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Palmar primary hyperhidrosis in children
Palmar Primary Hyperhidrosis in Children By G. O'Donoghue, D. Finn, and M. P. Brady Cork, Ireland 9 Palmar Primary Hyperhidrosis, though an uncommon problem in the paediatric age group, is an unpleasant and socially disabling one for the affected child. Although the condition occurring in adults has been extensively documented, little, if any, attention has been given to the problem in children. W e describe the clinical presentation of four such patients w h o presented in our unit over the past 4 yr. All had an upper dorsal sympathect o m y performed with excellent results. INDEX W O R D S : Palmar primary hyperhidrosis.
N C O U R A G E D by our experience ~ with hyperhidrosis in the adult age group we decided to focus our attention on a small but significant group of children with palmar primary hyperhidrosis. It became apparent to us from our adult series that in an appreciable number of patients (10 out of 19), their symptoms dated back to early childhood. There seems no good reason why therapy would not be initiated at this stage. From the results of surgery in our series and those of others, 2'3 we felt justified in submitting to surgery those children whose symptoms were of sufficient magnitude as to interfere significantly with their normal daily activities. It has been shown 4 that sweat production in any given area is roughly proportional to the number of sweat glands contained therein. The eccrine glands are distributed throughout the body surface but are most dense on the palms and soles. They are innervated by cholinergic sympathetic fibres--hence the rational of sympathectomy in hyperhidrosis.
E
MATERIALS AND METHODS Four children presented to the Surgical Professional Unit between 1975 and 1978 with troublesome hyperhidrosis
From the Department of Surgery, St. Finbarr's Hospital and University College, Cork, Ireland. Address reprint requests to G. O'Donoghue, Department of Surgery, St. Finbarr's Hospital and University College, Cork, Ireland. 9 1980 by Grune & Stratton, Inc. 0022-3468/80/1502-0008501.00/0
172
(Table 1). They were all females and their age range was from 6 to 13 yr. A resume of the clinical presentation of two of these patients is included to illustrate the manner in which these children are affected.
Case 1 Age 6 yr. Daughter of a warehouse supervisor living in the city. One sibling is alive and well. No relevant previous or family history. She was a pleasant intelligent child. Her mother noticed sweaty hands and feet about the age of 2 yr that became severe over the following year. There was no axillary hyperhidrosis. Her hands were continually wet and drops of sweat fell on the floor on several occasions. She took four handkerchiefs to school every day and was incessantly drying her hands and became severely embarrassed by the problem. She was unable to grasp her pencils due to the moisture and smudged all her homework. In the school playground, she was an outcast as her schoolmates refused to join hands with her in play. Knitting was also excluded as this aggravated her hyperhidrosis. The skin of her hands became macerated during bad episodes.
Case 2 Age 9 yr. This girl lived in a country village and had three healthy siblings. There was a past history of varicella at 4 mo and pertussis when 1-yr-old. She contracted a salmonella infection while in hospital for the latter. There was a distant family history of diabetes mellitus. She was cheerful and well adjusted. Her hands and feet were wet for as long as her mother could remember. Her hands often dripped sweat. She had mild axillary hyperhidrosis that did not affect her. Her hands were frequently excoriated, She smudged her school copybooks and became very anxious and distressed at school. While knitting, her hands became sore and the wool became wet with the sweat. The child was extremely conscious of the problem. All these children had a bilateral upper dorsal sympathectomy performed. We preferred the supraclavicular approach as originally described for this condition by Telford. 5'6 Kunchin et al. 7 have recently elaborated in detail on this procedure. We would like, however, to add certain technical points that emerged from our experience: (1) The excellence of the tissues in the young child greatly facilitates dissection; (2) The phrenic nerve need not be dissected but simply retracted behind the sternomastoid muscle. The scalenus anterior is then divided piecemeal; (3) Never was it necessary (even in our adult series) to go above the subclavian artery, thus obviating the need to ligate its superior branches. Furthermore, in the child, the delicate Sibson's fascia peels away with remarkable ease compared with the more adherent, fibrous adult structure. Only the ganglia and rami ofT1, T2, and T3 were resected (Fig. 1). All specimens were sent for histologic examination
Journal of Pediatric Surgery, VoI. 15, No. 2 (April), 1980
PALMAR PRIMARY HYPERHIDROSIS
173
Table 1. Four Cases of Palmar Primary Hyperhidrosis in Children: Presentation, Treatment, and Results Duration of Symptoms
Case Number
Age
Sex
1
6
F
4 yr
2
9
F
Always
Hyperhidrosis Elsewhere Feet slightly sweaty Soles very sweaty
Result of Upper Dorsal Sympathectomy Excellent Excellent
Moderate axillary sweating
3
4
7
13
5'/2 yr
F
Severe in feet Lumbar sympathectomy proposed in future Moderate sweating of feet
6 yr
F
and were confirmed as having ganglionated sympathetic tissue. Frozen sections were not done routinely. Blood transfusion was not required in any case.
