Cryotherapy application in detail for Oral Surgeons this will ease your effforts in learning cryotherapy in oral surgery

1. CRYOTHERAPY
PRESENTED BY
Dr.Akhil Sankar
2nd Year MDS

2. CONTENTS

3. • Also called cryotherapy or cryoablation
• It is the process of rapidly freezingtissue by exposing it to
intensly lowtempratures.
INTRODUCTION
• Cryosurgery, is a procedure used to destroy tissue of both benign
and malignant lesions by the freezing and re-thawing process.

4.  While it is not an ideal coagulating method, it minimize the extent of blood loss
in extensive ablative surgeries.
 Liquid nitrogen became available in the 1940s and currently isthe most widely
used cryogen.

5. HISTORY OF CRYOTHERAPY
 The controlled destruction of tissue by freezing is today widely practised in medicine.
 The benefits of cold have been appreciated for many thousands of years.
 The ancient Egyptians, and later Hippocrates, were aware of the analgesic and anti-
inflammatory properties of cold.
 Over the past 200 years cold treatment has evolved from generalized application such as
hydrotherapy to specific, focal destruction of tissue—today's cryosurgery.
 James Arnott (1797-1883), an English physician, published on the use of cold between 1819 and 1879
 Arnott was the first person to use extreme cold locally for the destruction of tissue.

6.  In 1899 White, was the first to use Cryogens in the form of liquefied gases for medical care
 William Pusey treated a large black hairy naevus on a young girl's face.
 showed the successful depigmentation of the lesion with the use of carbonic acid snow.
 Allington was the first to use liquid nitrogen in the treatment of skin lesions. He used a cotton swab
dipped in liquid nitrogen to treat skin tumors
 Contributions of Dr Irving S Cooper to cryosurgery was immense. An American neurosurgeon based in
New York, in 1913 he designed a liquid nitrogen probe that was capable of achieving temperatures of
-196°C.

7. Mechanism Of Action
 The basic thermal protocol for a cryosurgical procedure became rapid freezing, slow thawing,
and repetition of freeze-Thaw cycle.
 In cryosurgery tissue is frozen with a cryosurgical probe that is brought in good contact with the
undesirable tissue.
 Usually, the probe is cooled through the internal circulation of a cooling fluid.
 The cooling fluid gradually extracts heat from the tissue, through the probe. Within several minutes after
cooling begins, the temperature of the tissue in contact with the probe reaches the phase transition
temperature and begins to freeze.
 the temperature of the probe continues to drop and the freezing interface begins to propagate outward
from the probe into the tissue.

8.  A variable temperature distribution in both the frozen and unfrozen regions of the tissue ensues.
 The freezing interface propagates outward until either the flow of the cooling fluid is stopped or until the heat
that comes from the live tissue surrounding the frozen lesion becomes equal to the amount of heat that the
cooling fluid in the cryosurgical probe can remove.
 In typical cryosurgical protocols, after freezing is completed the cooling system keeps the tissue frozen for a
desired period of time, followed by heating and thawing.
 The primary mechanism for heating the frozen tissue is from the blood circulation and metabolism of the
surrounding tissue.
 Sometimes the frozen tissue is also warmed from the probe surface by a warming fluid circulating through the
cryosurgical probe.

9.  Cell damage during cooling and freezing occurs at several length scales:
o nanoscale (Angstrom),
o molecular;
o mesoscale (micron),
o cellular; and
o macroscale (millimeter)
 The time scales relevant to cryosurgery range between single minutes to tens of minutes.
 The damage during cryosurgery is of two types, immediately during the therapy and long term

10.  The mechanism of action in cryotherapy can be divided into 3 phases:
(1) heat transfer,
(2) cell injury, and
(3) inflammation.
Heat transfer
 The mechanism by which cryotherapy destroys the targeted cells is the quick transfer of heat from the skin to a
heat sink.
 The most commonly used cryogen is liquid nitrogen, which has a boiling point of -196°C.
 When using the spray cryotherapy technique, the liquid nitrogen is applied directly on the skin, and evaporation
(boiling heat transfer) occurs in which the heat in the skin is quickly transferred to the liquid nitrogen.
 This process results in the liquid nitrogen evaporating (boiling) almost immediately.

