1.cryosurgery Clinical Applications in Otorhinolaryngology

CRYOSURGERY
Clinical Applications in Otorhinolaryngology

CRYOSURGERY
KK Desarda MS FACS DLO (London)

Head
Department of Otolaryngology
King Edward Memorial Hospital
Pune, Maharashtra, India
Professor Emeritus (Otolaryngology)
BJ Medical College, Pune, Maharashtra, India
Foreword
SK Kaluskar
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Cryosurgery: Clinical Applications in Otorhinolaryngology
First Edition: 2013

ISBN 978-93-5025-208-6
Printed at
Dedicated to
My wife Sheela
and
Daughters
Chetana and Shilpa
who made it all worthwhile
Foreword
The quest for developing new technologies by bioengineers has been continuing
and open-ended since early and mid-19th century in the field of ENT and
Head & Neck Surgery. As the various diagnostic tools were designed, hand-in-
hand on the desire of the surgeons to treat underlying pathologies became more
intense.
Among many discoveries of the new technologies by late 19th and early 20th
centuries to treat various conditions in the field of ENT, one of the most important
innovations of treating the cells by “cold application” was seens; but, unfortunately,
it went unnoticed by most of ENT surgeons. Very few surgeons really expressed
any interest, if any, in the science of treating a cell with freezing temperature!
I am indeed delighted to learn that Dr KK Desarda took special interest in this
somewhat forgotten modality to treat so many common conditions for the benefit
of our patients. Following the first-hand experience and training in England, Dr
Desarda showed complete dedication and passion to treat his patients with this
approach of cryosurgery; and, as a result, he gained vast experience in treating
patients with various pathologies in ENT and Head & Neck Surgery.
The book in ENT and Head & Neck Surgery is scrupulously researched and
very well written in a detailed, concise and easy-to-understand format for the
novice and advanced surgeons practicing ENT surgery.
The book is comprehensive, unfolding the history of cryosurgery to the results
of cryosurgery in an organized fashion. The history of cryosurgery is particularly
attention grabbing.
The chapter based on the Principles of Cryosurgery is particularly well elucidated.
Dr Desarda highlights the details of pathophysiological considerations in an
undemanding manner. His wealth of experience in this field is well documented
in Cryosurgery: Clinical Applications in Otorhinolaryngology and he emphasizes
on the importance of meticulous, atraumatic details of cryosurgical techniques
in different pathologies. The minimally invasive nature of the modality is well
illustrated including certain applications in the field of Rhinology and Head &
Neck pathologies.
Throughout the book, there are important tips and quips for the surgeons.
The advent of the book is a notable milestone in the various modalities available
for the ENT surgeons to treat their patients. He has highlighted the importance
of this modality in terms of minimally invasive and reduced morbidity for the
patients in ENT and Head & Neck Surgery.
SK Kaluskar MS FRCS DLO (England)

Consultant, ENT and Head & Neck Surgeon
Tyrone County Hospital, Omagh
Northern Ireland, United Kingdom
viii
Preface
Since my interest in cryosurgical applications in otolaryngology began in 1974,

when I had gained the most experience with cryosurgical procedures with
Dr Harold Holden, Consultant and ENT Surgeon, Metropolitan Hospital,
London, United Kingdom, who was the pioneer in cryosurgical applications in
Otolaryngology and Head & Neck surgery.
Since then, I had been practising wide spectrum of cryosurgical procedures
in otolaryngology. It was almost three decades (1978–2008). The cryosurgery
procedures were done at King Edward Memorial Hospital, Pune, Maharashtra,
India, and I was extremely happy with the results achieved in cryosurgical
procedures in my clinical practice.
Cryosurgery, as we know, has crawled since almost three decades; but, now
cryosurgery has made a rapid progress in recent years. It has revolutionalized
the management of certain pathologies like benign and early malignant lesions
of oral cavity, oropharynx, laryngopharynx and larynx with better disease-free
period and least functional disabilities postoperatively. Its role in palliation and
pain relief of advanced oncological lesions has proved its value for terminal care
patients.
In recent times, cryosurgery has become very popular like those of laser and
radiofrequency treatment, but still the utility of cryoequipment is not understood
completely by many of us and hence, this book is prepared for the postgraduates
and practising otolaryngologists to understand the principles of cryosurgery.
Cryosurgery is a surgical technique that employs freezing to destroy
undesirable tissue. It has recently incorporated new imaging technologies and a
fast-growing minimally invasive surgical technique. A historical review of the field
of cryosurgery is presented, showing how technological advances have affected
the development of cryosurgery in the field of Otolaryngology and Head & Neck
Surgery.
The book on the basic aspects of modern cryosurgery is the first subject of
otolaryngology prepared, covering the entire spectrum of cryosurgical procedures
in otolaryngology and it is aimed to be an important contribution to the further
development of this branch of medicine. It can be said now safely that cryosurgery
is and it can be an important supplement and adjunct to both surgical knife and
radiation therapy, as well as being a tool in its own right.
It has become apparent that cryosurgery is most useful in benign,

premalignant and malignant lesions (palliation). The treatment takes much less
time than other conventional methods of therapy. It is a day surgery procedure. Its
effectiveness in eliminating pain is extremely important for oncosurgical patients.
The basics of cryosurgery is a unique contribution in that, the book has
concentrated in one source the available scientific aspects of cryobiology, cryo-
engineering, cryomechanisms, and clinical applications of cryosurgical procedures
performed in the field of otolaryngology. The intent of the book is to cover the
entire spectrum of cryosurgery in Otolaryngology and Head & Neck Surgery.
With recent addition of angled endoscopes, the cryosurgery has proved
feasible for remote lesions in otolaryngology. It is our firm belief that cryosurgery
should be a part of the armamentarium of all practising Otolaryngologists and
Oncologists.
The photo gallery of interesting cases is also included in each chapter of
otorhinolaryngology which will guide the students and practitioners in comparing
before and after results.
I sincerely hope that the book will guide the interested otolaryngologists who
intend to perform cryosurgery in their day-to-day clinical practice.
KK Desarda
x
Acknowledgments
I would like to thank Medical Director, Academic Director, Research Director

and nursing staff of King Edward Memorial Hospital, Pune, Maharashtra, India,
for their kind cooperation and timely help in my endeavor to publish the book.
The gratitude I feel towards my teacher who can be hardly put it into words. It
is with this profound sense of gratitude that I thank Dr Harold Holden, Consultant
and ENT Surgeon at Metropolitan and Charing Cross Hospital, London, United
Kingdom, for exposing me to the wide spectrum of cryosurgery in Clinical
Otolaryngology and Head & Neck Surgery. I cannot forget to express my sincere
thanks to Dr DM Anklesaria, Consultant and ENT Surgeon, with his inspiration I
could complete this book.
I deeply appreciate the help given by Mrs Sadhana Lokare and Mr Rajesh
Jadhav, for their computer work during the preparation of the book. I would
like to thank Mr Ali, Clinical Photographer, for constant help in taking various
photographs for this clinical monograph. I would also like to thank our librarian
Vaishali Kulkarni for reference work required for the book.
A special mention must be made for the constant support and dedicated
assistance of my residents, who despite being busy, contributed in collecting the
clinical materials, cases and pre- and postoperative management of all patients
subjected for this study.
I extend sincere thanks to my department staff for their constant support and
timely help in the preparation of this book.
I thank the publishers M/s Jaypee Brothers Medical Publishers (P) Ltd, New
Delhi, India, for accepting this book for publication.
Last but not least, I sincerely thank all my patients subjected for cryosurgical
procedures, without whom the book would not have been completed.
Contents
1. Introduction 1
2. Historical Overview 3
First Use of Refrigerants 4
Liquid Air and Liquid Oxygen 4
Carbonic Acid Snow 4
Liquid Nitrogen 5
3. Cryopathophysiological Considerations 7
Cryobiology 7
Cryomechanism 7
Cryohistology 9
Cryoimmunology 10
4. Principles of Cryosurgery 11
5. Cryosurgery Considerations in Otorhinolaryngology 12
Instruments 12
Cryosurgery Indications 14
Technique and Procedure 16
6. Clinical Applications in Otorhinolaryngology 20

Cryofreezing in Otology 20
Keloids and Hypertrophic Scars 20
Basal Cell and Squamous Cell Carcinoma of Ear and Face 20
Basal Cell Carcinoma of Ear 21
Photo Gallery of Otology 21
Cryosurgery in Oropharynx 25
Photo Gallery of Oral Cavity and Oropharynx 29
Cryosurgery in Nose and Nasopharynx 35
Epistaxis 35
Anterior Nasal Bleed 35
Posterior Nasal Bleed 36
Hemorrhagic Telangiectasia 36
Nasopharyngeal Angiofibroma and Carcinoma 37
Nasal-Polyposis 37
Chronic Allergic Rhinitis 37
Hypertrophic Rhinitis 38
Chronic Vasomotor Rhinitis 38
Photo Gallery of Nasal Lesions 39
Cryofreezing in Laryngopharynx 43
Juvenile Papilloma of the Larynx 43
Supraglottic Cavernous Hemangioma 43

Hypopharynx and Cervical Esophagus 44
Carcinoma in situ and Malignant Conditions 44
Photo Gallery of Laryngeal Lesions 45
Special but Rare Procedures 48
Hypophysectomy 48
Meniere’s Disease 48
Glomus Jugularae Tumors 49
Cryosurgery—Postoperative Care 49
7. Cryosurgery—Results 50
Photo Gallery—Cryosurgery Results 52
Justification 58
8. Cryosurgery—Conclusion 59
Bibliography 61
Index 65
xiv
1
C HA P T E R
Introduction
INTRODUCTION
For centuries surgeons have searched for a technique which eliminates pain
and bleeding in surgical procedures and reduces postoperative morbidity.
Recent experience suggests that cryosurgery produces localized destruction of
tissue with little or no discomfort and bleeding during or after surgery.
The use of freezing temperatures for the therapeutic destruction of
tissue began in England in 1845 to 51 when James Arnott described the use
of iced salt solutions (about 20°C) to freeze advanced cancers in accessible
sites, producing reduction in tumor size and amelioration of pain. Improved
freezing techniques were possible early in the 1890s when solidified carbon
dioxide came into use and later when liquid nitrogen and nitrous oxide became
available. Nevertheless, cryotherapy was a minor technique, used only for the
accessible lesions of skin and mucosa.
With the development of modern cryosurgical apparatus by Cooper in
1961, a resurgence of interest in cryosurgery was initiated and techniques
for diverse clinical conditions, including visceral cancer, evolved, after the
initial widespread clinical trials matured in the 1970s, some applications of
the technique fell into disuse while others became standard treatment. Late
in the 1980s, further improvements in apparatus and imaging techniques
have permitted increased clinical use of cryosurgery in wide spectrum of
otorhinolaryngology including head and neck neoplasm.
Cryosurgery, sometimes referred to as cryotherapy or cryoablation, is a
surgical technique in which freezing is used to destroy undesirable tissues.
Although the prefix “cryo” (from the Greek word “kruos” for cold) usually
refers to temperatures below 120°C.
The controlled destruction of tissue by freezing is today widely practiced
in medicine. Terms for it include cryotherapy, cryocautery, cryocongelation
and cryogenic surgery, but cryosurgery (literally, cold handiwork) seems most
appropriate. Cryosurgery is a cheap, easy, and safe treatment suitable for both
hospital-and office-based practice. Its major advantage is excellent cosmetic
results with minimal scarring.
Cryosurgery is an important minimally invasive surgical technique. It can
be potentially applied to any procedure in which scalpels are used to remove
undesirable tissues. Currently cryosurgery is being used in many medical field,

