Curettage and Cautery 11/7/01Bruce Davies2 Curette From the Latin curare, to care for or to cure....

Curettage and Cautery

11/7/01 Bruce Davies 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!


Cautery

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


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.


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.


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.


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!


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).


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.


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.


What for?

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


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.


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.


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.


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.


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.


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.


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.


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.


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


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.


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.


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.


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!


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!


Curettage

Specially good for:– Seborrhoeic warts– Kerato-acanthomas– Skin tags– Facial warts– Pyogenic granuloma

• (Chalazions)

If it extends beyond the dermis – excise it!


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!

Curettage and Cautery 11/7/01Bruce Davies2 Curette From the Latin curare, to care for or to cure....

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