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Challenging Case Presentation on Hyperhidrosis Management
by Fritz J. Baumgartner, MD
A 20 year old US serviceman in the Marines presents with massive palmar, plantar, and axillary hyperhidrosis impairing his ability to perform his duties and posing a danger in critical situations. How should this patient be managed? Should topical anticholinergic agents be applied to his palms, feet and underarms as an initial treatment? At what point and which anatomic location should injection of Botulinum A toxin be considered first line? What are the roles of oral anticholinergic medications, sedatatives, or psychotropic medications in management of this disorder? How labor-intensive is ionotophoresis before significant results are evident? At what point should thoracoscopic sympathectomy be considered, and should it be a last resort or considered first line treatment? What sympathectomy level gives the best results with the least side effects?
Dr. Baumgartner welcomes you to comment on your own experiences with treating this debilitating disorder.
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8 Comments
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October 16th, 2008 at 7:41 pm
Surgery should be first line of treatment given that all other treatments will either not work or be temporary at best and this is not acceptable in his situation. Thoracoscopic sympathectomy of the T2 and T3 ganglia will cure his palmar symptoms and in our experience 65% of the patients will heve improvement of their plantar symtoms as well. The axillae only respond about 50-60% of the time however if they fail to respond and remain troubling, one could then consider arthroscopic axillary shaving. Both surgeries can be done as outpatients with minimal recovery and while we see compensatory hyperhidrosis in 75% of patients, it is always minor. This would be the approach at the Medical College of Wisconsin.
October 17th, 2008 at 9:59 am
Thank you Dr. Gasparri for your interesting comments which I wholeheartedly concur with. We also take T2 and/or T3 with great success. For us, it is a sympathicotomy, i.e. transection of the sympathetic chain at the level of the costalhead, which generally is just superior to the corresponding ganglion. In essence, therefore, the ganglion is preserved. Do you think that preserving the ganglion itself plays a role in limiting the chance of severe compensetory sweating? For the axillary issue, what has been your experience with Botulinum toxin A injection vs. topical anticholinergics vs. axillary shaving/gland resection/suction-curettage?
October 17th, 2008 at 3:16 pm
With regard to the ganglion preservation question, I can only speculate based on my own experience of about 80 patients. I do a complete sympathectomy and take the chain from the top of the 2nd rib to the top of the 4th rib thus encompassing the T2 and T3 ganglia. I also stay basically on the chain and do not go 4 cm laterally as some authors suggest. I have not seen severe compensatory hyperhidrosis and palmar success has been 100%. Based on this, I think the issue is really extent of resection as the people I have seen or heard of who have experienced severe compensatory hyperhidrosis are those who have more chain resected (T4 and/or T5) in an effort to cure the axillary component. In my practice, I do not offer sympathectomy if axillary sweating is the only symptom as I think the potential for severe compensatory sweating becomes too high as you march down the chain.
With regards to treating the axillary component, it basically comes down to severity of symptoms and patient compliance. Some patients do OK with topical treatements or BoTox and are happy with this and do not mind having to continue with lifelong treatment. I encourage all of them, however, to at least see our Plastic Surgeons and consider axillary shaving because I am impressed by their results and the minimal recovery from it. If it were me and my axillary symptoms were severe, I would have axillary shaving.
October 19th, 2008 at 10:12 am
If the main area of concern for this patient, we would perform a VATS T3 dorsal sympathectomy. If the axilla was the worst area, then a T4 sympathectomy would be performed. We do not do more than one level, as we have not seen any advantage of this, and the issue of compensatory sweating if very real.
October 20th, 2008 at 11:14 pm
Thank you Drs. Gasparri and Meyer for your comments. I am fascinated and intrigued by the entire area of the relation between extent and level of resection and compensatory sweating. Dr. Gasparri mentions that although C.H. occurs in 75% of his patients, it is always minor, despite his actual resection of 2 complete ganglion levels. I have previously done combined T2 and T3 sympathicotomies over the costal heads, and am now 2 years into a prospective randomized trial directly comparing sympathicotomy over T2 vs. T3 (i.e. one or the other, not both). There has been some suggestion that including T2 results in worse C.H.; conversely there has been some suggestion that excluding T2 may result in less efficacy of the procedure. Is it possible that efficacy of the procedure in terms of completeness of palmar dryness is good for T2 and T3 and T4, but subtly less so as one marches down the chain? Dr. Meyer omits T2 - is this because of fear of severe CH? Dr. Meyer, have you seen failures with T3 or T4 for palmar hyperhidrosis? I do not know where Dr. Meyer practices, is it possible that Dr. Gasparri seems less concerned about CH because Wisconsin where Dr. Gasparri works is a colder or less humid environment? Dr. Meyer, you mention that you do sympathectomy for axillary hyperhidrosis. What are your thoughts about local surgery, Botox, or topical agents for axillary hyperhidrosis? The literature seems to imply far less satisfactory results for sympathectomy for axillary than palmar hyperhidrosis - do you find this to be true in your patients?
