PRIMARY HYPERHIDROSISPRIMARY HYPERHIDROSIS Disease or AnxietyDisease or Anxiety

N. I. PERINPANAYAGAM M.D, FRCS,N. I. PERINPANAYAGAM M.D, FRCS, FACSFACS

Professor of NeurosurgeryProfessor of Neurosurgery

NYU Medical CenterNYU Medical Center

New York, NYNew York, NY

PRIMARY PRIMARY HYPERHIDROSISHYPERHIDROSIS

Diagnosis of Primary Diagnosis of Primary HHHH -- Start in the Start in the

11stst or 2or 2ndnd decades of life & should be decades of life & should be

Bilaterally SymmetricalBilaterally Symmetrical

Occurs in 2.8% of the US populationOccurs in 2.8% of the US population

Typically affects the hands, Typically affects the hands, axillaeaxillae, feet , feet

& less commonly the face (facial & less commonly the face (facial

flushing)flushing)

INHERITANCEINHERITANCE

Primary HH is reported to be inherited Primary HH is reported to be inherited

as an Autosomal dominant gene, with as an Autosomal dominant gene, with

incomplete penetranceincomplete penetrance

PRIMARY HHPRIMARY HH

Has Psychological, Social, Economic & Has Psychological, Social, Economic &

Occupational implicationsOccupational implications

Most patients present in their teens and Most patients present in their teens and

twentiestwenties

Majority of pts. are on AntiMajority of pts. are on Anti--Anxiolytic Anxiolytic

drugsdrugs

TYPICAL PRESENTATIONTYPICAL PRESENTATION

PalmarPalmar, , AxillaryAxillary & plantar & plantar HHHH

PalmarPalmar HHHH onlyonly

AxillaryAxillary HHHH only, with or without only, with or without

BromhidrosisBromhidrosis

Facial Facial HHHH / Gustatory sweating with or / Gustatory sweating with or

without facial flushingwithout facial flushing

Plantar Plantar HHHH

DIAGNOSISDIAGNOSIS

Primary Primary vsvs Secondary Secondary HHHH

Endocrine workEndocrine work--up up –– Hyperthyroidism, Hyperthyroidism, HyperpituitarismHyperpituitarism, Dumping syndrome, , Dumping syndrome, Alcohol & drug withdrawal, Alcohol & drug withdrawal, menopause, Diabetes, febrile illnesses, menopause, Diabetes, febrile illnesses, paraplegia, stroke, anxiety etcparaplegia, stroke, anxiety etc

Objectively quantify degree/severity of Objectively quantify degree/severity of HHHH & the impact on ADL& the impact on ADL

Family historyFamily history

PATIENTS WITH PRIMARY HHPATIENTS WITH PRIMARY HH

Excessive sweating independent of Excessive sweating independent of

ambient temperature, worse with ambient temperature, worse with

anxiety!anxiety!

Excessive hand sweating leaves Excessive hand sweating leaves

puddles of sweat, avoid shaking handspuddles of sweat, avoid shaking hands

AxillaryAxillary sweaters change shirts 3sweaters change shirts 3--4 4

times/day, wear only darker clothestimes/day, wear only darker clothes

Plantar sweaters cannot wear sandals Plantar sweaters cannot wear sandals

or slippers, wear thick sox & closed or slippers, wear thick sox & closed

shoesshoes

NONNON--SURGICAL TREATMENTS FOR SURGICAL TREATMENTS FOR

PRIMARY HHPRIMARY HH

Antiperspirants (Aluminum Chloride Antiperspirants (Aluminum Chloride ––

DrysolDrysol))

AnticholinergicsAnticholinergics –– ((RobinulRobinul))

IontophoresisIontophoresis

Therapies based on BioTherapies based on Bio--feedbackfeedback

BotulinumBotulinum toxin “A” Injectiontoxin “A” Injection

IONTOPHORESIS (Drionic & Fischer)IONTOPHORESIS (Drionic & Fischer)

Immersing hands or feet in tap water Immersing hands or feet in tap water

through which a 15through which a 15--20ma direct current 20ma direct current

is passedis passed

Iontophoresis to deliver Iontophoresis to deliver

anticholinergicsanticholinergics

RecomRecom--20mts on days 1,2,4,7,10,15,22 20mts on days 1,2,4,7,10,15,22

& maintenance sessions every 4 wks& maintenance sessions every 4 wks

Side effects burning, tingling, skin Side effects burning, tingling, skin

irritation, erythemairritation, erythema

BOTULINUM TOXIN INJECTIONSBOTULINUM TOXIN INJECTIONS

IntraIntra--dermal botox blocks the release of dermal botox blocks the release of AchAch

