Atlas of Primary Care Procedures - T Zuber - 2

Front of Book
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Editors
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PREFACE
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ACKNOWLEDGMENTS

Table of Contents
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General Procedures
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1 - Incision and Drainage of Abscesses
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2 - Lumbar Puncture
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3 - Thoracentesis
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4 - Chest Tube Insertion
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5 - Abdominal Paracentesis
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6 - Ring Removal
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7 - Fishhook Removal
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8 - Tick Removal
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Dermatology
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9 - Local Anesthesia Administration
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10 - Punch Biopsy of the Skin
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11 - Shave Biopsy
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12 - Fusiform Excision
Page 1
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13 - Skin Tag Removal
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14 - Simple, Interrupted Skin Suture Placement
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15 - Running Cutaneous and Intracutaneous Sutures
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16 - Vertical Mattress Suture Placement
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17 - Horizontal Mattress Suture Placement
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18 - Minimal Excision Technique for Removing Epidermal Cysts
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19 - Skin Cryosurgery
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20 - Dermal Radiosurgical Feathering and Ablation
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21 - Scalp Repair Techniques
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22 - Tangential Laceration Repair
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23 - Field Block Anesthesia
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24 - Lipoma Removal
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25 - Basic Z-Plasty
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26 - Advancement Flap Placement
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27 - O-To-Z Plasty
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28 - Sclerotherapy
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Nail Procedures
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29 - Digital Nerve Block
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30 - Ingrown Nail Surgery
Page 2
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31 - Subungual Hematoma Drainage
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32 - Nail Bed Biopsy
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33 - Paronychia Surgery
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34 - Digital Mucous Cyst Removal
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Gynecology and Urology
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35 - Endometrial Biopsy
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36 - Cervical Polyp Removal
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37 - Colposcopy and Directed Cervical Biopsy
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38 - Cryotherapy for the Uterine Cervix
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39 - Loop Electrosurgical Excisional Procedure
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40 - Treatment of Bartholin's Gland Cysts and Abscesses
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41 - Treatment of Noncervical Human Papillomavirus Genital Infections
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42 - Fine-Needle Aspiration of the Breast
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43 - Fitting Contraceptive Diaphragms
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44 - Intrauterine Device Insertion and Removal
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45 - Gomco Clamp Circumcision
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46 - No-Scalpel Vasectomy
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Gastroenterology
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47 - Anoscopy with Biopsy
Page 3
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48 - Flexible Sigmoidoscopy
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49 - Esophagogastroduodenoscopy
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50 - Colonoscopy
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51 - Excision of Thrombosed External Hemorrhoids
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52 - Treatment of Internal Hemorrhoids
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Ear, Nose, and Throat Procedures
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53 - Conjunctival and Corneal Foreign Body Removal
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54 - Chalazia Removal
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55 - Treatment for Anterior Epistaxis
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56 - Flexible Nasolaryngoscopy
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57 - Cerumen Impaction Removal
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58 - Foreign Body Removal from the Auditory Canal and Nasal Cavity
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Musculoskeletal Procedures
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59 - Greater Trochanteric Bursa Injection
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60 - Shoulder Injection
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61 - Knee Joint Aspiration and Injection
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62 - Reduction of Radial Head Subluxation (Nursemaid's Elbow)
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63 - Plantar Fascia Injection
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64 - Trigger Point Injection
Page 4
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65 - Trigger Finger Injection
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66 - De Quervain's Tenosynovitis Injection
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67 - The Short Arm Cast
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68 - The Short Leg Cast
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69 - Extensor Tendon Repair
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70 - Carpal Tunnel Syndrome Injection
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71 - Aspiration and Injection of Olecranon Bursitis
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72 - Aspiration and Injection of Wrist Ganglia