11.  When using a cryoprobe for cryotherapy, conduction heat transfer occurs where the heat is transferred via the
copper probe.
C e l l i n j u r y
 Cell injury occurs during the thaw, after the cell is frozen.
 Because of the hyperosmotic intracellular conditions, ice crystals do not form until -5°C to -10°C.
 The transformation of water to ice concentrates the extracellular solutes and results in an osmotic gradient
across the cell membrane, causing further damage.
 Rapid freezing and slow thaw maximize tissue damage to epithelial cells and is most suitable for the treatment
of malignancies.
 Fibroblasts produce less collagen after a rapid thaw. [5] Therefore, a rapid thaw may be more suitable for the
treatment of keloids or benign lesions in areas prone to scarring. [6]

12.  Keratinocytes need to be frozen to -50°C for optimum destruction.
 Melanocytes are more delicate and only require a temperature of -5°C for destruction.
 This fact is the reason for the resulting hypopigmentation following cryotherapy on darker-skinned individuals.
 Malignant skin cancers usually need a temperature of -50°C, while benign lesions only require a temperature of -
20°C to -25°C.

14. Physiological Effects of Cold Application
 Circulatory Response
 The initial skin reaction to cooling is an attempt to preserve heat. It is
accomplished by an initial vasoconstriction. This haemostatic response has
the effect of cooling of the body part.

16. • After a short period of time, the duration depends on the area involved, a vasodilatation
follows with alternating periods of constriction and dilatation.
This reaction of “hunting” for a mean point of circulation is called “Lewis’s Hunting
Reaction”.
 that it is caused by inhibition of contraction in the smooth muscles ofthe blood vessel walls by extreme cold.

17. Physiotherapeutic Uses of the Circulatory Effect:
 The initial vasoconstriction is often used to limit the extravasations of blood into
the tissues following injuries (e.g. sports injuries).
 Ice therapy is then usually followed by some forms of compression bandage.
 The alternate periods of vasoconstriction and vasodilatation affect the capillary
blood flow and it is across the capillary membrane that tissue fluid can be
removed from the area and returned in the systemic circulation. Increased
circulation allows more nutrients and repair substances into the damaged areas.

18.  Thus ice therapy is very useful in removing swelling and accelerating tissue repair. i.e.
ice cubes massage may be used to accelerate the rate of repair of pressure sores.
 The reduced metabolic rate of cooled tissues allows cooled muscle to contract many
more times before fatigue sets in.

19. NEURAL RESPONSE
 The skin contains primary thermal receptors. Cold receptors are several times more numerous
than warm receptors. The cold receptors respond to cooling by a sustained discharge of
impulses, the rate of which increases with further cooling.
 The rate of conduction of nerve fibers in a mixed (motor and sensory) peripheral nerve is
reduced by cooling. The first fibers affected by gradual cooling are the A fibers (myelinated)
and eventually atvery low temperatures the B and C fibers (non- myelinated) are affected.

20.  The decrease in nerve conduction velocity that occurs with 5 minutes of cooling fully reverses
within 15 minutes in individuals with normal circulation
 after 20 minutes of cooling, nerve conduction velocity may take 30 minutes or longer to recover
due to the greater reduction in temperature caused by the longer duration of cooling
 A-delta fibers, which are small-diameter myelinated, pain-transmitting fibers,
demonstrate the greatest decrease in conduction velocity in response to cooling

21. Excitatory Cold Mechanism
 When cold is applied in an appropriate way on the skin, it can be used to increase the
excitatory bias around the anterior horn cell.
 Combined with other forms of excitation (brushing, tapping,…) and with the patients’
volition (Volition or will is the cognitive process by which an individual decides on and commits to a particular course of action), this
can often produce contraction of an inhibited muscle which is in spasm
 (only with intact peripheral nerve supply).
 This effect can be used when muscle are inhibited postoperatively or in the later stages of
regeneration of a mixed peripheral nerve

22. DIRECT EFFECTS
1. Ice crystal formation:
 Rapid cooling causes formation of ice crystals from intracellular and extracellular fluid
resulting in physical disruption of cell
2. Thermalshock
Damage of cell membrane due to freezing occurs and this alters cell permeability
leading to cell death.