such as dermatology, gynecology, urology, neurology, pulmonary medicine,
cardiology, oncology and many others. Cryosurgery is also used in veterinary
medicine. Imaging monitored cryosurgery has revived the field and numerous
new applications are continuously emerging. With new applications came
the need for better cryosurgical probes. New cryosurgical systems using
supercooled liquid nitrogen, Joule-Thomson refrigeration with gas mixtures,
closed cycle Stirling refrigeration. Since the advent of modern versatile
equipment, cryosurgery has become an accepted technique in a widerange of
situations. It is anticipated that cryosurgery will become a standard technique
in the minimally invasive surgery in the specialty of otorhinolaryngology.
2
2
C HA P T E R
Historical Overview
Cryosurgery is a surgical technique that employs freezing to destroy

undesirable tissue. Developed first in the middle of the 19th century it has
recently incorporated new imaging technologies and is becoming a fast
growing minimally invasive surgical technique. A historical review of the
field of cryosurgery is presented, showing how technological advances have
affected the history of cryosurgery.
Arnott (1797–1883), an English physician, published on the use of cold
between 1819 and 1879. He was the senior physician of Brighton Infirmary
but moved to London on winning fame. His brother, a scientist, had already
gained fame and fortune as inventor of the slow combustion stove. Arnott was
the first person to use extreme cold locally for the destruction of tissue. He
used a mixture of salt and crushed ice (two parts finely pounded ice and one
part of chloride of sodium) for palliation of tumors, with resultant reduction
of pain and local hemorrhage.
He stated that a very low temperature will arrest every inflammation which
is near enough to the surface to be accessible to its influence. He designed
his own equipment, consisting of a waterproof cushion applied to the skin,
two long flexible tubes to convey water to and from the affected part and a
reservoir for the ice/water mixture and a sump.
He exhibited this at the Great Exhibition of London in 1851 and won a prize
medal for his effort. (The Great Exhibition was a showcase for the Empire’s
scientific prowess not unlike the Millennium Dome but with considerably
more style).
Arnott treated breast cancer, uterine cancers and some skin cancers.
Although palliation was his main aim he recognized the potential of cold for
curing cancer, stating that the cases he had seen ‘are therefore, by no means
unfavorable to the supposition of the curability of cancer by congelation’.
He advocated cold treatment for acne, neuralgia and headaches, achieving
temperatures of –24°C. In addition he recognized the analgesic ‘benumbing’
effect of cold, recommending the use of cold to anesthetize skin before
operation. He was concerned about the safety of the new anesthetic agents
that were being introduced and advocated the use of cold as an alternative.
This was to become a lifelong crusade that was. Von Linde was responsible for
the first commercial production of liquid air in 1895, which led the way to its
widespread introduction. Ultimately unsuccessful, but his contribution to the

development of cryosurgery was crucial.
FIRST USE OF REFRIGERANTS

Salt/ice mixtures were not capable of reducing tissue temperatures sufficiently
to treat tumors effectively. It was not until refrigerants came into use that
lower tissue temperatures could be achieved. In the late 1800s, at a time of
tremendous scientific advance, there was an interest in liquefying gases.
Cailletet, on Christmas Eve 1877, demonstrated at the French Academy of
Science that oxygen and carbon monoxide could be liquefied under high
pressure. Pictet also demonstrated the liquefaction of oxygen but used a
mechanical refrigeration cascade.
LIQUID AIR AND LIQUID OXYGEN

Campbell White, of New York, was the first person to employ refrigerants for
medical use. He reported his success in 1899, advocating liquid air for the
treatment of a large range of conditions including lupus erythematosus, herpes
zoster, chancroid, nevi, warts, varicose leg ulcers, carbuncles and epitheliomas.
He recognized ‘the efficiency of liquid air in the treatment of carcinoma’ and
enthusiastically stated ‘I can truly say today that I believe that epithelioma,
treated early in its existence by liquid air, will always be cured’.
Whitehouse reviewed the effects of liquid air on normal skin, finding it to be
especially useful for epitheliomata, lupus erythematosus and vascular nevi. He
stated that liquid air out ranks some of the remedies on which we have placed
great reliance. He treated recurrences of epitheliomata after radiotherapy and
found liquid air to be more successful than repeat radiotherapy. Bowen and
Towle reported the successful use of liquid air for vascular lesions in 1907.
Liquid oxygen had a limited vogue in the 1920s and 1930s. It has similar
properties to liquid air, achieving temperatures of –182.9°C, but was chiefly
used for acne.
CARBONIC ACID SNOW

Around the time that liquid air was being investigated, William Pusey of
Chicago popularized the use of carbon dioxide snow (carbonic acid snow)
in preference to a salt and ice mixture. He advocated carbon dioxide snow
because of its easy availability (thanks to its use by manufacturers of mineral
waters). Liquid air was very difficult to obtain at this time. The liquid carbon
dioxide gas was supplied in steel cylinders under pressure.
4
Historical Overview
When the gas was allowed to escape, rapid expansion caused a fall in
temperature (the Joule–Thompson effect) and a fine snow was formed. The
snow was easily compressed into various shapes, known as pencils, suitable
for different treatments. Pusey’s first reported case was the treatment of a
large black hairy nevus on a young girl’s face. Impressive before-and-after
photographs showed the successful depigmentation of the lesion.
This was one of the first demonstrations of the extraordinary sensitivity
of melanocytes to cold. He successfully treated other nevi, warts and lupus
erythematosus. Pusey stated of carbon dioxide snow that ‘we have found a
destructive application whose action can be accurately gauged and is therefore
controllable’. He recognized the low scarring potential of cryosurgery although
he attributed this to regeneration of residual epidermal cells rather than to
collagen’s resistance to cold.
Hall-Edwards, of Birmingham, first described his carbon dioxide collection
model in The Lancet in 1911. Hall-Edward’s monograph, written later in 1913,
detailed the uses of carbon dioxide and methods of collection is contribution
to cryosurgery was all the more remarkable because he was a respected
radiotherapist in charge of much of the Midlands.
He would have been well aware of the place of cryosurgery in relation
to X-ray use. He detailed many conditions in which treatment was effective
but was particularly struck by its efficacy in rodent ulcers. At the same time
Cranston-Low, a physician in the Edinburgh skin department, was likewise
promoting the use of carbon dioxide snow. He observed that ‘thrombosis,
direct injury to tissues, and the inflammatory exudate probably all act together’
to produce the effects of freezing.
Solid carbon dioxide applied directly to the skin cannot get the surface
temperature below –79°C. This is insufficient for deeper freezing of tissue
necessary for treatment of malignancies, when a temperature of –50°C at a
tissue depth of 3 mm is required.
Nevertheless it proved very successful for a wide variety of benign skin
conditions and remained popular until the 1960s. Carbon dioxide slush,
a mixture of carbon dioxide and acetone, was used extensively for acne. As
the use of carbon dioxide snow became more widespread so did the range of
conditions treated. De Quervain reported the successful use of carbonic snow
for bladder papillomas and bladder cancers in 1917.
LIQUID NITROGEN
Allington is generally thought to have been first to use liquid nitrogen, in
1950. He recognized that the properties of liquid nitrogen were very similar
5
to those of liquid air and oxygen. After the Second World War, liquid nitrogen
became freely available and was preferable to liquid oxygen with its explosive
potential. He used a cotton swab for treating various benign lesions but poor
heat transfer between swab and skin meant this method was insufficient for
tumor treatment.
The contribution 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. With it
he treated Parkinson’s disease and other movement disorders by freezing the
thalamus, in addition to previously inoperable brain tumors.
Although Cooper was controversial in his lifetime because of his
showmanship, his work led to an explosion of interest in liquid nitrogen and
its eventual acceptance as a standard treatment in many specialties. More
general use of cryosurgery was facilitated by the development of devices
suitable for office-based practice.
Torre developed a liquid nitrogen spray in 1965 and Zacarian a hand-held
device, the Kryospray, in 1967. Zacarian popularized the use of this equipment.
Zacarian’s spray allowed one-handed operation with trigger type control, and
interchangeable tips permitted variations in spray diameter. Zacarian also
developed copper probes that allowed tissue-freezing to depths of up to 7 mm.
His contributions to cryosurgery equipment, understanding of the science of
the cryolesion and the published work on cryosurgery was very great.
Amoils developed a liquid nitrogen probe that achieved cooling by
expansion. He performed cataract extraction (cryoextraction) successfully but
cooling was slow and temperatures were not low enough for tumor work. This
system is still widely used in gynecology and ophthalmology.
The use of liquid nitrogen spread through different specialties. Rand
performed a transsphenoidal hypophysectomy with liquid nitrogen, Gage
treated oral cancers and Cahan performed cryosurgery of the uterus with a
liquid nitrogen probe.
The use of liquid nitrogen in Great Britain took off when Zacarian donated
the first hand-held liquid nitrogen spray to the Oxford dermatology department
in the 1970s. This center became the focus of cryosurgical research in Britain.
6
3
C HA P T E R
Cryopathophysiological
Considerations
CRYOBIOLOGY
The past 50 years have seen great advances in knowledge of the biological
effects of freezing. Almost all research has concerned the effects of liquid
nitrogen. The development of temperature probes that can be inserted into
skin has allowed measurement of tissue temperatures during freezing.
An accurate picture of the shape and depth of iceball formation with
different lengths of freeze has been built up, allowing development of guidelines
for freezing times (best established for cutaneous lesions). For malignant
lesions freezing times are longer than for benign lesions since destruction of
all malignant cells is vital.
Tissue temperatures must be below –50°C for adequate treatment of
tumors. A 30-second spot freeze, counted 30 seconds after an iceball formation,
is capable of achieving a tissue temperature of –50°C in the center of the iceball
and is usually the minimum time necessary for tumor work.
Other research has concentrated on determining the sensitivity of
individual cell types to freezing. Melanocytes are most sensitive, hence the
depigmentation of skin often seen after cutaneous cryosurgery. Collagen is
the most resilient tissue, and indeed preservation of the normal structure
of collagen bundles is observed on electron microscopy even after the deep
freezes necessary for tumor work. This explains why there is so little scarring.
Cartilage necrosis is extremely rare, so cryosurgery is particularly suitable in
otorhinolaryngological lesions.
Cryogens/Temperature (Degree C)
Liquid/20 (Cotton-wool bud)
Nitrogen/180 (Spray)/196 (Probe)
Carbon dioxide snow/78
Nitrous oxide/89 (Cryogun).
CRYOMECHANISM
Mechanism of Cell Death
Liquid nitrogen, which boils at –196°C (–320.8°F), is the most effective
cryogen for clinical use. It is particularly useful in the treatment of malignant
lesions. Temperatures of –25°C to –50°C (–13°F to –58°F) can be achieved
within 30 seconds if a sufficient amount of liquid nitrogen is applied by spray

