Craniofacial hyperhidrosis treated with video endoscopic sympathectomy

Craniofacial hyperhidrosis as well as palmar hyperhidrosis is an abnormal state of local excessive sweating of unclear etiology. The hyperhidrosis may be isolated in the craniofacial region or associated with palmar hyperhidrosis. The patient's face is so wet with sweat that their daily activities are often seriously disturbed. To the best of our knowledge, there has been no satisfactory medical therapy, nor any effective surgical treatment reported in the literature. In 1991, we started to treat a patient with such distress using endoscopic ablation of the sympathetic T2 segment, because we mastered the technique after treating a large series of palmar hyperhidrosis patients. Furthermore, we were impressed by concomitant reduction of craniofacial sweating after T2-3 sympathectomy resulting from the relatively different domination of sympathetic supply between the eye and face. It appears possible to relieve excessive sweating of the head and face, without producing ptosis or miosis by ablation of the T2 segment. During the past 2 years, 7 patients with severe craniofacial hyperhidrosis have been successfully treated with the method and all obtained a satisfactory result. No complete Horner's syndrome has been produced except in one patient, who showed a mild and transient left eye ptosis, in whom coagulation of the sympathetic trunk higher than the T2 segment was performed. Intraoperative monitoring of forehead skin perfusion and observation of the change of pupillary size is emphasized during the lesion making. The longest postoperative follow-up was 2 years, with a mean follow-up of 12.4 months.(ABSTRACT TRUNCATED AT 250 WORDS)     

Sympathotomy instead of sympathectomy for palmar hyperhidrosis: minimizing postoperative compensatory hyperhidrosis

OBJECTIVE: To determine whether anatomical modification of sympathectomy diminishes severe postoperative compensatory hyperhidrosis. PATIENTS AND METHODS: From January 1, 2000, to June 1, 2001, we prospectively studied 10 consecutive patients with primary palmar hyperhidrosis, aged 14 to 42 years. Medical therapy had failed in all patients. A preoperative and postoperative evaluation and thermoregulatory sweat testing were conducted in all patients. All patients underwent sympathotomy (bilateral simple disconnection) of the second thoracic ganglion input into the brachial plexus, and no sympathetic ganglia were violated. RESULTS: In the 10 patients, all 20 upper extremities improved postoperatively: 11 (55%) had near-complete cessation of palmar sweating, 8 (40%) had marked reduction in sweating, and 1 (5%) had delayed onset but full sweating at the end of the thermoregulatory sweat test. No intraoperative complications of hemopneumothorax or Horner syndrome occurred. Importantly, there were no moderate or severe postoperative hyperhidrosis complications. CONCLUSION: Sympathotomy to disconnect T2 ganglion input into the brachial plexus produces excellent results in the treatment of primary palmar hyperhidrosis and may lower the severity of postoperative compensatory hyperhidrosis complications. Long-term durability of the procedure requires further follow-up.     

Botulinum toxin in the treatment of focal hyperhidrosis

INTRODUCTION: Botulinum A toxin (BTX-A) acts primarily at peripheral cholinergic synapses, inhibiting the release of acetylcholine. Initially it has been used to block the neuromuscular junction in focal dystonic and spastic syndromes. Recently there has been suggestions for potential clinical indications in non-muscular diseases where cholinergic terminals play a role. GUSTATORY SWEATING: In 1995 physicians reported a long-lasting anhidrotic effect of intracutaneous BTX-A injections in patients suffering from gustatory sweating (Frey's syndrome). Consequently, a number of clinical studies demonstrated good efficacy of intradermal injections of botulinumtoxin in patients with focal hyperhidrosis. FOCAL HYPERHIDROSIS OF THE PALMS AND AXILLAE: Focal hyperhidrosis is usually confined to the palms and axillae. Excessive sweating may be a social handicap and an occupational hazard. The management of focal hyperhidrosis remains controversial. Topical antiperspirants are only effective in very mild cases. Iontophoresis with tap water or anticholinergic drugs is messy and time consuming with only short-lived effect. Sympathectomy, the cornerstone of surgical management, is usually effective in palmar hyperhidrosis. Complications of this technique include surgical risks, postoperative and cosmetic problems and compensatory hyperhidrosis. AXILLARY HYPERHIDROSIS: Several studies confirmed that intracutaneous injections of botulinum toxin are useful in the majority of patients with axillary hyperhidrosis resistant to conventional treatment. In axillary hyperhidrosis total doses are ranging from 200-400 mU Dysport or from 80 to 130 mU Botox to reach a good clinical response. Injections are usually well tolerated and no serious side-effects have been observed. The mean duration of anhidrotic effect ranges between 3 and 9 weeks. PALMAR HYPERHIDROSIS: The use of botulinumtoxin in patients with palmar hyperhidrosis is rather difficult. The therapeutic window is smaller because injections are complicated by transient weakness of the small hand-muscles. Furthermore the injections at the palms are painful which can be overcomed by application of local anaesthetics or the blockade of the ulnar and median nerves. The duration of anhidrotic effect ranges from 20 to 50 weeks. CONCLUSION: Intracutaneous injections of botulinum-toxin should be offered to patients with focal hyperhidrosis of the palms and axillae causing serious social, psychologic and occupational problems, resistant to other conventional treatment options.     

