Division of Thoracic and Cardiovascular Surgery

What is Hyperhidrosis?

Hyperhidrosis is a disorder characterized by excessive sweating that occurs in up to 1% of the population. The excessive sweating can occur in the hands (palmar hyperhidrosis), in the armpits (axillary hyperhidrosis), or in the feet (plantar hyperhidrosis). Although nobody understands the exact cause of this excessive sweating in specific individuals, it is known that the sweating is controlled by the sympathetic nervous system.

What is the Sympathetic Nervous System?

The human body possesses two different sets of nerves: the somatic nervous system and the autonomic system. The somatic nervous system is the system of voluntary nerves that give us sensation (pain, heat, and touch) as well as the control of our muscles that allow us to move the different portions of our body at will. The autonomic nervous system, on the other hand, is the involuntary nervous system. Many of our bodily functions occur without conscious control such as the rate at which we breathe, the beating of our heart, and the production of sweat, which is important for regulating body temperature. The autonomic nervous system is made up of two components: the sympathetic and the parasympathetic systems. It is the sympathetic nervous system that controls the sweating throughout our bodies.

What Causes The Sympathetic System To Malfunction?

Although there is ongoing research investigating this abnormality, it is not known what specific defect occurs that results in excessive sweating. Whether it is the over activity of the sympathetic nervous chain or the sweat glands themselves is uncertain.

What Are The Symptoms?

Patients with hyperhidrosis have excessive sweating that hampers their activities of daily living. It is sometimes brought on by stress, emotion, or exercise, but can also occur spontaneously. Patients with palmar hyperhidrosis have wet, moist hands that sometimes interfere with grasping objects. Most patients with palmar hyperhidrosis also consider it a difficult social problem since every time they shake hands, they leave the other person's palm very moist, a sensation most people find unpleasant. Those who suffer from axillary hyperhidrosis sweat profusely from their underarms causing them to stain their clothes shortly after they dress. Once again, this proves to be very unsightly and a social disadvantage. Plantar hyperhidrosis is the excessive sweating of the feet and leads to moist sock and shoes as well as increased foot odor.

What Is The Treatment For Hyperhisrosis?

The initial treatment for hyperhidrosis is usually medical and does not involve surgery. There are ointments and salves available (i.e., Drysol) that are astringents that tend to dry up the sweat glands. Another treatment is iontopheresis. This consists of a treatment of electrical stimulation, usually in the hands. Patients place their hands in a bath through which an electrical current is passed. This treatment tends to "stun" the sweat glands and can decrease the secretion of sweat for periods of 6 hours to one week. One of the most recent treatments proposed is the injection of botulinum toxin (Botox) into the area of excessive sweating. This is a toxin that affects nerve endings and decreases the transmission of the nerve impulses to the sweat glands thus resulting in decreased sweating. It generally requires several injections in the palms or underarms and it remains effective from one to six months. Repeated injections are nearly always required to maintain an adequate level of dryness.

In addition to the above treatments, many medicines have been utilized with varying success. These include both sedatives (in those patients with stress-induced hyperhidrosis) and medications that affect the nervous system. A family practitioner or internist often begins the initial treatment for hyperhidrosis.

While these treatments can be effective and are often the first line of treatment for many patients they can be costly and time consuming. Surgery is considered when these less invasive medical treatments have failed to provide adequate treatment.

What Surgery Is Performed To Treat This Condition?

Surgeons have known for a long time that a procedure called sympathectomy can cure excessive sweating in the hands, face, and underarms and sometimes the feet as well. It also cures problems with persistent facial blushing.

Sympathectomy involves cauterizing (cutting and sealing) a portion of the sympathetic nerve chain that runs down the backbone, parallel to the spinal cord. This operation permanently interrupts the nerve signal that is causing the body to sweat excessively.

In the past, this was a complicated procedure because surgeons needed to make a major incision to reach the sympathetic chain. They either had to open the chest cavity or approach through the back, just below the neck. In either case, the risks related to major surgery generally were thought to outweigh any potential benefits. However, recent advances in video-assisted thoracoscopic surgery (VATS) have made it possible for surgeons to perform the procedure with only very small incisions—in fact, less than one centimeter each. Using a video camera and small surgical instruments, the surgeon can locate and cut the right portion of the sympathetic chain in a relatively simple operation. Most patients require just an overnight stay in the hospital.

The Procedure: Endoscopic Thoracic Sympathectomy (EST)
Patients are placed under general anesthesia with their arms propped up at a 90-degree angle to the body. This provides access to the area just below the underarm, through which the operation is performed.

Starting on one side of the body, the surgical team deflates the lung so that the surgeon will be able to get to the sympathetic nerve chain. We make one or two small incision approximately 5 mm each underneath the armpit, usually between the second and third ribs.