or probe. Generally, destruction of benign lesions requires temperatures of
–20°C to –30°C (–4°F to –22°F). Effective removal of malignant tissue often
requires temperatures of –40°C to –50°C (–40°F to –58°F).
Nitrous oxide: It reaches a probe temperature of –89°C. It is readily
available and storable and easily applied, either through a probe or as a spray.
Whilst –20°C is adequate for the treatment of benign and more superficial
skin lesions, the subzero temperatures of –50°C are required for the treatment
of malignant lesions. Clearly, liquid nitrogen with its boiling point of –196°C
has the greatest “lethal” subzero temperature for tissue destruction and as it is
now readily available and relatively cheap, it is the cryogen of choice in both
primary and secondary care.
As the modern era of cryosurgery began in the mid 1960s, the basic
features of cryosurgical technique were established as rapid freezing, slow
thawing, and repetition of the freeze–thaw cycle. Since then, new applications
of cryosurgery have caused numerous investigations on the mechanism of
injury in cryosurgery with the intent to better define appropriate or optimal
temperature–time dosimetry of the freeze–thaw cycles.
A diversity of opinion has become evident on some aspects of technique,
but the basic tenets of cryosurgery remain unchanged. All the parts of the
freeze–thaw cycle can cause tissue injury. The cooling rate should be as fast as
possible, but it is not as critical as other factors. The coldest tissue temperature
is the prime factor in cell death and this should be −50°C in neoplastic tissue.
The optimal duration of freezing is not known, but prolonged freezing
increases tissue destruction. The thawing rate is a prime destructive factor and
it should be as slow as possible. Repetition of the freeze–thaw cycle is well
known to be an important factor in effective therapy.
A prime need in cryosurgical research is related to the periphery of the
cryosurgical lesion where some cells die and others live. Adjunctive therapy
should influence the fate of cells in this region and increase the efficacy of
cryosurgical technique. The fundamental principle governing cryodestructive
surgery is that living cells are at first injured and later, die from the effects of
freezing injury and that this change is uniform throughout the tissue involved.
The main mechanism in cryodestruction is related to the physical and
biological conditions of environmental cooling and thawing rather than
absolute temperature. Thus the mechanism of cryo leads to intracellular ice
crystal formation, extracellular ice crystals and subsequent intracellular
dehyderation and alteration of the membrane lipoproteins and direct cellular
inhibition. Of these, it is the formation of the ice crystals that is most favored
as the ultimate lethal effect causing cell death in cryolesion by the end of single
freez-thaw cycle.
8
Cryopathophysiological Considerations
The rupture of the cell membrane occurs, which follows intracellular

formation of ice crystals. The critical temperature for cell death is variable,
but lies between 0°C and –20°C (Fraser and Gill-1967), and majority of living
tissues subjected to a temperature of –20°C or below for longer than a minute
undergo cryogenic death. It is also important that the cycle of rapid freezing
and slow thawing should be repeated at least two or three times, particularly
when treating neoplastic tissue.
Clinically, after tissue has been treated with cryosurgery and the tissue
iceball has thawed out, the area appears the same as before treatment, but
gradually it becomes hyperemic and congested, and an inflammatory reaction
surrounds the treated area. After few days, definite necrosis is evident and a
slough forms. On separation of the slough, a clean granulating area is found,
which heals rapidly with a new epithelium without scarring or distortion.
Factors affecting the degree of cryonecrosis and size of cryolesion are,
probe temperature, size of probe tip, duration of the freez. Clearly the lower
the probe temperature and greater the size of the probe tip, the larger the
volume of cryo-freez tissue.
CRYOHISTOLOGY
Recognizable morphological changes can be seen immediately after freezing
and are easily recognized within 30 minutes after a return to normal ambient
temperature.The earliest changes consists of an area of an uniformly altered cells
sharply demarcated from the surrounding normal tissue, showing pyknotic
nuclei, edematous, coarsely granular and some times vacuolated cytoplasm
with slight disruption of the reticulin framework. Immediate fixation of the
frozen margin shows the familiar demarcating line, with typical ice crystal
spaces in the periphery of the lesions.Initially, there is no clear intermediate
zone but within 30 minutes, there is a distinct band, between 10 and 30 cells
broad,which separates the injured from the normal area.
Electron microscopy has added to our knowledge of the effects of very low
temperatures other than to confirm the light microscope findings and to allow a
more certain identification of small intranuclear ice crystals. It has also confirmed
the dramatic demarcation between totally injured and surviving cells. There are
nonspecific changes that affect the various cell membranes, and particularly the
plasma and nuclear membranes, and it has been suggested that the integrity of the
plasma membrane is the limiting factoring cell survival.
Repeated freez-thaw cycles produce a lesion with histological changes such
as nuclear pyknosis and chromatin clumping observed in a single freez lesion,
but in a more exaggerated fashion. Despite this “local homogenization” there
is a striking preservation of cellular detail at electron microscope level.
9
CRYOIMMUNOLOGY
Recent reports suggest that within a cryolesion tumor, destruction releases
either tissue proteins which acquire new antigenic properties or pre-existing
but unavailable antigens. The result is the creation of an autoimmune response
to the target tissue that is directly related to the freezing process.This release of
antigenic substance probably occurs during the relatively slow thawing period
rather than the preceding rapid freez and as such, differs from the effect of
other forms of tissue injury such as irradiation in which the potential antigenic
substance is simultaneously destroyed.
The first report of this antigenic response was made by Gonder and Soanes
who demonstrated tissue specific autoantibodies following cryocoagulation
which is clinically significant immune response against cryosurgically treated
tumors. On the other hand, should this phenomenon be substantiated its
potential application to cancer therapy would be a most exciting prospect.
Liquid gas circulated through closed system has been basis of many cryosurgical
units. Instruments were designed in which cooling process relied on “Joule-
Thompson” effect, which states that, when a compressed gas is allowed to
expand rapidly, a fall in temperature results. Cryoprobes work on the principle
of Joule-Thompson effect.
10
4
C HA P T E R
Principles of Cryosurgery
The fundamental effect of cryosurgery is based on in situ tissue destruction

using subzero temperatures. Cell death results from complex physiologic
mechanisms that rely on direct and indirect mechanical effects. These effects
include ice crystal formation and cellular anoxia during the frozen state,
followed by microvascular thrombosis. Experimental evidence also suggests
an adaptive immunologic tumor response in the postfrozen state. The
overall results are cell membrane destruction, enzyme denaturation, osmotic
dehydration, anoxia, and cellular necrosis.
The mechanism by which a cryogen destroys cells is complex. The formation
of a hemispherical iceball composed of thermogradients, each of which
maintains a temperature proportional to its distance from the application
point, initiates the cryoinjury. The cardinal rule of cryosurgery includes a
rapid freeze, which produces highly damaging intracellular ice formation
and closely-packed thermogradients, coupled with a slow thaw. Multiple
freeze/thaw cycles are most destructive, producing ischemic necrosis. Liquid
gas circulated through closed system has been basis of many cryosurgical
units. Instruments were designed in which cooling process relied on “Joule-
Thompson” effect, which states that, when a compressed gas is allowed to
expand rapidly, a fall in temperature results.
Cryoprobes work on the principle of Joule-Thompson effect which states
that cooling is produced when a rapidly expanding gas passes through a narrow
orifice a liquefied gas becomes gaseous at the tip of the probe. (Holden).
The basic features of cryosurgical technique were established as rapid
freezing-slow thawing and repetition of the freez-thaw cycle. Majority of living
tissues die on freezing below –20°C for longer than a minute. The thawing
rate is the prime destructive factor and should be as slow as possible. Nitrous
oxide gas is used in cryogun for freezing the various lesions. After freezing
the tissue, the normal appearance of tissue is regained as the ice crystals thaw
out leading to inflammatory reaction with ischemia and necrosis, follows the
slough formation. Within weeks time rapid healing occurs with formation of
new epithelium with minimum scarring or tissue distortion.
5
C HA P T E R
Cryosurgery Considerations
in Otorhinolaryngology
INSTRUMENTS (FIGS 5.1 TO 5.5)

1. Cryounit with cryogun mounted on Mayov’s trolley.
2. Nitrous oxide freshly filled cylinder.
3. Cryoprobes of different sizes.
4. Killian’s insulated nasal speculum set (right and left).
5. Tongue depressor, Freer’s septal elevators and nasal packing forceps,
suction cannulae, etc.
6. Dressing materials, K-Y jelly, micropore and septal splints.
7. Cidex tray for sterilization of cryoprobes.
Figure 5.1: Instrument for cryofreezing
Figure 5.2: Nitrous oxide cylinder with cryogun

Cryosurgery Considerations in Otorhinolaryngology
Figure 5.3: Nitrous oxide cryogun with instrument trolly
Figure 5.4: Picture of cryoprobes
Figure 5.5: Picture of cryoguns
13
CRYOSURGERY INDICATIONS
Otology
1. Aural cysts, dermoids, fibroma, keloids, papillomas.
2. Aural hematomas, hemangiomas, nevus warts.
3. Glomus tumor.
4. Meniere’s disease (selective cryofreezing).
5. Basal cell and squamous cell carcinoma of ear.
Oral Cavity
1. Tonsillitis and tonsil remnants, granular pharyngitis.
2. Epulis and papillomas, ranulas. Retension and mucous cysts, etc.
3. Palatal and cheek ulcers, papillary hyperplasia, vascular malformations.
4. Oral submucous fibrosis, hyperkeratosis and leukoplakia.
5. Cheek hemangiomas, lymphangiomas, leukoplakia.
6. Premalignant lesions.
7. Glossopharyngeal neuralgia.
Oropharyngolaryngeal Lesions
1. Premalignants and benign lesions of oropharynx.
2. Base tongue, pharyngeal and oral cavity tumors.
3. Cheek, tongue and tongue base lesions.
4. Postirradiated recurrences in oropharyngeal malignancy.
5. Granulomatous and hyperplastic lesions.
Rhinology
1. Vasomotor rhinitis, and chronic rhinitis.
2. Chronic hypertrophic turbinates.
3. Epistaxis and familial hemorrhagic telangiectasia.
4. Allergic rhinitis, noninfective rhinitis, and nasal polyposis.
5. Allergic polyposis–Ethmoidal.
6. Angiofibroma, hemangiomas, fibromas.
7. Papillomas, basal cell carcinoma of nose and face.
8. Post FESS recurrences.
Special Indications
1. Transnasal hypophysectomy.
2. Transnasal endoscopic vidian nerve cryofreezing.
3. Endoscopic cryofreezing of posterior epistaxsis.
4. Cryopalliation for head and neck malignancies.
5. Transtympanic cryofreezing of membranous labyrinth for Meniere’s disease.
14
Cryosurgery Advantages
1. Its office procedure.
2. No scar formation.
3. No primary bleeding (pre-and postcryo).
4. Palliation of painful neoplasms.
5. Well-accepted by elderly and debilitated patients.
6. No unpleasant odor of burning tissue (As in SMD).
7. Absence of scarring as associated with deep cautery.
8. Postcryo recovery is smooth.
9. No major complications encountered.
10. Most cost-effective as compared to laser or radiofrequency therapy.
Cryosurgery Disadvantages
1. Margins of the tumor cannot be made out.
2. Tissue not available for histopathology.
3. If biopsy is required, it must be done precryofreezing.
4. Depigmentation and loss of hair for skin lesions.
Cryosurgery Complications
1. No major complications are seen.
2. Infections (postcryo) rarely seen.
3. Bleeding during procedure if premature cryotip is withdrawn from tissue.
4. Intense headache is experienced.
5. Some times vasovagal attack is observed (xylocaine-reactions).
6. Hypopigmentation of skin.
7. Delayed healing.
Cryosurgery Morbidity
1. Pain for temporary period, relieved by analgesics.
2. Nasal obstruction and rhinorrhea lasting for one week.
3. Dental (incisors) paresthesia lasting for a month.
4. Healing takes two to three weeks.
5. Hospitalization for one day only.
Cryosurgery Economics
1. Low cost of equipment.
2. Low operating costs.
3. Minimal treatment time.
4. It is a day-procedure (office procedure).
5. Can be assisted with endoscopes.
6. Can be repeated any number of times if required.
15
Selection Criteria for Patients