Back of Book
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Resources
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INDEX
Page 5
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Editors
Thomas J. Zuber M.D., M.P.H., M.B.A., F.A.A.F.P.
Adjunct Associ ate Professor
Department of Fami l y Medi ci ne, Brody School of Medi ci ne at East
Carol i na Uni versi ty, Greenvi l l e, North Carol i na and Boone, North
Carol i na
E. J. Mayeaux Jr. M.D., D.A.B.F.P., F.A.A.F.P.
Professor of Fami l y Medi ci ne and Obstetri cs and Gynecol ogy
Loui si ana State Uni versi ty Heal th Sci ences Center, Shreveport,
Loui si ana
Illustrated by Wendy Beth Jackelow, Patricia Gast, and Laura
Pardi Duprey
Secondary Editors
Danette Somers
Acqui si ti ons Edi tor
Kerry Barrett
Devel opmental Edi tor
Toni Ann Scaramuzzo
Producti on Manager
Michael Mallard
Producti on Edi tor
Colin Warnock
Manufacturi ng Manager
David Levy
Cover Desi gner
Compositor: Lippincott Williams & Wilkins Desktop Division
Printer: Quebecor World-Taunton
Page 6
Editors: Zuber, Thomas J.; Mayeaux, E. J.
Title: Atlas of Primary Care Procedures, 1st Edition
Copyri ght 2004 Li ppi ncott Wi l l i ams & Wi l ki ns
> Front of Book > PREFACEPREFACE
Di agnosti c and therapeuti c procedures are an i ntegral part of the
practi ce of pri mary care medi ci ne. Offi ce procedures can provi de the
pati ent wi th val uabl e heal th benefi ts i n a fami l i ar and comfortabl e
l ocati on. Procedures provi ded by the pri mary care physi ci an can
enhance the doctor-pati ent rel ati onshi p, and resul t i n rapi d
deci si on maki ng by reduci ng fragmentati on i n heal th del i very. The
benefi ts of procedures i n pri mary care medi ci ne can be most cl earl y
demonstrated i n rural areas, where the ti me and expense of travel
to terti ary medi cal centers may represent a seri ous barri er to
pati ent care.
Thi s atl as i s desi gned to provi de pri mary care heal thcare provi ders
wi th a step-by-step i nstructi onal reference i n common offi ce
procedures. The i nformati on i ncorporates practi cal suggesti ons
devel oped by the authors duri ng thei r nearl y 50 years of teachi ng
procedural medi ci ne. Over 700 i l l ustrati ons have been added to
enhance the cl ari ty of i nstructi ons, and to provi de the reader wi th
vi sual cues. Provi ders-i n-trai ni ng and teachers shoul d benefi t from
a deeper comprehensi on of techni ques i ncorporated i nto these
procedures. Seasoned practi ti oners wi l l appreci ate the conci se
summary of each procedure's CPT codi ng, pi tfal l s, and
compl i cati ons. The 72 procedures covered i n thi s atl as range from
the si mpl e (cerumen removal ) to the compl ex (col onoscopy). These
procedures i ncorporate the vast majori ty of ski l l s requi red of
pri mary care practi ti oners, and far exceed the number performed by
most practi ci ng physi ci ans.
Each chapter begi ns wi th an overvi ew of background i nformati on
about the procedure. Indi cati ons and contrai ndi cati ons (both
rel ati ve and absol ute) are l i sted, provi di ng a framework for
eval uati ng pati ents bei ng consi dered for a parti cul ar procedure.
Il l ustrati ons and thei r accompanyi ng l egends provi de sequenti al
i nstructi ons i n the performance of the procedure. Bul l eted pi tfal l s
Page 7
are i ncl uded to demonstrate common errors or di ffi cul ti es that
practi ti oners hi stori cal l y have encountered. The codi ng secti on
i ncl udes suggested CPT codes, descri ptors, and reported 2002
average 50th percenti l e fees charged for the sel ected codes. The
i nstruments and materi al s secti on provi des exampl es of orderi ng
i nformati on (phone numbers and web si te addresses) for obtai ni ng
the materi al s menti oned i n the chapter. The bi bl i ography secti on
i ncl udes references used i n the chapter, as wel l as i nformati on of
i nterest when consi deri ng a procedure.
Modern heal th del i very offi ces and cl i ni cs must report servi ces to
thi rd-party payers usi ng nati onal codi ng resources. The CPT
codes are devel oped by the Ameri can Medi cal Associ ati on, and
general l y accepted by most nati onal i nsurers. The codes l i sted i n
each chapter are suggesti ons; other codes may be sel ected that
more appropri atel y descri be the procedure performed or servi ces
rendered. In addi ti on, certai n i nsurers may i ncorporate l ocal
reporti ng rul es that take precedent. The reader shoul d constantl y
update thei r knowl edge of annual codi ng changes.
Thi s atl as i ncl udes 2002 average 50th percenti l e fees for CPT
codes that are l i sted. Thi s i nformati on i s deri ved from the 2002
Physi ci ans' Fee Reference, Yal e Wasserman DMD Medi cal
Publ i shers, Mi l waukee, Wi sconsi n. The Physi ci ans' Fee Reference
i nformati on contai ned i n the Atl as has been added to hel p the
reader understand the medi cal marketpl ace and are not
recommended fees. These fees are provi ded to demonstrate
nati onal i nformati on, and not to serve as a recommendati on for
practi ces to set a speci fi c charge for servi ces.Thi s annual survey of
fees provi des i nval uabl e nati onal data on fees that can hel p
practi ti oners i nteract wi th the heal th del i very system. It i s not
uncommon for medi cal practi ces to be unfai rl y accused of
overbi l l i ng by thi rd-party payers who have set
rei mbursement l evel s excepti onal l y l ow. Bei ng equi pped wi th
nati onal fee data can hel p medi cal practi ces to counter these
i nappropri ate accusati ons. Starred procedures are smal l surgi cal
procedures that i nvol ve a readi l y i denti fi abl e surgery, but i ncl ude
Page 8
vari abl e preoperati ve and postoperati ve servi ces. Because of the
i ndefi ni te associ ated servi ces provi ded before and after the
surgery, the typi cal package concept does not appl y. Starred (*)
procedures i ncl ude just the servi ce l i sted; associ ated preoperati ve
or postoperati ve servi ces may be bi l l ed separatel y.
The resources l i sted i n the Instruments and Materi al s secti on are
not comprehensi ve. Materi al s may be i ncl uded because hi stori cal l y
they have demonstrated effecti veness or ease of use i n pri mary
care practi ces. Many of the i nstruments are l i sted because they
provi de accurate and cost-effecti ve i nformati on. Readers may use
materi al s that they bel i eve are superi or; the authors wel come
comments or suggesti ons for future edi ti ons of the atl as.
No book can repl ace experi ence. When l earni ng any new procedural
ski l l , i t i s recommended that the practi ti oner recei ve proctori ng
from someone ski l l ed i n the procedure. Precepted experi ence i s
strongl y urged for more compl ex procedures to reduce pati ent
compl i cati ons and medi col egal l i abi l i ty. Formal procedural trai ni ng
courses al so are avai l abl e through speci al ty soci eti es (such as the
Ameri can Academy of Fami l y Physi ci ans), medi cal i nterest soci eti es
(such as the Ameri can Soci ety of Col poscopy and Cervi cal
Pathol ogy), or l ocal or regi onal medi cal soci eti es. It i s hoped that
thi s reference wi l l serve as an i nval uabl e addi ti onal resource i n the
provi si on of hi gh-qual i ty procedural servi ces.
Thomas J. Zuber M.D., M.P.H., M.B.A.
E. J. Mayeaux Jr. M.D.
Page 9
> Table of Cont ent s > General Procedures > 1 - Incision and Drainage of
Abscesses1
Incision and Drainage of Abscesses
It i s an ol d axi om of medi ci ne that pus col l ecti ons must be drai ned
for heal i ng to occur. Pus that becomes l ocal l y trapped under the
ski n and produces an i nfl ammatory reacti on i s cal l ed an abscess
(i .e., furuncl e or boi l ). Carbuncl es are aggregates of i nfected
fol l i cl es. Cel l ul i ti s may precede or occur i n conjuncti on wi th an
abscess. An abscess i s not a hol l ow sphere; i t i s a cavi ty formed by
fi ngerl i ke l ocul ati ons of granul ati on ti ssue and pus that extends
outward al ong pl anes of l east resi stance. A paronychi a i s a
l ocal i zed abscess that i nvol ves a nai l fol d.
Abscesses are most commonl y found on the extremi ti es, buttocks,
groi n, axi l l a, breast, and areas prone to fri cti on or mi nor trauma.
Staphyl ococcus aureus and Streptococcus speci es are the most
common causati ve agents, but other mi croorgani sms, i ncl udi ng
gram-negati ve and anaerobi c bacteri a, may be present. Enteri c
organi sms are common i n peri anal abscesses.
Abscesses may fol l ow one of two courses. The abscess may remai n
deep and sl owl y reabsorb. Al ternati vel y, the overl yi ng epi thel i um
may attenuate (i .e., poi nti ng), al l owi ng the abscess to
spontaneousl y rupture to the surface and drai n. Rarel y, deep
extensi on i nto the subcutaneous ti ssue may be fol l owed by
sl oughi ng and extensi ve scarri ng. Conservati ve therapy for smal l
abscesses i ncl udes warm, wet compresses and anti staphyl ococcal
anti bi oti cs. The techni que of i nci si on and drai nage (I&D) i s a
ti me-honored method of drai ni ng abscesses. Routi ne cul tures and
anti bi oti cs are usual l y unnecessary i f an abscess i s properl y
drai ned.
After I&D, i nstruct the pati ent to watch for si gns of cel l ul i ti s or
recol l ecti on of pus. Trai n pati ents or fami l y to change packi ng, or
Page 10
arrange for the pati ent's packi ng to be changed as necessary.
Cel l ul i ti s, bacteremi a, and gangrene are rare compl i cati ons and
occur most commonl y i n pati ents wi th di abetes or other di seases
that i nterfere wi th i mmune functi on. I&D of a peri anal abscess may
resul t i n a chroni c anal fi stul a and may requi re a fi stul ectomy by a
surgeon.
P.4
INDICATIONS
An abscess that i s not spontaneousl y resol vi ng
CONTRAINDICATIONS
Consi der more aggressi ve therapy, cl oser observati on,
wound cul ture, and anti bi oti c therapy i n pati ents wi th
di abetes, debi l i tati ng di sease, compromi sed i mmuni ty,
or faci al abscesses l ocated wi thi n the tri angl e formed by
the bri dge of the nose and the corners of the mouth.
The l atter i nfecti ons carry a ri sk of septi c phl ebi ti s wi th
i ntracrani al extensi on.
P.5
PROCEDURE
Prep and drape the area i n a steri l e fashi on. Admi ni ster a fi el d
bl ock wi th l ocal anestheti c (see Chapter 23). The ski n overl yi ng the
top of the abscess al so i s anestheti zed.
Page 11
(1) Admi ni ster a fi el d bl ock wi th l ocal anestheti c.
PITFALL: Avoid injecting into the abscess cavity, because local
anesthetics usually work poorly in the acidic milieu of an
abscess.
P.6
The abscess i s ready for drai nage when the ski n has thi nned and
the underl yi ng mass becomes soft and fl uctuant (i .e., poi nti ng). A
no. 11 surgi cal bl ade i s i nserted and drawn paral l el to the l i nes of
l esser ski n tensi on, creati ng an openi ng from whi ch pus may be
expressed (Fi gure 2A). Often, an up-and-down i nci si on wi th the no.
11 bl ade i s adequate. Avoi d extendi ng the i nci si on i nto non-effaced
ski n. Appl y pressure around the abscess to expel pus from the
wound (Fi gure 2B).
Page 12
(2) Make an up-and-down i nci si on wi th a no. 11 surgi cal bl ade, and
appl y pressure around the abscess to expel the pus from the
wound.
PITFALL: Abscesses can explode upward on entry. Wear
protective eyewear if the abscess contents appear to be under
pressure.
PITFALL: Abscesses most often recur because of an incision that
is not wide enough to prevent immediate closure.
P.7
Insert a probe, cotton-ti pped appl i cator, hemostats, or curette
through the openi ng, and draw i t back and forth to break adhesi ons
and di sl odge necroti c ti ssue. If a cul ture i s desi red, obtai n i t from
deep i n the abscess cavi ty.
Page 13
(3) Insert a probe through the openi ng, and draw i t back and forth
to break adhesi ons and di sl odge necroti c ti ssue.
If the cavi ty i s l arge enough, pack i t wi th a ri bbon of pl ai n or
i odoform gauze to promote drai nage and prevent premature cl osure.
Grasp the end of the ri bbon wi th a pai r of forceps, and pl ace i t
through the i nci si on to the base on the abscess (Fi gure 4A). Fol d
addi ti onal ri bbon i nto the cavi ty unti l i t i s fi l l ed. Leave
approxi matel y 12 cm of gauze on the surface of the ski n (Fi gure
4B). Appl y a steri l e dressi ng over the area.
(4) If the cavi ty i s l arge enough, pack i t wi th pl ai n or i odoform
gauze to promote drai nage and prevent premature cl osure.
P.8
CODING INFORMATION
Page 14
P.9

CPT Code Description 2002 Average 50th Percentile Fee
10040* Acne surgery $95
10060* I&D of si ngl e or si mpl e abscess $120
10061 I&D of mul ti pl e or compl ex abscesses $275
10080* I&D of pi l oni dal cyst, si mpl e $144
10081 I&D of pi l oni dal cyst, compl i cated $338
10140* I&D of hematoma, seroma, or fl ui d col l ecti on $150
10160* Puncture aspi rati on of abscess, hematoma,
bul l a, or cyst
$120
10180 I&D, compl ex, of postoperati ve wound
i nfecti on
$424
21501 I&D of deep abscess of neck or thorax $605
23030 I&D of deep abscess of shoul der $579
23930 I&D of deep abscess of upper arm or el bow $642
23931 I&D of deep abscess of upper arm or el bow
bursa
$525
25028 I&D of deep abscess of forearm or wri st $675
26010* I&D of si mpl e abscess of fi nger $204
26011* I&D of compl i cated abscess of fi nger or
fel on
$448
26990 I&D of deep abscess of pel vi s or hi p joi nt
area
$763
26991 I&D of i nfected bursa of pel vi s or hi p joi nt
area
$686
27301 I&D of deep abscess of thi gh or knee regi on $777
27603 I&D of deep abscess of l eg or ankl e $730
28001* I&D of bursa of the foot $377
40800* I&D of abscess, cyst, or hematoma i n the
vesti bul e of the mouth, si mpl e
$138
40801 I&D of abscess, cyst, or hematoma i n the
vesti bul e of the mouth, compl i cated
$375
Page 15
41000* Intraoral I&D of abscess, cyst, or hematoma
of tongue or fl oor of the mouth, l i ngual
$217
41005* Intraoral I&D of abscess, cyst, or hematoma
of tongue or fl oor of the mouth, subl i ngual ,
superfi ci al
$227
41006 Intraoral I&D of abscess, cyst, or hematoma
of tongue or fl oor of the mouth, subl i ngual ,
deep
$468
41800* I&D of abscess, cyst, or hematoma from
dentoal veol ar structures
$187
54015 I&D of deep abscess of peni s $375
54700 I&D of abscess of epi di dymi s, testi s, or
scrotal space
$395
55100* I&D of abscess of scrotal wal l $276
56405* I&D of abscess of vul va or peri neum $242
56420* I&D of abscess of Barthol i n's gl and $190
67700* I&D of abscess of eyel i d $184
69000* I&D of abscess of external ear, si mpl e $138
69005 I&D of abscess of external ear, compl i cated $438