T2-4与T3-4交感神经链切断治疗手足多汗症术后代偿性出汗比较

目的:通过比较胸腔镜下T2-4与T3-4交感神经链切断治疗手足多汗症术后代偿性出汗发生情况,探讨其发生的可能机制.方法:手足多汗症患者146例,按不同手术方式分为T2-4组(行T2-4水平交感神经链切断术,共66例)与T3-4组(行T3-4水平交感神经链切断术,共80例).比较两组术后第1日、第6个月手术效果以及代偿性出汗发生部位和严重程度.结果:术后两组手汗治愈率100％,最常见代偿性出汗部位是背部和胸部.术后第1日T2-4组代偿性出汗发生率明显高于T3-4组(39％对比21％,P＜0.05),T2-4组出现2例重度代偿性出汗,T3-4组无重度者.术后6个月T2-4组代偿性出汗发生率依然明显高于T3-4组[24％ (16/66)对比11％ (9/80),P＜0.05].T2-4组仍有1例重度代偿性出汗患者.结论:降低胸交感神经链切断位置可减少代偿性出汗发生率和严重程度,T3-4切断术是一种较为理想的手术方式.代偿性出汗可能随时间有缓解趋势.     

Remission of facial and scalp hyperhidrosis with clonidine hydrochloride and topical aluminum chloride

Axillary and palmar hyperhidrosis are featured prominently in the literature, but no previous studies have detailed a treatment regimen for specific excessive localized sweating of the face and scalp. In this report, a patient was treated for this condition with a combination of clonidine hydrochloride (0.3 mg to 0.4 mg, with 0.25 mg to be taken at bedtime, to prevent daytime sedation) [corrected] and a topical solution of 20% aluminum chloride in anhydrous ethyl alcohol (Drysol). Over a period of 2 or 3 weeks, the patient achieved a complete remission of symptoms, while having only mild side effects. The treatment regimen also had the added advantage of lowering generalized anxiety.     

胸腔镜下交感神经链切除术治疗双手多汗症(12例报告)

目的评价内镜下胸交感神经链切除术治疗多汗症的临床效果。方法回顾性分析内镜下胸交感神经链切除术治疗12例多汗症的结果。结果12例术后多汗症均治愈，2例术后2d发生背部、双股部不同程度代偿性出汗，3～6个月后缓解，术后获得随访的10例未见复发。结论胸腔镜下交感神经链切除手术安全、疗效确切、创伤小，缩短住院时间。     

Effect of botulinum toxin in stellate ganglion for craniofacial hyperhidrosis: a case report

Craniofacial hyperhidrosis causes sweating of the face and scalp due to excessive action of the sweat glands and manifests when patients become tense/nervous or develop an elevated body temperature. If noninvasive treatments are ineffective, invasive treatments such as a sympathetic block and resection are considered. A 32-year-old woman with no specific medical history was referred for uncontrolled craniofacial hyperhidrosis that included excessive sweating and hot flushing. Physical examination showed profuse sweating, and infrared thermography showed higher temperature in the neck and face than in the trunk. The patient underwent several stellate ganglion blocks, and her symptoms improved; however, the treatment effect was temporary. Botulinum toxin was then injected into the stellate ganglion. At the time of this writing, her sweating had been reduced for about 6 months and she was continuing to undergo follow-up. Craniofacial hyperhidrosis is a clinical condition in which patients experience excessive sweating of their faces and heads. It is less common than palmar and plantar hyperhidrosis. Botulinum toxin injection into the stellate ganglion is simple and safe and produces longer-lasting effects than other treatments, such as endoscopic sympathectomy and a single nerve block.     