1. Highly anxious patients.
2. Cosmatically inclined patients.
3. The formal excision surgery is refused.
4. High surgical risks patients.
5. Palliation for infiltrating cancer cases.
Cryosurgery–Investigations
1. Preoperative investigations are mandatory.
2. Routine lab work-up as hemogram, coagulation profile, BSL, urea
creatinine, etc.
3. Radiology and CT or MRI as indicated.
4. Medical and anesthetic fitness.
5. Briefing and consent for the procedures.
6. Preoperative antibiotics, anti-inflammatory and antihistaminics drugs are
given.
7. Xylocaine sensitivity test is must for all patients.
Precautions in Cryosurgery
1. Gas cylinders should not be stored at temperature above room temperature
(18–30°C) or near radiators, furnaces, or other heat supply.
2. Use only nitrous oxide gas cylinder.
3. Use presterilized cryoprobes (immersed in cidex tray).
4. Freezing-thaw cycles should be complete for required time duration.
5. Patients are warned not to blow nose too hard to avoid bleeding.
6. Nasal douches with normal saline are advised after one week to keep the
nasal cavity clean.
7. Patients should continue antibiotic therapy for full one week.
8. Patients are advised to keep the nasal splint for full 7 days to avoid synechiae
formation.
TECHNIQUE AND PROCEDURE

1. Operator should wear disposable protective plastic gloves (avoid any
possibility of cryogen contacting the skin of involved personnel).
2. General anesthesia is usually necessary for pediatric cases (to allow
accurate delivery of cryogen). But most of the cases are done under local
anesthesia with small sedation.
3. Remove the hairs from the area, wash and dry and apply a little paraffin
jelly or vaseline for improved initial adhesion.
16
4. If spray is to be used, mask off surrounding area with piece of plastic sheet,
or apply white petroleum, Styrofoam cups or X-ray film to prevent freezing
of underlying or adjacent tissue.
5. Large tumors are debulked as much as possible, prior to freezing to produce
a flat surface for easy contact freezing and to reduce the amount of tissue to
be frozen.
6. Select suitable probe needle for example, 10 or 20 mm diameter or spray
attachment depending on desirability.
Methods of Treatment
The dose of liquid nitrogen and the choice of delivery method depend on the
size, tissue type and depth of the lesion. The area of the body on which the
lesion is located and the required depth of freeze also should be considered.
Also the additional factors should be considered which include the thickness
of the tissue, the water content of the tissue and local blood flow.
The Cryofreeze-Spot Freeze

During a cryofreeze, a white “Ice field” is formed on the skin surface.
Histologically, the cryofreeze causes ischemia and necrosis by direct cellular
damage and whilst the degree of tissue damage is partly related to the length of
the freeze time employed, other factors play an important part. Different cells
and tissues have their own sensitivity to cold.
Cryoprobes
While the open spray technique can be used for the most easily accessible
lesions, a cryoprobe attached to the liquid nitrogen spray gun can provide
added versatility, depending on the site and type of the lesion. In this regard
various sizes and types of cryoprobes are available. The cryoprobe is applied
directly to the lesions. A gel interface medium often is used between the probe
and the skin surface. These are frequently used in the treatment of smaller
facial lesions, where scatter of liquid nitrogen is undesirable. Probes also are
useful in the management of vascular lesions where its pressure can be used
to remove blood from the tissues thus allowing more adequate treatment. The
tissue must be frozen to a temperature of –20°C to –30°C.
Preparation and Technique of Cryofreezing (Figs 5.6A and B)

1. Ten percent xylocaine spray in nasal cavity or any selected cryofreez area
15 minutes before cryoprocedure.
2. Observe absolute aseptic precautions in procedures to avoid postoperative
complications.
17
A B
Figures 5.6A and B: Instrument showing freezing tips; (A) Nitrous oxide cryojet;
(B) Nitrous oxide cryocan
3. Two percent xylocaine with Adrenaline 1;200000 cons.infiltration around

the lesion site.
4. Observe for xylocain shock reaction.
5. Nasal toilet with normal saline before cryo application.
6. Protect the septal mucosa from thermal injury released by cryounit, and
also prevent synechiae formation.The septal splints are routinely used in
our set-up.
7. Middle and inferior turbinates are out fractured by septal elevator to
accommodate the cryotip for freezing. Gross DNS needs septoplasty.
Presterilized cryotips are lubricated with K-Y jelly.
8. Moisture is absolutely essential for successful cryosurgery. After
thoroughly moistening the tissue, the tip must be placed on the tissue
before activating the probe. If the probe tip is applied cold, the efficiency
substantially reduces, due to an interface layer of soft ice crystals, which
serves as an insulator. Cryogun is applied as squeeze to freez and release
to defrost. Freez until iceball involves all tissue to be destroyed, plus 1
to 2 mm, into normal tissue. When freezing is complete as determined
visually, release the trigger to defrost.
9. Insulated probe stem will protect the near tissue from untoward freezing
and prevents accumulation of frost crystals. Pistol grip control gives
natural grasp of the probe tip for steady manipulation and unobstructed
visibility of the operated field.
18
10. The procedure is always repeated on both sides in allergic and vasomotor
rhinitis cases to achieve complete relief from the symptoms.
11. The most important step in cryoprocedure is not to withdraw cryoprobe
prematurely so as to avoid catastrophic bleeding from the lesion. Probe is
released only after complete defrost.
12. No major dressings are required apart from simple sterile tulle gras or
soframycin soaked dressing, or presterile avalon pack.
13. Simple micropore dressing is given which will absorb the excessive nasal
secretions.
Tissue Temperature Monitoring Techniques

Target tissue are two basic techniques for temperature determination, by
thermocouples and by visualization and palpation.
Thermocouples or pyrometers are the most accurate method of monitoring
tissue temperature. Two thermocouple needles are used to monitor the
temperature. The temperature sensitive device in the tip of each hypodermic
needle is placed at the periphery of the lesion and at the depth of the lesion.
Visualization and palpation: They make digital assessment of size and position
of the iceball. Only 75% of the visible iceball can be expected to slough.
Postoperative tissue changes: Immediately after freezing, the target area becomes
erythematous. Within the next three to four hours, there is considerable
swelling and edema which persists for 24 to 48 hours; this is attributed to
vascular stasis, thrombus and ischemia. There is also oozing of serum or blood.
If the target tissue was ulcerated before surgery or if the freeze was performed
on a biopsy site, hemorrhage may be a complication.
During the initial 24 to 48 hours, of postoperative period, a scab (Esher) is
formed which demarkes the necrotic tissue from the healthy tissue. Within the 10
to 14 days, the scab usually falls off, exposing granulation tissue. Epithelialization
and wound contraction progress rapidly and usually are completed by
postoperative day 21. Following a healing, into a depigmented area of alopecia
or white hair (if hair follicles survive) may be observed.
Factors affecting tissue susceptibility to cryonecrosis: Tissue temperature and
vascularity: if systemic body temperature and vascularity of the tissue is high;
it takes more time to freeze and thaw more rapidly. Whereas, high water
contents in the tissue facilitates freezing.
19
6
C HA P T E R
Clinical Applications in
Otorhinolaryngology
CRYOFREEZING IN OTOLOGY
Cryofreezing is very effective in lesions of external ear, particularly the pinna
and some part of external auditory canal, such as keloids, hemangioma,
papillomas, basal cell and squamous cell carcinoma. The postoperative results
are excellent and without tissue distortion. It does not cause any deformity.
The minimum two or three cryo-thaw cycles are required to complete the
procedure. All otological procedures are done under local anesthesia (Figs 6.1
to 6.10) .
KELOIDS AND HYPERTROPHIC SCARS

Cryosurgery treatment is very effective treatment for keloids. Here two
or three repeat cycles are used. The cryolesion is either infiltrated with 2%
xylocaine local anesthetic solution or the lesion can be sprayed with 10%
xylocaine spray which will act as surface anesthetic. Postoperative healing
is excellent and within 10 days the tissue is healed without tissue distortion.
(82%). Recurrences are treated by repeat cryofreezing and will need three to
five sittings.
BASAL CELL AND SQUAMOUS CELL CARCINOMA OF EAR AND FACE

About two-thirds of basal cell carcinomas occur on sun-exposed areas of the
body. One-third occurs on areas of the body that are not exposed to sunlight,
emphasizing the genetic susceptibility of basal cell cancer patients. Patients
present with a shiny, pearly nodule. However, superficial basal cell cancer
can present as a red patch like eczema. Infiltrative or morphea-form basal
cell cancers can present as a skin thickening or scar tissue-making diagnosis
difficult without using tactile sensation and a skin biopsy.
It is often difficult to distinguish basal cell cancer from acne scar, actinic
elastosis.To diagnose basal cell carcinomas, a skin biopsy is taken for histo-
pathological study. The most common method is a shave biopsy under local
anesthesia. Most nodular basal cell cancers can be diagnosed clinically,
however, other variants can be very difficult to distinguish from benign lesions
such as intradermal nevus, sebaceomas, fibrous papules, early acne scars, and
hypertrophic scarring.
BASAL CELL CARCINOMA OF EAR

The method of cryoradiotherapy allows to achieve a complete regression of
the tumor in cases of advanced form of basal cell carcinoma of head and neck
region, and to save local tissue with good esthetic and functional results. Basal
cell carcinoma is successfully treated by cryofreez technique. Basal cell tumors
that are small and locally malignant with distinct margins and are readily
accessible. The results are as good as radiotherapy and far less scarring is
caused than with surgical excision. In freezing the lesion 10% xylocaine spray
or local infiltration of 2% xylocaine is used as anesthetic agent.
It is very important to take precryofreez biopsy to confirm the diagnosis.
It is also very important to take care of normal tissue around the freezing site
to protect the normal tissue, particularly around the eye by tulle gras packing.
Freezing should include a 5 mm margin around the lesion. Freezing time
should be 2 to 3 minutes with nitrous oxide cryogun. A double freez cycle will
produce excellent results. There will be some edema of the soft tissues for two
or three days and some blistering of the lesion itself. Slough may form, but
the area quickly heals. Most basal cell carcinomas recur within 18 months so
follow-up is must in all cases under going cryotherapy.
PHOTO GALLERY OF OTOLOGY
Figure 6.1: Hemangioma of auricle
21
Figure 6.2: Keloid of pinna
Figure 6.3: Keloid of ear lobule
Figure 6.4: Keloid of pinna
22
Figure 6.5: Auricular hemangioma
Figure 6.6: Auricular hemangioma
Figure 6.7: Hemangioma of ear lobule
23
Figure 6.8: Glomus jugulare
Figure 6.9: Basal cell carcinoma of ear
Figure 6.10: Basal cell carcinoma of auricle
24
CRYOSURGERY IN OROPHARYNX (FIGS 6.11 TO 6.30)

