Cryosurgery

3
CRYOSURGERY
DAVID BARNARD, F.D.S.R.C.S. (ENG.),
F.D.S.R.C.P.S. (GLASG.)
CRYOSURGERY 33
INDICATIONS nerves to achieve symptomatic relief in the manage-

ment of chronic facial pain, and this technique has
Cryosurgery is the clinical application of extreme been found to be particularly useful in the manage-
low temperature to achieve tissue destruction. Its ment of idiopathic paroxysmal trigeminal neuralgia.
consideration as an alternative to conventional sur-
gery depends on the nature of the lesion to be treated, EQUIPMENT
the expected response to cryosurgery, and whether
this treatment modality is likely to offer positive Two basic types of cryosurgical apparatus are cur-
advantages over excision. Cryosurgery is a simple, rently available. The Amoils probe, in which nitrous
noninvasive technique and therefore frequently offers oxide is used as the refrigerant, achieves a tempera-
particular advantages in the management of the ture of approximately -70° C. The liquid nitrogen
elderly or debilitated patient. Ultimate healing is system, which may be applied either as a spray or in a
excellent with minimal scarring. When histologic closed probe, achieves a minimum temperature of -
confirmation of clinical diagnosis is felt to be 196° C. The freezing power of the nitrous oxide
necessary, an incisional biopsy may be taken system is sufficient for most oral surgical situations,
preoperatively by conventional methods or intra- although liquid nitrogen may be preferred for the
operatively by removal of frozen tissue with a ron- freezing of bone and in the management of malignant
geur. It must be remembered that an excised speci- disease where an iceball of larger volume is often
men for detailed histologic examination will not be desirable. Temperature monitoring is unnecessary
available, and this may influence the decision to use with a nitrous oxide system but mandatory for a liquid
the technique. nitrogen system.
Cryosurgery has been found to be useful in the
management of a variety of oral mucosal lesions.
Hemangiomas, lymphangiomas, and pyogenic gran- PREPARATION Tissue
ulomas respond well, and postoperative bleeding is
rarely a problem. Treatment of mucoceles is effective, Ablation
and the technique avoids the scarring and lumpiness
in the lip that are often the sequelae of effective Small lesions may be frozen without anesthesia, but
excision. Areas of leukoplakia may be simply treated, it may be preferable to inject local anesthetic solution
but confirmation of the diagnosis by biopsy and post- prior to treatment, particularly in highly vascular
treatment management should follow accepted clinical tissues, such as the lip, to achieve vasocon-striction.
practice, particularly when dysplastic change has been This increases the rate of freeze and decreases the
demonstrated. Isolated polyps and papillomas are rate of thaw, thereby improving the efficacy and
treated equally well by conventional excision and predictability of treatment. For large lesions or
cryosurgery, but widespread lesions, e.g., those in the uncomfortable sites, e.g., the soft palate or posterior
palate, may be more simply managed by freezing. part of the tongue, general anesthesia may be
Fibrous and relatively avascular lesions often show a preferred.
disappointing response to cryosurgery. Cryosurgery
for the primary treatment of oral malignancy is gen- Cryogenic Peripheral Nerve
erally restricted to patients in whom other treatment is
inappropriate or has been refused, but it may be Blockade
useful for palliation. Chronic lip fissures may be
treated simply and effectively by cryosurgery, and the When a cryogenic peripheral nerve block is being
technique offers positive advantages over con- considered to achieve symptomatic relief of chronic
ventional surgical excision for this minor but dis- facial pain, a diagnostic injection of local anesthetic
tressing problem. The technique has been used in solution should first be placed to confirm the branch
combination with conventional surgery in the man- of the nerve involved and to assess the effect on the
agement of odontogenic keratocysts (see Chapter 8). pain and the patient's tolerance of cutaneous anes-
The cryoprobe may be used to block peripheral thesia.
34 CRYOSURGERY
PROCEDURE Tissue applied warm and the freeze started only after contact
is made with the tissue to be frozen. When the freeze
Ablation is begun a white flare will appear, indicating
adhesion between probe and tissue (Fig. 3-2). This
As an example, treatment of a small hemangioma of will spread outward from the probe until thermal
the right buccal mucosa is illustrated (Fig. 3-1). A equilibrium is reached. The freeze should then be
probe tip that will produce an iceball that extends just timed; for most oral surgical situations 1 minute is
beyond the lesion should be selected, although for appropriate. After the selected freeze time the probe is
large lesions applications at multiple sites will be allowed to defrost; only then is it removed from the
required. It must be remembered that the effective tissues (Fig. 3-3). When the thaw is complete it is
zone lies within, and is not coincident with, the important to repeat the freeze cycle at least once. A
periphery of the iceball. Thus with multiple applica- fissure in the lower lip (Fig. 3-4) or a mucocele (Fig.
tions the iceballs should overlap. Thermal contact 3-5) may be treated in a similar fashion. For larger
between probe and tissue is essential and is ensured lesions, such as those of the tongue (Fig. 3-6),
by gentle pressure of the probe on the mucosa and the multiple overlapping applications may be necessary.
use of a water-soluble gel. The probe must be
Figure 3-1 Figure 3-2