CPT i s a trademark of the Ameri can Medi cal Associ ati on.
INSTRUMENT AND MATERIALS ORDERING
Standard ski n tray suppl i es are shown i n Appendi x A. A suggested
anesthesi a tray that can be used for thi s procedure i s l i sted i n
Appendi x G. Ski n preparati on recommendati ons appear i n Appendi x
H.
BIBLIOGRAPHY
Habi f TP. Cl i ni cal dermatol ogy: a col or gui de to di agnosi s and
therapy, 2nd ed. St Loui s: Mosby, 1996:201.
Hedstrom SA. Recurrent staphyl ococcal furuncul osi s: bacteri al
fi ndi ngs and epi demi ol ogy i n 100 cases. Scand J I nfect Di s
1981;13:115119.
Ll era JL, Levy RC. Treatment of cutaneous abscess: a doubl e-bl i nd
cl i ni cal study. Ann Emerg Med 1985;14:1519.
Page 16
Mei sl i n HW, Lerner SA, Graves MH, et al . Cutaneous abscesses:
anaerobi c and aerobi c bacteri ol ogy and outpati ent management.
Ann I ntern Med 1977;87:145149.
Usati ne RP. Inci si on and drai nage. In: Usati ne RP, May RL, Tobi ni de
EL, Si egel DM, eds. Ski n surgery: a practi cal gui de. St Loui s:
Mosby, 1998:200210.
Page 17
> Table of Cont ent s > General Procedures > 2 - Lumbar Punct ure2
Lumbar Puncture
Lumbar puncture (LP) i s a common di agnosti c and therapeuti c
procedure. It i s most commonl y performed to obtai n a sampl e of
cerebrospi nal fl ui d (CSF) to hel p establ i sh neurol ogi c di agnoses. LP
i s the most accurate method for di agnosi ng central nervous system
i nfecti on.
CSF i s produced by the choroi d pl exus i n the brai n and ci rcul ates
around the brai n and spi nal cord wi thi n the subarachnoi d space.
Duri ng an LP, the spi nal needl e penetrates the ski n, subcutaneous
ti ssue, spi nal l i gaments, dura, and arachnoi d before enteri ng the
subarachnoi d space. Four sampl es of CSF are usual l y obtai ned, and
the usual studi es i ncl ude bacteri al cul ture and Gram stai n from
tube 1, protei n and gl ucose from tube 2, bl ood cel l counts and
di fferenti al cel l counts from tube 3, and opti onal tests such as vi ral
cul tures, fungal cul tures, countercurrent i mmunoel ectrophoresi s,
Indi a i nk studi es, or l atex aggl uti nati on tests from tube 4. Common
CSF fi ndi ngs are shown i n Tabl e 2-1.
TABLE 2-1. COMMON PROPERTIES OF CEREBROSPINAL FLUID

Cerebros
pinal Fluid
Character
istic
Normal
Values
Acute
Bacteria
l
Meningit
is
Subacut
e
Meningit
is
Viral
Infectio
n
Pseudotu
mor
Cerebri
Cerebral
Hemorrh
age
Openi ng
pressure
(cm H2O)
520 >20 Normal
to
i ncrease
d
Normal
to
i ncrease
d
Increased Increased
Whi te <5 1007 5005010020Normal Bl oody
Page 18
bl ood cel l
count
(cel l s/mm
3
)
00 00 00 sampl e
Gl ucose
(mg/dL)
5010
0 (or
6070
% of
bl ood
gl ucose)
Decrease
d
Decrease
d
Normal Normal Normal
Protei n
(mg/dL)
1545 100 Increase
d
Normal
or
i ncrease
d
Normal or
decreased
Increased

