Endoscopic thoracic sympathectomy for primary facial blushing

# Recommendations
Current evidence on the efficacy and safety of endoscopic thoracic sympathectomy (ETS) for primary facial blushing is adequate to support the use of this procedure with normal arrangements for clinical governance, consent and audit.
Clinicians wishing to undertake ETS for primary facial blushing should ensure that patients understand the risks of the procedure. In particular they should explain that:
there is a risk of serious complications
hyperhidrosis is usual after the procedure: this can be severe and distressing and some patients regret having had the procedure (especially because of subsequent and persistent hyperhidrosis)
the procedure sometimes does not reduce facial blushing.Clinicians should also provide patients considering the procedure with clear written information.
In view of the risk of side effects this procedure should only be considered in patients suffering from severe and debilitating primary facial blushing that has been refractory to other treatments.
This procedure should only be undertaken by clinicians trained and experienced in thoracic endoscopy, and there should be the capacity to deal with intraoperative complications.
Further research into ETS for primary facial blushing should include clear information on patient selection and should seek to identify which patient characteristics might predict severe side effects. All complications should be reported. Outcomes should include measurements of efficacy, including quality of life and social functioning both in the short and long term, and in particular the frequency and severity of compensatory hyperhidrosis.# Indications and current treatments
Blushing or facial reddening is an involuntary reaction, usually as a result of a strong emotional response that stimulates the sympathetic nervous system to increase the flow of blood to the skin of the face. People with facial blushing may also have hyperhidrosis (excessive sweating).
Conservative treatment for facial blushing includes oral medications such as beta-blockers or anticholinergics. When anxiety is the cause of blushing, psychological treatments such as cognitive behavioural therapy may be used.
If blushing fails to respond to conservative medical treatment or behavioural therapy, then surgical sympathectomy is an option: this can be done either by open or endoscopic approaches. Endoscopic sympathectomy is now usually the preferred technique because it is associated with less pain, improved cosmesis and more rapid recovery than open sympathectomy.# The procedure
The aim of endoscopic thoracic sympathectomy (ETS) for primary facial blushing is to reduce the frequency and duration of blushing by dividing the sympathetic nerves that lie along the sympathetic chain beside the vertebral column.
ETS is usually done with the patient under general anaesthesia. Small incisions are made in the axilla and an endoscope is inserted. The lung is partially collapsed. The sympathetic chain is visualised and the chosen part of the chain is divided by electrocautery or endoscopic scissors, or surgical clips may be applied. The extent of division varies but usually involves the part of the sympathetic chain over the second or third ribs, or both. Gas is removed from the pleural space, allowing the lung to re-expand, and the wounds are closed. The procedure is then usually repeated on the other side.# Efficacy
This section describes efficacy outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the interventional procedure overview.
In a case series of 831 patients with facial blushing who had endoscopic thoracic sympathectomy (ETS), mean symptom improvement score (assessed on a visual analogue scale; scores from 0 to 10, with 10 indicating worst possible symptoms) decreased from 9 before the procedure to 3 after the procedure in patients with facial blushing at a mean follow-up of 29 months; this difference was significant (p<0.0001).
A case series of 80 patients (12 patients with isolated facial blushing) reported complete resolution in 33% (4/12) of patients with isolated facial blushing at a mean follow-up of 20 months.
A case series of 180 patients with isolated facial blushing reported symptom recurrence (1 month to 1 year after the procedure) in 2% (4/173) of patients; all patients subsequently underwent reoperation with 'good results'.
In the case series of 80 patients (59 patients with facial blushing, isolated or in association with hyperhidrosis) quality of life (assessed on a 5-point Likert scale) was reported to be 'much better' in 63% (37/59) of patients, and there was 'some improvement' in 15% (9/59) of patients and 'no change' in 8% (5/59) of patients.
A case series of 1700 patients (648 patients with blushing or blushing with hyperhidrosis) reported satisfaction rates of 74% in patients with facial blushing (n=536) at a mean follow-up of 15 years (absolute number not reported). In a case series of 1152 patients, 85% of the 244 patients with facial blushing reported being 'totally satisfied' at a mean follow-up of 8 months (absolute number not reported).
The specialist advisers stated that key efficacy outcomes were symptom improvement, absence of symptoms and the patient's perception of improvement of symptoms.# Safety