The area to be treated is outlined using The area to be treated is outlined using the “starchthe “starch--iodine test” the area is iodine test” the area is marked out into 1.5cm squares and marked out into 1.5cm squares and 2units of Botox is injected 2units of Botox is injected intradermally to each square intradermally to each square

(max dose 100units)(max dose 100units)

Works best for axilla and less well in Works best for axilla and less well in the hands and feet the hands and feet

MEDICAL MANAGEMENTMEDICAL MANAGEMENT

AntiperspirantsAntiperspirants –– 11stst line of Rx line of Rx --Palmar, Palmar, Plantar, Axillary HH (DrysolPlantar, Axillary HH (Drysol-- Aluminum Aluminum based)based)

IontophoresisIontophoresis –– nonnon--responsive to responsive to above Palmar & Plantarabove Palmar & Plantar

Anticholinergics Anticholinergics –– Robinul (1mg tid) Robinul (1mg tid) palmar, plantar, axillary ( 1palmar, plantar, axillary ( 1stst line in line in whole body HH & facial HH)whole body HH & facial HH)

Botox InjectionsBotox Injections –– Axillary HH not Axillary HH not responsive to 1 & 2 (not recom. In responsive to 1 & 2 (not recom. In palmar palmar –– muscle wasting & hand muscle wasting & hand weakness)weakness)

STARCH IODINE TEST SHOWING STARCH IODINE TEST SHOWING

LOCATION OF EXCESSIVE SWEATINGLOCATION OF EXCESSIVE SWEATING

SURGICAL TREATMENT OF SURGICAL TREATMENT OF

PRIMARY HHPRIMARY HH

Excision of Excision of ApocrineApocrine glands glands ––AxillaAxilla

(liposuction)(liposuction)

RadioRadio--frequency frequency lesioninglesioning of the of the

Sympathetic ganglia (Imprecise)Sympathetic ganglia (Imprecise)

Endoscopic Thoracic Endoscopic Thoracic SympathectomySympathectomy

Isolates the sympathetic supply to the Isolates the sympathetic supply to the

sweat glandssweat glands

Immediately stops sweating, hands after Immediately stops sweating, hands after

sympathectomysympathectomy slightly warmer & pinkslightly warmer & pink

Approaches Approaches ––

SupraSupra--clavicularclavicular; Trans; Trans--axillaryaxillary

PosteroPostero--lateral thoracic (midline lateral thoracic (midline

approach)approach)

Endoscopic Thoracic Endoscopic Thoracic SympathectomySympathectomy

THORACIC SYMPATHECTOMY FOR THORACIC SYMPATHECTOMY FOR

HHHH

INTERNATIONAL NOMENCLATURE FOR INTERNATIONAL NOMENCLATURE FOR

SYMPATHECTOMY SURGERY(ISSS)SYMPATHECTOMY SURGERY(ISSS)

Notation of level or levels where Notation of level or levels where sympathetic chain isolated sympathetic chain isolated

Rib basedRib based -- R2R2, , R3R3, , R4R4, , R5R5

Ganglion basedGanglion based –– G2G2 ((R2R2--3) 3) G3G3((R3R3--4), 4), G4G4((R4R4--5), 5), G5G5((R5R5--6)6)

Old terminology Old terminology –– SympathicotomySympathicotomy / / T2T2, , T3T3, , T4T4, , T5T5 SympathectomySympathectomy. .

T2T2 –– ((R2R3R2R3//G2G2), ), T3T3 –– ((R3,R4R3,R4//G3G3),),

T4T4--((R4,R5R4,R5//G4G4), ), T5T5 –– ((R5,R6R5,R6//G5G5))

INDICATIONS FOR ENDOSCOPIC INDICATIONS FOR ENDOSCOPIC

THORACIC SYMPATHECTOMY(ETS)THORACIC SYMPATHECTOMY(ETS)

Severe Palmar with Mod. Axillary, & Severe Palmar with Mod. Axillary, &

Plantar Hyperhidrosis (failed medical Plantar Hyperhidrosis (failed medical

Rx)Rx)

Isolated AxillaryIsolated Axillary

Facial Flushing or RednessFacial Flushing or Redness

Reflex Sympathetic Dystrophy (CRPS)Reflex Sympathetic Dystrophy (CRPS)

