Curettage and Cautery

1. Curettage and Cautery www.bradfordvts.co.uk

2. Curette • From the Latin curare, to care for or to cure. • Then to the French curer, to cure. • Bronze curettes have been found in Egyptian tombs! Bruce Davies

3. Cautery • From the Latin cauterium, a branding iron. • An old usage is a cauterant, a chemical used to burn! • Used for several thousand years Bruce Davies

4. Cautery • One of the earliest surgical techniques and one that is still very useful especially in a general practice setting. • It is often quick to perform and provided simple precautions are observed it is safe and effective. Bruce Davies

5. Cautery • As a additional incentive the "Minor surgery" scheme allows most forms of cautery to be a claimable "minor op". • The regulations are not specific as to what constitutes claimable cautery so the interpretation can be fairly broad. Bruce Davies

6. Cautery • There are 3 types of cautery relevant to general practice, the use of specialist operating theatre type equipment is out side the normal scope of general practice. • These are Cryocautery, Chemical cautery and Electro cautery [ hot wire - DC types ]. • All have uses in general practice. Bruce Davies

7. Cautery • By definition cautery does not produce a tissue sample for histology ( unless used as a adjuvant in another procedure) so it must Never be used if there is any doubt as to the nature of the lesion. • Medical records must be meticulous as to the procedure and the diagnosis of the lesion concerned. • As in all things there is no substitute for practical experience, Good sources of practical training are Dermatology outpatients, ENT outpatients, A&E and gynae - but your training practice may the best bet! Bruce Davies

8. Cryocautery • Works by causing cellular lysis after freeze thaw cycle, relatively painless with liquid nitrogen but stings with warmer techniques. • There are 4 different techniques, carbon dioxide snow(now rarely used), liquid nitrogen, nitrous oxide and commercial freezing mixtures (e.g. Histofreeze). Bruce Davies

9. Liquid Nitrogen • Very cold and causes lots of tissue destruction can be over applied and cause full thickness skin loss. • Only one application usually needed. Applied with cotton wool buds or proprietary sprays. • Can be kept in a Dewar flask(fancy thermos) for 2 days. • BOC won't sell small amounts so need to arrange supply from local hospital or industry. • This means saving up suitable patients and arranging a special session. Bruce Davies

10. Nitrous Oxide • Used to cool special heads via gun. • Difficult to over treat lesion, may need 2-3 goes to clear thicker lesions - about 10-14 days apart. • Always to hand from cylinder, gas prescribable on FP10. • Convenient and to hand but more painful and needs more treatment, less skill needed. Bruce Davies

11. What for? • Suitable for surface skin lesions of known type, e.g. viral warts, seb. warts, small moles, Keratoacanthoma, solar keratosis etc. Bruce Davies

12. Warnings to Patients • The patient should be warned that the treated lesion will throb for up to 12 hours, paracetamol may be suitable. • The lesion will blister, the blister should not be "popped" if possible but allowed to dry off as "natural" dressing. • This area of dead skin will slough off 7-14 days after treatment leaving a red area. • The red area will fade to normal colour after up to 12 weeks - usually 6. Bruce Davies

13. Electro-cautery • Works by simple burning of tissue via DC current. Needs local anaesthesia. • Cheap machines readily available. • Quick to use. • Very easy to cause marked scars, good haemostasis. Bruce Davies

14. Electro-cautery • Unsuitable for viral warts as highest recurrence rate of any wart therapy. • May be useful adjuvant to straight scalpel surgery for stopping bleeding. • Needle point tips available for the treatment of spider naevi and capillary flares. Bruce Davies

15. Chemical Cautery • The chemical destruction of a surface lesion. • Usually employs silver nitrate. • This comes in the forms of pencils - sold to the public (!) for shaving cuts, but a simple cheap source for certain applications. Bruce Davies

16. Chemical Cautery • It is also available on sticks - looking like a very long match with a black head. • These are very cheap. • They need storage in a dry dark place. • Silver nitrate stains clothing, worktops and skin, WARN the patients and always wear gloves when handling. Bruce Davies

17. Chemical Cautery • The stain will go as the top layer of skin is shed. • The lesion or the head of the stick needs to be moist to work, it is usual to dip in a galipot with some water and knock off excess water before use. Bruce Davies

18. Nasal Cautery • Cautery to Little's area for recurrent nose bleeds is a quick and simple procedure, well within the remit of general practice. • It should only be done when the practitioner has had supervised prior experience. Bruce Davies

19. Nasal Cautery • The area needs to well visualized with good lighting. • It should also only be done if a obvious vessel is seen to cauterise - one is not trying to burn the whole nasal septum! • The technique is not suitable when there is active bleeding. Bruce Davies

20. Nasal Cautery • The area needs to be free of debris and large clots, washing the area with Adrenaline diluted to about 1 in 10,000 from a syringe without a needle will remove debris and will usually temporarily stop bleeding. • The upper lip should be covered with Vaseline to prevent chemical burns to the upper lip - medico-legally important Bruce Davies

21. Nasal Cautery • And the patient warned to leave the Vaseline on over night. • The procedure may need to be repeated. • It is unsuitable for nasal bleeding other than from Little's area. • After preparation the area is simply touched with the stick using a rolling movement. Bruce Davies

22. Granuloma cautery • Post op, bits of granuloma tissue in wounds can be simply touched to induce involution. • Pyogenic granuloma can be easily and quickly treated. The pressure required on the lesion may be quite painful. Bruce Davies

23. Adjuvant • Can usefully be employed to stop bleeding from a raw area, particularly useful after a shave excision. • MUST not be used to stop bleeding if the treated area is in a wound - the silver nitrate incorporated into deeper layers will cause considerable damage. Bruce Davies

24. Curettage • Allowable under the minor surgery scheme. • Usually needs some sort of anaesthetic. • Produces tissue for cytology, NOT histology. • Quick and simple. • Surface lesions only. • Often blunt. • Possible to sharpen them! Bruce Davies

25. Curettage • Disposable curettes cost £2-3 each. Very sharp! • A joy to use! • 4mm and 7mm ring sizes available. • Any surface skin lesions that one is pretty sure of! • May need to apply haemostatic. • Avoid on possible carcinomas! Bruce Davies

26. Curettage • Specially good for: • Seborrhoeic warts • Kerato-acanthomas • Skin tags • Facial warts • Pyogenic granuloma • (Chalazions) • If it extends beyond the dermis – excise it! Bruce Davies

27. Curettage • Basal cell carcinomas. • Said to be good. • 90% cure with selected lesions. • Maybe a place in elderly and infirm. • I don’t do it intentionally! Bruce Davies