The i ndi cati ons for LP i n neonates are not as cl ear as they once
were. The once common practi ce of performi ng an LP i n al l i l l
newborns wi th suspected sepsi s or respi ratory di stress i s no l onger
recommended unl ess other fi ndi ngs suggest meni ngi ti s. LP i s often
reserved for babi es who demonstrate hypothermi a, hyperthermi a,
poor feedi ng 24 hours after bi rth, coma, or sei zures. Bedsi de
ul trasound scanni ng has l argel y repl aced LP for the di agnosi s of
i ntracrani al hemorrhage. Onl y about one hal f of LPs i n newborns are
successful l y compl eted, and traumati c (bl oody) taps are common.
The most common compl i cati on i s the post-LP (spi nal ) headache,
whi ch occurs i n 10% to 25% of pati ents. The headache often
persi sts for days. The use of smal l er-di ameter needl es, ensuri ng
adequate hydrati on, and keepi ng the pati ent supi ne (or better,
prone) after the procedure can reduce thi s compl i cati on. When the
headache i s persi stent, an epi dural bl ood patch may be appl i ed by
an anesthesi ol ogi st. Traumati c (bl oody) taps resul t from
i nadvertent puncture of the spi nal venous pl exuses and may rarel y
l ead to spi nal hematoma. Other temporary compl i cati ons i ncl ude
shooti ng pai ns i n the l ower extremi ti es and l ocal pai n i n the back.
A more seri ous potenti al compl i cati on i s brai n herni ati on from
Page 19
el evated i ntracrani al pressure that often i s caused by a
supratentori al mass. However, research has shown that severe
meni ngi ti s al so may cause el evated i ntracrani al pressure and
herni ati on. Before performi ng an LP, al ways check the opti c fundi
P.11
for papi l l edema. If i ncreased pressure due to a tumor or an
i ntracrani al bl eed i s suspected, an emergency computed
tomography (CT) scan shoul d be obtai ned before LP to reduce the
potenti al of herni ati on. Inadvertent aspi rati on of nerve roots on
needl e wi thdrawal can be prevented by repl aci ng the styl et before
needl e removal . Meni ngi ti s as a resul t of the procedure i s a
theoreti cal compl i cati on. Epi dermoi d spi nal cord tumors have been
associ ated wi th the performance of LP i n i nfants wi th unstyl etted
needl es.
INDICATIONS
Suspected central nervous system i nfecti on
Suspected subarachnoi d hemorrhage
Suspected neurosyphi l i s
Suspected Gui l l ai n-Barr syndrome
Support for the di agnosi s of pseudotumor cerebri (i .e.,
i ncreased CSF pressure wi thout i nfecti on)
Seri al removal of CSF
Support for the di agnosi s of mul ti pl e scl erosi s (i .e.,
el evated IgG l evel and ol i gocl onal bandi ng on
el ectrophoresi s)
CONTRAINDICATIONS
Dermati ti s or cel l ul i ti s at i nserti on si te
Rai sed i ntracrani al pressure
Supratentori al mass l esi ons (eval uate wi th CT scan fi rst)
Severe bl eedi ng di athesi s (rel ati ve)
Lumbosacral deformi ty (rel ati ve)
Uncooperati ve pati ent
P.12
Page 20
PROCEDURE
Posi ti on the pati ent i n the l eft l ateral decubi tus posi ti on, wi th the
back near the edge of the bed or exami nati on tabl e and wi th the
spi ne fl exed and knees drawn toward the chest. Ensure the
shoul ders and back are perpendi cul ar to the tabl e. Pl ace a pi l l ow
under the pati ent's head to keep the spi ne as strai ght as possi bl e.
An al ternati ve method i s to pl ace the pati ent i n the si tti ng
posi ti on, l eani ng on a bedsi de tabl e or wi th two l arge pi l l ows i n the
pati ent's l ap, wi th the spi ne fl exed anteri orl y.
(1) Posi ti on the pati ent i n one of two ways: i n a si tti ng posi ti on
wi th pati ent l eani ng on a tabl e wi th the spi ne fl exed anteri orl y or
i n the l eft l ateral decubi tus posi ti on wi th the pati ent's back near
the edge of the bed, the spi ne fl exed, and knees drawn to the
Page 21
chest.
PITFALL: Avoid forced flexion of the neck during the procedure
because cardiorespiratory arrest may occur if a child' s neck is
excessively flexed.
P.13
Cl ean the back wi th povi done-i odi ne. Set up the steri l e tray,
remove the tops of the sampl e tubes, and don a mask and steri l e
gl oves whi l e the povi done-i odi ne ai r dri es on the ski n. Steri l e
drapi ng typi cal l y i s used for adul t pati ents, but i t can be omi tted
for the i nfant i n favor of a wi de prep to maxi mi ze l andmark
exposure and proper posi ti oni ng. Inject a smal l amount (13 mL)
of 1% l i docai ne subcutaneousl y and i nto the area between the
spi nous processes.
(2) Inject a smal l amount (13 mL) of 1% l i docai ne
subcutaneousl y and i nto the area between the spi nous processes.
The opti mal needl e i nserti on si te i s i n the center of the spi nal
col umn, as defi ned by the spi nous processes. The L3-4 i nterspace
can be found where the l i ne joi ni ng the superi or i l i ac crests meets
the spi nous process of L4. Inserti on i s usual l y at the L3-4
i nterspace, but i t may be performed one space above or bel ow.
Page 22
(3) Opti mal needl e i nserti on i s usual l y obtai ned at the L3-4
i nterspace.
P.14
Wi th the styl et i n pl ace, sl owl y i nsert the 22- or 20-gauge spi nal
needl e mi dway between the two spi nous processes. The correct
angl e for the needl e i s approxi matel y toward the umbi l i cus, al ong
the sagi ttal mi dpl ane of the body. If bone i s encountered, wi thdraw
the needl e sl i ghtl y, and change i ts angl e. Feel for a l oss of
resi stance, a gi ve, or a pop as the needl e enters the
subarachnoi d space, and then advance the needl e 1 to 2 mm
farther. The pop may not be fel t i n younger chi l dren. Wi thdraw the
styl us, and check the hub for fl ui d. If there i s no fl ui d, repl ace the
styl us, and advance another fracti on before repeati ng.
Page 23
(4) Wi th the styl et i n pl ace, sl owl y i nsert a 22- or 20- gauge spi nal
needl e mi dway between the two spi nous processes.
PITFALL: Make sure the bevel of the needle enters and exits the
dura parallel to the long axis of the spinal column. This may
lower the incidence of spinal nerve root damage and
postprocedure headache.
After fl ui d i s obtai ned, obstruct the passage of fl ui d wi th the styl et
or your thumb. Pl ace the stopcock and manometer onto the hub of
the needl e. As the CSF ri ses i n the manometer, observe the col or of
the fl ui d and the openi ng pressure (Tabl e 2-1).
(5) Once fl ui d i s obtai ned, obstruct the passage of fl ui d wi th the
styl et, and pl ace the stopcock and manometer onto the hub of the
needl e.
Page 24
PITFALL: Have the patient relax his or her legs to prevent
falsely elevating the opening pressure.
PITFALL: Accurate pressure measurements can only be made in
the decubitus position.
P.15
Turn the stopcock to al l ow 2 to 3 mL of the CSF i n chi l dren or 4 to 5
mL i n adul ts to fl ow i nto each test tube. If desi red, measure the
cl osi ng pressure, but thi s has l i ttl e val ue and removes addi ti onal
CSF.
(6) Turn the stopcock to al l ow 2 to 3 mL of the CSF i n chi l dren or 4
to 5 mL i n adul ts to fl ow i nto each test tube.
PITFALL: Allow the fluid in the manometer tube to flow into the
tubes first to lower the amount of CSF removed.
PITFALL: If the tubes are not prelabeled, make sure to place the
tubes in order, so that you can easily identify and label each
tube after the procedure.
P.16
Page 25
Repl ace the styl us, and wi thdraw the needl e. Wash off the
povi done-i odi ne, and cover the puncture si te wi th a steri l e
dressi ng. Have the pati ent turn to the supi ne posi ti on and remai n
hori zontal for the next 2 hours.
(7) Repl ace the styl us, and wi thdraw the needl e.
P.17
CODING INFORMATION
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Page 27
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Page 28
ark of
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ati on.
Spi nal tray sets may be obtai ned through Arrow Medi cal Products,
Ltd., 2400 Bernvi l l e Road, Readi ng, PA 19605 (phone:
800-233-3187; http://www.arrowi ntl .com/products/cri ti cal _care/).
Many ki ts and suppl i es from vari ous compani es, i ncl udi ng Baxter
and Ameri can Hospi tal Suppl y, can be obtai ned from Cardi nal
Heal th, Inc., 7000 Cardi nal Pl ace, Dubl i n, OH 43017 (phone:
800-234-8701; http://www.cardi nal .com/ must regi ster onl i ne) and
from Owens and Mi nor, 4800 Cox Road, Gl en Al l en, VA 23060-6292
(phone: 804-747-9794; fax: 804-270-7281).
BIBLIOGRAPHY
Chordas C. Post-dural puncture headache and other compl i cati ons
after l umbar puncture. J Pedi atr Oncol Nurs 2001;18:244259.
Errando CL, Pei ro CM. Postdural puncture upper back pai n as an
atypi cal presentati on of postdural puncture symptoms.
Anesthesi ol ogy 2002;96:10191020.
Fl aatten H, Thorsen T, Askel and B, et al . Puncture techni que and
postural postdural puncture headache: a randomi sed, doubl e-bl i nd
study compari ng transverse and paral l el puncture. Acta
Anaesthesi ol Scand 1998;42:12091214.
Grande PO, Myhre EB, Nordstrom CH, et al . Treatment of
i ntracrani al hypertensi on and aspects on l umbar dural puncture i n
severe bacteri al meni ngi ti s. Acta Anaesthesi ol Scand
2002;46:264270.
Page 29
Hasbun R, Abrahams J, Jekel J, et al . Computed tomography of the
head before l umbar puncture i n adul ts wi th suspected meni ngi ti s. N
Engl J Med 2001;345:17271733.
Hol dgate A, Cuthbert K. Peri l s and pi tfal l s of l umbar puncture i n the
emergency department. Emerg Med 2001;13:351358.
Levi ne DN, Rapal i no O. The pathophysi ol ogy of l umbar puncture
headache. J Neurol Sci 2001;192:18.
Marton KI, Gean AD. The spi nal tap: a new l ook at an ol d test. Arch
I ntern Med 1986;104:840848.
Thoenni ssen J, Herkner H, Lang W, et al . Does bed rest after
cervi cal or l umbar puncture prevent headache? A systemati c revi ew
and meta-anal ysi s. Can Med Assoc J 2001;165:13111316.
Thomas SR, Jami eson DR, Mui r KW. Randomi sed control l ed tri al of
atraumati c versus standard needl es for di agnosti c l umbar puncture.
BMJ 2000;321:986990.
Page 30
> Table of Cont ent s > General Procedures > 3 - Thoracent esis3
Thoracentesis
Thoracentesi s i s a procedure commonl y performed to eval uate or
treat fl ui d col l ecti ons i n the pl eural space. Di agnosti c thoracentesi s
i s i ndi cated for most newl y di scovered pl eural fl ui d col l ecti on of
unknown ori gi n. Approxi matel y 1.5 mi l l i on i ndi vi dual s i n the Uni ted
States devel op a pl eural effusi on annual l y, and the cause can be
determi ned i n 75% of these cases by performi ng appropri ate
cytol ogi c, hematol ogi c, mi crobi ol ogi c, and chemi cal anal yses of the
fl ui d.
Approxi matel y 10 to 20 mL of fl ui d i s normal l y present i n the
pl eural space. Thi s l ow-protei n fl ui d acts as a l ubri cant duri ng
respi rati on. The pl eural pressure gradi ent between the systemi c
ci rcul ati on to the pari etal surface (chest wal l ) and the pul monary
ci rcul ati on to the vi sceral surface (l ung) produces a dai l y fl ow of
about 10 mL of fl ui d through the pl eural space. Many di sease
states can produce di srupti on of hydrostati c pressure, osmoti c
pressure, capi l l ary permeabi l i ty, or l ymphati c drai nage, wi th the
resul ti ng formati on of abnormal col l ecti ons of fl ui d i n the pl eural
space. Esti mates of the vol ume of pl eural fl ui d can be made from
the chest x-ray fi l m. Bl unti ng of the costophreni c angl e correl ates
wi th 100 to 150 mL of fl ui d, opaci fi cati on of one hal f of a
hemi thorax i s produced by 1.0 to 1.5 L of fl ui d, and compl ete
opaci fi cati on of a hemi thorax i s produced by 2.5 to 3.0 L of fl ui d.
Several l aboratory tests hel p to characteri ze abnormal pl eural fl ui d
col l ecti ons as transudates or exudates (Tabl e 3-1). Transudates,
wi th a l i mi ted number of di agnosti c possi bi l i ti es, are general l y
associ ated wi th i mbal ances of hydrostati c and oncoti c pressures.
Transudates are noni nfl ammatory effusi ons that general l y have l ow
numbers of l ymphocytes and a predomi nance of monocytes.
Exudates
Page 31
P.19
resul t from a l egi on of di agnosti c possi bi l i ti es and are caused by
pl eural i nfl ammati on and i mpai red l ymphati c drai nage of the pl eural
space. In acute stages, exudates have hi gh l eukocyte counts and a
predomi nance of l ymphocytes. The di sti ncti on between a transudate
and exudate di rects the cl i ni ci an to the appropri ate di fferenti al
di agnoses and subsequent treatment opti ons (Tabl es 3-2 and 3-3).
Excepti ons exi st i n the cl assi fi cati on of effusi ons, because 20% of
effusi ons associ ated wi th pul monary embol us and 6% associ ated
wi th mal i gnancy are transudates. Observati on of the pl eural fl ui d
al so can provi de cl ues to i ts cause (Tabl es 3-4 and 3-5).
TABLE 3-1. CHARACTERISTICS OF PLEURAL EXUDATES

Pl eural fl ui d protei n l evel >3 g/dL
a
Pl eural fl ui d to serum protei n rati o >0.5
Pl eural fl ui d l actate dehydrogenase (LDH) l evel >200 uni ts
Pl eural fl ui d to serum LDH rati o >0.6
Pl eural fl ui d pH >7.3
Pl eural fl ui d speci fi c gravi ty >1.016

a
Transudates have the opposi te si gn (l ess than the cutoff) for the val ues l i sted for
exudates (e.g., pl eural fl ui d protei n l evel <3 g/dL).
Adapted from Erasmus JJ, Goodman PC, Patz EF. Management of mal i gnant pl eural
effusi ons and pneumothorax. Radi ol Cl i n North Am 2000;38:375383.
TABLE 3-2. CAUSES AND PROPERTIES OF TRANSUDATIVE PLEURAL EFFUSIONS
Page 32

Disease
a
Protein (g/dL) LDH (units)

Congesti ve heart fai l ure 0.63.8 10190
Peri toneal di al ysi s <1.0 <100
Uri nothorax (uri nary
obstructi on)
<1.0 <175
Nephroti c syndrome <1.0 <100

a
Ci rrhosi s (usual l y wi th asci tes) and atel ectasi s usual l y demonstrate the characteri sti c
pl eural fl ui d to serum rati os for protei n (<0.5) and l actate dehydrogenase (LDH) (<0.6).
Adapted from Sahn SA. The pl eura. Am Rev Respi r Di s 1998;138:184234.
TABLE 3-3. CAUSES AND PROPERTIES OF EXUDATIVE PLEURAL EFFUSIONS

Disease
a
Protein (g/dL) LDH (Units)

