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ETS Surgery: Efficacy
Palmar hyperhidrosis
Axillary hyperhidrosis
Facial hyperhidrosis
Treating children
Variation: Stereotactic percutaneous thermoablation
Palmar hyperhidrosis
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 conservative
treatment fails, however, ETS is an option. 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, and all patients went home the next day. All
had successful control of sweating in the 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 but would go through the procedure again.
As with adults, compensatory sweating continues to be a major
problem about which patients and parents need to be well informed
before considering ETS.
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.
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