CRYOSURGERY 35

36 CRYOSURGERY
Cryogenic Peripheral Nerve POSTOPERATIVE MANAGEMENT
Blockade
Following cryosurgery of oral mucosal lesions the
As examples, blockades of the infraorbital (Fig. 3-7) patient must be reassured about postoperative swelling
and lingual (Fig. 3-8) nerves are illustrated. The nerve and sloughing. When the lip is involved, 1%
to be frozen is exposed surgically, usually under local hydrocortisone ointment in a greasy base may be
anesthesia. The nerve is isolated as far as possible prescribed, and an effervescent mouthwash promotes
from the surrounding tissues, and the area is kept dry healing.
to reduce the heat sink and increase the rate of freeze. Postoperative pain is not generally a problem, but
A small probe is used to minimize the unnecessary mild analgesics may be indicated. The possibility of
freezing of adjacent tissue. Two 2-minute freeze-thaw tissue swelling around the airway should be remem-
cycles should be used. bered but this is not generally a problem.
Following cryogenic peripheral nerve blockade the
surgical site should be reviewed in accordance with
normal practice, and pretreatment medication, e.g.,
carbamazepine, should be slowly withdrawn.
LONG-TERM PROGNOSIS
With appropriate case selection and careful tech-
nique many lesions will be eliminated in one treat-
ment session. However, residual tissue or recurrence
may be treated by repeating the treatment. Long-term
response and the need for review will depend on the
type of pathology. For example, a treated mucocele
requires no long-term follow up, but leu-koplakia
with dysplasia should be followed up indefinitely.
The prognosis following cryogenic peripheral nerve
blockade is variable, and the reader is referred to
reports in the literature.
KEY REFERENCES
Ball, G., Barnard, D.: The treatment of chronic lip fissures with
cryotherapy. Br Dent J 157:64-66, 1984. Barnard, D.:
Figure 3-7 Cryoanalgesia in the management of paroxysmal
trigeminal neuralgia. Hosp Dent Maxillofac Surg 1:58-60, 1987.
Bradley, P.P. (ed.): Cryosurgery of the Maxillofacial Region, Vols.
I and II. Boca Raton, FL, CRC Press, Inc., 1986. Zakrzewska,
J.M.: Cryotherapy in the management of paroxysmal
trigeminal neuralgia. Neurol Neurosurg Psychol 50:485-487,
1987. Zakrzewska, J.M., Nally, F.F.: The role of cryotherapy
(cryoanal-
gesia) in the management of paroxysmal trigeminal neuralgia: a
six year experience. Br J Oral Maxillofac Surg 26:18-25, 1988.

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INDICATIONS nerves to achieve symptomatic relief in the manage-

Figure 3-1 Figure 3-2

Figure 3-3 Figure 3-4

Figure 3-5 Figure 3-6

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