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 Possible Complications and Side Effects of ETS 

Compensatory Hyperhidrosis
Horner's Syndrome
Brachial plexus injury
Hemothorax
Pneumothorax
Gustatory sweating
Neuritis
Post operative rib pain
Decreased heart rate
Dry facial skin and absence of facial blush



Compensatory Hyperhidrosis 
Compensatory hyperhidrosis (CH), also called Compensatory Sweating (CS), is the common side effect of ETS. This is reported to occur in 50-85% of patients who undergo sympathectomy for hyperhidrosis. It occurs regardless of whether the procedure is an open or endoscopic procedure. 

Compensatory hyperhidrosis is a condition where the sweating is shifted from the hands, armpits, face and feet to the back, lower chest, abdomen, buttocks and the backs of the thighs. The brain does this is order to get rid of body heat. There has been no recorded history of patients developing heat stroke after the operation because there are other ample areas where the body can sweat. It has been theorized that the CS would only happen if more than one level (T2) were clipped, but it is well known that severe CS may occur when only T2 is clipped. Mild to moderate sweating occurs in most cases it is and is usually tolerable. Most patients feel, "I can tolerate it as long as my hands don't sweat or my face doesnt blush," 

The symptoms of CS may occur intermittently or even be constant throughout the day. What matters is the severity of the syndrome. Mild CS causes moisture to appear on the back and chest during sleeping. Moderate CS involves moisture on the lower chest, abdomen, back, and buttocks and back of the legs, but it does not show through their clothes. Severe CS causes profuse dripping of sweat from the nipple down to the groin, back, buttocks and the backs of the thighs and knees. Some patients have reported that the condition can be made worse during intimate moments. All or one location of sweating may be present. Those who develop severe CS may feel that this side effect is worse than their previous symptoms. Some patients have express regret regarding their sympathectomy. 

There is currently no method of determining who will get compensatory hyperhidrosis. The compensatory hyperhidrosis may occur soon after the operation or many years later. The mechanism for compensatory hyperhidrosis has not been adequately explained. As far as we know, compensatory hyperhidrosis is the result of a feedback loop involving the brain. The brain detects that the hands are dry and then sends out a signal (perhaps increased nerve firing) to the remaining sympathetic nerves and compensatory hyperhidrosis occurs. For example, if sweating is stopped in the hands, the brain may then respond by causing sweat to appear heavily in other areas. There are even reported cases where cessation of sweating of hand hyperhidrosis from using Drysol* has led to heavy sweating on the back, abdomen and thighs. Again, most people say, "I can tolerate the compensatory hyperhidrosis as long as my hands are not sweating." It is the few patients who develop the severe form of compensatory hyperhidrosis who wish that they had never had the procedure. 

For those in which the compensatory sweating is severe and unmanageable, the new technique of clipping the sympathetic nerve clip is the best option currently available. The technique for clipping is the same endoscopic technique as the original sympathectomy, except that the nerve clip is removed instead of inserted. In a recent study, 3.6% of all post sympathectomy patients requested reversal of the procedure for intolerable compensatory sweating. 

Medications do exist that may lessen the effects of CS. 

The most useful medications for compensatory hyperhidrosis are Robinul Forte and Serzone 

Robinul Forte is the first line of medical treatment of this condition. It causes generalized body dryness; because of this, it should be used only when necessary and should be avoided heavy physical exercise. Side effects can include dryness of the mouth (cottonmouth), headaches or constipation. 

Serzone used in low doses has recently bee n found to be very effective in the treatment of severe CS. 

A recent development is to Botox injections, which are spaced on the skin of the back or the chest every 1-2 inches. 

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Horner's Syndrome 
Horner's Syndrome is ptosis (a droopy eyelid), meiosis (a constricted pupil) and anhydrosis (absence of sweating). Also, the patient may develop nasal congestion. This is due to disruption of the Stellate nerve, or first thoracic (T1) sympathetic nerve. This condition may occur following ETS and may be temporary or permanent. A temporary Horner's Syndrome is not uncommon following ETS. These symptoms are rarely permanent. The incidence of permanent Horner's Syndrome following ETS in Dr. Garza's practice has been about 0.3%. The permanent Horner's can be treated by a skilled facial plastic surgeon that will tighten the eyelid muscle and relieve the droopy eye. 
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Brachial Plexus Injury 
Injury to the spinal nerve roots may cause pain, muscle weakness or paralysis in the arm and hand. Treatment of this syndrome is extremely difficult. Fortunately, this is a very rare condition and Dr. Garza has not encountered this problem. 
Occasionally, a brief period of inner arm discomfort is felt in a small number of patients. 

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Hemothorax 
This is a condition where there is bleeding into the chest cavity. This is most commonly due to bleeding from a small artery that runs underneath the ribs. It is treated by chest tube drainage. The frequency of this is less than 1%. 
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Pneumothorax 
This is a condition in which the lung does not fully expand. This happens in about 1% of all patients and may become an issue if the patient has severe lung problems such as Emphysema. 
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Gustatory Sweating 
This condition causes facial sweating after eating or smelling foods. People describe it as similar to facial sweating that follows after eating hot spicy foods such as chili. The condition occurs in about 10% of all patients. If it does occur, it happens years after the ETS. 
Treatment of this condition is with a Robinul Forte topical suspension in a cream solution. 

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Neuritis 
Neuritis or pain between the shoulder blades may develop in a small percentage of patients. This discomfort is due to inflammation of the underlying nerves. In rare cases, it may be severe and possibly last two to three weeks. Treatment consists of steroids and non-steroidal anti-inflammatory agents. 
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Post Operative Rib Pain 
Occasionally, there is pain between the ribs at the site where the endoscope was inserted. A sensory nerve runs below each rib. Compression of this sensory nerve by the endoscope may cause this problem. This usually resolves on its own in a short time. Rarely is this is a continuing problem. 
About 20% of Dr. Garzas patients may develop a strong pressure-like sensation on their breastbone immediately after the operation. This is due to bruising of the intercostal nerve when the endoscope was introduced between the ribs. Patients report that it "feels like someone is standing on my chest and I can't breathe." The patients can breathe but their rib nerves are telling them otherwise. If one does develop this sensation, it usually abates after the first hour and rapidly fades away. 

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Decreased Heart Rate 
Ten percent of all patients who undergo ETS experience a 10% decrease in resting heart rate. Studies have shown that the level of exercise tolerance, strength and endurance are not diminished. While the heart rate may slow down, the heart makes up for this by increasing the total amount of blood volume (increasing the stroke volume) that is pumped per beat. This form of compensation is the same that occurs in highly conditioned athletes. 
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Dry facial skin 
Dry facial skin and improvement of complexion problems may occur following ETS. The dryness is rarely severe and patients rarely quire a facial skin moisturizer. An unexpected benefit from the sympathectomy is that any acne complexion problems usually resolve within the first week after the operation. Most patients can stop taking their Accutane after the procedure. Some patients may develop dandruff after the procedure. 
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