Hyperhidrosis: evolving therapies for a well-established phenomenon

The socially embarrassing disorder of excessive sweating, or hyperhidrosis, and its treatment options are gaining widespread attention. In order of frequency, palmar-plantar, palmar-axillary, Isolated axillary, and cranlofacial hyperhidrosis are distinct disorders of sudomotor regulation. A common link among these disorders is an excessive, nonthermoregulatory sweat response often to emotional stimuli in body regions influenced by the anterior cingulate cortex as opposed to the thermoregulatory sweat response regulated by the preoptic-anterior hypothalamus. Diagnosis of these mechanistically ambiguous disorders is primarily from patient history and physical examination, whereas results of laboratory studies performed with indicator powder reveal the distribution and severity of resting hyperhidrosis and document the integrity of thermoregulatory sweating. Treatment options lie on a continuum based on the severity of hyperhidrosis and the risks and benefits of therapy. In general, therapy begins with antiperspirants or anticholinergics. Iontophoresis is available for palmar-plantar and axillary hyperhidrosis. Botulinum toxin type A or local excision/curettage is effective for isolated axillary hyperhidrosis not responsive to topical application of aluminum chloride. Endoscopic thoracic sympathectomy may be used for severe cases of palmar-plantar and palmar-axillary hyperhidrosis. No sole therapy of choice has emerged for craniofacial sweating. The long-term sequelae of hyperhidrosis and its treatment also are discussed.     

Endoscopic transthoracic limited sympathotomy for palmar-plantar hyperhidrosis: outcomes and complications during a 10-year period

OBJECTIVETo review surgical results of endoscopic transthoracic limited sympathotomy for palmar-plantar hyperhidrosis during the past decade.PATIENTS AND METHODSWe retrospectively reviewed 155 consecutive patients who underwent surgery from June 30, 2000, through December 31, 2009, for medically refractory palmar-plantar hyperhidrosis using a technique of T1-T2 sympathotomy disconnection, designed for successful palmar response and minimization of complications.RESULTSOf the 155 patients, 44 (28.4%) were male, and 111 (71.6%) were female; operative times averaged 38 minutes. No patient experienced Horner syndrome, intercostal neuralgia, or pneumothorax. The only surgical complication was hemothorax in 2 patients (1.3%); in 1 patient, it occurred immediately postoperatively and in the other patient, 10 days postoperatively; treatment in both patients was successful. All 155 patients had successful (warm and dry) palmar responses at discharge. Long-term follow-up (>3 months; mean, 40.2 months) was obtained for 148 patients (95.5%) with the following responses to surgery: 96.6% of patients experienced successful control of palmar sweating; 69.2% of patients experienced decreased axillary sweating; and 39.8% of patients experienced decreased plantar sweating. At follow-up, 5 patients had palmar sweating (3 patients, <3 months; 1 patient, 10-12 months; 1 patient, 16-18 months). Compensatory hyperhidrosis did not occur in 47 patients (31.7%); it was mild in 92 patients (62.2%), moderate in 7 patients (4.7%), and severe in 2 patients (1.3%).CONCLUSIONIn this series, a small-diameter uniportal approach has eliminated intercostal neuralgia. Selecting a T1-T2 sympathotomy yields an excellent palmar response, with a very low severe compensatory hyperhidrosis complication rate. The low failure rate was noted during 18 months of follow-up and suggests that longer follow-up is necessary in these patients.     