Tonsillectomy
The following factors are important in assessing the suitability of the patient
for cryotonsillectomy.
The size of the tonsil: The small infected tonsil or infected tonsillar remnant
is an ideal lesion for cryotonsillectomy. The large tonsils causing obstructive
sleep apnea will need numerous repeat cryofreezing and hence will need
standard tonsillectomy procedure.
Age of the patient: The adult patient is most suitable because most of these
patients are treated as OPD basis under local anesthesia, and demand fairly
high degree of patient’s cooperation. In addition most children have large
bulky tonsils and also need an adenoidectomy under general anesthesia.
Hemorrhagic factors: The use of cryosurgery eliminates the risk of both primary
and reactionary hemorrhage. Patients of blood dyscrasias can be treated very
effectively such as telangiectasia hemorrhagica, (Osler disease).
The operation can usually be performed under local anesthetic, but general
anesthesia is preferred for uncooperative patients. A dose of atropine about 30
minutes preoperatively will prevent hypersalivation.
Ten percent xylocaine spray is used along with 2% xylocaine and adrenaline
(1:200000) concentration. Infiltration into the tonsillar area. Then the tonsillar
cryoprobe is applied to upper and lower poles of each tonsil and administer
two freez-thaw cycles, of 3 to 5 minutes duration.
Postoperative pain is also less and necrotic tissue gradually separates in
ten days time. Postoperative antibiotic along with analgesics and mouthwash
are prescribed for ten days. The only disadvantage is it is time consuming and
hence the procedure is rarely advised. Tonsil remnants are the ideal cases for
cryofreezing with excellent results.
Adenoidectomy
Since the adenoid is not accessible for cryoprobe application. A special
adenoid probe is required for the procedure. This can be done effectively but
since it is very time consuming and is less reliable than a conventional adeno-
tonsillectomy. Cryoadenoidectomy is unlikely ever to replace the conventional
curettage technique. Now special adenoid debriders are available, but its very
costly for general hospital patients. We feel the standard good old technique
of adenoid curettage is still the best technique used all over world. We do not
recommended cryosurgery for this indication.
25
Infected Lymphoid Hyperplasia

Cryosurgery is of particular value in destroying nonencapsulated masses of
infected lymphoid tissue in the region of lingual tonsils, lateral pharyngeal
bands, and granular pharyngitis of posterior pharyngeal wall. In this the
cryoprobe of small diameter (3 mm) is applied to the hypertrophied lymphoid
tissues for 2 to 3 minutes at each site with 2 to 3 freez-thaw cycles. The
postoperative care is as tonsillectomy. The tissue heals within 7 days time
without scarring and distortion.
Glossopharyngeal Neuralgias
In 1946 Wilson and McAlpine described the operation for glossopharyngeal
neuralgias by dividing the nerve in the tonsillar fossa. It is difficult to identify
the nerve because of fibrosis following tonsillectomy. It is much easier and
equally effective to destroy the nerve by the application of cryosurgical probe
to the lower half of the tonsil fossa. The actual exposure of the nerve through
the muscular fibers is unnecessary.
The cryoprobe of oval shape is applied to the anticipated course of the nerve
in lower pole of the tonsil. Two freez–thaw cycles of five minutes duration are
usually necessary. In cases of recurrence a second application may be required
Although, results are excellent, but unpredictable.
Leukoplakia
Oral leukoplakia was predominantly seen in elderly age group. Addiction to
tobacco was observed in majority of patients (80.8%). Clinically commonest
site of involvement was buccal mucosa (67.33%), followed by labial mucosa
(13.86%). Majority of patients (57.35%) were having homogenous type of
leukoplakia, followed by verrucous variety (25%). 26 to 48% cases were
also having oral submucous fibrosis. Histologically various combinations of
hyperkeratosis, hyperorthokeratosis and acanthosis were observed in 77.93%
of cases. Dysplastic lesions were reported in 17.65% cases. In 80% of dysplastic
lesions, band-like infiltrate of mononuclear cells in subepithelial zone was seen.
Malignant transformation was noticed in 2.94% cases. Excellent therapeutic
results were obtained by cryosurgery. In resistant cases good results were
observed with high dosage of vitamin A.
Cryosurgery is an ideal form of treatment for areas of leukoplakia in the
mouth and buccal cavity. The procedure is done on OPD basis under local
anesthetic infiltration or spray. Areas of leukoplakia are treated in parts rather
than attempting to freez a large surface area at one attempt. The flat cryoprobe
of nitrous oxide is applied to the lesion and two to three freez-thaw cycles of
five minutes are used. Freezing of deeper layers is not necessary. It is painless
26
with minimal inflammatory reaction and subsides in two to three days with
excellent slough. The healing is excellent without distortion of mucosa. It is
advisable to excise the leukoplakic patch for frozen section if malignancy is
suspected.
Oral Ulcerations
Cryosurgery is successfully used for many oral conditions. Cryoprobe have
been used alone or associated with other surgical methods in various types
of oral lesions, such as pyogenic granuloma, angioma, actinic cheilitis,
keratoacanthoma, fibroma, HPV lesions in HIV and non-HIV patients,
hypertrophic lichen planus, leukoplakia and erythroplakia, verrucous
carcinoma, mucous cysts, and papillary hyperplasia of the palate, among others.
All procedures of oral cavity are performed under 10% xylocaine spray or
2% xylocaine with 1:200000 adrenaline infiltration. The lesions are infiltrated
all around the tissue and then cryofreez-thaw cycles are repeated for 3 to 5
minutes. The results are excellent without any distortion of oral mucosa. Our
experience and review of literature have shown that cryosurgery is a very
useful technique for treatment of oral lesions. The tissue healing is fast (within
a week).
The oral mucosa because of its characteristics of humidity and smoothness,
is an ideal site for this technique. It shows a very good esthetic result and
it may be either the first choice or an alternative option to conventional
surgery. Cryosurgery is a very safe, easy to perform, and relatively inexpensive
technique for treating various oral lesions in an outpatient clinic.
Lichen Planus
Lichen Planus: This condition presents as a white lace-like pattern on the
inside of the cheeks. It can be confused with many other conditions and
evaluation by a physician is mandatory to make sure other serious problems
are not present. Often the condition is caused by a reaction to medications.
Beta blockers and oral hypoglycemics are the most common offending
medications. Lichen planus can also be associated with other conditions such
as Hepatitis C. Treatment is with oral prednisone (5 mg/5 cc) rinses, mixed
(1:1) with kopectate to allow the medication to stick to the oral mucosa. The
cryofreez-thaw cycles are applied for the lesions. The results are excellent and
the mucosa appears normal after a week without ant scarning.
Lingual Cavernous Hemangioma

Lingual cavernous hemangioma—This is a benign lesion but one which is very
hard to treat. Surgery is difficult. Angiography is often needed to outline the
feeding vessels.
27
Hemangiomas
The oral or pharyngeal hemangioma has an older age at diagnosis than lesions
from other sites. In adults, the mucosal hemangioma most often arises from
the frequently traumatized mucosal sites: the lip mucosa (63% of oral cases),
the buccal mucosa (14% of cases) and the lateral borders of the tongue (14%
of cases), but it may occur at any oral or pharyngeal location. In population
studies there is a strong (2:1) male predilection, although there is minimal
gender predilection in hospital-based studies. Congenital and neonatal lesions
do occur, especially in the lips and parotid glands.
The mucosal hemangioma is typically a soft, moderately well-circumscribed,
painless mass which is red or blue in coloration. The more superficial ones are
often lobulated and will blanch under finger pressure. Deeper lesions tend to
be dome-shaped with normal or blue surface coloration; they seldom blanch.
A lesion with a thrill or bruit, or with an obviously warmer surface, is most
likely a special vascular malformation, called arteriovenous hemangioma
(arteriovenous aneurysm, A-V shunt, arteriovenous malformation), with
direct flow of blood from the venous to the arterial system, bypassing the
capillary beds.
The lesion is usually less than 2 cm in greatest dimension, but may be so
extensive as to encompass much of the oral/pharyngeal tissues. Congenital
lesions tend to keep pace with body growth, while adult-onset lesions tend to
slowly enlarge over a period of months or years. The preoperative embolization
must be done before cryofreezing therapy is applied. The postoperative results
are excellent. Most congenital capillary hemangiomas will spontaneously
regress or disappear by the fifth or sixth years of life.
Lymphangiomas
These lesions are usually present at birth and occur most commonly in the
mouth, neck, axilla, etc. Surgical excision is always difficult because these
cystic lesions frequently invest and mingle with nerves, blood vessels and
muscles. They can be large and multiple in nature.
The aspirations and injecting sclerosing fluids are far from satisfactory.
Cryosurgery is probably the best answer to this problem. The 10% xylocaine
spray is used for surface anesthesia. The flat cryoprobes lubricated with K-Y
jelly are applied to the localized lymphangiomatous lesions and 2 to 3 freez-
thaw cycle are repeated for 3 to 5 minutes. The results are very gratifying with
no morbidity. The recurrences are treated by repeat cryoapplications.
28
PHOTO GALLERY OF ORAL CAVITY AND OROPHARYNX
Figure 6.11: Cryofreezing of mucous cyst of tongue
Figure 6.12: Cryofreezing of fungal ulcers of tongue
Figure 6.13: Cancer of tongue
29
Figure 6.14: Stomatitis
Figure 6.15: Ulcers of tongue
Figure 6.16: Leukoplakia—cheek
30
Figure 6.17: Lingual cavernous hemangioma
Figure 6.18: Cryofreezing of hemangioma of tongue
Figure 6.19: Cryofreezing of ranula of tongue
31
Figure 6.20: Deep ulcer of tongue
Figure 6.21: Cryofreezing of leukoplakia of tongue
Figure 6.22: Mucous cyst of lower lip
32
Figure 6.23: Retension cyst of lower lip
Figure 6.24: Deep ulcer of soft palate
Figure 6.25: Ranula of the tongue
33
Figure 6.26: Tongue fibroma
Figure 6.27: Tongue hemangioma
Figure 6.28: Bilateral tongue hemangioma
34
Figure 6.29: Cheek fibroma
Figure 6.30: Lingual–hemangioma
CRYOSURGERY IN NOSE AND NASOPHARYNX (FIGS 6.31 TO 6.40)

EPISTAXIS
ANTERIOR NASAL BLEED
Most of the anterior nose bleeds from the septum and turbinates are treated by
applying flat cryoprobe of 3 to 4 mm size to bleeding sites which usually stops
in a short time. The little’s area bleed could be treated by applying the flat probe
covering the complete bleeding zone and two freez-thaw cycles are given for
2 to 3 minutes. This procedure is commonly done under 10% xylocaine spray,
and there is no need for any nasal pack apart from a sterile cotton wool or
small soframycin dressing. The supportive antibiotics, antihistaminics, and
anti-inflammatory therapy is prescribed for 10 days.
35
POSTERIOR NASAL BLEED

