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PubMed1992

Endoscopic transthoracic sympathectomy: experience in the south west of England.

Thoracic sympathectomy has an established role in the management of primary palmar and axillary hyperhidrosis, Raynaud's phenomenon and occlusive vascular disease. Potential problems with traditional surgical approaches to the sympathetic chain include poor exposure, risk of damage to adjacent structures and postoperative pain. A minimally invasive endoscopic approach helps to overcome these problems. Using this technique, 45 procedures have been performed on 26 patients in two districts in the South West of England over the past five years. Follow-up information was available for 39 procedures. All 27 procedures for hyperhidrosis and both for occlusive vascular disease have produced a long-term improvement. Nine of the 10 procedures for Raynaud's phenomenon have also produced some degree of long-term improvement. Complications included four asymptomatic pneumothoraces, two patients with temporary unilateral Horner's syndrome and two instances of intercosto-brachial numbness. On the positive side, patients expressed satisfaction with the efficacy, rapid recovery and small unobtrusive scars produced by the procedure. Endoscopic transthoracic sympathectomy is effective, safe and well accepted by patients and we believe is now the method of choice for this procedure.

Adolescent↗
PubMed2001

Bilateral pulmonary edema after endoscopic sympathectomy in a patient with glucose-6-phosphate dehydrogenase deficiency.

Transaxillary endoscopic sympathectomy of thoracic ganglia (T2-T3) has recently gained wider acceptance as the treatment of choice for palmar hyperhidrosis. It requires one-lung ventilation to facilitate the surgery. One-lung ventilation, however, is not without complications, among which acute pulmonary edema has been reported. In this case report, we present a patient with palmar hyperhidrosis complicated by glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, who received bilateral endoscopic sympathectomy under alternate one-lung anesthesia, and developed acute pulmonary edema immediately after recruitment of the successive collapsed lung. The effects of hypoxemia, G-6-PD deficiency and sympathectomy might all add to the development of acute pulmonary edema secondary to reexpansion of each individual lung after alternate one-lung ventilation. The possibilities of the inferred causes are herein discussed.

Acute Disease↗
PubMedDate not supplied

Clinical evaluation of atopic hand-foot dermatitis.

Clinical manifestations of atopic hand-foot (H-F) dermatitis have not been well studied. This study examined 108 atopic dermatitis (AD) patients with H-F dermatitis between May 1997 and July 1999 at our AD clinic to determine the clinical characteristics of atopic H-F dermatitis and to assess its etiologic associations. It usually began in childhood with an early onset of AD. Pruritus was the most frequent symptom, and erythema, scales, lichenification, hyperkeratosis, fissures, and keratolysis exfoliativa were also common signs. Both the hands and feet were involved in 47 (44.0%) patients, and either hand or foot involvement was observed in 15 (13.9%) and 46 (42.6%) patients, respectively. Palmar or plantar surfaces were more frequently involved than the dorsal aspects. The great toe was affected more often than the other toes. Two-thirds of patients presented with manifestations of the ichthyosis triad and sandpaper-like skin lesions on the elbow, knee, and lateral malleolus. Palmar or plantar hyperhidrosis was reported in 15% and 20%, respectively. The ichthyosis triad-associated group showed a significantly higher incidence of sandpaper-like (thickened, roughened) skin lesions, and these patients had lesions on the dorsal hands or heels and lateral malleolus more frequently than ichthyosis triad-absent patients. The hyperhidrosis-associated group showed an association with glassy lesions, localized to palmar or plantar areas. Atopic H-F dermatitis is associated with the nonallergic etiologies of AD and clinical subgroups can be identified on the basis of nonallergic backgrounds.

Child↗
PubMed2004

BOTOX delivery by iontophoresis.

We report two patients with severe palmar hyperhidrosis who responded to BOTOX delivered not by injection, the usual method of delivery, but by iontophoresis. The Botulinum molecule has been considered too large for delivery into the skin this way. However, other large peptides, both non-ionic and cationic, have been delivered successfully by this method, so we suspected that BOTOX could in fact be iontophoresed. Our saline-controlled treatment of these two patients with a small iontophoresis unit (Iomed Phoresor II) allowed small volumes of standard BOTOX dilutions to be used, and demonstrates that iontophoresis can indeed deliver BOTOX successfully. This has important therapeutic potential for the large number of patients with focal hyperhidrosis. They may be spared painful injections, and in more severe cases, invasive surgery.

Adult↗
PubMed1997

Carbon dioxide laser treatment vs subcutaneous resection of axillary osmidrosis.

