ETS Surgery for Recurrent Sweating Symptoms
CASE HISTORIES & RESULTS
Missed Kuntz nerves are an important
factor in recurrence of symptoms prompting many of the 142 redo
ETS surgeries Dr. Nielson has performed. Intact Kuntz nerves is
the most common reason Dr. Nielson finds
for persistent symptoms after a patient has undergone bilateral
regeneration has also been found in many redo
surgeriesby Dr. Nielson on patients who had a sympathectomy
by another doctor.
Much less commonly, persistent
symptoms is due to mis-identifying the T3 as the T2 level and therefore
leaving the T2 level completely untouched and free to carry sympathetic
nerve signal to the fingers and face.
Redo ETS R2 caused warming of cold 3/4/5 fingers of both hands!
37 year old man developed recurrent Raynaud's (episodes of
cold fingers) of the 3rd, 4th, and 5th finger and Blushing
8 months following T2/3/4 sympathectomy. Prior to the
redo ETS, touching objects that were slightly cool would
trigger cold 3rd, 4th, and 5th fingers - right hand worse than
the left hand and sparing his 1/2 (thumb and index) fingers
of both hands. His first and second fingers of both hands would
remain warm when the 3rd, 4th, and 5th finger would become
very cold and numb.
Successful redo ETS caused immediate warming
of his 3rd, 4th, and 5th finger of both hands after the scar
tissue overlying the 2nd rib head (location of previous sympathectomy)
was precisely divided using a micro scissor. The divided ends
were cauterized to lessen the chance of some of the neurons
being able to reconnect. He was discharged the same day a
few hours after the redo ETS with warm and dry hands (all 5
fingers per hand).
April 2008 CT
guided Thermal (RFA) Sympathectomy of T2. Redo surgery of patient
who was not a candidate for traditional ETS due to adhesions
of the left lung covering the 2nd and 3rd rib heads.(Click
April 2008 Only
the second patient to have CT guided Thermal (RFA) Sympathectomy
of T2. Redo surgery of patient who was not a candidate for traditional
Previous surgeries by another
doctor unsuccessful, Dr. Nielson performs successful repeat surgery:
T4 clamping attempt to resolve facial sweating and blushing
fails by another surgeon. Patient
comes to Dr. Nielson for REDO. After Micro ETS is performed
by Dr. Nielson, the patient's symptoms resolve. (Click
Here to See Video)
12 Clamps placed by another surgeon
caused severe irritation of the nerve (neuroma) making the
patient's symptoms worse than before the clamps were placed. Dr.
Nielson removed the clamps, cut the nerves, and the patient's
symptoms improved. (Click
Here to See Video)
Why have people come to
you to have redo Micro ETS surgery?
Some individuals have come
to me with persistent symptoms (sweating for example) after having
had ETS surgery performed by someone else. I have treated them
with redo Micro ETS successfully and discharged them the same
day despite undergoing a redo procedure.I
have found the cause(s) to be hidden sympathetic nerve/ganglia
under thick tissue making it easy to have been missed the first
time, intact Kuntz
sympathetic nerves crossing the second and/or third
rib(s), and dislodged
clamps that are no longer in contact with the nerves
and cannot interrupt the nerve signal!
Other doctors do a partial
pleurectomy, cutting out a window of pleura so they can see the
sympathetic nerve. This is quite traumatic and causes scar
tissue that sticks like glue to the chest wall.
Probably part of the reason re-do patients tell us their post
op pain and recovery is much less with the Micro single incision
ETS re-do than their original surgery.
T2 Sympathetic Innervation
to The Sweat Glands of the Face
Over several years of experience
in treating patients with recurrent and/or persistent sweating
of the face after undergoing T2 sympathectomy, I have found that
persistence of any sympathetic nerve innervation across the second
rib level, just above the T2 ganglion, plays a significant role
in persistent sweating conditions of the face after undergoing
a T2. T3, or T4 sympathectomy.
It is apparent in some patients
that there are neuronal contributions from lower levels such as
the T3 that pass up over the second rib level on their way to the
face that participate in the sweating symptoms of the face. Some
physicians misunderstand the sympathetic nerve innervation of the
face and believe in order to treat facial sweating it is important
to cut the sympathetic nerve at the T1 level or above, thereby
causing the dreaded Horner’s Syndrome. This, in my experience,
I’ve found not to be the case.
In summary, for successful
treatment of facial sweating, it is imperative that all sympathetic
nerve innervation crossing the second rib level be divided as opposed
to clamped or having lower levels cut or clamped. Also, accessory
nerve branch pathways bypassing the T2 ganglion can or may contribute
to persistent facial symptoms.