This is treated either by endonasal or endoscopic procedure under local
or general anesthesia. A prior nasal endoscopy is performed to locate the
bleeding site which most of the time will be from sphenopalatine artery or
posterior ethmoidal arcade. The bleeding is controlled by applying the angled
cryoprobes and 2 to 3 freez-thaw cycles are given to arrest the bleeding points.
Nasal cavity is packed with BIPP or avalon pack. Sometimes you may need
anterior and postnasal packing. Postoperative care is as general management
of nasal surgery. Postoperative check nasal endoscopy is mandatory.
HEMORRHAGIC TELANGIECTASIA
Hereditary hemorrhagic telangiectasia (HHT) or Rendu-Osler-Weber disease
is a genetic disorder with a dominant autosomic transmission. Its prevalence
is estimated in one in 5 to 8,000 individuals. Two different mutations have
been described involving endoglin and ALK-1 genes, resulting in HHT type
1 and 2 respectively. It is characterized by the occurrence of spontaneous
and recurrent episodes of epistaxis. Telangiectasia shows the presence of
arteriovenous malformations mainly affecting nasal mucous membrane
involving septum, turbinates and lateral nasal wall, tongue and oral mucosa
which are responsible for the clinical manifestations of intractable bleed.
This condition can be treated under local 10% xylocaine spray or under
general anesthesia. Familial hemorrhagic telangiectasia (Osler disease) can be
treated by cryoapplications for 3 to 5 minutes at each sites covering the bleeding
zone on the septum,turbinates and lateral wall of the nose. The cryoprobe size
should be 3 to 6 mm and freez-thaw cycles of 3 to 5 minutes are used. Most of
the time this treatment will control the bleeding.
The results are extremely satisfactory. Great care is taken to ensure that
the cryoprobe is not withdrawn until the reheat mechanism has thawed the
tip. The avulsion of iceball by premature withdrawal may cause catastrophic
hemorrhage. In cases of recurrence, the septo-dermography procedure is
advisable. Bleeding from the choana is treated by curved nasal cryoprobes.
There is no contraindication to repeat cryoprocedures in this condition.
Postcryofreezing, the nasal and oral mucosa regains its normal physiological
integrity without distortion. In treating small angiomas, over the septum or
lateral nasal wall, or turbinates and oral mucosa cryoprobes of suitable size
(2 to 3 mm) are used. The larger angiomata in the anterior nasal passages
are occasionally the cause of profuse epistaxis. The bleeding surfaces of these
lesions may be frozen with extremely good results. The rhinosporidiosis is
another bleeding disorder which can be effectively treated by cryosurgery with
two or three repeat cycles.
36
NASOPHARYNGEAL ANGIOFIBROMA AND CARCINOMA

Cryosurgery is particularly useful in nasopharyngeal carcinoma as there is
no other effective form of treatment for recurrent or persistent growths after
a maximum dose of irradiation therapy has been administered. Combined
cryoradiation treatment is beneficial for carcinoma of nasopharynx which is
clinically proved.
Juvenile angiofibroma of the nasopharynx are also excellent targets for
cryosurgery. Small lesions may be frozen completely and allowed to regress.
In larger or more extensive lesions, cryotherapy will control the hemorrhage
during the surgical excision or deal with remnants or recurrence later.
The vascularity, size and site of these lesions varies greatly. Cryosurgery
offers no advantage over conventional resective surgery. As an adjunct it is
invaluable. The frozen fragments may be resected piecemeal with marked
reduction in bleeding. In irradiated cases of nasopharyngeal carcinomas the
residual masses can be treated by cryoapplications effectively by two freez
–thaw cycles. The angled endoscopes is a great advantage in treating the
residual masses with cryoprobe applications. The tumor mass may be treated
with several stages. A special curved nasal cryoprobes are used for the freezing
procedure. It is absolutely mandatory to have preoperative embolization which
will assist in controlling hemorrhage, and better clearance.
NASAL-POLYPOSIS
Nasal polypi are avascular structures with a narrow pedicle and are therefore
vulnerable to freezing. The cryoprobe of 3 to 5 mm size are used to freez the
poypi which will go in cryonecrosis. Gross polypi can be effectively frozen only
in stages and thus will need several repeat procedures. The most important of
these are ethmoidal polypi which frequently recur after FESS surgery, even
if the debrider is used. Cryonecrosis technique is preferable when freezing
localized polypoidal bed or tags. The procedure is performed under local
anesthesia with general cryoprobes. The pedicles should be given two freez-
thaw cycles for 3 to 5 minutes. The rilastic septal splints are kept in the nasal
cavity for a week to prevent adhesions or synechiae. The healing following
cryofreezing is excellent.
CHRONIC ALLERGIC RHINITIS

Nasal allergy is a common problem difficult to treat. Most of the chronic
patients feel frustration even after completing all conventional modalities of
treatment. We have used cryosurgery as an alternative mode of treatment for
providing the excellent relief with regards to this disease. Cryosurgery basically
37
freezes and debulks the hypertrophied inferior turbinates as well as destroys

the autonomic innervation, by a cryoprobe at 90°C.
This study comprises 180 patients of allergic rhinitis. The patients were
followed up for an average period of 6 to 9 months and the response was evaluated
in terms of relief in three basic clinical presentation namely rhinorrhea, nasal-
obstruction and sneezing. Complete cure was obtained in 86% cases.
HYPERTROPHIC RHINITIS
The cryosurgical flat probe used to reduce the bulk of turbinates in cases of
hypertrophic rhinitis, either allergic or nonspecific types. The turbinate is
infiltrated with 2% xylocaine solution from anterior to posterior ends. A flat
cryoprobe is applied to the turbinate for 5 minutes each on either sides and
2 to 3 freez-thaw cycles are used. During the procedure intense headache is
experienced but it could be relieved by simple analgesics. Tissue ischemia and
necrosis takes place in about 7 days time and the turbinate will shrunk in its
size which will improve the nasal airways. The results are extremely good.
Our results show that the cryoturbinectomy is the best method of treatment
because it most effectively maintains satisfactory nasal physiologic integrity
without damaging nasal mucosa or underlying nerves.
CHRONIC VASOMOTOR RHINITIS

This cryotherapy technique provides significantly improved results in the
treatment of chronic vasomotor rhinitis when proper patient selection and
technique are utilized.
This is the most gratifying procedure for chronic VMR and best treated
transnasally or endoscopically. Here the main site is sphenopalatine ganglion.
The cryoprobe is applied to posterior end of middle turbinate for 1 to 2 minutes
on either sides. The septal mucosa is protected by septal splints or rilastic sheets.
Immediately after the procedure the tissue becomes hyperemic and edematous
causing more nasal obstruction than before, but this is a temporary phase.
Clinical experience with a newly designed device for cryosurgery on
autonomic nerves in cases of vasomotor rhinitis is reported. The device
consists of a handy cryogun of nitrous oxide gas and a slender probe 2.5 mm
in diameter. The posterior nasal branches of the pterygopalatine ganglion were
destroyed by freezing for 3 to 5 minutes with a jet of supercooled nitrogen gas
delivered by cryogun onto the pterygopalatine foramen under 10% xylocaine
spray anesthesia. Satisfactory results were obtained by this procedure in 102
cases of vasomotor rhinitis which have failed to respond to antihistaminics.
This original technique of cryosurgery which is not time-consuming and can
be performed as a day procedure, will prove useful in clinical practice. This
38
procedure (vidian nerve cryosurgery) is based on the fact that the autonomic
nerve supply to the nasal cavity is through sympathetic and parasympathetic
fibers, carried by the vidian nerve.
The vasomotor instability is manifested mainly by rhinorrhea, sneezing,
nasal obstruction and headache which is attributed to the overactivity of
sympathetic and parasympathetic of autonomic system. The target of vidian
nerve is always the superior turbinate which acts as a pointer to sphenopalatine
foramen, which is frozen for three to five minutes by cryogen.
All patients were instructed that they will have excessive lacrimation
and nasal obstruction for first 24 to 48 hrs. This is because of excessive
overactivity of the seromucinous glands. The healing takes place within two
to three weeks with minimal fibrosis, less scarring, than with either linear
cautery or submucosal diathermy. Results are extremely good with regard to
improvement of airway, rhinorrhea, sneezing and nasal obstruction. All three
components of VMR are best treated by cryofreezing with encouraging results.
Complete relief is obtained after six weeks. Although, results are encouraging,
reduction of rhinorrhea occurs after about three weeks but the procedure may
offer relief for months only rather than years, as the nerves can regenerate and
hence repeat cryofreezing is recommended for chronic VMR cases.
Verrucous Vulgaris
Verrucous vulgaris is a wart which is on the inside of the nose. This is a skin
growth which is caused by a virus. In this case, it may have been implanted in
the nose by nose picking. The ideal treatment is cryofreezing with two rapid
thaw cycles for 2 to 3 minutes. The complete resolution of the lesion is seen in
six weeks. No postoperative scarring is seen.
PHOTO GALLERY OF NASAL LESIONS
Figure 6.31: Basal cell carcinoma of nose

39
Figure 6.32: Cryofreezing of hemangioma of septum
Figure 6.33: Cryofreezing of middle and inferior turbinates
40
Figure 6.34: Chronic rhinitis
Figure 6.35: Anterior epistaxis
Figure 6.36: Anterior epistaxis

41
Figure 6.37: Posterior epistaxis
Figure 6.38: Hemangioma of septum
Figure 6.39: Squamous papilloma of nasal septum

42
Figure 6.40: Verrucous vualgaris
CRYOFREEZING IN LARYNGOPHARYNX (FIGS 6.41 TO 6.49)

JUVENILE PAPILLOMA OF THE LARYNX
Cryosurgery offers excellent treatment for juvenile papillomas of larynx
without postoperative scarring in surrounding tissues. Multiple papillomas
are frozen by special microlaryngeal round cryotips for 2 to 3 minutes and
freez-thaw cycles repeated all over the laryngeal lesions. The healing takes
place in 4 to 6 weeks time without scarring.
It has distinct advantage that lesions of both cords can be treated
simultaneously without danger of glottic web forming. A tracheostomy is
essential as there may be considerable postoperative edema and cosquent
formation of slough. An appropriately shaped cryoprobe is applied either
endoscopically or through tracheostomy opening. Several applications of
5 minutes duration are required to freez the multiple papillomas of larynx.
Recurrences are treated with repeat cryofreezing.
SUPRAGLOTTIC CAVERNOUS HEMANGIOMA

Cryosurgery is gaining more and more importance as a therapeutic modality
within the field of head and neck surgery. It has been used effectively in the
treatment of cavernous hemangiomas of the skin and oral cavity. Supraglottic
cavernous hemangiomas present a challenge in management when surgical
intervention is indicated. The results of cryosurgery in the treatment of such
a lesion are excellent. This treatment will require 3 to 5 sittings of cryofreez.
43
HYPOPHARYNX AND CERVICAL ESOPHAGUS

In these situations treatment of malignancies by cryosurgery is purely palliative
and should be restricted to inoperable growths, provided adequate freezing is
achieved which will improve dysphagia to some extent.
Freezing is done endoscopically, the long laryngeal nitrous oxide cryo
probes are used to freez the malignant tissue for 5 to 7 minutes duration and
should be repeated two or three times. During this treatment a nasogastric
tube is insereted for few days to allow adequate nutrition and also allow
superficial slough to clear. This may need 3 to 4 repeat cryocycles of 5 minutes.
CARCINOMA IN SITU AND MALIGNANT CONDITIONS

Freezing for a suspected carcinoma in situ is ideal in many situations. It allows
adequate biopsy to be taken with full treatment of the lesion at the same time,
and does not preclude formal surgical measures or radiotherapy at a later
stage. Freez must extend beyond the margin of the lesion for 1 to 2 cm and
a biopsy- excision of the frozen tissue is performed. The area will require two
freez applications of 3 to 5 minutes duration.
Various types of equipment and probes are commercially available for
cryosurgery, but it was only after the development of reliable, versatile
cryosurgical systems cooled by liquid nitrogen that numerous applications
for cryosurgery were proposed, including therapy for cancer. In the treatment
of cancer, clinical success with cryosurgery has led to the more widespread
application of this modality in selected patients.
Cryosurgery has been used for readily accessible lesions in specific anatomic
areas, most frequently the skin and oral cavity. It is an attractive alternative
to extirpative surgery, particularly in the head and neck, where removal of
large portions of the mandible or maxilla are often required to control cancer.
Therefore, it is not surprising that many of the pioneering efforts in the
treatment of cancer have been conducted by otorhinolaryngologists.
The full theoretic potential of cryotherapy was somewhat slow to be realized
because many early endeavors were directed toward palliation, especially of
accessible tumors of the skin and oral cavity, after failure of tumor control by
radiation or surgery or both. This limited application during the early period
of evaluation reflected a naturally timorous course that was taken by those
who introduced the new modality into clinical practice.
This period paralleled the development of new apparatus, early clinical
trials, and the assessment of the clinical potential of cryosurgery in patients
with incurable cancer-those whose conditions were deemed hopeless. Today,
cryosurgery is selectively applied for the treatment of patients with tumors
44
PHOTO GALLERY OF LARYNGEAL LESIONS
Figure 6.41: Hemangiomatous polyp of left vocal cord
Figure 6.42: Anterior commissure polyp
Figure 6.43: Bilateral vocal nodules