RESULTS
The results were very gratifying (Table 1). All four patients had dry hands following the procedure and have remained so to the present time. Their newly acquired social acceptance by their peers gave them a happier outlook on life. Their performance at school was also enhanced and 2 school reports of cases 2 and 3 since surgery were marked "improved." Both parents and children in all cases were unequivocally satisfied. There were no major complications following surgery. The dilated right pupil (in case 2) unaccompanied by any other features of Horner's syndrome 1 ~n f e r i o r an~
i n.
TI.
'
ss~ . . . . ss First Thoracic so"
Tz.
Second
~ '
Thoracic
~hird 'horaclc
T3.
I
!
I !
Fig. 1.
L
Upper limb sudomotor supply.
.
Postop Complications Upper respiratory tract infection Right pupil slightly enlarged
Hospital Stay (days) 9 7
Excellent
No ptosis or enophthalmus Interscapular pain
9
Excellent
None
9
resolved 5 mo following the operation. Undoubtedly, this was due to contusion of the pupillary fibres in the region of the stellate ganglion. The interscapular pain (case 3) we felt was due to post sympathectomy neuralgia and lasted only about 10 days. A lumbar sympathectomy is being considered for this patient. Compensatory hyperhidrosis was not observed. DISCUSSION
The vast literature of palmar hyperhidrosis has established the place of upper dorsal sympathectomy in its treatment. Little attention has been paid to the problem as it affects children who can be greatly upset by it and who, in our experience, greatly benefit from surgery. We endorse the supraclavicular approach which we found particularly suitable in children. When done meticulously, it avoids the pulmonary and other problems associated with alternative methods. When evaluating any surgery for hyperbidrosis, it must be borne in mind that this is a functional, nuisance, disorder and only surgery that carries a low mortality and morbidity is justified for it. REFERENCES 1. Finn D J, Buckley DB, Callaghan J, et al: Hyperhidros i s - - A clinical, histological and follow-up of study of 23 patients. (in press) 2. Keaveny TV, et al: The surgical treatment of hyperhidrosis. J Irish Med Assoc 67:544-545, 1974 3. Hartfall WG, Jochimsen PR: Hyperhidrosis of the
174
upper extremity and its treatment. Surg Gynaecol Obstet 135:586-588, 1972 4. Roddie IC, et al: The regional distribution of emotional sweating in man. J Physiol 235:749-759, 1973 5. Telford ED: Technique of sympathectomy. Br J Surg 23:448, 1935
O'DONOGHUE, FINN, AND BRADY
6. Telford ED: Sympathetic denervation of the upper extremity. Lancet 1:70, 1938 7. Kurchin A, et al: Upper dorsal sympathectomy for palmar primary hyperhidrosis by the supraclavicular approach. World J Surg 1:667-673, 1973
N C O U R A G E D by our experience ~ with hyperhidrosis in the adult age group we decided to focus our attention on a small but significant group of children with palmar primary hyperhidrosis. It became apparent to us from our adult series that in an appreciable number of patients (10 out of 19), their symptoms dated back to early childhood. There seems no good reason why therapy would not be initiated at this stage. From the results of surgery in our series and those of others, 2'3 we felt justified in submitting to surgery those children whose symptoms were of sufficient magnitude as to interfere significantly with their normal daily activities. It has been shown 4 that sweat production in any given area is roughly proportional to the number of sweat glands contained therein. The eccrine glands are distributed throughout the body surface but are most dense on the palms and soles. They are innervated by cholinergic sympathetic fibres--hence the rational of sympathectomy in hyperhidrosis.
E
MATERIALS AND METHODS Four children presented to the Surgical Professional Unit between 1975 and 1978 with troublesome hyperhidrosis
From the Department of Surgery, St. Finbarr's Hospital and University College, Cork, Ireland. Address reprint requests to G. O'Donoghue, Department of Surgery, St. Finbarr's Hospital and University College, Cork, Ireland. 9 1980 by Grune & Stratton, Inc. 0022-3468/80/1502-0008501.00/0
172
(Table 1). They were all females and their age range was from 6 to 13 yr. A resume of the clinical presentation of two of these patients is included to illustrate the manner in which these children are affected.
Case 1 Age 6 yr. Daughter of a warehouse supervisor living in the city. One sibling is alive and well. No relevant previous or family history. She was a pleasant intelligent child. Her mother noticed sweaty hands and feet about the age of 2 yr that became severe over the following year. There was no axillary hyperhidrosis. Her hands were continually wet and drops of sweat fell on the floor on several occasions. She took four handkerchiefs to school every day and was incessantly drying her hands and became severely embarrassed by the problem. She was unable to grasp her pencils due to the moisture and smudged all her homework. In the school playground, she was an outcast as her schoolmates refused to join hands with her in play. Knitting was also excluded as this aggravated her hyperhidrosis. The skin of her hands became macerated during bad episodes.