Histories and Results
had a Dorsal Sympathectomy who then developed regeneration
of the sympathetic nerve 6 years later. She had had
a dorsal (posterior approach 6 yrs ago with clamps
and excision).Dr Nielson found tremendous lung adhesions
from the previous surgery (Lung adhesions are possible
negative effects of more invasive surgical approaches
by other techniques).
had four previous clampings by another surgeon for
Blushing persisted of his face after all four clamping
attempts. After Micro ETS, facial blushing/hyperpyrexia
resolved completely on both sides.
is a male who had two previous clampings by another
surgeon for facial sweating. Sweating persisted
on one side of his face after both clamping attempts. After
Micro ETS, his facial sweating resolved completely
on both sides.
is a 49 year old female who had ETS five years ago
with a different surgeon and technique. Her facial
blushing persisted after the surgery. She had
Micro ETS of T2 (above) to improve blushing. She feels
much less anxious now with NO post op pain or CS. She
is "very satisfied"
with the results.
had persistent facial sweating after clamping/cutting
of the T2. Dr. Nielson performs a redo on him
and finds that the clamps have fallen off the nerve
where they had beenplaced
just above the T2 ganglion on both sides. By precisely
cutting the sympathetic nerve at the upper border of
the 2nd rib the patient was successfully treated for his facial
Patient had persistent facial sweating after clamping/cutting
of the T2. Dr. Nielson did a redo on him and found that the clamps
had fallen off the nerve where they had been placed just above
the T2 ganglion on both sides. Dr. Nielson reduced patient's facial
sweating (forehead) by cutting the nerve at the 2nd rib level.
His previous surgeon had told him that his persistent forehead
sweating after T2 clamping/cutting was due to T1 innervation to
his eye which if cut to reduce his forehead sweating would also
cause Horner's syndrome. This wasn't the case and Dr. Nielson successfully
treated his persistent forehead sweating by precisely cutting
the sympathetic nerve at the upper border of the 2nd rib.
has previous surgeries with clamps at 2nd, 3rd, and
4th ribs. Patient's facial blushing does not resolve
with either surgery and he developes severe CS and
facial sweating. Twelve days after surgery with Dr.
Nielson, patient reports facial blushing is getting
Patient had two previous surgeries with clamps
at 2nd, 3rd, and 4th ribs. His facial blushing was not resolved
with either surgery, he developed severe CS and facial sweating.
Twelve days after surgery patient reports facial blushing seems
to be getting a little bit better everyday. Rates his facial blushing
as a 1 (on a scale of 1 to 3, being the most severe), but says
he hasn't really been in a situation that would trigger the most
severe episode of facial blushing.
CS of the back and trunk are much improved. Started using the Oxytrol
transdermal patch, but discontinued. CS still seems improved after
has bilateral T2 in Sweden. Four years after surgery,
severe Blushing and moderate facial sweating and moderate
cold hands (but hands still dry) developed. Dr. Nielson
performs micro ETS of T2(above) and blushing resolves
along with facial sweating.
Professional prior to first ETS was terrible.
After has been great, however recurring symptoms are beginning
to effect again. Social and personal have been better since first
ETS as a whole. Since nearly every social activity involves eating,
however, the gustatory sweating has made life miserable from that
standpoint. The Levsin takes an hour to kick in and you can't do
anything spontaneously that way. Gustatory sweating began 6 mo
post op, hands are still warm and dry after first ETS, all other
symptoms started about 4 years post op (facial blushing and sweating).
CS of the chest is moderate, worse with heat and humidity.
Patient thinks the surgeon cauterized T2 bilaterally. Gustatory
sweating started one month after surgery.
Patient has bilateral T2 in Sweden. Bilateral
cautery distruction of the T2 ganglia. Palmar sweating ceased.
6 months later gustatory sweating developed. 4 years after surgery,
severe Blushing and moderate facial sweating and moderate cold
hands (but hands still dry) developed.