45
Figure 6.44: Intubation granuloma
Figure 6.45: Extensive papilloma larynx
Figure 6.46: Synechiae of vocal cords
46
Figure 6.47: Keratosis of vocal cord
Figure 6.48: Carcinoma of vocal cord
Figure 6.49: Carcinoma of anterior commissure and vocal cords

47
involving structures such as bone, oropharyngeal mucosa, temporal bone,

skin, brain, and tracheobronchial tree.
The majority of malignant conditions suitable for cryosurgery are those in
which more formal measures have failed or when palliation only is required.
Many are squamous cell carcinomas that have persisted or recurred and they
are often in fungating state.The use of cryosurgery in these instances is not
to effect cure but to obtain adequate regression of fungating lesions to lessen
the secondary infection, allevating pain, and in some situations, to improve
function.
A multiple-pointed probes that can be pressed into the lesion is somewhat
better than the blunt contact probe. Two applications of 3 to 5 minutes are
given or a single freez of 5 to 7 minutes is equally effective. For best results
the temperature of the tumor tissue must be lower than –20°C and as a rough
guide, the thermocouple temperature should be less than –40°C.
SPECIAL BUT RARE PROCEDURES

HYPOPHYSECTOMY
Hypophysectomy can be done by transsphenoidal route and curved nasal
cryoprobe is applied for 2 minutes and thus gland is frozen. Here the cavernous
sinuses on either side act as good thermal insulator against the brain tissue
being frozen. This procedure is now rarely performed since endoscopic
surgery is more precise and effective.
MENIERE’S DISEASE
The rational of cryosurgery in Meniere’s disease is to create a periotic-
endolymphatic shunt, allowing endolymph to seep into the perilymphatic
fluid space as the endolymphatic pressures are raised.
The cryoprobe is applied either to thinned bone over the surface of the
promontory or thinned bone overlying the horizontal semicircular canal and
membranous labyrinth is thus frozen. Long-term results are as variable as
other forms of treatment for Meniere’s disease.
The postsurgical rate of decline in semicircular canal function was found to
be directly related to the temperature and exposure time employed. For a given
exposure time, decreasing cryosurgical temperatures provided loss of function
in fewer days. When temperature was held constant, increases in duration of
cryosurgical application produced a more rapid decline in semicircular canal
function.
48
Cooling the horizontal crista to –90°C produced partial degeneration of

the specialized cells and the sensory-epithelium. The membranous wall of the
horizontal canal was ruptured and the cupula detached.
The above procedures is not done routinely but may be considered as a
form of treatment.
GLOMUS JUGULARAE TUMORS

It has been suggested that cryosurgery is the treatment of choice for these
lesions and certainly, like all benign vascular tumors, they regress very readily
after adequate freezing.The lesion can be approached by tympanotomy or
trans-mastoid route. The cryoprobe of 2 mm diameter is applied to the glomus
tumor for 2 to 3 minutes by freez-thaw cycle and application is repeated
at least twice. Great care is taken not to move the probe during freezing which
could traumatize the lesion or surrounding area. There may be temporary
transient vertigo and facial weakness which can be treated with steroids and
antivertigo therapy. Excessive freezing of the tympanic membrane could lead
to a perforation, needing secondary grafting.
CRYOSURGERY—POSTOPERATIVE CARE
Immediately following cryofreezing, patients will experience intense headache
and watering from eyes. The simple analgesics will relieve the pain. All patients
undergoing nasal cryofreezing are instructed not to blow their nose too hard
and too frequently, since intense freezing will lead to excessive nasal discharge.
Next 3 to 4 days nasal cavity will remain more blocked than before cryofreez.
The block will be cleared after the Escher is formed which comes out on its own
by gentle blowing or it can be removed by nasal forceps or suction cannulae
after two weeks.
Patients are prescribed analgesics, antibiotics, and anti-inflammatory agents
for full two weeks. Nasal obstruction immediately following cryofreezing is
relieved by steroidal spray (Flixonase nasal spray). Escher is formed on 5th
or 7th day which is end result of cryoischemia and necrosis. After the Escher
is released the nasal cavity is cleaned and Betnovate cream is applied to nasal
mucosa. The healing is fast and without any tissue distortion. All patients are
seen in follow-up clinic in 2 weeks, 4 weeks, 6 weeks. The complete recovery is
seen after six weeks.
49
7
C HA P T E R
Cryosurgery—Results
INTRODUCTION
Applications of cryofreezing to the inferior turbinate and transnasal
cryodegeneration of the vidian nerve using endoscope were evaluated. The
study consisted of 180 patients with chronic vasomotor rhinitis and 102
patients of allergic rhinitis. All were refractory to conservative treatment,
including allergic desensitization. The cryosurgery was repeated once a week
for 3 weeks. After the third cryoapplication, the area that was endoscopically
estimated to be the sphenopalatine foramen was frozen over the mucous
membrane by an extrafine pointed cryoprobe. The subjective results 3 months
after the operation ware promising, and no major complications were noted.
The cryoapplications using endoscope is a minor surgical procedure with
high efficacy and minimal postoperative morbidity. The results in chronic
vasomotor rhinitis and allergic rhinitis were extremely gratifying and patient
satisfaction. More cases and a longer follow-up are necessary to provide long-
term results.
Our results of KEM study infer that cryosurgery may be prescribed as an
effective method of treatment in patients of chronic vasomotor rhinitis and
allergic rhinitis (Tables 7.1 to 7.3). The results were extremely promising
(72%) and repeat cryo was required for (28%) cases. The recurrence after
FESS surgery responded very well with cryofreezing (30%) which required
few repeat sittings. The hemangiomatous polyps, telangiectasia hemorrhagica
and papillomas were treated with cryofreezing for two to five minutes and
results were very satisfactory (Figs 7.1 to 7.16). Benign tumors of nasal cavity
also responded effectively and patients were comfortable after cryofreezing.
Most of the cases healed well without tissue damage and scarring. Cryohealing
takes 7 to 10 days no postoperative complications seen as bleeding, infections,
and distortion of normal tissue. Recurrences seen in hemangiomas and,
papillomas needed repeat cryofreezing. Tissue destruction is essentially well-
circumscribed and without scarring. Its inherent anesthetic and hemostatic
properties make it suitable for OPD procedures.
Benign, premalignant and malignant lesions in the oral cavity were treated
by cryosurgery, extremely good results have been obtained in the treatment of
small to moderate, superficially situated angiomas, simple cysts, papillomas,
pyogenic granuloma, keratoacanthoma, etc. Cryotherapy has also been found
TABLE 7.1: Patient’s postcryosurgery relief criteria

1. No change in symptoms 0.6%
2. Improvement but not complete 74%
3. Complete relief 90%
4. Best results are seen in VMR 84%
5. Palliative treatment for malignant lesions 68%
TABLE 7.2: Cryosurgeries—oropharyngeal lesions (1980–2008)

Sr. No. Lesions Cases
1. Granular pharyngitis 238
2. Epulis 024
3. Palatal ulcers 112
4. Papillomas of nasal and oral cavity 122
5. Hemangiomas of tongue 048
6. Oral submucous fibrosis 148
7. Malignant lesions (palliation) 068
Total 760
TABLE 7.3: Cryosurgeries—nasal lesion

Sr. No. Lesions Cases
1. Chronic hypertrophied turbinates 180
2. Chronic VMR and allergic rhinitis 282
3. Recurrent nasal polyposis 136
4. Post FESS recurrences 124
5. Osler disease 032
6. Epistaxis 366
Total 1120
Total cases done at KEM Hospital, Pune: 1880
to be satisfactory in the treatment of papillary hyperplasia of the palate and

painful erosive lichen planus.
Symptomatic cryotherapy may be of some use in these cases, especially to
relieve pain.The results were excellent in leukoplakia lesions of oral cavity. The
pathologically changed mucous membranes could be completely eliminated
in most of the cases without severe scar formation or impairment to functions.
The quality of life is much better after cryosurgery than mutilating surgery of
oral cavity and this is more important psychologically for patients.
In oncological lesions of H and N, it is generally agreed that considerable
palliation of distressing symptoms caused by incurable cancer may be
51
PHOTO GALLERY—CRYOSURGERY RESULTS
Figure 7.1: Leukoplakia–Before cryofreezing
Figure 7.2: Leukoplakia–After cryofreezing
Figure 7.3: Basal cell carcinoma of nose—Before cryosurgery

52
Figure 7.4: After cryosurgery
Figure 7.5: Nasal-polyp before cryofreez
Figure 7.6: Nasal-polyp after cryofreez

53
Figure 7.7: Cryofreezing for hemangioma of the tonsil
Figure 7.8: Cryofreezing in process
Figure 7.9: Hemangioma of tonsil after 3 weeks

54
Figure 7.10: Hemangioma of tonsil after 6 weeks
Figure 7.11: Hemangioma tongue-pre-op
Figure 7.12: Hemangioma tongue-cryofreezing

55
Figure 7.13: Cryofreezing of hemangioma
Figure 7.14: Cryofreezing
Figure 7.15: Post cryohemangioma clearance–4 weeks

56
Figure 7.16: Complete regression of tongue hemangioma
achieved by cryosurgery, even when other methods have failed or cannot be

used. Freezing reduces tumor bulk, lessens drainage and odor, controls pain,
and relieves bleeding and obstruction in a large variety of neoplasms. This is
the best form of psychological relief for oncologically dying patients.
The effective cryosurgical treatment for 102 patients of benign premalignant
and malignant oral lesions proved very satisfactory results without any
complications. The procedure was performed by direct application of liquid
nitrogen to the lesion using a cotton swab on an outpatient basis. This treatment
required no sophisticated equipment and gave very satisfactory results. There
was no intra- or postoperative bleeding, no surgical defects, minimal scarring,
and no infection following treatment. The results demonstrate that this is an
atraumatic form of therapy in comparison to conventional surgery.
In Meniere’s disease cryosurgery is one conservative approach designed
to control vertigo without adversely affecting the hearing in most cases. All
patients were unresponsive to medical therapy. An initial freeze at –160°C.
for two minutes is done, and the vestibular and auditory function is retested.
By this method a significant improvement of vertiginous symptoms resulted
in 70 to 80% patients. The postcryocaloric response revealed absent caloric
functions.
Sac decompression and vestibular nerve sections are commonly performed
surgical procedures in Meniere’s disease. But these procedures are always
with high risk to cochlea. Moreover recent advances revealed transtympanic
gentamicin infusion therapy is the latest choice of treatment modality which
preserves the cochlear function and improves vertigo in 92% of patients.
Because of this treatment modality with excellent results, the cryoapplications
have fallen in the management of Meniere’s disease, and now cryosurgery is
rarely done for the treatment of Meniere’s disease.
57
Our results, revealed that cryosurgery was successful and promising in