Parapneumoni c effusi on 1.46.1 400 to >1000
Tubercul osi s >4.0 <700
Bl astomycosi s 4.26.6 >225
Hi stopl asmosi s 4.15.7 200425
Cocci di omycosi s 3.56.5 Rati o >0.6
b
Cryptococcosi s 2.55.7 Rati o >0.6
b
Vi ral syndrome 3.24.9 Rati o >0.6
b
Mycopl asma i nfecti on 1.84.9 Rati o >0.6
b
Carci noma 1.58.0 300
Mesothel i oma 3.55.5 36600
Hepati ti s 3.05.0 Rati o >0.6
b
Asbestos pl eural effusi on 4.77.5 Rati o >0.6
b
Rheumatoi d pl euri sy Up to 7.3 Frequentl y >1000
Injury after myocardi al
i nfarcti on
3.7 202
Uremi c effusi on 2.16.7 102770
a
Exudates associ ated wi th pul monary embol i sm often have varyi ng l evel s of protei n and
l actate dehydrogenase (LDH). Aspergi l l osi s, acti nomycosi s, nocardi osi s, echi nococcosi s,
Legi onel l a i nfecti on, chyl othorax, esophageal perforati on, l upus pl euri ti s, sarcoi dosi s,
Page 33
pancreati ti s, pancreati c pseudocyst, Mei gs syndrome, hepati ti s, l ymphoma, radi ati on
pl euri ti s, and ruptured upper abdomi nal abscesses produce the characteri sti c pl eural
fl ui d to serum rati os for protei n (>0.5) and LDH (>0.6). Pul monary embol us al so
produces characteri sti c rati os i n 80% of pati ents; 20% have transudates.
b
Rati o refers to the pl eural fl ui d to serum rati o of LDH.
TABLE 3-4. DIAGNOSIS SUGGESTED BY EXAMINATION OF PLEURAL FLUID

Finding Suggested Diagnosis

Ammoni a odor of the fl ui d Uri nothorax
Bl ack fl ui d Aspergi l l us i nvol vement of the pl eura
Bl oody fl ui d Trauma, traumati c thoracentesi s, pul monary
embol i sm, or mal i gnancy
Brown fl ui d Rupture of an amebi c l i ver abscess i nto the
pl eural space
Food parti cl es i n the fl ui d Rupture of the esophagus i nto the pl eural
space
Putri d odor of the fl ui d Anaerobi c i nfecti on of the pl eura or
empyema
Vi scous fl ui d Mal i gnant mesothel i oma due to i ncreased
l evel s of hyal uroni c aci d
Whi te fl ui d Chyl othorax, chol esterol i n the fl ui d, or
empyema
Yel l ow-green fl ui d Rheumatoi d pl euri ti s
TABLE 3-5. STUDIES PERFORMED IN COMPLETE PLEURAL FLUID ANALYSIS
Page 34

Most cost-effecti ve studi es: l actate dehydrogenase (LDH), total protei n, whi te bl ood cel l
count and di fferenti al count, gl ucose, and pH
a
Si mul taneousl y draw serum for protei n, LDH, and gl ucose l evel s
Consi der arteri al pH measurement i f pl eural fl ui d pH <7.30
Consi der serum creati ni ne (to determi ne rati o) i f uremi c pl eural effusi on suspected
Determi ne i f the fl ui d i s a transudate or exudate; then consi der the fol l owi ng i f exudate
and
Infecti on i s suspected: Gram stai n, cul ture and sensi ti vi ty, potassi um hydroxi de
(KOH) stai n, fungal cul tures, aci d-fast baci l l i smears and cul ture, speci fi c anti gens,
ti ters and cul tures dependi ng on cl i ni cal presentati on
Mal i gnancy i s suspected: cytol ogy
Mi l ky fl ui d obtai ned: l i pi d studi es
Pancreati ti s or esophageal rupture suspected: amyl ase
Rheumatoi d or l upus pl euri ti s suspected: compl ement l evel s, rheumatoi d factors, LE
cel l s