October 21st, 2008 at 11:34 am
I must admit I was hesitant to switch from T2->T2 sympathectomy when we did a number of years ago, but the efficacy remains the same for palmar hyperhidrosis. For the axillary issue, we have about 85-90% resolution with T4 sympathectomy. I have no problems with a trial of botox for the axillary region, as that may be a good option. I practice in Dallas so our pts get a good test of their surgery. We also see nearly a 60% incidence of CH, although rarely it is severe.
October 21st, 2008 at 4:03 pm
I find all of these comments very interesting, especially the fact that we all are experiencing very good success with palmar symptoms using different (albeit similar) operations.
Some comments /questions and I apologize as they are a bit off the topic of the original case scenario.
With regards to symptoms and climate changes in Wisconsin, interestingly, these patients’ symptoms are independent of weather and many actually say that symptoms are worse in the winter months as opposed to during our hot, humid summers.
I find Dr Meyer’s comment about switching from T2/T3 to T3 very interesting. I have been reluctant to change from T2/T3 to T3 as I have feared it may decrease efficacy (which at this point for me is 100% for palmar symptoms) however may try it based on his comments. I must admit, however, it is always difficult to change something that is working well.
I am also impressed with Dr Meyer’s results for axillary symptoms with limited T4 and will explore this although I still maintain that axillary shaving as done by our plastic surgeons has had very impressive results and carries even less morbidity than VATS sympathectomy.
I have questions regarding craniofacial and pedal symptoms.
As you know, the typical presenting symptoms are hands and feet and we have noted that roughly 60% of our patient’s pedal symptoms improve as well with T2/T3 sympathectomy. Have you seen similar results? Would you ever offer surgery if pedal symptoms were the main/only complaint (I have seen 4 or 5 dancers who are having difficulty as their symptoms worsen)? If you would offer surgery, what is your preferred level(s)?
With regards to craniofacial symptoms, I have had success with T2 only although my experience is limited to 6 patients as I have been reluctant to offer this as primary therapy given that the literature is variable with respect to success (50-70%). What is your experience? Do you offer surgery for isolated craniofacial symptoms? If so what is your approach? Do you consider Botox or Robinul first as this is the only distribution where I have noticed some efficacy for oral anticholinergics?
October 22nd, 2008 at 1:32 am
Interesting comments and issues. Dr. Meyer, in the humid Dallas environment have you seen a difference between T2 vs. T3 in terms of degree of compensatory hyperhidrosis? You mentioned the efficacy comparing T2 vs. T3 is the same in your series. In our ongoing study comparing T2 vs. T3, there have been 0 failures for curing palmar hyperhidrosis at the T2 level. However at the T3 level, there have been 2 failures out of about 60 patients. In these 2 patients (one lady and one teenage boy), their symptoms of massive dripping palmar sweating recurred. Both of them underwent re-do surgery performing sympathicotomy at the T2 level, and both are cured now. Yazbek (J Vasc Surg 2005;42:281)also prospectively studied T2 vs. T3 sympathicotomy and found good results for both, but found that 1 out of 30 of his T3 patients failed to have the palmar sweating cured. That patient went back to surgery for re-do surgery, again at T3, and again failed. Would that patient have been cured if T2 had been done? I think so, although this has not in any way reached statistical significance in any study. Is the reason for this a missed Kuntz nerve at the level of T2? Do Kuntz nerves cross over the 3rd rib? Do Kuntz nerves really have any significance, or are they just an excuse or explanation for failed sympathectomy?
Dr. Gasparri, I would be very cautious about using thoracoscopic sympathectomy to treat isolated axillary hyperhidrosis. Studies from many contries repeatedly show less patient satisfaction when the procedure is done for the axilla than the palms, and in one Austrian study (Zacherl et al, Eur J Surg1998)nearly 20% of these axillary patients regretted the operation because of CH and gustatory sweating. It should be noted, however, that Zacherl performed T2-4 sympathectomy; perhaps a T4 procedure would be more satisfactory. I personally have had good results in T3-4 sympathectomy for axillary hyperhidrosis, but am reluctant now to do this because I think a more direct axillary surgery approach spares the patient systemic effects. In any event, I would definitely use topical agents and/or Botox in the axilla before resorting to surgery, either local axillary or sympathectomy. As for craniofacial hyperhidrosis, we have had good experience with T2 sympathectomy for the disorder, and I would rather do sympathectomy for severe facial hyperhidrosis than for axillary hyperhidrosis. The Boras experience report from Sweden seems to confirm overall happier facial than axillary patients after sympathectomy; I’m sure Dr. Drott will have alot to say about this at the meeting.
Finally, I would never do an upper thoracic sympathectomy for isolated plantar hyperhidrosis, since the possible side effects undermine whatever unreliable plantar benefit may occur. Similarly, I do not recommend a typical open lumber sympathectomy, even for massive plantar hyperhidrosis. Has anyone been able to do a less invasive lumbar sympathectomy e.g. radiographically guided?