Raynaud’s SyndromeRaynaud’s Syndrome

Idiopathic cardiac arrythmiasIdiopathic cardiac arrythmias--childrenchildren

BILATERAL ENDOSCOPIC THORACIC BILATERAL ENDOSCOPIC THORACIC

SYMPATHECTOMYSYMPATHECTOMY--ETSETS

DIVISION OF THE TRUNK AT R3,R4 DIVISION OF THE TRUNK AT R3,R4

ISOLATES THE 3ISOLATES THE 3rdrd GANGLIONGANGLION

CLINICAL MATERIALS & METHODSCLINICAL MATERIALS & METHODS

Retrospective review of 185 patients for Retrospective review of 185 patients for

a total of 370 sympathectomies.a total of 370 sympathectomies.

138 patients were available for follow138 patients were available for follow--

up up

(very mobile young Pt. population)(very mobile young Pt. population)

Chwajol M, Barrenechea IJ, Chakraborty S, Ichiba T, Lesser JB, Connery

CP, Perin NI, Impact of symptomatic improvement, recurrence and

compensatory hyperhidrosis on patient satisfaction after endoscopic

thoracic sympathectomy. Neurosurgery. 2008; 64:511-518.

RESULTS RESULTS -- 11

ETS for HH ETS for HH -- 182pts, 182pts,

ETS for facial Flushing ETS for facial Flushing -- 3pts.3pts.

Avg. time from ETS to questionnaire Avg. time from ETS to questionnaire --

1.3yrs1.3yrs

Of the 138 patients, 81 females (59%) & Of the 138 patients, 81 females (59%) &

57 males(41%)57 males(41%)

Age range 10 Age range 10 -- 67yrs. (mean 28, SD 8.9)67yrs. (mean 28, SD 8.9)

RESULTS WITH ETS FOR HHRESULTS WITH ETS FOR HH

98% reduction of sweating in Palmar 98% reduction of sweating in Palmar

HHHH

80% Reduction in Axillary HH80% Reduction in Axillary HH

60% Reduction in Plantar HH 60% Reduction in Plantar HH

Facial Flushing / Facial sweating Facial Flushing / Facial sweating

inconsistent responseinconsistent response

Recurrence 1Recurrence 1--2% (Higher in patients 2% (Higher in patients

treated for Axillary HH)treated for Axillary HH)

COMPENSATORY COMPENSATORY HYPERHIDROSISHYPERHIDROSIS

Major source of dissatisfaction after Major source of dissatisfaction after ETS for HHETS for HH

Occurrence Occurrence -- All Pts. have some degree All Pts. have some degree of compensatory HH following ETS, of compensatory HH following ETS, especially during exercise and hot especially during exercise and hot weatherweather

However Intractable Compensatory HH, However Intractable Compensatory HH, occurs in less than 5% of patientsoccurs in less than 5% of patients

Incidence of the severe Intractable CHH Incidence of the severe Intractable CHH has decreased with going to lower has decreased with going to lower levels in the chain (R3,R4levels in the chain (R3,R4--3G,R4,R53G,R4,R5--4G)4G)

OCCURRENCE OF COMPENSATORY HHOCCURRENCE OF COMPENSATORY HH

Almost all Pts. experienced some Almost all Pts. experienced some

degree of degree of CHHCHH during exercise & hot during exercise & hot

weather(130 of 138 = 94%)weather(130 of 138 = 94%)

CHHCHH occurred mostly in the back, lower occurred mostly in the back, lower

chest, abdomen & thighschest, abdomen & thighs

18 had one body area affected, 41 had 18 had one body area affected, 41 had

two areas, 35 three areas & 36 had four two areas, 35 three areas & 36 had four

areas affectedareas affected

SEVERITY OF COMPENSATORY HH & SEVERITY OF COMPENSATORY HH &

POSSIBLE PREDISPOSITIONPOSSIBLE PREDISPOSITION

AgeAge of the patientof the patient--Tendency older ptsTendency older pts

PrePre--operative operative BMIBMI--Tends higher with Tends higher with

higher BMIhigher BMI

# of levels# of levels of the sympathetic chain of the sympathetic chain

/ganglion divided/ganglion divided-- Tends higher with more Tends higher with more

levelslevels

Occurrence of Compensatory Occurrence of Compensatory HHHH related related

to to upper versus lower ganglionupper versus lower ganglion isolationisolation

Shown to reduce severe Shown to reduce severe CHHCHH ( ( T2T2 to to T3T3 & &

T4T4))