BACKGROUND: Axillary osmidrosis is a distressing disorder characterized by unpleasant odor, profuse sweating, and occasional staining of clothes that may handicap those affected both socially and in the work place. Various types of surgical procedures have been developed for the treatment of axillary hyperhidrosis and osmidrosis. OBJECTIVE: Our purpose is to seek a more effective surgical procedure than preexisting various subcutaneous resection techniques for axillary osmidrosis. METHODS: After single transverse incision in the center of one axilla, undermining was performed from the incision edges to make a wide subcutaneous tunnel and then apocrine glands and subcutaneous fats were vaporized with a CO2 laser. Subcutaneous resection technique was performed on the opposite axilla in the same patient. A total of 20 patients have been evaluated for 4 months to 1 year, with an average of 8 months. RESULTS: The results from commonly used surgical procedures can be improved upon by the use of the CO2 laser. The frequency of complications and the mean duration of suture removal were diminished on the laser-operated side. CONCLUSIONS: CO2 laser vaporization in osmidrosis produces significant patient-benefit during the postoperative course. We believe that this laser-assisted combined surgical procedure can be a viable option for the treatment of axillary hyperhidrosis and osmidrosis.

Adolescent↗
PubMed2005

[Therapeutic application of botulogenic toxin].

Botulogenic toxin infiltration for the treatment of idiopathic local hyperhidrosis is a safe and well tolerated procedure, with minimum side effects and with an effectiveness demonstrated throughout the years, especially in axillary hyperhidrosis; in the majority of patients with this condition is an effective alternative to surgery. In other locations, the results are more modest and the clinical experience more limited, which forces us to advise the surgery as alternative with an incidence far from desirable.

Animals↗
PubMed2000

Effect of thoracic sympathectomy on arm and leg exercise capacity and on lung function.

BACKGROUND: Thoracic T(2-4) sympathectomy (TS) relieves palmar hyperhidrosis. These same roots innervate the heart and the lung. Thoracoscopic TS minimizes damage to the chest wall so that the effect of sympathectomy itself on these organs can be studied. We attempted to determine whether attenuated sympathetic output affects arm or leg exercise tolerance and lung function in young adults who underwent this operation. METHODS: Seven subjects, aged 17-30 years, had lung function tests (water spirometer, Godart, Holland), and leg and arm maximal exercise (CPX, MedGraphics, USA), before and 3-6 months after TS. RESULTS: After TS, resting and exercise heart rate and blood pressure were reduced. Baseline leg and arm peak O(2) uptake, 2.08 (0.6) and 1.44 (0.5) liters/min, respectively, were not different from the post-TS values, 2.06 (0.7) and 1.54 (0.5) liters/min (nonsignificant). Post-TS lung functions were not significantly reduced. CONCLUSION: Thoracoscopic T(2-4) sympathectomy does not lead to a clinically important fall in lung function and does not compromise arm or leg exercise capacity. Therefore, TS can be done safely in young subjects with palmar hyperhidrosis.

Adolescent↗
PubMed2004

Speckled lentiginous nevus syndrome: report of a further case.

A 42-year-old man had a large speckled lentiginous nevus on the left side of his trunk. The involved area was painful when touched and paresthetic. Moreover, the ipsilateral half of his body showed a pronounced hyperhidrosis. This case can be categorized as a typical example of speckled lentiginous nevus syndrome, a recently recognized phenotype characterized by a speckled lentiginous nevus of the papular type and ipsilateral neurological abnormalities in the form of dysesthesia, muscular weakness or hyperhidrosis. Speckled lentiginous nevus syndrome represents a mosaic phenotype. Most likely it originates from loss of heterozygosity occurring in a heterozygous embryo at an early developmental stage.

Adult↗
PubMed2000

Sympathetic denervation of the upper limb improves forearm exercise performance and skeletal muscle bioenergetics.