a
Studi es ordered are based on the cl i ni cal presentati on; i t i s not necessary or
cost-effecti ve to order the enti re battery of tests for every pati ent.
Medi cati ons can produce pl eural fl ui d col l ecti ons. A number of
medi cati ons (e.g., procai nami de, hydral azi ne, i soni azi d, phenytoi n,
qui ni di ne) produce drug-i nduced l upus syndrome and pl eural fl ui d
col l ecti ons that are i ndi sti ngui shabl e from those of nati ve l upus
erythematosus. Medi cati ons that can di rectl y produce effusi ons
i ncl ude ni trofurantoi n, dantrol ene, methysergi de, methotrexate,
bromocri pti ne, mi noxi di l , and ami odarone.
P.20
Thoracentesi s i s consi dered rel ati vel y safe. The most common
compl i cati on after thoracentesi s i s pneumothorax, wi th an average
i nci dence of 6% to 19%. Uncontrol l abl e coughi ng duri ng the
procedure and the use of l arge-bore needl e wi thout catheters may
i ncrease the l i kel i hood of pneumothorax. Reexpansi on pul monary
edema can be seen when l arge effusi ons are removed or when fl ui d
removal al l ows atel ectati c l ung ti ssue to re-expand, especi al l y i f
Page 35
the l ung has been col l apsed for more than 7 days. Hemorrhage
devel ops i n l ess than 2% of procedures and necessi tates thoraci c
surgery consul tati on i f the bl eedi ng i s not control l ed i n 30 to 60
mi nutes.
Chest radi ographs have been routi nel y performed after
thoracentesi s. Several studi es questi on the practi ce and suggest
that routi ne performance of the study i n an asymptomati c i ndi vi dual
after an uncompl i cated procedure adds no management benefi t. If
mul ti pl e needl e passes are requi red before fl ui d i s obtai ned, i f the
pati ent has a hi story of chest i rradi ati on or a pri or scl erosi ng
techni que, or i f an ai r l eak i s detected duri ng the procedure,
obtai ni ng chest radi ograph i s i ndi cated.
P.21
INDICATIONS
Di agnosi s of a newl y di scovered pl eural effusi on
(thoracentesi s provi des a defi ni ti ve or presumpti ve
di agnosi s i n about 75%)
Therapeuti c removal of fl ui d for symptomati c
i mprovement (e.g., mal i gnant effusi on)
RELATIVE CONTRAINDICATIONS
Known cause for the pl eural effusi on (e.g., congesti ve
heart fai l ure)
Bl eedi ng di athesi s or anti coagul ati on
A smal l vol ume of pl eural fl ui d (e.g., i n a vi ral
syndrome) i f the procedure l i kel y wi l l produce
pneumothorax
Pati ents on mechani cal venti l ati on
P.22
PROCEDURE
The pati ent i s seated, wi th the arms crossed and the body resti ng
Page 36
comfortabl y on a support (e.g., sturdy adjustabl e tabl e) pl aced
hori zontal l y i n front of the body. A footstool can be used to fl ex
the pati ent's upper l egs. The thorax shoul d be erect. Al ternatel y,
for pati ents who cannot tol erate a seated posi ti on, the l eft l ateral
decubi tus posi ti on can be used.
(1) Seat the pati ent wi th the arms crossed and body resti ng
comfortabl y on a support pl aced hori zontal l y i n front of the body.
PITFALL: Complications can develop if the table supporting the
patient suddenly shifts during the procedure. Make sure the
table will not shift and that it can support the weight of the
patient' s torso during the procedure.
PITFALL: Avoid having the patient lean too far forward.
Gravitational forces may cause the fluid to shift more anteriorly,
increasing the likelihood of a postprocedure pneumothorax.
P.23
Determi ne the l evel of effusi on by percussi on (Fi gure 2A). The l evel
i s determi ned by the poi nt where the resonant percussi on tone of
the l ungs changes to a dul l percussi on tone of the fl ui d. The needl e
i nserti on si te shoul d be one i ntercostal space bel ow the l evel of
effusi on, at the upper porti on of the ri b and mi dway between the
Page 37
posteri or axi l l ary l i ne and the paraspi nal muscl es (Fi gure 2B). An
al ternate approach i s to i nsert the needl e above the ei ghth ri b, as
l ow i n the effusi on as possi bl e. Mark the si te by i ndenti ng the ski n
fi rml y wi th a fi ngernai l or pen cap.
(2) After you have determi ned the l evel of effusi on by percussi on,
mark the needl e i nserti on si te, whi ch i s l ocated one i ntercostal
space bel ow the l evel of the effusi on, at the upper porti on of the
ri b, and mi dway between the posteri or axi l l ary l i ne and the
paraspi nal muscl es, by i ndenti ng the ski n fi rml y wi th a fi ngernai l or
pen cap.
PITFALL: Have the preprocedure chest radiograph immediately
available for review. Aspiration of the wrong hemithorax is an
embarrassing and dangerous error.
PITFALL: Most experts recommend a lateral decubitus x-ray film
to make sure the fluid layers. Loculated fluid collections can be
difficult to tap and are best approached with imaging guidance
(i.e., ultrasound or computed tomography scan). Obtain the
Page 38
decubitus films before performing thoracentesis.
PITFALL: Routine approaches that are performed lower in an
effusion (to hit the main fluid collection) may have greater risk
of liver or splenic perforation.
P.24
Appl y steri l e gl oves, and have an assi stant open the steri l e
thoracentesi s tray. Swab a l arge area around the i nserti on si te wi th
povi done-i odi ne. Al ternatel y, some physi ci ans appl y anti septi c
sol uti on before appl i cati on of steri l e gl oves. Center the
fenestrati on on the drape over the i nserti on si te. Avoi d
contami nati on of the steri l e gl oves duri ng thi s step.
(3) Once gl oved, swab a l arge area around the i nserti on si te wi th
povi done-i odi ne, and center the fenestrati on of the drape over the
si te.
P.25
Draw up the l i docai ne i nto the 5-mL syri nge. Use the smal l
(25-gauge, 5/8-i nch) needl e to create a ski n wheal (about 1 cm
3
) at
Page 39
the i nserti on si te. The l arge (22-gauge, 1-i nch) needl e i s then
pl aced on the syri nge, and the needl e ti p i s i nserted to the upper
porti on of the ri b. A smal l amount (about 1 mL) of anestheti c i s
admi ni stered, and the needl e ti p i s backed up and redi rected above
the ri b unti l the pl eural surface i s reached. Some authors advocate
admi ni steri ng l i docai ne after passi ng the upper ri b every 2 mm of
i nserti on of the needl e ti p. Fl ui d may be aspi rated on reachi ng the
pl eura. After fl ui d i s detected, back up the needl e sl i ghtl y, and
admi ni ster the remai ni ng anestheti c. Note the depth of i nserti on of
the needl e to reach the pl eura. Remove the anesthesi a needl e, and
pl ace i t back on the tray.
(4) Create a ski n wheal (about 1 cm
3
) at the i nserti on si te by usi ng
a smal l -gauge needl e, and then wi th a l arge-gauge needl e attached
to a 5-mL syri nge contai ni ng l i docai ne, i nsert the ti p i nto upper
porti on of ri b, admi ni ster a smal l amount (about 1 mL) of
anestheti c, and conti nue to redi rect above ri b unti l pl eural space i s
reached.
P.26
The thoracentesi s needl e i s attached to the l arge (60-mL) syri nge
Page 40
and i nserted through anestheti zed ski n unti l the ri b i s reached. The
needl e i s then redi rected above the ri b i nto the pl eural space
(Fi gure 5A). The path of the needl e i s a Z i nserti on track (Fi gure
5B). On removal of a needl e through a Z track, the natural posi ti on
of the ti ssues tends to reduce the chances for l eaki ng fl ui d.
(5) Insert the thoracentesi s needl e through anestheti zed ski n i nto
the pl eural space usi ng the Z i nserti on track techni que.
PITFALL: Extensive bleeding can result from damage to an
intercostal artery from the large thoracentesis needle. Always
insert the needle just at the upper edge of the rib to avoid the
neurovascular bundle that lies beneath each rib.
P.27
Al though many physi ci ans perform thoracentesi s usi ng a strai ght
needl e, others prefer to wi thdraw fl ui d wi th a bl unt (Tuohy) needl e
Page 41
or fl exi bl e catheter because of concern about i njury to the l ung as
the fl ui d i s wi thdrawn. The fol l owi ng text descri bes the use of a
catheter system. On reachi ng the pl eural fl ui d, advance the soft
pl asti c catheter through the needl e. The needl e can be wi thdrawn
from the chest cavi ty whi l e the catheter i s hel d fi rml y stati onary
(i .e., needl e wi thdrawn whi l e the catheter remai ns i n the pl eural
cavi ty.) The hard pl asti c catheter guard can be fastened over the
needl e ti p to prevent damage to the catheter from the sharp bevel .
The syri nge can be reattached and pl eural fl ui d aspi rated. Do not
permi t ai r to enter the pl eural space duri ng thi s porti on of the
procedure. Usual l y, 35 to 50 mL i s adequate for the pl eural fl ui d
studi es. If a therapeuti c procedure i s performed, the stopcock can
be attached to the drai nage tubi ng and bag and a l arger vol ume of
fl ui d col l ected.
(6) After the pl eural fl ui d has been reached, advance the soft
Page 42
pl asti c catheter through the needl e, and aspi rate the pl eural fl ui d.
PITFALL: Do not attempt to withdraw the catheter through the
needle, because the plastic catheter can be severed and fall into
the pleural space.
PITFALL: Make sure an adequate length of catheter is inserted
into the pleural space before the needle is withdrawn. It is
frustrating if the catheter inadvertently comes out of the pleural
space when the needle is withdrawn and before fluid has been
obtained.
PITFALL: Do not attempt the removal of more than 1.5 L of fluid
in a single setting. Reexpansion pulmonary edema can result,
exacerbating the temporary (and usually minor) hypoxemia that
follows thoracentesis. Oxygen should be administered if dyspnea
occurs after the procedure. Close clinical monitoring is
advocated whenever an individual has more than 1 L of fluid
removed.
P.28
The catheter i s removed at the end of the procedure (or needl e and
catheter si mul taneousl y). The i nserti on si te i s gentl y rubbed, and
pressure i s appl i ed wi th gauze to the si te to ensure the absence of
a fl ui d l eak. The ski n si te i s washed cl ean, and a bandage i s
appl i ed to the si te.
(7) Remove catheter or needl e, or both, and rub and appl y pressure
to the si te, maki ng sure no fl ui d i s l eaki ng. Concl ude by washi ng
Page 43
and dressi ng the si te.
P.29
CODING INFORMATION
If i magi ng i s used to gui de the needl e pl acement, al ternate codes
are sel ected (76003, 76360, or 76942). Code 32002 i s used for
thoracentesi s wi th i nserti on of a tube (wi th or wi thout a water
seal ) for drai nage of a pneumothorax; code 32002 i s not used to
report chest tube pl acement for drai nage of the pl eura of bl ood or
pus (32020).
Medi care al l ows for the separate bi l l i ng of a thoracentesi s tray
(Heal thcare Common Procedure Codi ng System [HCPCS] code
A4550), and other i nsurance compani es may al so permi t separate
bi l l i ng for a tray (99070) i n addi ti on to 32000 when the procedure
i s performed i n offi ce.
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Page 45