82% and revision cryosurgery required in 18% of our patients of chronic
allergic rhinitis and vasomotor rhinitis. The oral cavity lesions revealed
successful cryosurgery in 72% and revision cryosurgery was required for 28%
patients. In otological lesions 74% were successful and 26% required repeat
cryofreezing in multiple sittings. whereas in oncological group 64% were
successful in palliation and 36% patients needed revision cryosurgery. 10%
patients did not get any relief from cryosurgery procedures.
It is our observation that this modality is ideal, economic and cost-effective
for patients. Most of the common procedures performed by cryofreez as day
procedure revealed very gratifying results.
JUSTIFICATION
The potential benefits certainly justify its place as a valuable therapeutic agent.
Cryosurgery appears to be more effective than current standard treatment
options. The complication rate is also lower in our series. It is also a promising
modality in patients who are radiation therapy failures. Hence we strongly
recommend this therapy in clinical practice of otolaryngology and oncology.
58
8
C HA P T E R
Cryosurgery—Conclusion
Cryosurgery is a therapeutic method of treating both benign, premalignant

and malignant tissue by freezing in situ to achieve devitalization. Cell death
results from exposure to severe cold (below –40°C for at least 1 minute) as well
as from the process of freezing and thawing, which disrupts cellular integrity.
Modern cryosurgical technique involves insertion of hollow probes into the
tumor, through which circulating liquid nitrogen and gaseous nitrogen can
achieve tissue and tumor freezing and thawing for tumor control. Cryoablation
is now a recognized approach to the treatment of various malignant and
premalignant tumors, and it is generally well-tolerated and accepted by all
patients.
Since the advent of modern versatile equipment, cryosurgery has been
universally accepted therapy for treating otorhinolaryngeal and head and neck
lesions. It is an easy procedure to perform under local anesthesia with small
dose sedation and is a day surgery procedure. All age group of patients are
treated very effectively with minimum time than other conventional methods
of therapy.
It is also very cost effective as compared to laser or radiofrequency
treatment. The cryoprocedures can be repeated any number of times until the
desired goal is achieved. No major complications are seen after the cryosurgery.
There are many conditions in which the results of cryosurgical treatment
have been encouraging, but in some situations its use is of limited value and
continued critical assessment with careful evaluation is still required in order
that over enthusiastic claims should not be made.
It can now safely be said that cryosurgery is an important supplement and
adjunct to both surgical knife and radiation therapy, as well as being a tool
in its own right. It has become apparent that cryosurgery is most useful in
benign, premalignant and malignant lesions. Its effectiveness in eliminating
pain is extremely important for palliative treatment. It is our firm belief that
cryosurgery should be a part of the armamentarium of otorhinolaryngologists
in his clinical practice.
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63
Index
Page numbers followed by f refer to figure
of leukoplakia of tongue 32f

A of middle and inferior turbinates 40f
Adenoidectomy 25 of mucous cyst of tongue 29f
Allergic of ranula of tongue 31f
polyposis 14 Cryoguns 13f
rhinitis 14, 51 Cryoimmunology 10
Angiofibroma 14 Cryopalliation for head and neck
Anterior malignancies 14
commissure polyp 45f Cryoprobes 13f, 17
epistaxis 41f of different sizes 12
nasal bleed 35 Cryosurgery 16, 49, 59
Aural considerations in otorhinolaryngology 12
cysts 14 economics 15
hematomas 14 in nose and nasopharynx 35
Auricular hemangioma 23f in oropharynx 25
B morbidity 15
Cryounit with cryogun mounted on
Basal cell 20
Mayov’s trolley 12
and squamous cell carcinoma of ear 14
carcinoma of D
auricle 24f
ear 21, 24f Deep ulcer of
nose 14, 39f, 52f soft palate 33f
Bilateral tongue 32f
tongue hemangioma 34f Dermoids 14
vocal nodules 45f Dressing materials 12
C E
Cancer of tongue 29f Endoscopic cryofreezing of posterior
Carbonic acid snow 4 epistaxis 14
Carcinoma Epistaxis 14, 35, 51
in situ and malignant conditions 44 Epulis 14, 51
of anterior commissure and vocal Extensive papilloma larynx 46f
cords 47f
of vocal cord 47f F
Cervical esophagus 44 Familial hemorrhagic telangiectasia 14
Cheek Fibromas 14
fibroma 35f Freer’s septal elevators 12
hemangiomas 14 Freezing tips 18f
Chronic
allergic rhinitis 37 G
hypertrophic turbinates 14 Glomus
rhinitis 14, 41f jugulare 24f
vasomotor rhinitis 38 tumors 49
Cidex tray for sterilization of cryoprobes 12 tumor 14
Complete regression of tongue Glossopharyngeal neuralgia 14, 26
hemangioma 57f Granular pharyngitis 14, 51
Cryobiology 7 Granulomatous and hyperplastic lesions 14
Cryofreeze spot freeze 17
Cryofreezing 56f H
for hemangioma of tonsil 54f Hemangioma 14, 28
in laryngopharynx 43 of auricle 21f
in otology 20 of ear lobule 23f
of fungal ulcers of tongue 29f of septum 42f
of hemangioma 56f of tongue 51
of septum 40f of tonsil 54, 55f
of tongue 31f tongue-cryofreezing 55f
Hemangiomatous polyp of left vocal cord 45f Oropharyngolaryngeal lesions 14

Hemorrhagic telangiectasia 36 Osler disease 51
Hyperkeratosis 14 Otology 14, 21
Hypertrophic rhinitis 38 Otorhinolaryngology 20
Hypopharynx 44
Hypophysectomy 48 P
Palatal
I and cheek ulcers 14
Infected lymphoid hyperplasia 26 ulcers 51
Instrument for cryofreezing 12f Papillary hyperplasia 14
Intubation granuloma 46f Papillomas 14
of nasal and oral cavity 51
J Parkinson’s disease 6
Juvenile papilloma of larynx 43 Postcryohemangioma 56f
Posterior
K epistaxis 42f
Keloid 14 nasal bleed 36
and hypertrophic scars 20 Postirradiated recurrences in oropharyngeal
of ear lobule 22f malignancy 14
of pinna 22f Precautions in cryosurgery 16
Keratosis of vocal cord 47f Premalignant and benign lesions of oropharynx 14
Killian’s insulated nasal speculum set 12 Preparation and technique of cryofreezing 17
K-Y jelly 12 Principles of cryosurgery 11
L R
Leukoplakia 14, 26, 30f, 52f Ranula 14
Lichen planus 27 of tongue 33f
Lingual Recurrent nasal polyposis 51
cavernous hemangioma 27, 31f Retension cyst of lower lip 33f
hemangioma 35f Rhinology 14
Liquid
air and liquid oxygen 4 S
nitrogen 5 Size of tonsil 25
Lymphangiomas 14, 28 Squamous
cell carcinoma of ear and face 20
M papilloma of nasal septum 42f
Malignant lesions 51 Stomatitis 30f
Mechanism of cell death 7 Suction cannulae 12
Meniere’s disease 14, 48, 57 Supraglottic cavernous hemangioma 43
Micropore and septal splints 12 Synechiae of vocal cords 46f
Minimal treatment time 15
Mucous T
cyst of lower lip 32f Tissue temperature monitoring
cysts 14 techniques 19
Tongue
N depressor 12
Nasal fibroma 34f
lesions 39 hemangioma 34f
packing forceps 12 Tonsillectomy 25
polyposis 14, 37 Tonsillitis and tonsil remnants 14
Nasopharyngeal angiofibroma and carcinoma 37 Transnasal
Nevus warts 14 endoscopic vidian nerve cryofreezing 14
Nitrous oxide hypophysectomy 14
cryocan 18f Transtympanic cryofreezing of
cryogun with instrument trolly 13f membranous labyrinth for Meniere’s disease 14
cryojet 18f
freshly filled cylinder 12 U
Noninfective rhinitis 14 Ulcers of tongue 30f
O V
Oral Vascular malformations 14
cavity 14 Vasomotor rhinitis 14
and oropharynx 29 Verrucous vulgaris 39, 43f
tumors 14
submucous fibrosis 14, 51 Z
ulcerations 27 Zacarian’s spray 6
66

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CRYOSURGERY

Clinical Applications in Otorhinolaryngology

KK Desarda MS FACS DLO (London)

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Jaypee Brothers Medical Publishers (P) Ltd.

Website: www. jaypeebrothers.com

© 2013, Jaypee Brothers Medical Publishers

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

Cryosurgery: Clinical Applications in Otorhinolaryngology

First Edition: 2013

SK Kaluskar MS FRCS DLO (England)

Since my interest in cryosurgical applications in otolaryngology began in 1974,

It has become apparent that cryosurgery is most useful in benign,

I would like to thank Medical Director, Academic Director, Research Director

6. Clinical Applications in Otorhinolaryngology 20

Supraglottic Cavernous Hemangioma 43

undesirable tissues. Currently cryosurgery is being used in many medical field,

Cryosurgery is a surgical technique that employs freezing to destroy

widespread introduction. Ultimately unsuccessful, but his contribution to the

FIRST USE OF REFRIGERANTS

LIQUID AIR AND LIQUID OXYGEN

CARBONIC ACID SNOW

within 30 seconds if a sufficient amount of liquid nitrogen is applied by spray

The rupture of the cell membrane occurs, which follows intracellular

The fundamental effect of cryosurgery is based on in situ tissue destruction

INSTRUMENTS (FIGS 5.1 TO 5.5)

Figure 5.1: Instrument for cryofreezing

Figure 5.2: Nitrous oxide cylinder with cryogun

Figure 5.3: Nitrous oxide cryogun with instrument trolly

Figure 5.4: Picture of cryoprobes

Figure 5.5: Picture of cryoguns

Selection Criteria for Patients

TECHNIQUE AND PROCEDURE

The Cryofreeze-Spot Freeze

Preparation and Technique of Cryofreezing (Figs 5.6A and B)

3. Two percent xylocaine with Adrenaline 1;200000 cons.infiltration around

Tissue Temperature Monitoring Techniques

KELOIDS AND HYPERTROPHIC SCARS

BASAL CELL AND SQUAMOUS CELL CARCINOMA OF EAR AND FACE

BASAL CELL CARCINOMA OF EAR

PHOTO GALLERY OF OTOLOGY

Figure 6.1: Hemangioma of auricle

Figure 6.2: Keloid of pinna

Figure 6.3: Keloid of ear lobule

Figure 6.4: Keloid of pinna

Figure 6.5: Auricular hemangioma

Figure 6.6: Auricular hemangioma

Figure 6.7: Hemangioma of ear lobule

Figure 6.8: Glomus jugulare

Figure 6.9: Basal cell carcinoma of ear

Figure 6.10: Basal cell carcinoma of auricle

CRYOSURGERY IN OROPHARYNX (FIGS 6.11 TO 6.30)

Infected Lymphoid Hyperplasia

Lingual Cavernous Hemangioma

PHOTO GALLERY OF ORAL CAVITY AND OROPHARYNX

Figure 6.11: Cryofreezing of mucous cyst of tongue

Figure 6.12: Cryofreezing of fungal ulcers of tongue

Figure 6.13: Cancer of tongue

Figure 6.14: Stomatitis

Figure 6.15: Ulcers of tongue

Figure 6.16: Leukoplakia—cheek

Figure 6.17: Lingual cavernous hemangioma

Figure 6.18: Cryofreezing of hemangioma of tongue