BACKGROUND: Sympathetic activation may limit exercise performance by restraining muscle blood flow or by negatively affecting skeletal muscle metabolic behavior. To test this hypothesis, we studied the effect of thoracoscopic sympathetic trunkotomy (TST) on forearm exercise duration, blood flow, and muscle bioenergetics in 13 patients with idiopathic palmar hyperhidrosis. METHODS AND RESULTS: Heart rate and beat-by-beat mean arterial pressure were recorded at rest and during right and left rhythmic handgrip before and 4 to 7 weeks after right TST. Forearm blood flow was measured bilaterally at rest and on the right during exercise. Right forearm muscle phosphocreatine content and intracellular pH were assessed by (31)phosphorus magnetic resonance spectroscopy. After right TST, exercise duration increased from 8.9+/-1.4 to 13.4+/-1.8 minutes (P<0.0001) with the right forearm and from 5.7+/-0.4 to 7.6+/-0.9 minutes (P<0.05) with the left (P<0.05 for the interaction between treatment and side). Right forearm blood flow at rest was 66% higher (P<0.01) after right TST, but this difference decreased as the exercise progressed. After right TST, a significant reduction occurred in muscle acidification and phosphocreatine depletion during ipsilateral forearm exercise. This was associated with a significantly reduced mean arterial pressure response to right handgrip, whereas the pressor response to left handgrip did not change. CONCLUSIONS: Sympathetic denervation of the upper limb significantly improves forearm skeletal muscle bioenergetics and exercise performance in patients with idiopathic palmar hyperhidrosis.

Adult↗
PubMedDate not supplied

Xenografting human T2 sympathetic ganglion from hyperhidrotic patients provides short-term restoration of catecholaminergic functions in hemiparkinsonian athymic rats.

Previous studies have suggested that allografting peripheral sympathetic ganglia, such as superior cervical ganglia, partially relieves clinical or behavioral deficits in parkinsonian patients and animals. However, removal of these ganglia can cause Homer's syndrome, which limits the utilization of this approach. Hyperhidrosis, a disease of excessive sweating, is commonly seen in young Orientals. Treatment of hyperhidrosis often involves surgical removal of the second thoracic sympathetic ganglia (T2G), which contain catecholaminergic neurons. The purpose of our study was to investigate behavioral responses and tyrosine hydroxylase (TH) immunoreactivity in hemiparkinsonian rats at different time points after transplantation of human T2G from hyperhidrotic patients. Athymic Fisher 344 rats were injected unilaterally with 6-hydroxydopamine into the medial forebrain bundle to destroy the nigrostriatal dopaminergic (DA) pathway. The effectiveness of lesions was tested by measuring methamphetamine (MA)-induced rotations. These unilaterally lesioned rats were later transplanted with T2G or T2 fiber tract (T2F) obtained from adult hyperhidrotic patients. Animals grafted with T2G showed a reduction in MA-induced rotation by 2 weeks; however, rotation returned to the pregrafting levels by 3 months. Animals receiving T2F grafts did not show any reduction of rotation over a 3-month period. Animals were later sacrificed for TH immunostaining at different time points. Tyrosine hydroxylase-positive [TH(+)] cell bodies and fibers were found in the lesioned striatum 2-4 weeks after T2G grafting, suggesting the survival of transplants. Two to 3 months after grafting, TH(+) fibers were still found in almost all the recipients. However, TH(+) cell bodies were found in only three of seven rats studied. Animals receiving T2F grafting did not show any TH immunoreactivity in the lesioned striatum over the 3-month period. These data indicate that T2G transplants from adult hyperhidrotic patients can survive and provide transient normalization of the motor behavior in the hemiparkinsonian athymic rats. Because of the short-term improvement in behavior after grafting, the use of T2G in human trials should be cautious at the present time. Further laboratory research is required.

Animals↗
PubMedDate not supplied

Iatrogenic Horner's syndrome.

PURPOSE: To report two cases of Horner's syndrome. One presented after the ablation of a schwannoma of the cervical sympathetic chain, the second after upper thorascopic sympathectomy for primary palmar hyperhidrosis. METHODS: A 42-year-old man underwent excision of a left neck mass found during routine physical examination. A 20-year-old girl with axillary and palmar hyperhidrosis was treated with cervical sympathectomy. RESULTS: In the early postoperative days, miosis, ptosis, anhidrosis, and enophthalmos were observed. CONCLUSIONS: In the ablation of a schwannoma, postoperative Horner's syndrome is associated with the relationship between nerves and the tumor mass, which makes it impossible to separate them surgically in most cases. In thorascopic sympathectomy, patients should be warned of this complication.

Adult↗
PubMed1991

Sequential cerebrospinal fluid and plasma sampling in humans: 24-hour melatonin measurements in normal subjects and after peripheral sympathectomy.