23. 3. Cellular dehydration and electrolyte disruption:
 Initially during freezing the extracellular fluid alone forms ice which is limited by intracellular fluid and there is
increase concentration of electrolyte in the extracellular fluid, this causes movement of intracellular fluid to
extracellular spaces where they again form ice crystals.
 This results in dehydration of cell, cell shrinkage, intracellular increase in electrolyte which is toxic to the cell and all
together causes’ cell death.
4. Enzyme inhibition:
 Each enzyme requires particular temperature for their functioning which when altered prevents their function.
5. Effect on proteins:
 During the phase after cooling when the cells return to normal temperature imbibes more water as it has high
concentration of electrolyte which result in swelling and rupture

24. INDIRECT EFFECTS
1. Vasculareffect:
 Ischemic necrosis results due to vascular thrombus and micro-thrombus formation.
2. Immunological effect:
 Massive release of pathological cell antigen occurs making them susceptible for host
surveillance mechanism.

25. Uses of Ice Therapy
1. Reduces pain.
2. Reduces spasticity.
3. Reduces muscle spasm.
4. Reduces swelling.
5. Promote repair of the damaged tissues.
6. Provide excitatory stimulus to inhibited muscles.

26. Stages of Analgesia induced by Cryotherapy
 Cold Sensation
 Burning or aching
 Local numbness or analgesia
 Deep tissue vasodilation without increase in metabolism 12-15 Mints
0-3 Mints
2-7 Mints
5-12 Mints

27. Muscle Spasm
 Cold therapy affects pain threshold
  nerve conduction velocity by slowing communication at the synapse
  pain by reducing the threshold of afferent nerve endings.
  sensitivity of muscle spindles
 May inhibit the stretch reflex mechanism reducing muscle spasm & breaking pain-spasm cycle

28. Liquid Nitrogen Cryoprobes
 In liquid nitrogen cryoprobes the liquified gas is allowed to boil within the tip of the instrument.
 It is an efficient method of cooling, because for every gram of liquid nitrogen that boils in the tip, -
1960c /209 J of heat is absorbed in turning the nitrogen from liquid to gas at the boiling point.
 While doing this this liquid withdraws heat from tissues which is it coming in continue

29. METHODSOF CRYOTHEARPY
 There are two systems and both require a cryogen.
 Open Method/ spray method
 Closed method/ probe technique

30. COMMONLY USED
CRYOGENS

31. Various techniques of cryosurgery

33. INDICATIONS FOR CRYOTHERAPY IN OMFS
 Acute or subacute inflammation
 Acute pain
 Chronic pain
 Acute swelling
 Myofascial trigger points
 Muscle guarding
 Muscle spasm
 Acute muscle strain
 Acute ligament sprain
 Acute contusion
 Tendinitis
 Delayed onset muscle soreness

34. Decreases in posttraumatic edema, in which inflammation particularly those
mediated by prostaglandins and histamine and serotonin during the acute stage
 Changes in cellular function & blood dynamics serve to
control effects of acute inflammation.
 Cold suppresses the inflammatory response by:
  the release of inflammatory mediators (histamine, prostaglandin)
  prostaglandin synthesis
  capillary permeability
  leukocyte/endothelial interaction
  creatine-kinase activity

35. .

36. Pain control
Cold therapy acts as a counterirritant
Cold application affects pain perception & transmission by:
 Interrupting pain transmission (stimulates large-diameter A-beta nerve fibers)
 Decreasing nerve conduction velocity

37. Indications of cryosurgery in oral and maxillofacial surgery
Cryosurgery is used as a therapeutic modality for a variety of oro-facial lesions.
• P r e m a l i g n a n t l e s i o n s
• B e n i g n o r a l a n d o r o f a c i a l l e s i o n s
• M a l i g n a n t s o f t t i s s u e l e s i o n s o f o r a l c a v i t y , p h a r y n x , f a c e a n d s c a l p
• B o n e l e s i o n s
• C r y o s u r g e r y o f n e r v e
• C r y o s u r g e r y o f b l o o d v e s s e l s
• C r y o s u r g e r y o f s a l i v a r y g l a n d s
• C r y o n e u r o t o m y f o r i n t r a c t a b l e t e m p o r o m a n d i b u l a r j o i n t p a i n
• Cryosurgical treatment of melaninpigmented gingiva
Cryosurgery is a simple and effective technique to eliminate the pigmentation of gingiva. It requires no
anesthesia or sophisticated equipment. The treated gingiva appeared normal within 1 to 2 weeks after
cryosurgical treatme

