroscopy using a stereotactic frame and the ganglion is injected with lidocaine. Temperature increase in the ipsilateral thumb demonstrates successful infiltration around the ganglion. Then a thermocoagulation probe is placed using the stereotactic frame and each ganglion is treated for 5 minutes. Sweating ceased after the procedure in 99.5%, and when it recurred within 2 to 59 months after treatment, it was successfully retreated in all cases. In the more recent group of over 1500 patients, only the T2 ganglia were treated, with similar results. Pneumothorax and Horner’s syndrome were uncommon complications, occurring in 0.2% and 0.15% of cases, respectively. The rate of compensatory hyperhidrosis was not reported. Requiring only local anesthesia and mild analgesia, this procedure could be an alternative to ETS for the patient with severe hyperhidrosis, but there are no other reports of this technique in the medical literature at the present time.