Simultaneous measurements of plasma and cerebrospinal fluid (CSF) melatonin and urinary excretion of 6-hydroxymelatonin were performed in four normal volunteers and one patient before and after upper thoracic sympathectomy for the control of essential hyperhidrosis. For normal individuals, hourly 24-h melatonin concentrations in plasma and CSF exhibited similar profiles, with low levels during the day and high levels at night. Peak plasma levels varied from 122-660 pmol/L, and the peak CSF levels from 94-355 pmol/L. The onset of the nocturnal increase in melatonin did not occur at the same time for each individual. Urinary 6-hydroxymelatonin levels also exhibited a daily rhythm, with peak excretion at night. The individual with the lowest nocturnal levels of circulating melatonin also had the lowest excretion of 6-hydroxymelatonin. In the patient with hyperhidrosis, a prominent melatonin rhythm was observed preoperatively in the CSF and plasma. After bilateral T1-T2 ganglionectomy, however, melatonin levels were markedly reduced, and the diurnal rhythm was abolished. These results provide direct evidence in humans for a diurnal melatonin rhythm in CSF and plasma as well as regulation of this rhythm by sympathetic innervation.

Adult↗
PubMed2003

Differential effects of surgical sympathetic block on sudomotor and vasoconstrictor function.

OBJECTIVE: To assess the effects of a surgical block of the sympathetic chain at the T2 level on vasoconstriction and palmar sweating in patients with palmar hyperhidrosis. METHODS: In a prospective study, sympathetic vasoconstriction was measured by laser-Doppler imaging and by computer-assisted infrared thermography (rewarming kinetics following immersion of both hands in ice water [4 degrees C, 30 seconds]) in 61 patients with hyperhidrosis preoperatively and 2 days and 3 months postoperatively. In addition, palmar sweating preoperatively and 3 months postoperatively was assessed by quantitative sudometry. RESULTS: Before surgery, rewarming kinetics was significantly slower in the patients (n = 61) than in the healthy control subjects (n = 28). Two days after the block, baseline skin temperature increased by about 5 degrees C, and rewarming was massively accelerated in each of the patients. Three months postoperatively, rewarming kinetics was still accelerated in 36 hands, was unchanged from the preoperative condition in 42, and had worsened in 12. These changes were accompanied by parallel alterations of laser-Doppler flux. However, palmar sweating was massively reduced in all but one patient, irrespective of the different rewarming kinetics. CONCLUSIONS: T2 sympathectomy leads to long-lasting inhibition of palmar sweating, which does not correlate to loss of vasoconstriction. Recurrent and enhanced vasoconstrictor function 3 months following endoscopic sympathetic block has major implications for its use to treat enhanced vasoconstriction.

Adolescent↗
PubMed1987

Orthostatic hypotension-induced autonomic dysreflexia.

Three patients with chronic traumatic cervical myelopathy had severe orthostatic hyperhidrosis. Orthostatic challenge revealed that hypotension preceded hyperhidrosis, hypertension, and chills, all manifestations of autonomic dysreflexia. Treatment of orthostatic hypotension with fludrocortisone acetate relieved these symptoms. Therefore, orthostatic hypotension may trigger autonomic dysreflexia and the usual way of managing such patients, propping them upright, may be counterproductive.

Adult↗
PubMed2005

Palmar skin blood flow and temperature responses throughout endoscopic sympathectomy.

Thoracic surgical sympathectomy is often performed to treat primary palmar and axillary hyperhidrosis. An increase in palmar skin temperature is frequently used to identify the success of the procedure. Because changes in palmar skin temperature occur secondary to changes in skin blood flow, the objective of this study was to test the hypothesis that monitoring palmar skin blood flow would provide greater temporal resolution relative to monitoring palmar skin temperature. In 11 patients with palmar and/or axillary hyperhidrosis, we measured palmar skin temperature and blood flow (via laser Doppler flowmetry) throughout the sympathectomy procedure. Five minutes after the initial cautery, skin blood flow increased from 48 +/- 7 perfusion units to 121 +/- 17 perfusion units (P <0.001), whereas no significant change in temperature was observed (31.0 degrees C +/- 0.5 degrees C to 31.3 degrees C +/- 0.5 degrees C; P >0.05). The time required to reach peak skin blood flow (22 +/- 3 min) was significantly less than the time required to reach peak skin temperature (34 +/- 0.3 min; P <0.001). Finally at 5, 10, and 15 min after the initial cautery, skin blood flow increased to a larger percentage of the total increase in skin blood flow relative skin temperature (all P <0.006). These data suggest that monitoring skin blood flow provides greater temporal resolution when compared with monitoring skin temperature during thoracic sympathectomy. However, the initial cautery of the parietal pleura over the ganglion may result in increases in skin blood flow before physical disruption of the ganglion. This occurrence may limit the utility of skin blood-flow measurements in identifying the success of the procedure.

Adult↗
PubMed2002

Effects of endoscopic transthoracic sympathicotomy on hemodynamic and neurohumoral responses to exercise in humans.