38. The advantages to the patient of modern cryosurgery in comparison to
conventional surgical methods
 • Short duration of surgery
 • Minimal operative and anesthesia trauma
 • Surgery without bleeding
 • Surgery without scar formation
 • Prevention of metastasis at time of excision of tumour
 • Surgically uncomplicated results, the high rate of curative success, short hospital stays, lower
hospital costs, as well as increased quality of life for the patient
 • Anesthesia is usually unnecessary, as the cold itself functions as an anesthetic
 • The period of convalescence is a fraction of that usual for stationary hospital admissions
 • No local complications stemming from the area of surgery
 • Quick and technically simple method of tumour removal
 • Both benign and malignant tumours are easily extirpated
 • Improved subjective state of the patient through palliative cryosurgical methods, lessening of pain
and fetor, as well as improvement in the general condition of the patient by containment of tumour
growth.

40. © 2019 The British
Association of Oral
Surgeons and John
Wiley & Sons Ltd

41. Human Pappilloma Virus
• Many form of HPV infections can be treated with cryotherapy
• Multiple lesions can be treated with single appointment therapy with
excellent results
• For verrucuous form keratolytic are used one week prior to cryotherapy
• more precise results from using cone shaped tip
• Topical anesthesia reduces the pain during treatment.
• .
• Duration:10 sec
• Temp:-196

42. MOLLUSCUM CONTAGIOSUM
• Highly contagious
• Both open and closed technique can be used
• In open method spray at the centre of the lesion no pendular or
broom stick motion
• In closed method allow the tip for precooling ,it helps to avoid
sticking
• And this is faster and allows to treat multiple lesions at a single
visit
• Time:10-20 sec according to size
• Can use as 2 cycles of 10 seconds
• Temp:-196 0c

43. Seborrheic keratosisis
 It is common noncancerous skin growth.
 People tend to get more of them as they get older.
 Seborrheic keratoses are usually brown, black or light tan.
 The growths look waxy, scaly and slightly raised.
 They usually appear on the head, neck, chest or back.
 Fastest,cheapest and safest way to treat is cryosurgery
 Best to use open method with medium sized tip to spray unmtil the white hallow extend 1-2 mm beyond the
border
 Since freezing is followed by immideate vasodilation hemostatic agents are to be kept ready eg aluminium
chloride
 Time:10-30 sec in 2-3 cycles
 Temp:-196
 Usually excellent results obtained

44. SOLAR LENTIGO(Liver spots)
• Most commonly seen in midface region,Very sensitive to cold
• Caused by UV rays in sunlight
• Superficial and single layer in thickness
• Can be treated with single freezing cycle and high prognosis rate
• Intermittent spraying for no more than 3-5 seconds from a distance of 2 mm is
always advised
• The freezing hallow should be allowed to advance barely outside the margins of
lesions
• Leaving an untreated rim of lesion will cause a pigmented rim which is unesthetic
• Time:5-20 sec according to size
• Temp:-86/-1960 c

45. ACNE VULGARIS
 Cryotherapy treatments for acne are usually performed once a week.
 Side effects of this treatment may include stinging and redness of the skin; there may also be some
pain for some period after the treatment.
 The painful aftereffects of cryotherapy may be reduced by applying a steroid to the treated area
immediately after the treatment.
 In very rare cases, a patient with extremely sensitive skin may experience some swelling and
blistering after a cryotherapy session.
 No need to freeze beyond the outer limit of the lesion ,the treated area will be drained later and may need to
be covered with antibiotic ointment
 Never to be done in inciused or drained acne lesions
 Time:5-10 sec if needed 2-3c cycles
 Temp:-86/-196

