CT-guided Percutaneous Ethanol Sympatholysis for Hyperhidrosis: How I Do It

Hyperhidrosis, excessive sweating from the eccrine sweat glands, is caused by overactivity of the sympathetic nerves. Facial, axillary, and/or palmar hyperhidrosis (excessive sweating of the face, armpits, and hands) has a reported prevalence of 1%-1.6%. This condition is initially treated conservatively using a combination of topical and pharmacologic treatments. Surgical sympathectomy or percutaneous sympatholysis are treatment options for severe hyperhidrosis (grade 3 or 4) that does not respond to conservative management. The aim of intervention is to permanently disrupt the sympathetic signal by targeting the thoracic vertebral levels T2, T3, and T4 of the paravertebral ganglia, located on the anterolateral surface of the vertebral body. This review presents the step-by-step technique for CT-guided percutaneous ethanol sympatholysis and discusses patient selection for the procedure, potential complications, and treatment outcomes. Although more than 90% of patients report complete resolution of hyperhidrosis immediately after sympatholysis, as many as 40% report symptom recurrence within 6 months. The probability of remaining hyperhidrosis-free long term (ie, more than 6 months) after CT-guided sympatholysis is 60%. Procedural risks include a 15% risk of compensatory hyperhidrosis elsewhere in the body, 8% risk of Horner syndrome (mostly self-limiting), 5% risk of pneumothorax, and 3% risk of severe intercostal neuralgia due to nontarget ethanol deposition. Despite the risks, this intervention can be life-altering for those with severe disease.