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Article Summary  

Avoiding Disabling Compensatory Hyperhidrosis- Tips from an Expert 


by Hratch L Karamanoukian, MD
Posted: February 9, 2004


Summary:
There are some well known side-effects of thoracic sympathectomy, whether it is achieved by cutting, coagulating or clipping the thoracic sympathetic trunk. I would like to focus on compensatory hyperhidrosis in this article. 

What is the most likely location for compensatory hyperhidrosis?

Compensatory hyperhidrosis can occur following endoscopic thoraic sympathectomy. It can occur in the the upper or lower torso (chest), abdomen, groin, buttocks and sometimes the feet. 

It can be localized in the breast fold (under the bra) as the only location in women who have had endoscopic thoracic sympathectomy for axillary and palmar hyperhidrosis. The compensatory hyperhidrosis here is minimal, provided that the surgeon has clipped the appropriate nerves (see below). But remember, there is individual variation in symptoms. 

Why does compensatory hyperhidrosis occur?

Compensatory hyperhidrosis is a way to get rid of excess body heat. Normally, perspiration is the way we get rid of excess body heat. Once the neural pathways to conduct this information is interrupted in the face, scalp, armpits or hands, the sympathetic nervous system "shifts its focus" to other parts of the body that have high surface area. Most commonly, it is the lower chest in the back (lower torso), groin or feet.

A case report of a patient who had severe form of hyperhidrosis is presented for your consideration. This case was particularly distrubing to me but is not unusual, as I have been referred many patients to me who have had surgery elsewhere and who have developed similar symptoms. 

The wife of a patient recently reported to me that he sought help to eliminate axillary hyperhidrosis. Here is what she said:

"This is our situation. My husband had a T2 T3 sympathectomy [somewhere in California] last March with his only complaint being axillary sweating. Now, he still sweats from his armpits (slightly better though) [but} he has compensatory/reflex sweating all over his chest, back and groin area. This has resulted in a worse condition than he started with, as now he gets jock itch from the moisture in his groin plus the discomfort and embarrassment of wetness in more obvious places. The nerves were cut, so I understand that the reversal possiblity is not so promising. We are in California. Where are you located and can you make any suggestions.... ].... [he has been on] all the different drugs, i.e. Robinul, ditropan, to name a few [without success].

The note above is verbatim except for the [bracketed] editorial notes that I have added to make the e mail more readable.

I have found that patients can get mild, moderate or severe forms of compensatory hyperhidrosis and it is related to the degree of hyperhidrosis they presented with in the first place. Patients with severe hyperhidrosis usually are the ones more likely to develop moderate compensatory hyperhidrosis. 

Patients with mild hyperhidrosis can usually be spared compensatory hyperhidrosis. 

So, what about the above patient who developed "disabling" compensatory hyperhidrosis after endoscopic sympathectomy for isolated axillary hyperhidrosis? 

This patient underwent endoscopic thoracic sympathectomy by a well meaing surgeon who believed that he will cure his symptoms by dividing the T2 and T3 nerve trunks. The results of this type of surgery are no longer acceptable to patients and experienced surgeons. 

High sympathectomy for axillary hyperhidrosis is associated with the development of severe compensatory hyperhidrosis. As a matter of fact, he would have been better served with clipping of the sympathetic trunk at T4 and T5. 

Sympathetic denervation by clipping or cutting at the level of T2 and T3 is associated with "disabling" compensatory hyperhidrosis in the upper and lower torso, groin, upper thighs and feet. This can occur in up to 15% of patients. Most patients, however, can live with it because they have been relieved of severe hyperhidrosis in the afflicted areas, namely armpits or hands! In this particular case, however, the results are worse than the presenting symptoms to the patient and his wife!

I don't recommend cutting the sympathetic trunk as reversal is impossible once the nerves are cut. If one does develop disabling compensatory hyperhidrosis after clipping the T2 and T3 nerve trunks, then the clips can be removed! This is not an option when your surgeon routinely cuts sympathetic nerve trunks!

Therefore, high sympathectomy by an experienced surgeon is reserved for patients with facial blushing and/or hyperhidrosis alone. 

I use lower levels of thoracic sympathetic interruption with titanium clips for palmar hyperhidrosis or palmar and axillary hyperhidrosis. 

As in the patient noted above, medications have not helped! He has tried Robinul and Ditropan without success. I have been referred patients who have developed severe compensatory hyperhidrosis from all over the U.S. and have made some individual recommendations which have worked quite well. The best solution is to have your surgery done by an expert who understands these problems amd understands the physiology and anatomy of the sympathetic trunk and hyperhidrosis. 

Please do not hesitate to contact me for more information. Providing Expert Care for Hyperhidrosis is my surgical motto. 



Reference:
Technical Pitfalls - Avoiding Compensatory Hyperhidrosis, diagnosissweatypalms.com


Date of Article Publication:
2003, November


Web Site: http://www.diagnosissweatypalms.com
