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Ann Thorac Surg 2006;81:1043-1047
© 2006 The Society of Thoracic Surgeons

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Original article: General thoracic

Gustatory Side Effects After Thoracoscopic Sympathectomy

Department of Cardiothoracic Surgery, Skejby Sygehus, Aarhus University Hospital, Aarhus, Denmark

Accepted for publication September 21, 2005.

^_* Address correspondence to Dr Licht, Department of Cardiothoracic Surgery, Odense University Hospital, Sdr Boulevard 29, Odense, DK-5000, Denmark (Email: licht{at}dadlnet.dk).

	Abstract

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BACKGROUND: Compensatory sweating is a frequent side effect after thoracoscopic sympathectomy for primary hyperhidrosis. Gustatory sweating is less commonly reported. It is defined as facial sweating when eating certain foods (particularly spicy food or acidic fruits) and has no generally accepted pathophysiologic explanation. We decided to investigate this phenomenon in patients who underwent thoracoscopic sympathectomy for primary hyperhidrosis and analyze whether the occurrence was influenced by the extent of sympathectomy.

METHODS: During an 8-year period (1997 to 2005) a total of 238 patients were treated by thoracoscopic sympathectomy for primary hyperhidrosis or blushing. Sympathectomy was performed bilaterally at T2 for facial hyperhidrosis or blushing (n = 97), T2–T3 for palmar hyperhidrosis (n = 76), and T2–T4 for axillary hyperhidrosis (n = 65). All patients received the same questionnaire at follow-up.

RESULTS: The questionnaire was returned by 96% of patients after a median of 17 months. Overall, gustatory sweating occurred in 32% of patients, and the incidence was significantly associated with extent of sympathectomy (p = 0.04). However, because the extent of sympathectomy was always decided by the location of primary hyperhidrosis, the latter may also explain the risk of gustatory sweating.

CONCLUSIONS: Gustatory sweating is a frequent side effect after thoracoscopic sympathectomy. This is the first study to report that its incidence is significantly related to the extent of sympathectomy or the location of primary hyperhidrosis. Although there is no pathophysiologic explanation of gustatory sweating, these findings should be considered before planning thoracoscopic sympathectomy and patients should be thoroughly informed.

	Introduction

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Primary hyperhidrosis is a pathophysiologic condition of unknown origin characterized by perspiration beyond physiologic needs. A recent national survey of 150,000 households concluded that the prevalence of primary hyperhidrosis is almost 3% in North America [1]. During the last 50 years several hundred papers have been published on primary hyperhidrosis and the different treatment modalities. Medical management is often frustrating, and the response is generally transient [2]. If medical management fails, surgery may be effective. Surgical treatment is based on interruption of transmission of impulses from the sympathetic ganglia to the eccrine sweat glands, and video-assisted thoracoscopic sympathectomy is considered the surgical treatment of choice [3, 4].

Compensatory sweating is a common side effect after sympathectomy although the reported frequencies vary considerably in the literature. Only a minority of studies mentions gustatory sweating, which is defined as facial sweating when eating certain foods. It frequently occurs after ingestion of spicy food or acidic fruits, and there is no generally accepted pathophysiologic explanation. We decided to investigate this phenomenon in patients who underwent thoracoscopic sympathectomy for primary hyperhidrosis and analyze whether its occurrence was influenced by the extent of sympathectomy.

	Material and Methods

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Patients
During an 8-year period (January 1997 to January 2005) 238 patients were treated at our institution for isolated or combinations of palmar or axillary hyperhidrosis or facial hyperhidrosis or blushing. Objective methods for quantifying sweating before surgery were not applied. The indications for operation were disabling hyperhidrosis or blushing as defined by the patient.

One hundred sixty-eight patients were women (71%). The median age of the patients was 29 years (range, 12 to 61 years). All hospital records were retrieved, and the following data were recorded: (1) symptoms, (2) length of hospital stay, (3) postoperative complications, and (4) duration of the surgical procedure.

Identical questionnaires were mailed to all patients for follow-up except 2 patients who had emigrated. Informed consent was obtained in accordance with relevant guidelines. Each patient was asked whether the operation had resulted in any gustatory sweating defined as abnormal facial sweating as felt by the patient when eating certain foods. Further, patients were asked to mark their disability, both professionally and socially, from their symptoms before surgery (very much, some, or none at all) and mark the effect they had achieved from the operation (excellent, satisfactory, some effect, or no effect). Patients were asked to comment on occurrence and location of any compensatory sweating, defined as excessive sweating after the operation that was considered abnormal. In an attempt to assess the severity of compensatory sweating, our patients were asked whether they had to change clothes sometimes during the day because of this side effect. Finally, they were asked whether they were satisfied with or regretted the operation.

