Letter to the Editor, Regarding “Treatment of Harlequin Syndrome”

To the Editor:

We read with interest the article by Sribnick and Boulis.They successfully treated a unilateral hyperhidrosis and blushing by T2-T3 excision using the posterior open approach. Before the advent of endoscopic surgery, there were 4 approaches to this procedure: the supraclavicular, the posterior, the axillary, and the transthoracic,2 the axillary actually being a limited-incision axillary thoracotomy. Of these 4 methods, the supraclavicular approach required the most demanding technique but was the less painful procedure. The posterior approach required rib transection, and although it allowed excision of root ganglia, it has been shown that, for blushing and hyperhidrosis, this was not required and sympathetic ganglia ablation sufficed. It is understandable why the authors openly approached the sympathetic chain in the present case because the patient had only 1 lung. We cannot understand, however, why the posterior approach was chosen and not the supraclavicular. Could the authors explain?

The appearance of unilateral hyperhidrosis after a previous contralateral sympathectomy has been described.3 The mechanism of this phenomenon is completely unknown. Could the authors elaborate on their case in terms of whether the sympathetic chain on the contralateral side was affected during the pneumonectomy? Were the ipsilateral hand and/or side of the face anhidrotic?

Again, we compliment the authors for publishing this very interesting and rare pathology and its treatment.

Connery, Cliff P.; de Campos, Jose Ribas M.; Hashmonai, Moshe; Licht, Peter B.; Schick, Christoph H.; Bischof, Georg; Cameron, Alan E.P.; On Behalf of the International Society of Sympathetic Surgery
New York, New York
Sao Paolo, Brazil
Haifa, Israel
Odense, Denmark
Munich, Germany
Vienna, Austria
Suffolk, United Kingdom
1. Sribnick EA, Boulis NM. Treatment of Harlequin syndrome by costotransversectomy and sympathectomy: case report. Neurosurgery. 2011;69(1):E257–E259.
2. Hashmonai M, Schein M. Upper thoracic sympathectomy: open approaches. In: Paterson-Brown S, Garden J, eds. Principles and Practice of Surgical Laparoscopy. London, UK: W.B. Saunders; 1994:587–603.
3. Kopelman D, Hashmonai M, Assalia A, Bahous H. Primary palmar hyperhidrosis presenting with unilateral symptoms: a report of two cases and review of the literature. Cardiovasc Surg. 1998;6(1):94–96.