Quality-of-life assessment in patients with hyperhidrosis before and after treatment with botulinum toxin: results of an open-label study

BACKGROUND: Patients with hyperhidrosis, a disorder characterized by increased sweat production, experience substantial functional and emotional problems. Botulinum toxin type A (BTX-A) has been shown to be useful in the treatment of hyperhidrosis; however, few studies have considered the effects of treatment on patients' quality of life (QOL). OBJECTIVES: The objectives of this study were to assess QOL in patients with focal hyperhidrosis; to investigate whether the impairment in QOL in these patients is related to the type of hyperhidrosis or the number of sites involved; and to compare the changes in QOL and the response to BTX-A treatment in patients with axillary and palmar hyperhidrosis. METHODS: Patients with focal primary hyperhidrosis of the axillae, palms, and soles who had experienced decreased QOL and whose condition had not responded to conventional topical and physical therapies were included in this open-label study. Patients completed a self-administered Dermatology Life Quality Index (DLQI) questionnaire before and 2 weeks after treatment with BTX-A. RESULTS: All 41 patients had experienced a decrease in QOL as measured by the DLQI. The impairement in QOL was not dependent on the number or types of sites involved. Treatment with BTX-A led to improvement in QOL in all patients, with the median DLQI score decreasing (ie, improving) significantly from pretreatment level (P < 0.001). The improvement in QOL and response to treatment were similar in patients with axillary and palmar hyperhidrosis. CONCLUSIONS: Further studies with a longer follow-up period are needed to assess the long-term effects of BTX-A; however, preliminary data from the present study suggest that BTX-A improves QOL in patients with focal hyperhidrosis, independent of the presenting clinical picture.     

针式胸腔镜胸交感神经干切断术治疗手汗症的观察与研究

目的 评价针式胸腔镜在手汗症胸交感干神经切断术处理中的安全性和有效性。方法 60例手汗症患者分为A组（普通胸腔镜，30例）和B组（针式胸腔镜，30例），分别采用普通胸腔镜和2mm针式胸腔镜进行胸交感神经干切断术，比较手术疗效和术后并发症发生率。结果 2组手术均获成功，手术操作时间、气胸发生率、术后代偿性多汗发生率、复发率无显著性差异；术后切口疼痛评分、恢复时间有显著性差异。结论 针式胸腔镜胸交感神经干切断术治疗手汗症的疗效、安全性与普通胸腔镜相同，但患者满意度更高。     

Craniofacial hyperhidrosis successfully treated with topical glycopyrrolate

Treatment of craniofacial hyperhidrosis currently consists of thoracic sympathectomy, which is not widely available. Oral anticholinergic agents and beta-blockers may be effective but also carry significant side effects. We describe a healthy, active 27-year-old male resident physician who had excessive facial sweating with minimal exertion or stress. The sweating was especially pronounced on the forehead, nose, and upper lip. Daily topical application of a 0.5% glycopyrrolate solution to the face and forehead was offered. After the first treatment, facial sweating was significantly reduced and was well controlled under stressful situations, without any discomfort to the skin. No loss of efficacy was seen after multiple face washings. Facial hyperhidrosis recurred after withdrawal of the glycopyrrolate for 2 days, confirming its therapeutic effect. Two years later, he continues to use glycopyrrolate as needed. We conclude that topical glycopyrrolate is effective in treating craniofacial hyperhidrosis and is associated with few adverse effects.     

Are We Paying a High Price for Surgical Sympathectomy? A Systematic Literature Review of Late Complications

The purpose of this article was to systematically review the literature in order to assess (1) the current indications for surgical sympathectomy and (2) the incidence of late complications collectively and per indication. All types of upper or lower limb surgical sympathectomies are included. An extensive search strategy looked for controlled trials and observational studies or case series with an english abstract. Out of 1,024 abstracts from MEDLINE and 221 from EMBASE, 135 articles reporting on 22,458 patients and 42,061 procedures (up to april 1998) fulfilled the inclusion criteria. Weighted means were used to control for heterogeneity of data. No controlled trials were found. The main indication was primary hyperhidrosis in 84.3% of the patients. Compensatory hyperhidrosis occurred in 52.3%, gustatory sweating in 32.3%, phantom sweating in 38.6%, and horner's syndrome in 2.4% of patients, respectively, with cervicodorsal sympathectomy, more often after open approach. Neuropathic complications (after cervicodorsal and lumbar sympathectomy) occurred in 11.9% of all patients. Compensatory hyperhidrosis occurred 3 times more often if the indication was palmar hyperhidrosis instead of neuropathic pain (52.3% versus 18.2%), whereas neuropathic complications occurred 3 times more often if the treatment was for neuropathic pain instead of palmar hyperhidrosis (25.2% versus 9.8%). Surgical sympathectomy, irrespective of approach, is accompanied by several potentially disabling complications. Detailed informed consent is recommended when surgical sympathectomy is contemplated.     