CURRENT PROTOCOL FOR CURRENT PROTOCOL FOR

SYMPATHECTOMYSYMPATHECTOMY IN IN HHHH

Presently all patients with Presently all patients with PalmarPalmar HHHH

receive a receive a T3T3 Ganglion isolation Ganglion isolation

((R3,R4R3,R4//3G3G))

Patients with Patients with PalmarPalmar & & AxillaryAxillary HHHH ––

T3GT3G & & T4GT4G ((R3R3--R4R4//3G3G, , R4R4--R5R5//4G4G))

Patients with facial Patients with facial HHHH & Facial & Facial

Flushing Flushing –– T2GT2G ((R2R2--R3R3//2G2G))

SATISFACTION RATES REPORTED SATISFACTION RATES REPORTED

ON THE QUESTIONNAIREON THE QUESTIONNAIRE

Very Satisfied 88 pts (64%)Very Satisfied 88 pts (64%)

Somewhat Satisfied 36 pts (26%)Somewhat Satisfied 36 pts (26%)

Somewhat Unsatisfied 9 pts (7%)Somewhat Unsatisfied 9 pts (7%)

Regretted having the surgery Regretted having the surgery 5pts5pts (3%)(3%)

Satisfaction rates highest in patients with Satisfaction rates highest in patients with severe severe palmarpalmar HHHH, and lowest in patients , and lowest in patients with isolated severe with isolated severe AxillaryAxillary HHHH

Results in Facial flushing & facial sweating Results in Facial flushing & facial sweating inconsistantinconsistant

Some improvement in Plantar Some improvement in Plantar HHHH (60%)(60%)

REVERSIBILITYREVERSIBILITY

Cutting or Clipping of the Sympathetic Cutting or Clipping of the Sympathetic chainchain

Possible to remove the clips in very Possible to remove the clips in very severe Compensatory severe Compensatory HHHH to revert to to revert to original state original state –– Inconclusive evidence Inconclusive evidence of reversalof reversal

Nerve Grafting for reversal ( Nerve Grafting for reversal ( suralsural vsvs IntercostalIntercostal nerve for grafting)nerve for grafting)--

Latif MJ, Afthinos JN , Connery CP, Perin NI, Bhora FY, Chwajol M, Todd GJ, Belsley SJ,

Robotic intercostal nerve graft for reversal of thoracic sympathectomy: a large animal feasibility model. Int J MedRobotics Comput Assist Surg. 2008; 4:258-226.

ROBOTIC INTERCOSTAL NERVE GRAFTROBOTIC INTERCOSTAL NERVE GRAFT

IRB to perform IRB to perform -- Robotic Intercostal Robotic Intercostal

nerve to sympathetic trunk grafts, nerve to sympathetic trunk grafts,

to reverse Intractable to reverse Intractable

compensatory sweating.compensatory sweating.

CONCLUSION CONCLUSION

Sympathectomy for intractable Palmar Sympathectomy for intractable Palmar HH is a very effective treatmentHH is a very effective treatment

There was a 98% reduction of hand There was a 98% reduction of hand sweating, an 80% reduction of Axillary sweating, an 80% reduction of Axillary sweating & a 60% reduction of plantar sweating & a 60% reduction of plantar sweating after upper Thor.ETSsweating after upper Thor.ETS

94% of patients in our series developed 94% of patients in our series developed some degree of CHH. There was a some degree of CHH. There was a statistically significant association statistically significant association between advancing age & CHH(p=0.02), between advancing age & CHH(p=0.02), Higher BMI showed a trend towards Higher BMI showed a trend towards increased CHH (p=0.14)increased CHH (p=0.14)

CONCLUSION CONCLUSION

Higher satisfaction rates were noted in Higher satisfaction rates were noted in Pts. treated for Palmar (100%) even Pts. treated for Palmar (100%) even with asso. CHH vs. Axillary HH(73%). with asso. CHH vs. Axillary HH(73%). Overall satisfaction rate in both groups Overall satisfaction rate in both groups was 92% at one year.was 92% at one year.

With sectioning of the Sympathetic With sectioning of the Sympathetic trunk from T2G to T3G & T4G for trunk from T2G to T3G & T4G for palmar HH &, T4G,T5G for axillary HH palmar HH &, T4G,T5G for axillary HH has significantly reduced the incidence has significantly reduced the incidence of severe CHHof severe CHH