Case 2 Age 9 yr. This girl lived in a country village and had three healthy siblings. There was a past history of varicella at 4 mo and pertussis when 1-yr-old. She contracted a salmonella infection while in hospital for the latter. There was a distant family history of diabetes mellitus. She was cheerful and well adjusted. Her hands and feet were wet for as long as her mother could remember. Her hands often dripped sweat. She had mild axillary hyperhidrosis that did not affect her. Her hands were frequently excoriated, She smudged her school copybooks and became very anxious and distressed at school. While knitting, her hands became sore and the wool became wet with the sweat. The child was extremely conscious of the problem. All these children had a bilateral upper dorsal sympathectomy performed. We preferred the supraclavicular approach as originally described for this condition by Telford. 5'6 Kunchin et al. 7 have recently elaborated in detail on this procedure. We would like, however, to add certain technical points that emerged from our experience: (1) The excellence of the tissues in the young child greatly facilitates dissection; (2) The phrenic nerve need not be dissected but simply retracted behind the sternomastoid muscle. The scalenus anterior is then divided piecemeal; (3) Never was it necessary (even in our adult series) to go above the subclavian artery, thus obviating the need to ligate its superior branches. Furthermore, in the child, the delicate Sibson's fascia peels away with remarkable ease compared with the more adherent, fibrous adult structure. Only the ganglia and rami ofT1, T2, and T3 were resected (Fig. 1). All specimens were sent for histologic examination
Journal of Pediatric Surgery, VoI. 15, No. 2 (April), 1980
PALMAR PRIMARY HYPERHIDROSIS
173
Table 1. Four Cases of Palmar Primary Hyperhidrosis in Children: Presentation, Treatment, and Results Duration of Symptoms
Case Number
Age
Sex
1
6
F
4 yr
2
9
F
Always
Hyperhidrosis Elsewhere Feet slightly sweaty Soles very sweaty
Result of Upper Dorsal Sympathectomy Excellent Excellent
Moderate axillary sweating
3
4
7
13
5'/2 yr
F
Severe in feet Lumbar sympathectomy proposed in future Moderate sweating of feet
6 yr
F
and were confirmed as having ganglionated sympathetic tissue. Frozen sections were not done routinely. Blood transfusion was not required in any case.
RESULTS
The results were very gratifying (Table 1). All four patients had dry hands following the procedure and have remained so to the present time. Their newly acquired social acceptance by their peers gave them a happier outlook on life. Their performance at school was also enhanced and 2 school reports of cases 2 and 3 since surgery were marked "improved." Both parents and children in all cases were unequivocally satisfied. There were no major complications following surgery. The dilated right pupil (in case 2) unaccompanied by any other features of Horner's syndrome 1 ~n f e r i o r an~
i n.
TI.
'
ss~ . . . . ss First Thoracic so"
Tz.
Second
~ '
Thoracic
~hird 'horaclc
T3.
I
!
I !
Fig. 1.
L
Upper limb sudomotor supply.
.
Postop Complications Upper respiratory tract infection Right pupil slightly enlarged
Hospital Stay (days) 9 7
Excellent
No ptosis or enophthalmus Interscapular pain
9
Excellent
None
9
resolved 5 mo following the operation. Undoubtedly, this was due to contusion of the pupillary fibres in the region of the stellate ganglion. The interscapular pain (case 3) we felt was due to post sympathectomy neuralgia and lasted only about 10 days. A lumbar sympathectomy is being considered for this patient. Compensatory hyperhidrosis was not observed. DISCUSSION
The vast literature of palmar hyperhidrosis has established the place of upper dorsal sympathectomy in its treatment. Little attention has been paid to the problem as it affects children who can be greatly upset by it and who, in our experience, greatly benefit from surgery. We endorse the supraclavicular approach which we found particularly suitable in children. When done meticulously, it avoids the pulmonary and other problems associated with alternative methods. When evaluating any surgery for hyperbidrosis, it must be borne in mind that this is a functional, nuisance, disorder and only surgery that carries a low mortality and morbidity is justified for it. REFERENCES 1. Finn D J, Buckley DB, Callaghan J, et al: Hyperhidros i s - - A clinical, histological and follow-up of study of 23 patients. (in press) 2. Keaveny TV, et al: The surgical treatment of hyperhidrosis. J Irish Med Assoc 67:544-545, 1974 3. Hartfall WG, Jochimsen PR: Hyperhidrosis of the
174
upper extremity and its treatment. Surg Gynaecol Obstet 135:586-588, 1972 4. Roddie IC, et al: The regional distribution of emotional sweating in man. J Physiol 235:749-759, 1973 5. Telford ED: Technique of sympathectomy. Br J Surg 23:448, 1935
O'DONOGHUE, FINN, AND BRADY
6. Telford ED: Sympathetic denervation of the upper extremity. Lancet 1:70, 1938 7. Kurchin A, et al: Upper dorsal sympathectomy for palmar primary hyperhidrosis by the supraclavicular approach. World J Surg 1:667-673, 1973