Palmoplantar hyperhidrosis: a therapeutic challenge

Excessive sweating from the palms and soles, known as palmoplantar hyperhidrosis, affects both children and adults. Diagnosis of this potentially embarrassing and socially disabling condition is based on the patient's history and visible signs of sweating. The condition usually is idiopathic. Treatment remains a challenge: options include topical and systemic agents, iontophoresis, and botulinum toxin type A injections, with surgical sympathectomy as a last resort. None of the treatments is without limitations or associated complications. Topical aluminum chloride hexahydrate therapy and iontophoresis are simple, safe, and inexpensive therapies; however, continuous application is required because results are often short-lived, and they may be insufficient. Systemic agents such as anticholinergic drugs are tolerated poorly at the dosages required for efficacy and usually are not an option because of their associated toxicity. While botulinum toxin can be used in treatment-resistant cases, numerous painful injections are required, and effects are limited to a few months. Surgical sympathectomy should be reserved for the most severe cases and should be performed only after all other treatments have failed. Although the safety and reliability of treatments for palmoplantar hyperhidrosis have improved dramatically, side effects and compensatory sweating are still common, potentially severe problems.     

Management of postsurgical hyperhidrosis with direct current and tap water

BACKGROUND AND PURPOSE: Excessive sweating, known as hyperhidrosis, involves the eccrine sweat glands of the axillae, soles, palms, and/or forehead. The use of iontophoresis to reduce or eliminate excessive sweating has been described since 1952. The purpose of this case report is to describe the use of tap water galvanism (TWG) using direct current (DC) with a patient who had postsurgical hyperhidrosis. CASE DESCRIPTION: The patient was a 36-year-old male electrician with traumatic phalangeal amputation and postsurgical development of hyperhidrosis. Tap water galvanism was administered using a DC generator, 2 to 3 times per week for 10 treatments. The patient's hands were individually submerged in 2 containers of tap water with the electrodes immersed directly into the containers. Each hand was treated with 30 minutes of TWG at 12 mA. Hyperhidrosis was measured by a 5-second imprint and subsequent tracing of the left hand placed on dry paper toweling. OUTCOMES: The patient's hyperhidrosis decreased from the full left palmar pad, with a surface area of 10.3x12.0 cm, to a reduced area of wetness that covered a 2.2-x2.7-cm area. The patient returned to work as an electrician without needing absorbent gloves, which had prevented him from performing electrical work. DISCUSSION: Following use of TWG, the patient's palmar hyperhidrosis returned to normhidrosis.     

一孔法胸腔镜下交感神经链切断术治疗手汗症30例临床研究

目的探讨一孔法电视胸腔镜下T3或T4交感神经链及其侧支切断术治疗手汗症的可行性。方法在全麻双腔气管插管下施行T3或T4交感神经链及其侧支切断术治疗手汗症30例。结果30例手术均获成功,术后患者手掌多汗症状消失,有效率为100％,术后掌温升高（2．5±0．8）℃。30例随访1．5-12个月,平均8月,无一例复发及严重代偿性多汗．轻度代偿性多汗1例,占3．3％0／30）。结论一孔法电视胸腔镜下]r3或T4交感神经链及其侧支切断术治疗手汗症疗效确切,创伤小,疼痛较轻,且术后代偿性多汗发生率低,程度轻微,是一种安全、有效的手术方式。     