46. Hypertrophic scars and keloids
 Can be used as amonotherapy,but best results are obtained when combained with other treatment
such as laser therapy and intralesional steroids
 According to studies ,lesions less than 2 years old and sessions more than 3 cycles every weeks
rendered best results
 Shows 33% of recurrence when used alone inspite of better primary results
 Intra lesional cryotherapy improved prognosis than open method
 Co2 laser excision intramarginally improved the results as well
 Time:30 sec minimum 4-5 sessions
 Temp:-196 0 c

48. GINGIVAL MELANIN PIGMENTATION with increasing awareness to esthetic, people have become highly concerned about black gums.
 Various treatment modalities like abrasion, scrapping, scalpel technique, cryosurgery, electrosurgery and laser
are available for treatment of gingival pigmentation.
 Cryosurgery technique is easy and rapid to apply, since melanin is one of the most sensitive tissue towards cold.
 It does not require anesthesia or suturing, and finally it does not cause any bleeding
 However, cryosurgery is followed by considerable swelling.
 And it is also accompanied by increased soft tissue destruction.
 Time:2-3x10 secs freeze and 30-45 sec thawing period
 Temp:-1020c

50. ACTINIC CHELITIS
• Actinic cheilitis is a clinical variant of actinic keratoses developing typically on the lower lip (the more
sunexposed area).
• It has a greater risk of progression to invasive squamous cell carcinoma compared with normal skin
• Focal actinic cheilitis is easily treated with cryosurgery
• Loacal anesthesia is used for better tolerance of pain
• Open method is easy and effective method for this lesion
• Time:20-30 sec 1 or 2 cycles as per the size
• Temp:-86/-196

51. MUCOUS RETENTION CYST
 Mucus retention cysts respond to cryosurgery without recurrence and detectable scarring and are better
accepted by children.
 Toida M, Ishimaru JI, and Hobo N treated 12 female and 6 male patients with mucus cysts on the lower lip and
the tip of the tongue, by direct application of liquid nitrogen with a cotton swab.
 Each lesion was exposed to four or five cycles composed of freezing of 10-30 seconds and thawing of double the
freezing time.
 No anesthesia was required. All lesions had disappeared completely 2-4 weeks after one or two treatment
courses of cryosurgery.
 In all cases, neither scarring nor recurrence was noted during the 6 months to 5 years of follow-up.

52. ORAL LEUKOPLAKIA It’s a simple and generally effective method of treatment for these potentially malignant or premalignant lesions.
 closed-system cryotherapy with two consecutive freeze-thaw cycles of up to 1.5 minutes to treat over 40 OL lesions in a 3-year
period.
 The lesion site should be air-dried before treatment to prevent the cotton swab from sticking to the oral mucosa
 The cotton swab was dipped into liquid nitrogen for at least 5 seconds and applied to the lesion with pressure for 20 seconds
to form an ice ball and then allowed to thaw for another 20 seconds
 single liquid nitrogen spray for 45 to 60 seconds to treat OL lesions on the hard palate, soft palate, and buccal mucosa; all OL
lesions were successfully eliminated after treatment.
 Liquid nitrogen spray of two consecutive freezeethaw cycle to treat seven OL lesions.
 Time :10 sec x 5-6 cycles of freeze and thaw 20 s.
 Temperature: -196

53. Lichen planus
 Lichen planus is a premalignant condition that has both cutaneous and mucous manifestation.
 Oral lichen planus(OLP) presents itself with bilateral white striae, papules, or plaques that may be present in
buccal mucosa, tongue, or gingiva.
 They have been treated using topical steroids, lasers, antifungal mouthwashes, surgical excision, and
cryosurgery
 In patients with overlying systemic conditions that contraindicate the usage of steroids, cryosurgery is the
best treatment option.
 Another added advantage is that no supra added infections such as candidiasis occur with cryosurgery
 Freezing time was 1½ min followed by a 3 min thaw.