Surgical Technique
All patients were operated on in the supine position with abduction of both arms. Patients underwent single-lumen intubation for administration of anesthesia. Two ports were made. The first incision (5 mm) was made anteriorly in the hairline. The endotracheal tube was briefly disconnected by the anesthesiologist to deflate the lung when the pleural cavity was entered to avoid damaging the lung parenchyma. A 5-mm blunt-tip trocar was introduced for the use of a 0-degree video-thoracoscope (Olympus Winter & Ibe, Hamburg, Germany). An additional 5-mm trocar was placed posteriorly in the hairline for the introduction of electrocautery or a harmonic scalpel. The sympathetic chain was identified at the level of the crossing of the second, third, and fourth costal heads. The parietal pleura was opened, and the sympathetic chain was transected. The incision was extended laterally for approximately 2 cm on the second costa to include any accessory nerve fibers (the nerve of Kuntz). In the first 50 patients we used unipolar electrocautery to transect the sympathetic chain, and in the remaining patients we used a harmonic scalpel (UltraCision, Ethicon Endo Surgery, Cincinnati, OH). The procedure was performed bilaterally on the second costa (T2) for facial hyperhidrosis or blushing (n = 97), on the second and third costa (T2–T3) for palmar hyperhidrosis (n = 76), and on the second, third, and fourth costa (T2–T4) for axillary hyperhidrosis (n = 65). In patients who suffered from combinations of hyperhidrosis the extent of sympathectomy was always planned attempting to treat all the patients' symptoms, ie, if the patient suffered from both palmar and axillary hyperhidrosis we would perform a T2–T4 procedure. All procedures were completed by insertion of a 4-mm chest tube through the trocar, and the lung was reinflated under visual control. The chest tube was aspirated while the anesthesiologist ventilated the patient manually, exerting continuous positive pressure for a few seconds, to prevent pneumothorax before the drain was subsequently removed. The surgical wounds were closed with Steri-Strip (3M Health Care, St. Paul, MN).

Statistical Analysis
Statistical analysis included analysis of variance in a linear regression model implemented in the SPSS 10.1 statistical software package (SPSS, Inc, Chicago, IL). All p values less than 0.05 were considered statistically significant.

	Results

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No conversion to open technique was necessary, and there was no operative mortality. Four patients exhibited unilateral Horner's syndrome, which was permanent in 2. The median duration of the surgical procedure was 20 minutes (range, 7 to 115 minutes). The median hospital stay was 2 days (range, 1 to 12 days), and the median postoperative hospital stay was 1 day (range, 0 to 6 days). Both the hospital stay and the postoperative hospital stay were significantly shorter in the last half of the study period (p < 0.001).

A total of 229 patients answered the questionnaire (96%) after a median follow-up time of 17 months (range, 1 to 72 months). Seven patients did not return the questionnaire despite a reminder, and the remaining 2 patients never received a questionnaire because they had emigrated. All patients answered the question of social disability because of their primary symptoms: very much in 217 cases (95%) and some in 12 cases (5%). The question of professional disability was answered by 226 patients: very much in 209 cases (93%), some in 16 cases (6%), and none in 1 patient (1%).

The outcome of the operation is shown in Table 1. Outcome was significantly better after T2–T3 sympathectomy (F = 4.58; p = 0.03). Six patients described mild recurrent symptoms after an otherwise excellent result after T2 sympathectomy for facial blushing (n = 4) or satisfactory result after T2–T4 sympathectomy for axillary hyperhidrosis (n = 2). Gustatory sweating occurred in 74 patients (32%), and Table 2 shows that it occurred significantly more frequent after T2–T4 sympathectomy for axillary hyperhidrosis (F = 4.21; p = 0.04). Compensatory sweating occurred in 90% of patients and was located on the back in 75%, the abdomen in 66%, the lower extremities in 44%, and the chest in 15%. Table 3 demonstrates that it was significantly more frequent after T2–T4 sympathectomy for axillary hyperhidrosis (F = 5.32; p = 0.02). Seventy-two patients (35% of the patients who suffered from compensatory sweating) answered that they often had to change clothes during the day because of this side effect. This problem was also significantly more frequent after T2–T4 sympathectomy for axillary hyperhidrosis (F = 4.05; p = 0.04). Thirty-two patients (14%) regretted the operation because of side effects (n = 14), lack of effect from the operation (n = 8), or both (n = 10). Regretting the operation was significantly more frequent after T2–T4 sympathectomy for axillary hyperhidrosis (F = 6.98; p = 0.01). The 18 patients who did not have any effect from the operation originally presented with blushing (n = 8), palmar hyperhidrosis (n = 3), and axillary hyperhidrosis (n = 7).