Thoracoscopic sympathectomy for palmaris hyperhidrosis

INTRODUCTION: Palmaris hyperhidrosis is a disorder mediated by the sympathetic nervous system. It causes excessive sweating. This study evaluated the safety, efficacy, and outcome after thoracoscopic sympathectomy in patients with palmaris hyperhidrosis. METHODS: We reviewed the medical records of 18 patients (10 male) who underwent bilateral thoracoscopic sympathectomy between July 1998 and June 2001. RESULTS: The patients' mean age was 34 years. No conversions to thoracotomy occurred. Three 2- to 5 mm trocars were used.The thoracic sympathetic chain was resected from ganglia T2-T4, except in one patient with axillary hyperhidrosis requiring resection to T5. The mean operating time was 112 minutes, the mean blood loss was 50 ml, and the mean postoperative hospital stay was 1.2 days. Two patients had a unilateral pneumothorax requiring tube thoracostomy; one patient developed a chest wall hematoma at a trocar site that resolved without treatment, and one patient developed a transient unilateral Horner's syndrome. There have been no hospital readmissions. After a mean follow-up period of 14 months, 11 patients (56%) reported compensatory sweating. Sixteen patients (89%) were satisfied with their outcomes. One patient was dissatisfied because of excessive compensatory sweating, and another continues to have mild unilateral sweating on one hand and compensatory sweating of the face. CONCLUSION: Thoracoscopic sympathectomy is a safe and effective alternative treatment for palmaris hyperhidrosis. Compensatory sweating occurs in more than 50% of patients but is tolerable in most. The majority of patients are satisfied with their short-term outcomes.     

Sialorrhea, hyperhidrosis and botulinum toxin]

OBJECTIVE: The first clinical studies indicate that Botox provides effective treatment for hyperhidrosis and sialorrhea. The aim of this work is to sum up current evaluation of this use. METHOD: A systematic literature search was conducted on the Pub Med database, along with on chapters in other publications. The most interesting articles in relation to our own personal experience were chosen. RESULTS: Despite recent use of BT to treat focal hyperhidrosis, there have been numerous publications since 1997. However, the injected areas have not been listed so frequently. Axillary hyperhidrosis has been studied most; it is also in this case and in the case of gustatory sweating that the best results have been obtained. Publications about palmar and especially plantar hyperhidrosis are much rarer, almost anecdotic. It has been demonstrated to a lesser extent that BT injections are effective in these cases. Literature about sialorrhea is just beginning. However, the reduction of the production of saliva following intra parenchymatic injection of toxin into the parotid and submandibular glands, thus rarifying drooling, has been demonstrated.For each of the pathological indications, both the injection techniques and the optimal doses remain to be determined. DISCUSSION: Because BT blocks all cholinergic transmission, including the autonomous nervous system, it was plausible to expect a reduction in sweating and salivation on local injection of the product. In fact, the first publications indicated such efficiency without serious side effects.For hyperhidrosis, there has developed a consensus for making intracutaneous injections only. Of the injections in axillary areas, the palms of the hands, the plantar regions, the face or other cutaneous areas, palmoplantar hyperhidrosis is the least accessible, in any case causes the most technical problems, because of difficulty in pain management. For sialorrhea and the drooling that accompanies certain chronical neurological diseases, BT seems to have very promising effects. However, it has not been precisely determined whether to inject the parotid gland, the submandibular gland, or both. Necessary and sufficient means of targeting are still imprecise. It also remains to be determined the number of sites per gland and the doses to be injected.     

胸腔镜一孔法治疗手汗症

目的通过胸腔镜一孔法切断胸交感神经干治疗多汗症,总结其安全性和有效性。方法自1996年6月至2008年12月,46例多汗症患者在全麻双腔插管下通过胸腔镜一孔法行胸交感神经切除术。治疗方法采用电凝毁损胸2交感神经节。结果术后多汗症状全部消失,11例（39．5％）病人出现上肢以外的代偿性多汗,但基本可以忍受,不影响生活,不需进一步治疗。全组无复发病例,无手术死亡,效果满意。结论胸腔镜胸交感神经切除术是当今外科治疗手汗症的金标准,单一孔切口更加符合现代美容要求,创伤性更小,其手术技巧至关重要。     

"一孔法"胸腔镜胸2交感神经节切除术治疗手汗症

目的评价"一孔法"胸腔镜胸2交感神经节切除术治疗手汗症的安全性和有效性.方法自2004年5月～2004年9月,17例手汗症患者在全麻双腔插管下行双侧胸腔镜胸2交感神经节切除术.术毕排出胸腔残余气体,不置胸腔引流管.结果术后手掌多汗症状消失.全组无手术死亡.平均双侧手术时间39min,平均随访时间2.1个月.无病例复发.结论"一孔法"腔镜胸2交感神经节切除是一种安全有效治疗手汗症的微创方法.