54. TRIGEMINAL NEURALGIA
 Identification of the affected branch or branches was achieved prior to cryotherapy by injection of local
anaesthesia with consequent abolition of pain.
 Identifying the affected divisions of trigeminal nerve is identified.
 Patients were treated under intravenous sedation, together with local anaesthesia.
 The affected nerves were exposed to cold using intra-oral techniques as far as possible.
 If multiple branches were affected, both were treated simultaneously.
 May require multiple sessions for complete resolution of the pain,henceence always combine with
carbamazepine 200mg per day for atleast 4 days
 Time:30 sec x 4-5 cycles 4-5 sessions.
 Temp:–98°C, and pressure 70 kg/cm2 or 100 ps

56. Basal Cell Carcinoma
 Basal cell carcinoma can be treated with open or closed methodwith liquid nitrogen
 Superficial basal cell carcinoma is Treated with open method
 The halo of freeze should reach at least 5 mm beyond the visible border of the lesion.
 The time and sessions of freezing will be determined by the size of the lesion
 A 95.3% cure rate was achieved in the treatment of facial basal cell carcinomas with a double
freeze-thaw cycle was reported and considered to be better than single freeze thaw cycle
 Time:2-3x30 sec with thawing period of 2 minutes for atleast 6 weeks
 Temp:-196oc

57. A 95.3% cure rate was achieved in the treatment of facial basal cell carcinomas with a double freeze-thaw cycle and a
cure rate of only 79.4% when facial lesions were treated with a single freeze-thaw cycle.

58. SQUAMOUS CELL CARCINOMA
 In situ squamous cell carcinoma have shown excellent results towards cryotherapy
 Well localized and well differentiate lesions of small diameter which has no lymphnode involvement
is the best candidate for cryiotherapy
 It is important to select proper patients for the therapy
 Can use open or spray method or probe method for the same
 The freeze should go atleast 1-1.5 cm beyond the visible margin of the lesion
 Always use 2-3 cycles of freeze thaw cycle
 TIME:2X45 Sec with 2-3 mints thawing time
 Temp:-1960c

61. CRYOTHERAPY CONTRAINDICATIONS
 Cold Hypersensitivity (Cold-induced Urticaria).
 Cold intolerance
 Cryoglobulinemia
 Paroxysmal cold hemoglobinuria
 Raynaud's disease or Raynaud's phenomenon

62. • Some individuals have a familial or acquired hypersensitivity to cold
that causes them to develop a vascular skin reaction in response to cold
exposure.
• This reaction is marked by the transient appearance of smooth, slightly
elevated patches, which are redder or more pale than the surrounding
skin and are often attended by severe itching.
• These symptoms can occur only in the area of application or all
over the body.
Cold Hypersensitivity (Cold-induced Urticaria)

64. Cold intolerance
 It is in the form of severe pain, numbness, and color
changes in to cold, can occur in patients with some
types of rheumatic diseases or following severe
accidental or surgical trauma to the digits

65. Cryoglobulinemia
 It is an uncommon disorder characterized by the aggregation of serum proteins in the
distal circulation when the distal extremities are cooled.
 These aggregating proteins from a precipitate or gel that can impair circulation,
causing local ischemia and then gangrene.
 This disorder may be idiopathic or may be associated with multiple myeloma,
systemic lupus erythematosus rheumatoid Arthritis , or other hyperglobulinemic
states.
 Therefore therapist should check with the referring physician before applying
cryotherapy to the distal extremities of any patient with these predisposing disorders.

66. Paroxysmal Cold hemoglobinuria
 It is the release of hemoglobin into the urine from lysed red blood cells
in response to local or general exposure to cold
Rash on lower extremities typical of cutaneous small-vessel
vasculitis dueto cryoglobulinemia secondary to hepatitis C infection

67. Raynaud’s Disease or Raynaud's phenomenon
 Raynaud’s Disease It is the primary or idiopathic form of paroxysmal digital cyanosis
 Raynaud's phenomenon, which is more common, is paroxysmal digital cyanosis due to some
other regional or systemic disorder.
 Both conditions are characterized by sudden pallor and cyanosis followed by redness of the skin
of the digits precipitated by cold or emotional upset and relieved by warmth
 These disorders occur primarily in young women
 In Raynaud's disease the symptoms are bilateral and symmetric even when cold is applied to
only one area
 In Raynaud's phenomenon, the symptoms generally occur only in the cooled extremity
 Raynaud's phenomenon may be associated with thoracic outlet syndrome, carpal tunnel
syndrome, or trauma.