This section describes safety outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the interventional procedure overview.
A non-systematic review article reported that 5 patients died because of major intrathoracic bleeding after endoscopic thoracic sympathectomy (ETS) but the total number of patients treated by the procedure was not documented: in 2 patients a trocar lacerated the subclavian artery; in 1 patient an intercostal vein was damaged; the causes in the other 2 patients were not described.
An additional 4 deaths after ETS were reported in the non-systematic review article: 3 were due to problems related to anaesthetic technique, and 1 patient had an unexplained cerebral event 'some hours' after ETS. The total number of patients treated by the procedure was not documented.
Compensatory hyperhidrosis occurring mainly at the axillae, trunk and groin (assessed using Hyperhidrosis Disease Severity Scale; scores range from 1 to 4, with higher score indicating intolerable sweating interfering with daily activities) was reported to be 'intolerable' in 4% (n=1) of patients, 'hardly tolerable' in 21% (n=5) of patients, and 'tolerable' in 54% (n=13) of patients with facial blushing in a case series of 73 patients (denominator unclear). Half of the patients had compensatory hyperhidrosis within 1 month of the procedure. Severe compensatory hyperhidrosis on the trunk and regret associated with having had the procedure was reported in 6% of patients in the case series of 831 patients at a mean follow-up of 29 months (absolute number not reported). Compensatory hyperhidrosis that was considered 'incapacitating' and regret associated with having had the procedure was reported in 11% (190/1700) of patients with facial blushing or hyperhidrosis at a mean follow-up of 15 years.
Horner's syndrome on one side of the face was reported in 10% (2/21) of patients with facial blushing in a case series of 202 patients (1 patient underwent blepharoplasty; no further details) and in 1 patient in the case series of 180 patients with isolated facial blushing: this resolved after 2 days.
Pneumothorax (needing a chest tube) was reported in 1 patient in the case series of 180 patients with isolated facial blushing. A chest drain was needed postoperatively (no further details provided) in 9% (5/59) of patients with facial blushing in the case series of 80 patients.
Worsening of symptoms was reported in 1 patient and worsening of quality of life was reported in 14% (8/59) of patients with isolated facial blushing or blushing with hyperhidrosis (n=59) in the case series of 80 patients.
In the case series of 1152 patients (244 patients with facial blushing), 13% of patients were 'dissatisfied to some extent' and 2% regretted the operation at a mean follow-up of 8 months (absolute numbers not reported). A randomised controlled trial (comparing sympathectomy of the second versus the second and third thoracic ganglia) of 100 patients with isolated facial blushing reported that overall 13% (12/93) of patients regretted the operation (reasons not reported) at a mean follow-up of 12 months; there was no significant difference between the groups treated by different extents of sympathectomy.
Additional safety events reported in a series of endoscopic thoracic sympathectomies done for a variety of indications were bleeding, haemothorax, chylothorax, pulmonary embolus and brachial plexus damage; it is unclear if these events were in patients with facial blushing.
The specialist advisers listed harlequin face, post-thoracoscopy chronic pain, and wound infection as adverse events reported in the literature. They listed anecdotal adverse events as air embolism and arm ischaemia. Theoretical adverse events were reported as death, dry hands and visceral injury.# Further information
For related NICE guidance see the NICE website.

# Information for patients
NICE has produced information on this procedure for patients and carers (Information for the public). It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# About this guidance
NICE interventional procedures guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS.
This guidance was developed using the NICE interventional procedures guidance process.
We have produced a summary of this guidance for patients and carers.
NICE produces guidance, standards and information on commissioning and providing high-quality healthcare, social care, and public health services.  We have agreements to provide certain NICE services to Wales, Scotland and Northern Ireland.  Decisions on how NICE guidance and other products apply in those countries are made by ministers in the Welsh government, Scottish government, and Northern Ireland Executive. NICE guidance or other products may include references to organisations or people responsible for commissioning or providing care that may be relevant only to England.

# Changes after publication
November 2014: Minor maintenance
Your responsibility
This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
Copyright
 National Institute for Health and Care Excellence 2014. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
ISBN: 978-1-4731-0436-5