A small camera device, or videoscope, is placed through the incision in order to see inside the chest and identify the sympathetic nerve chain. Through the scope, a cautery device to cut and seal the appropriate level, as determined in advance by the person’s symptoms, is placed. The incision is closed with sutures that will eventually dissolve on their own.

In order to treat palmar (hand) hyperhidrosis, the T2 ganglion is divided. Many surgeons will also divide the third ganglion to maximize the chance of completely preventing sweating of the hands. In order to treat the axillary hyperhidrosis, the third and fourth ganglia are divided.

Following completion of the operation, the lung is re-expanded and the incisions are closed. Occasionally a small tube is left inside the chest to allow evacuation of air, however, this is usually removed within hours of the surgery. After one side is completed, the surgeon then turns his/her attention to the opposite side and an identical procedure is performed.

Typically, the patient remains in the hospital for a period of 12-24 hours following surgery. There is post-operative pain following surgery and most patients will require some oral pain medication for a period of 5-7 days following surgery. The patient usually can return to work or school within a few days.

What Are The Risks Of Surgery?

Benefits and Risks
Patients with severe hyperhidrosis who have exhausted other medical treatments are finding that the surgery offers a permanent solution to their problem. In almost all cases, it cures excessive sweating in the hands, face, and underarms, and many people experience the side benefit of decreased sweating in the feet. Moreover, the effect of the surgery is immediate. Patients are often amazed when they wake up and find their hands warm and dry for the first time in years.

There are certain risks that are common to all forms of surgery. These include allergic reaction to anesthetic agents or drugs, or infection at the site of operation. The risks specifically associated with the procedure are minimal, but still need to be taken into account. These may include:

1. Compensatory Hyperhidrosis: This is the most common side effect reported by people who undergo EST. While they may no longer experience excessive sweating in their hands, underarms, and/or feet, they often notice that they sweat more in another part of the body, such as the chest, back, or legs. In effect, the body is "redirecting" the sweat. This happens in up to 50-70% of patients who have the procedure—sometimes temporarily, sometimes permanently. However, most people report that they can deal with this to get the benefit of curing excessive sweating in the hands, face, and underarms. While this appears to be merely a nuisance for most patients, occasionally (5-10% of the time) it can be severe and interfere with the patient's lifestyle.
2. Gustatory Sweating: Some people experience increased sweating when they eat.
3. Horner’s Syndrome: Resulting from inadvertent damage to the higher nerves, this condition causes decreased facial sweating, drooping of the eyelid, and enlarged pupils. It is very rare (1% in the reported literature) and unlikely to happen when an experienced surgeon performs the procedure. This syndrome is sometimes reversible over a period of weeks to months, but may also prove to be permanent. Although the incidence of this is quite low (1%), it is a potential complication of which all patients should be aware.
4. Pneumothorax: Sometimes air or gas can collect in the chest cavity, which may cause the lung to collapse. In most cases, however, it does not pose a major problem and resolves itself spontaneously. Pneumothorax does prohibit someone from flying, which should be taken into account when traveling to a distant medical center for the procedure.
5. Pain: Pain may be caused by the surgical instruments pressing on nerves along the ribs during surgery. Most people find that the pain is tolerable and does not last long.
6. Hemothorax. A rare complication (<1%), is excessive bleeding and/or injury to the surrounding organs and tissues.

For most people, the benefits of the procedure far outweigh the risks. However, there are certain cases in which the surgery should not be performed. People who have severe heart and/or respiratory disease, a currently active infection, or low heart rate should not undergo EST. Also, people who have had prior chest surgery generally are not good candidates.

Overall, with the exception of compensatory sweating, the incidence of complications or side effects remains gratifyingly low.

What Are The Chences To Success?

The probability of success varies with the anatomic location of the excessive sweating. EST will cure approximately 95-98% of excessive hand (palmar) hyperhidrosis and approximately 75-80% of armpit (axillary) hyperhidrosis. Approximately 25% of patients with hyperhidrosis of the feet (plantar) will note some improvement; however, the operation is not designed to treat this disorder and should not be used primarily if this is the only complaint.

Summary

Although ETS is overall a safe and highly effective method of treatment for the hyperhidrosis syndrome, it must be realized that it remains a surgical procedure with the inherent risks described above. As with most disorders, non-invasive medical forms of therapy should be tried prior to surgery. It is only when these prove to be unsuccessful or impractical for long-term use that a surgical procedure should be contemplated. Once the decision to pursue surgery is made, patients would best be served looking for a board certified thoracic surgeon experienced in performing video-assisted thoracic surgery (VATS) otherwise known as thoracoscopy.