Curettage and Cautery

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Curettage and Cautery

• www.bradfordvts.co.uk

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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!

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Cautery

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

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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.

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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.

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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.

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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, AE and gynae - but your training
  practice may the best bet!

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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).

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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.

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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.

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What for?

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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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.

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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!

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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!

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Curettage

• Specially good for
• Seborrhoeic warts
• Kerato-acanthomas
• Skin tags
• Facial warts
• Pyogenic granuloma
• (Chalazions)
• If it extends beyond the dermis excise it!

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Curettage

• Basal cell carcinomas.
• Said to be good.
• 90 cure with selected lesions.
• Maybe a place in elderly and infirm.
• I dont do it intentionally!