Dr. Nielson performs micro ETS of T2(above) (5
years after patient had undergone ETS) and Blushing resolved
along with facial sweating.
year old white male underwent ETS-C (clamping) of T2
for severe Blushing and mild palmar hyperhidrosis that
was unsuccessful. After bilateral Micro ETS of T2(above)
complete resolution of Blushing and palmar hyperhidrosis
22 year old white male underwent ETS-C (clamping)
of T2 for severe Blushing and mild palmar hyperhidrosis. Four months
later he presented with persistent severe cranio-facial erythema
(blushing) and mild hyperhidrosis of the palms despite ETS-C of
T2. Micro ETS of T2(above) was then performed (by me) with precise
division of the sympathetic nerve at the 2nd rib bilaterally. The
titanium clamp was across the nerve 4 mm below the 2nd rib on the
right and had become dislodged from the nerve and was lying 5 mm
away from the nerve on the left side. Complete resolution of Blushing
and palmar hyperhidrosis occurred after bilateral Micro ETS of
at T2 level for blushing & hyperpyrexia (burning)
is successful. Two previous surgeries were performed
at the T3/T4 and later at the T2 level by other surgeon
29 year old asian male with severe Blushing, facial
sweating and mild palmar sweating who underwent ETS-clamping of
T3/T4 without improvement in his facial symptoms and developed
cs (compensatory sweating). His hands had become mostly dry but
were still slightly cool. One month later he elected to have ETS-clamping
of T2 without any improvement in his facial blushing or sweating
and no change in his cs.
He then presented to me 20 months later to haveMicro
ETS of T2 (above) with division (cutting) of the nerve where it
crossed the 2nd rib. Dense lung adhesions to the 2nd and 3rd rib
heads made it too invasive to remove the clamps. The nerve was
divided where it crossed the 2nd rib head using the tips of micro
endoshears. Immediate significant decrease in both Blushing and
facial Hyperpyrexia (burning) symptoms occurred as well as facial
sweating. His fingers became warm too. No change in the degree
of cs that he had preoperatively.
at T2 level for blushing & hand sweat is successful.
A previous surgery was performed at the T3 level by other
Icon to view surgery)
facial blushing after sympathectomy can occur if any kuntz nerve
that crosses the second thoracic rib is left intact, and can
therefore continue to carry nerve signals to the face.
In the many redo's Dr. Nielson has performed for persistent facial
blushing, he has found that the most common reason for persistent
blushing has been missed Kuntz nerves crossing the second thoracic
rib and less commonly dividing the sympathetic nerve at the T3
level by mistake rather than the T2 level.
that arise from T4 can actually cross the second rib several
inches lateral to the main sympathetic nerve trunk, making them
easily missed especially if not examined from an optimized angle
and if the surgeon's technique is one where only very large Kuntz
nerves can be seen. In instances such as these, the incidence
of finding Kuntz nerves is reportedly as low as 5 to 20%.
surgery at T2 level shows scar tissue resulting from
clamping. Missed kuntz nerves are divided & symptoms
Icon to view surgery)
tell us their post op pain and recovery is much less with re-do
than their original surgery.
surgery for facial blushing at T2 level. Symptoms resolve.
Icon to view surgery)
A 24 year
old white male sufferred from severe blushing with severe facial
hyperpyrexia (face/head heat) and moderate palmar hyperhidrosis
for 14 years. These symptoms were refractory to Ativan, Valium,
Effexor and Prozac. He elected to undergo bilateral ETS of T2
by clamping technique three months ago. At that time, two clamps
were placed above and two clamps below the the T2 ganglion bilaterally.
Postop pain the following day he described was significant when
raising his arms but gradually diminished over time. His hands
had become warm and dry immediately after that surgerybut he
had only noticed a 40% decrease in his blushing and no improvement
at all in his facial hyperpyrexia.
to have me perform Micro ETS of T2 todivide
any missed Kuntz nerve branches present crossing the second rib
and to divide the main sympathetic nerve by my micro cutting
technique precisely at the upper border of the 2nd rib on each
underwent Micro ETS of T2 by me and I found a large Kuntz nerve
2mm under the pleural surface crossing the second rib approximately
2.5 cm lateral to the main sympathetic nerve trunk on the right
side and 3.0 cm lateral to the main nerve on the left side. There
were two metal clamps across the main sympathetic nerve at the
second rib level and two at the third rib level (above and below
the T2 ganglion).
By my Micro
ETS technique, precise division of these Kuntz nerves was done
without having to remove a pleural window of tissue just to see
the nerves. After both sides had been precisely divided by my
Micro ETS technique, the patient's blushing completely resolved
as did his severe hyperpyrexia.
The next day after Micro ETS redo surgery, he was in no pain but
just a slight amount of soreness of the inner chest wall lining
(pleura) on deep breaths. He has been enjoying complete cessation
of his facial blushing and hyperpyrexia ever since then.
I find that
the most common reason for recurrence of symptoms or failure
to resolve them is missed Kuntz nerves crossing the second rib.
The second most common reason for recurrence is mis-identified
T2 where T3 is mistaken for T2 and the clamps or cutting is at
the T3 level rather than the T2.