i s a
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Thoracentesi s trays that i ncl ude al l i nstruments needed to perform
the procedure can be ordered from Al l egi ance Heal thcare Corp.,
McGraw Park, IL 60085 (phone: 847-689-8410;
http://www.cardi nal .com/al l egi ance) and from AVID Medi cal , Inc.,
Toano, VA 23168 (phone: 888-564-7153;
http://www.avi dmedi cal .com). Compl ete trays often i ncl ude the
fol l owi ng i tems:
Three-way stopcock and connector tubi ng
Luer l ock syri nge, 60 mL and 5 mL
Li docai ne hydrochl ori de (1%), 5 mL
Anesthesi a needl es, 25 gauge 5/8 i nch and 22 gauge
1 i nch
Seven-i nch Intracath wi th a 14-gauge needl e (some
trays do not have a thoracentesi s needl e)
Needl e guard for the thoracentesi s needl e
Drai nage tubi ng
Fl ui d col l ecti on bag
Three prel abel ed speci men tubes wi th caps, 10 mL
Two swab sti cks (povi done-i odi ne)
Gauze sponges 3 3 i nch
Anti septi c prep wel l
Towel
Fenestrated drape
Page 46
Puncture si te bandage (Band-Ai d)
Hospi tal wrap
P.30
BIBLIOGRAPHY
Barbers R, Patel P. Thoracentesi s made safe and si mpl e. J Respi r
Di s 1994;15:84151.
Candei ra SR, Bl asco LH, Sol er MJ, et al . Bi ochemi cal and cytol ogi c
characteri sti cs of pl eural effusi ons secondary to pul monary
embol i sm. Chest 2002;121:465469.
Col i ce GL, Curti s A, Desl auri ers J, et al . ACCP consensus
statement: medi cal and surgi cal treatment of parapneumoni c
effusi ons: an evi dence-based gui del i ne. Chest
2000;118:11581171.
Col l i ns TR, Sahn SA. Thoracentesi s: cl i ni cal val ue, compl i cati ons,
techni cal probl ems, and pati ent experi ence. Chest
1987;91:817822.
Col t HG, Brewer N, Barbur E. Eval uati on of pati ent-rel ated and
procedure-rel ated factors contri buti ng to pneumothorax fol l owi ng
thoracentesi s. Chest 1999;116:134138.
Erasmus JJ, Goodman PC, Patz EF. Management of mal i gnant pl eural
effusi ons and pneumothorax. Radi ol Cl i n North Am
2000;38:375383.
Fartoukh M, Azoul ay E, Gal l i ot R, et al . Cl i ni cal l y documented
pl eural effusi ons i n medi cal ICU pati ents: how useful i s routi ne
thoracentesi s? Chest 2002;121:178184.
Heffner JE, Brown LK, Barbi eri CA. Di agnosti c val ue of tests that
di scri mi nate between exudati ve and transudati ve pl eural effusi ons.
Chest 1997;111:970980.
Johnson RL. Thoracentesi s. In: Saunders manual of fami l y practi ce.
Rakel RE, ed. Phi l adel phi a: WB Saunders, 1996:166167.
Khorasani A, Appavu SK, Nader AM, et al . Tuohy needl e and l oss of
resi stance techni que: a safer approach for thoracentesi s [Letter].
Anesthesi ol ogy 1999;90:339340.
Page 47
Li ght RW, MacGregor MI, Luchsi nger PC, et al . Pl eural effusi ons: the
di agnosti c separati on of transudates and exudates. Ann I ntern Med
1972;77:507513.
Meeker D. A stepwi se approach to di agnosti c and therapeuti c
thoracentesi s. Mod Med 1993;61:6271.
Petersen WG, Zi mmerman R. Li mi ted uti l i ty of chest radi ograph
after thoracentesi s. Chest 2000;117:10381042.
Rubi ns JB, Col i ce GL. Eval uati ng pl eural effusi ons: how shoul d you
go about fi ndi ng the cause? Postgrad Med 1999;105:3948.
Sahn SA. The pl eura. Am Rev Respi r Di s 1988;138:184234.
Sahn SA, Good JT. Pl eural fl ui d pH i n mal i gnant effusi ons. Ann
I ntern Med 1988;108:345349.
Sarodi a BD, Gol dstei n LS, Laskowski DM, et al . Does pl eural fl ui d
pH change si gni fi cantl y at room temperature duri ng the fi rst hour
fol l owi ng thoracentesi s? Chest 2000;117:10431048.
Vi l l ena V, Perez V, Pozo F, et al . Amyl ase l evel s i n pl eural
effusi ons: a consecuti ve unsel ected seri es of 841 pati ents. Chest
2002;121:470474.
Zuber TJ. Offi ce procedures. AAFP Academy col l ecti on qui ck
reference gui des for fami l y physi ci ans. Bal ti more: Wi l l i ams &
Wi l ki ns, 1999:195204.
Page 48
> Table of Cont ent s > General Procedures > 4 - Chest Tube Insert ion4
Chest Tube Insertion
Chest tube pl acement i s a common therapeuti c procedure used to
provi de evacuati on of abnormal col l ecti ons of ai r or fl ui d from the
pl eural space. Chest tube i nserti on i s often requi red i n a setti ng of
trauma and can be a medi cal urgency. Chest trauma i s a common
cause of emergency department vi si ts and may resul t i n
pneumothorax, hemothorax, or secondary i nfecti on. Pati ents wi th
chest trauma shoul d be assessed for si gns of respi ratory
i nsuffi ci ency, such as restl essness, agi tati on, al tered or absent
breath sounds, or respi ratory di stress. In more severe cases,
pati ents may al so exhi bi t symptoms of cyanosi s, devi ated trachea,
and paradoxi cal chest wal l segment moti on or shock. Coagul ati on
studi es and a chest radi ograph shoul d be avai l abl e.
Sedati on may be used i f the pati ent i s not i n severe respi ratory
di stress, because the procedure i s pai nful . Fol l ow uni versal
precauti ons for body fl ui ds, and use good steri l e techni que,
i ncl udi ng a face mask and steri l e gown whenever possi bl e.
Sel ecti on of the proper chest tube i s i mportant. An 18- to 24-Fr
chest tube typi cal l y i s used for a pure pneumothorax. For a
hemothorax, empyema, or other fl ui d accumul ati on, a 32- to 40-Fr
catheter i s more commonl y empl oyed.
Injury to the heart, great vessel s, or l ung may occur duri ng chest
tube i nserti on. Other possi bl e compl i cati ons i ncl ude
subdi aphragmati c pl acement of the tube, open or tensi on
pneumothorax, subcutaneous emphysema, unexpl ai ned or persi stent
ai r l eakage, or l ocal i zed hemorrhage. Some physi ci ans bel i eve that
pri mary care physi ci ans shoul d have surgi cal backup avai l abl e,
especi al l y i n trauma si tuati ons, i n case one of the major
compl i cati ons occurs. As wi th al l procedures that penetrate the
ski n, i nfecti on i s a possi bi l i ty. There conti nues to be controversy
Page 49
concerni ng the need for prophyl acti c anti bi oti cs i n pati ents
requi ri ng a chest tube. Some data suggest that, for a traumati c
hemothorax or pneumothorax, there i s a reducti on i n the i nci dence
of empyema when at l east one dose of anti bi oti cs i s admi ni stered.
Tradi ti onal l y, experts recommended that a chest tube be pul l ed out
when the pati ent reached ful l i nspi rati on, often wi th a concomi tant
Val sal va maneuver. The theory i s that thi s i s the poi nt when
i ntrathoraci c pressure and l ung vol ume are maxi mal . The
i nvol untary refl ex whi l e the tube i s bei ng pul l ed i s a qui ck
i nspi ratory effort because of the pl eural pai n. In theory, thi s coul d
suck i n ai r just as the tube i s bei ng removed, necessi tati ng
rei nserti on of another tube. However, research i ndi cates that
di sconti nuati on of chest tubes at the end of i nspi rati on or
P.32
at the end of expi rati on has a si mi l ar rate of pneumothorax after
removal and that both methods are equal l y safe. Wi th al l other
thi ngs bei ng equal , the end-i nspi rati on ti mi ng remai ns the
preferred techni que.
INDICATIONS
Pneumothorax
Hemothorax
Chyl othorax
Empyema
Drai nage of recurrent pl eural effusi on
Preventi on of hydrothorax after cardi othoraci c surgery
CONTRAINDICATIONS
Bl eedi ng dyscrasi a
Systemi c anti coagul ati on
Smal l , stabl e pneumothorax (may spontaneousl y
resol ve)
Empyema caused by aci d-fast organi sms
Locul ated fl ui d accumul ati on
P.33
Page 50
PROCEDURE
Identi fy the i nserti on si te, whi ch i s usual l y at the fi fth i ntercostal
space i n the anteri or axi l l ary l i ne (just l ateral to the ni ppl e i n
mal es) i mmedi atel y behi nd the l ateral edge of the pectoral i s major
muscl e. Di rect the tube as hi gh and anteri orl y as possi bl e for a
pneumothorax. For a hemothorax, the tube i s usual l y i nserted at
the l evel of the ni ppl e and di rected posteri orl y and l ateral l y.
El evate the head of the bed 30 to 60 degrees, and pl ace (and
restrai n) the arm on the affected si de over the pati ent's head.
(1) Identi fy the i nserti on si te, whi ch i s usual l y at the fi fth
i ntercostal space i n the anteri or axi l l ary l i ne (just l ateral to the
ni ppl e i n mal es) and i mmedi atel y behi nd the l ateral edge of the
pectoral i s major muscl e.
PITFALL: Do not direct the tube toward the mediastinum
because contralateral pneumothorax may result.
PITFALL: The diaphragm, liver, or spleen can be lacerated if the
patient is not properly positioned or the tube is inserted too low.
P.34
Page 51
Assembl e the sucti on-drai n system accordi ng to manufacturer's
recommendati ons. Connect the sucti on system to a wal l sucti on
outl et. Adjust the sucti on as needed unti l a smal l , steady stream
of bubbl es i s produced i n the water col umn. If a sucti on-drai n
system i s not i mmedi atel y avai l abl e, pl ace a Penrose drai n at the
end of the chest tube to act as a one-way val ve unti l an
appropri ate system i s avai l abl e.
Page 52
(2) Connect the sucti on system to a wal l sucti on outl et, and adjust
the sucti on as needed unti l a smal l , steady stream of bubbl es i s
produced i n the water col umn.
P.35
Prep the area around the i nserti on si te wi th povi done-i odi ne
sol uti on, and drape wi th a fenestrated sheet. Usi ng the 10-mL
Page 53
syri nge and 25-gauge needl e, rai se a ski n wheal at the i nci si on
area (i n the i nterspace one ri b bel ow the i nterspace chosen for
pl eural i nserti on) wi th a 1% sol uti on of l i docai ne wi th epi nephri ne.
Li beral l y i nfi l trate the subcutaneous ti ssue and i ntercostal muscl es,
i ncl udi ng the ti ssue above the mi ddl e aspect of the i nferi or ri b to
the i nterspace where pl eural entry wi l l occur and down to the
pari etal pl eura. Usi ng the anestheti c needl e and syri nge, aspi rate
the pl eural cavi ty, and check for the presence of fl ui d or ai r. If none
i s obtai ned, change the i nserti on si te.
(3) Usi ng a 10-mL syri nge and 25-gauge needl e, rai se a ski n wheal
at the i nci si on area wi th 1% l i docai ne wi th epi nephri ne, and
l i beral l y i nfi l trate the subcutaneous ti ssue and i ntercostal muscl es.
PITFALL: Use less than 0.7 mL/kg of lidocaine with epinephrine
to avoid toxicity.
PITFALL: Be careful to keep away from the inferior border of rib
Page 54
to avoid the intercostal vessels.
P.36
Make a 2- to 3-cm transverse i nci si on through the ski n and the
subcutaneous ti ssues overl yi ng the i nterspace (Fi gure 4A). Extend
the i nci si on by bl unt di ssecti on wi th a Kel l y cl amp through the
fasci a toward the superi or aspect of the ri b above (Fi gure 4B). After
the superi or border of the ri b i s reached, cl ose and turn the Kel l y
cl amp, and push i t through the pari etal pl eura wi th steady, fi rm,
and even pressure (Fi gure 4C). Open the cl amp wi del y, cl ose i t, and
then wi thdraw i t.
(4) Make a 2- to 3-cm transverse i nci si on through the ski n and the
subcutaneous ti ssues overl yi ng the i nterspace, and extend the