Endoscopic transthoracic sympathicotomy (ETS) is a minimal invasive procedure of thoracic sympathetic block and has been used successfully in the treatment of primary palmar hyperhidrosis. To examine the effect of Th 2-3 ETS on hemodynamic responses to submaximal upright treadmill exercise in humans, cardiac output, plasma noradrenaline and adrenaline at rest and during the last 40s of stage 2 in a modified Bruce protocol were measured before and after ETS in 21 patients with primary palmar hyperhidrosis. Heart rate, mean arterial pressure, rate-pressure product, and noradrenaline decreased at rest and at submaximal exercise after ETS. Cardiac index at rest did not change either before or after ETS, but decreased (8.9 +/- 0.6 vs 6.8 +/- 0.4L x min(-1) m-2; p<0.01, mean +/- SEM) at submaximal exercise after ETS. Stroke index and systemic vascular resistance were similar both at rest and at submaximal exercise before and after ETS. Thus, ETS reduces myocardial oxygen demand and plasma noradrenaline levels both at rest and during exercise without significantly depressing cardiac function in terms of stroke volume.

Adult↗
PubMed2005

Are patients better than the laboratory in assessing sweating? Validation study.

BACKGROUND: Primary focal hyperhidrosis is a hereditary condition characterized by excessive sweating affecting a variety of areas, including the palms. In most cases, the decision to treat a patient is based only on the patient's own description of the symptoms because laboratory tests have not been established in clinical practice. OBJECTIVE: To validate a subjective self-assessment scale for sweating in comparison with an objective method of quantifying evaporation from the skin surface. METHODS: We studied palmar sweating in 20 patients with primary focal hyperhidrosis and 20 age- and gender-matched controls. Four times in each subject, we obtained measurements of the evaporation in palms and the self-evaluation scale (SES) scores on a proportional scale from 0 (no sweating) to 10 (worst imaginable sweating). RESULTS: Good correlation was found between the SES score and evaporation assessment (R = .65). The SES score was easier to obtain and provided better diagnostic sensitivity and specificity. They leveled out at over 80% when a score of 3 was used as the threshold level; for evaporimetry, sensitivity equalled specificity at 70% at the threshold 90 mg -2h(-1). CONCLUSION: We confirm the usefulness of the SES in assessing palmar sweating and discuss the current restrictions in its use in clinical diagnosis. We propose that the scale can be added effortlessly to research or clinical protocols to provide the necessary validation in wider spectra of patients.

Adolescent↗
PubMed2004

Evaluation of cardiac sympathetic nerve function by myocardial 123I-metaiodobenzylguanidine scintigraphy before and after endoscopic sympathectomy.

OBJECT: The purpose of this study was to analyze the change in cardiac sympathetic function by performing a 123I-metaiodobenzylguanidine (MIBG) imaging study after endoscopic upper thoracic sympathectomy (EUTS) in patients with palmar hyperhidrosis before and after surgery. METHODS: Between February 1999 and February 2002, 135 patients underwent bilateral EUTS to treat palmar hyperhidrosis. Between September 2001 and February 2002, 12 of these consecutively enrolled patients were also included in a 123I-MIBG imaging study. These patients underwent cardiac 123I-MIBG imaging 1 day before and 7 days after they had undergone EUTS. The heart/mediastinum (H/M) ratio and the washout rate were calculated for both early and late phases, and single-photon emission computerized tomography (SPECT) imaging of the early phase was performed. Excessive perspiration from the palms disappeared immediately after EUTS in all patients, and they showed no symptoms of a circulatory condition following the procedure. On the 123I-MIBG imaging studies, the early H/M ratio before EUTS was 2.35 +/- 0.26 and postoperatively it was 2.29 +/- 0.23. The delayed H/M ratio before EUTS was 2.59 +/- 0.3 and after the procedure it was 2.66 +/- 0.27. There was no significant difference between the H/M ratio before and after EUTS. The washout rate after EUTS (14.27 +/- 4.71%) was significantly lower than that measured before EUTS (18.36 +/- 5.13%: p < 0.01). No apparent local defects of accumulation of MIBG were found on SPECT images obtained post-EUTS. CONCLUSIONS: Endoscopic upper thoracic sympathectomy is a minimally invasive procedure; no local denervation was found after EUTS. Findings on 123I-MIBG imaging studies indicate that EUTS suppresses the activation of the sympathetic nervous system slightly, similar to beta-blocker therapy.

3-Iodobenzylguanidine↗