69. Over a superficial main branch of a nerve
 Applying cold direcdy over the superficial main branch ofa nervemay causea
nerve conduction 5block.
 Therefore when applying cryotherapy to such an area, one should monitor
for signs of changes in nerve conduction, such as distal numbness or
tingling, and discontinue cryotherapy if these occur.

70. Over an open wound
 Cryotherapy should not be applied directly over any deep open wound, because it can delay
wound healing by reducing circulation and metabolic rate as Cryotherapy may be applied in
areas of superficial skindamage.
 however, it is important to realize that this can reduce the efficacy and safety of the
treatment because when there is superficial skin damage, the cutaneous thermal receptors
may also be damaged or absent.
 These receptors play a part in activating the vasoconstriction, pain control, and spasticity
reduction produced by cryotherapy; therefore, these responses are likely to be less pronounced
when cryotherapy is applied to areas with superficial skin damage, caution should also be used
if cryotherapy is applied to such areas because the absence of skin reduces the insulating
protection of the subcutaneous layers and increases the risk of excessivce cooling to these
tissues.

71.  Do you have any unsual responses to cold?
 If yes to this question, ask for further details. Includethe
 following questions:
 Do you develop a rash when cold?
 a sign of cold hypersesnsitivity
 Do you have severe pain, numbness and color changes in
 your fingers when expose to cold?
 Signs of Raynaud’s disease/phenomenon
 Do you get blood in your urine after being cold?
 A sign of paroxysmal coldhemoglobinuria
 If the responses are positive then cold should not be applied

72. Precautions
 Over the superficial main branch of a nerve
 Over an open wound
 Hypertension
 In patients with poor sensation or poor
mentation
 Very young and very old patients

73. ADVANTAGES
 • Short duration of surgery
 • Minimal operative and anesthesia trauma
 • Surgery without bleeding
 • Surgery without scar formation
 • Prevention of metastasis at time of excision of tumour
 • Surgically uncomplicated results, the high rate of curative success, short hospital stays, lower
hospital costs, as well as increased quality of life for the patient
 • Anesthesia is usually unnecessary, as the cold itself functions as an anesthetic
 • The period of convalescence is a fraction of that usual for stationary hospital admissions
 • No local complications stemming from the area of surgery
 • Quick and technically simple method of tumour removal
 • Both benign and malignant tumours are easily extirpated
 • Improved subjective state of the patient through palliative cryosurgical methods, lessening of pain
and fetor, as well as improvement in the general condition of the patient by containment of tumour
growth.

74. Complications of cryosurgery Immediate and common
Immediate and common
 • Pain during the freezing and thawing period
 • Blister formation
 • Intradermal hemorrhage
 • Edema
Immediate and less common
 • Headache affecting forehead, temples and
 scalp
 • Syncope
Delayed and rare
 • Postoperative infections
 • Hemorrhage from the wound site
 • Pyogenic granuloma
Prolonged and rare
• Hyperpigmentation
• Milia
• Hypertrophic scars
• Neuropathy
Permanent
• Hypopigmentation (common)
• Ectropion and notching of eyelids
• Notching and atrophy of tumors overlying cartilage
• Tenting or notching of the vermilion border of the upper lip
• Atrophy
• Alopecia

75. Disadvantage
 1. Healing is slow.
 2. In lesions of the tongue the procedure can limit its function.
 3. Volume of lesion can be beyond capacity
 4. Extensive lesions are difficult to treat.
 5. hypopigmentation

76. CONCLUSION
 Cryotherapby conducting more research based developments and advanesy by
virtue of its ability to deliver easy and effective treatment measures for the
common beningn and malignant lesions gained popuklarity in the dermatology
and oral maxillofacial lesions
 Utilizing the modility in appropriate way and conducting more researches to
produce more advances will help the clinicians and also the patients in a
great way

77. RECENT ADVANCES IN CRYOTHERAPY
 ENDOSCOPIC CRYOTHERAPY
 CRYOPEN

78.  CRYOABLATION

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