	Comment

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Gustatory sweating is also a known side effect after sympathectomy, but only a minority of papers mentions it. We have identified 23 such references [4–27], and the reported incidence varies considerably. Some authors describe it but do not encounter it [6–9], others see it in a few percent of cases [10–13], but it has been reported in 50% to 70 % of patients [14, 15]. It occurred in 32% of our patients and was particularly related to spicy foods or foods with moderate acidity such as apples or oranges. There is no generally accepted pathophysiologic explanation for this phenomenon. One study speculated that it could result from sprouting of vagal nerve fibers into the severed sympathetic chain [26]. It has a striking similarity with Frey's syndrome, which is a rare complication after parotid gland surgery [28], submaxillary gland surgery, trauma, or radical neck dissection [29]. This syndrome is characterized by localized gustatory sweating in the preauricular area. Although the pathophysiologic events during the development of Frey's syndrome are not fully explained [30], it has been suggested to result from damage of the auriculotemporal nerve, which carries parasympathetic fibers to the parotid gland and sympathetic fibers to the sweat glands in this region [28, 31, 32]. Injury may be followed by aberrant regeneration of parasympathetic nerve fibers along sympathetic pathways to the sweat glands. Consequently, after the ingestion of food, salivation is accompanied by sweating because parasympathetic fibers stimulate the sweat glands, which are innervated by the auriculotemporal nerve. Frey's syndrome occurs several months to years after parotid surgery [31], favoring the theory of regrowth. However, the present study demonstrates that gustatory sweating after sympathectomy occurred in several patients after a follow-up period of just 1 month, a short time interval in which regrowth seems unlikely. Thus, the pathophysiology of gustatory sweating may be more complex. It is tempting to speculate that the innervation of the facial eccrine sweat glands is not entirely sympathetic and that a possible parasympathetic component would be left intact after sympathectomy. Treatment options for gustatory sweating include oral anticholinergic drugs, topical application of anticholinergics or aluminum chloride, or the injection of botulinum toxin [30], and recently topical glycopyrrolate showed an excellent subjective effect in 77% of patients [33].

In our previous study we discovered that severe compensatory sweating was significantly more frequent after T2–T4 sympathectomy for axillary hyperhidrosis, but our data failed to show a significant association with simple compensatory and gustatory sweating [5]. The present study demonstrates that there is a significant association between the extent of sympathectomy and both compensatory and gustatory sweating. Consequently, we suspect that the former study suffered from a statistical type 2 error. We emphasize that both studies are retrospective and cannot distinguish between extent of sympathectomy and location of primary hyperhidrosis as the primary factor responsible for gustatory or compensatory sweating. Both are intimately linked as cofactors because the extent of sympathectomy is determined by the location of primary hyperhidrosis. We strongly recommend a prospective randomized trial to distinguish between the two.

In spite of frequent side effects the present study demonstrates that the majority of our patients were satisfied with their operation and would even recommend it to others. However, 14% regretted the operation primarily because of lack of effect or side effects. We discovered that regretting the operation was significantly more frequent in patients who had a T2–T4 sympathectomy for axillary hyperhidrosis. Despite an otherwise excellent or satisfactory result on their axillary symptoms (Table 3), many regretted the operation because of side effects. These findings have changed our daily practice: We now recommend that thoracoscopic sympathectomy for primary hyperhidrosis should only be considered in patients in whom symptoms severely interfere with daily activities and all medical treatment have failed. In particular, our study demonstrates that patients who are scheduled for an extensive sympathectomy because of axillary hyperhidrosis should be warned about the increased risks of gustatory as well as compensatory and severe compensatory sweating. New surgical approaches are emerging in which the sympathetic trunk is not transected but treated by endoscopic clamping [13, 34, 35], and in some patients with intolerable compensatory sweating their side effect improved from the reverse operation [34, 35]. It was not reported, however, whether gustatory sweating was also reversible.

	References

Top Abstract Introduction Material and Methods Results Comment References

 

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