i nci si on by bl unt di ssecti on wi th a Kel l y cl amp through the fasci a
toward the superi or aspect of the ri b above.
PITFALL: Be careful to prevent the tip of the clamp from
Page 55
penetrating the lung, especially if no chest radiograph was
obtained or if the x-ray film does not clearly show that the lung
is retracted from the chest wall.
PITFALL: Avoid being contaminated by the air or fluid that may
rush out when the pleura is opened.
P.37
Insert an i ndex fi nger to veri fy that the pl eural space, not the
potenti al space between the pl eura and chest wal l , has been
entered. Check for unanti ci pated fi ndi ngs, such as pl eural
adhesi ons, masses, or the di aphragm.
(5) Insert an i ndex fi nger to veri fy that the pl eural space has been
entered, and check for adhesi ons, masses, or the di aphragm.
P.38
Page 56
Grasp the chest tube so that the ti p of the tube protrudes beyond
the jaws of the cl amp, and advance i t through the hol e i nto the
pl eural space usi ng your fi nger as a gui de. Di rect the ti p of the
tube posteri orl y for fl ui d drai nage or anteri orl y and superi orl y for
pneumothorax evacuati on. Advance i t unti l the l ast si de hol e i s 2.5
to 5 cm (1 to 2 i nch) i nsi de the chest wal l . Attach the tube to the
previ ousl y assembl ed sucti on-drai nage system. Ask the pati ent to
cough, and observe whether bubbl es form at the water-seal l evel . If
the tube has not been properl y i nserted i n the pl eural space, no
fl ui d wi l l drai n, and the l evel i n the water col umn wi l l not vary wi th
respi rati on.
(6) Advance the chest tube through the hol e i nto the pl eural space
usi ng your fi nger as a gui de unti l the l ast si de hol e i s 2.5 to 5 cm
i nsi de the chest wal l .
PITFALL: If a significant hemothorax is present, consider
Page 57
collecting the blood in a heparinized autotransfusion device so
that it can be returned to the patient.
P.39
Suture the tube i n pl ace wi th 1-0 or 2-0 si l k or other nonabsorbabl e
sutures. The two sutures are ti ed so as to pul l the soft ti ssues
snugl y around the tube and provi de an ai rti ght seal . Ti e the fi rst
suture across the i nci si on, and then wi nd both suture ends around
the tube, starti ng at the bottom and worki ng toward the top. Ti e
the ends of the suture very ti ghtl y around the tube, and cut the
ends.
(7) Suture the tube i n pl ace wi th 1-0 or 2-0 si l k or other
nonabsorbabl e sutures.
Pl ace a second suture i n a hori zontal mattress or purse-stri ng
sti tch around the tube at the ski n i nci si on si te. Pul l the ends of
thi s suture together, and ti e a surgeon's knot to cl ose the ski n
around the tube. Wi nd the l oose ends ti ghtl y around the tube, and
fi ni sh the suture wi th a bow knot. The bow can be l ater undone and
used to cl ose the ski n when the tube i s removed.
Page 58
(8) Pl ace a second suture i n a hori zontal mattress or purse-stri ng
sti tch around the tube at the ski n i nci si on si te.
P.40
Pl ace petrol eum gauze around the tube where i t meets the ski n.
Make a strai ght cut i nto the center of two addi ti onal 4 4 i nch
steri l e gauze pads, and pl ace them around the tube from opposi te
di recti ons. Tape the gauze and tube i n pl ace, and tape together the
tubi ng connecti ons. Obtai n posteroanteri or and l ateral chest
radi ographs to check the posi ti on of the chest tube and the amount
of resi dual ai r or fl ui d as soon as possi bl e after the tube i s
i nserted.
Page 59
(9) Pl ace petrol eum gauze around the tube where i t meets the ski n,
and tape the gauze and tube i n pl ace al ong wi th the tubi ng
connecti ons.
PITFALL: A bedside, portable x-ray device is preferable to
sending the patient to another location, because the suction
usually must be removed and the tube may become displaced.
PITFALL: If the patient is sent to another location for
radiographs, do not clamp the chest tube, because any
continuing air leakage can collapse the lung or produce a tension
pneumothorax. Keep a water-seal bottle 1 to 2 feet lower than
the patient' s chest during transport. If a significant air leak
develops, perform chest films.
P.41
Use seri al chest auscul tati on, chest radi ographs, vol ume of bl ood
l oss, and amount of ai r l eakage to assess the functi oni ng of chest
Page 60
tubes. If a chest tube becomes bl ocked, i t usual l y may be repl aced
through the same i nci si on. Chest tubes are general l y removed when
there has been ai r or fl ui d drai nage of l ess than 100 mL/24 hours
for more than 24 hours.
(10) The chest tube i s general l y removed when there has been ai r
or fl ui d drai nage or l ess than 100 mL/24 hour for more than 24
hours.
PITFALL: Trying to open a blocked chest tube by irrigating or
passing a smaller catheter through it seldom works well and
increases the risk of infection.
PITFALL: Consider keeping the chest tube in place if the patient
is on a ventilator in case a new pneumothorax suddenly
develops.
P.42
Page 61
For chest tube removal , pl ace the pati ent i n the same posi ti on i n
whi ch the tube was ori gi nal l y i nserted. Prep the area wi th
povi done-i odi ne sol uti on. Unti e the suture wi th the bow knot,
l oosen the purse-stri ng sti tch, and cut the other suture near the
ski n. Cl amp the chest tube, and di sconnect the sucti on system. Ask
the pati ent to take a deep breath and perform a Val sal va
maneuver. Pl ace a gauze over the i nserti on si te, and remove the
tube wi th a swi ft moti on. Ti e the purse-stri ng suture.
(11) For chest tube removal , pl ace gauze over the i nserti on si te,
and remove the tube wi th a swi ft moti on.
Appl y petrol eum gauze or anti bi oti c oi ntment on gauze, and tape
securel y. Obtai n a chest radi ograph i mmedi atel y and at 12 to 24
hours to rul e out a recurrent pneumothorax.
Page 62
(12) Appl y petrol eum gauze or anti bi oti c oi ntment on gauze, and
tape securel y.
PITFALL: If the patient is on a ventilator, pause the ventilator
during chest tube removal.
P.43
CODING INFORMATION
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ati on.
Chest tubes ki ts, thoracostomy trays, and sucti on-drai nage system
are avai l abl e from Arrow Medi cal Products Ltd.; 2400 Bernvi l l e
Road, Readi ng, PA 19605 (phone: 800-233-3187;
http://www.arrowi ntl .com/products/cri ti cal _care/). Many ki ts and
suppl i es from vari ous compani es (i ncl udi ng Baxter and Ameri can
Hospi tal Suppl y) can be obtai ned from Cardi nal Heal th, Inc., 7000
Cardi nal Pl ace, Dubl i n, Ohi o 43017 (phone: 800-234-8701);
Al l egi ance Heal thcare Corp., McGraw Park, IL 60085 (phone:
847-689-8410; http://www.cardi nal .com/al l egi ance), and Owens and
Mi nor, 4800 Cox Road, Gl en Al l en, VA 23060-6292 (phone:
804-747-9794; fax: 804-270-7281). Chest tubes that are equi pped
wi th an i ntral umi nal trocar are not recommended, because they are
associ ated wi th a hi gher i nci dence of i ntrathoraci c compl i cati ons.
BIBLIOGRAPHY
Bal dt MM, Banki er AA, Germann PS, et al . Compl i cati ons after
emergency tube thoracostomy: assessment wi th CT. Radi ol ogy
1995;195:539543.
Bel l RL, Ovadi a P, Abdul l ah F, et al . Chest tube removal :
end-i nspi rati on or end-expi rati on? J Trauma 2001;50:674677.
Chan L, Rei l l y KM, Henderson C, et al . Compl i cati on rates of tube
thoracostomy. Am J Emerg Med 1997;15:368370.
Col l op NA, Ki m S, Sahn SA. Anal ysi s of tube thoracostomy
performed by pul monol ogi sts at a teachi ng hospi tal . Chest
Page 66
1997;112:709713.
Gi l bert TB, McGrath BJ, Soberman M. Chest tubes: i ndi cati ons,
pl acement, management, and compl i cati ons. J I ntensi ve Care Med
1993;8:7386.
Graber RE, Garvi n JM. Chest tube i nserti on. Pati ent Care
1988;9:159.
Hessel i nk DA, Van Der Kl ooster JM, Bac EH, et al . Cardi ac
tamponade secondary to chest tube pl acement. Eur J Emerg Med
2001;8:237239.
Jones PM, Hewer RD, Wol fenden HD, et al . Subcutaneous
emphysema associ ated wi th chest tube drai nage. Respi rol ogy
2001;6:8789.
Nahum E, Ben-Ari J, Schonfel d T, et al . Acute di aphragmati c
paral ysi s caused by chest-tube trauma to phreni c nerve. Pedi atr
Radi ol 2001;31:444446.
Parul ekar W, Di Pri mi o G, Matzi nger F, et al . Use of smal l -bore vs
l arge-bore chest tubes for treatment of mal i gnant pl eural
effusi ons. Chest 2001;120:1925.
Rashi d MA, Wi kstrom T, Ortenwal l P. Medi asti nal perforati on and
contral ateral hemothorax by a chest tube. Thorac Cardi ovasc Surg
1998;46:375376.
Schmi dt U, Stal p M, Geri ch T, et al . Chest tube decompressi on of
bl unt chest i njuri es by physi ci ans i n the fi el d: effecti veness and
compl i cati ons. J Trauma 1998;44:98101.
Page 67
> Table of Cont ent s > General Procedures > 5 - Abdominal Paracent esis5
Abdominal Paracentesis
Abdomi nal paracentesi s i s a safe and effecti ve di agnosti c and
therapeuti c procedure used i n the eval uati on of a vari ety of
abdomi nal probl ems, i ncl udi ng asci tes, abdomi nal i njury, acute
abdomen, and peri toni ti s. Asci tes may be recogni zed on physi cal
exami nati on as abdomi nal di stenti on and the presence of a fl ui d
wave. Therapeuti c paracentesi s i s empl oyed to rel i eve respi ratory
di ffi cul ty due to i ncreased i ntraabdomi nal pressure caused by
asci tes.
Mi dl i ne and l ateral approaches can be used for paracentesi s, wi th
the l eft-l ateral techni que more commonl y empl oyed. The l eft-l ateral
approach avoi ds ai r-fi l l ed bowel that usual l y fl oats i n the asci ti c
fl ui d. The pati ent i s pl aced i n the supi ne posi ti on, and sl i ghtl y
rotated to the si de of the procedure to further mi ni mi ze the ri sk of
perforati on duri ng paracentesi s. Because the cecum i s rel ati vel y
fi xed on the ri ght si de, the l eft-l ateral approach i s most commonl y
used.
Abdomi nal radi ographs shoul d be obtai ned before paracentesi s,
because ai r may be i ntroduced duri ng the procedure and may
i nterfere wi th i nterpretati on. It i s unnecessary to perform
abdomi nal ul trasound before paracentesi s, except i n cases of
di agnosti c uncertai nty. The bl adder and stomach may need to be
empti ed to decrease the ri sk of perforati on of these organs. Other
possi bl e compl i cati ons of paracentesi s i ncl ude bowel perforati on,
l acerati on of a major bl ood vessel , l oss of catheter or gui de wi re i n
the peri toneal cavi ty, abdomi nal wal l hematomas,
pneumoperi toneum, bl eedi ng, perforati on of the pregnant uterus,
and i nfecti on.
Most asceti c fl ui d reaccumul ates rapi dl y. Some expert recommend
that no more than 1.5 L of fl ui d be removed i n any si ngl e
Page 68
procedure. Pati ents wi th severe hypoprotei nemi a may l ose
addi ti onal al bumen i nto reaccumul ati ons of asci tes fl ui d and
devel op acute hypotensi on and heart fai l ure. Cancer pati ents wi th
mal i gnant effusi ons may al so need repeti ti ve therapeuti c
paracentesi s. Intravenous fl ui d and vascul ar vol ume support may be
requi red i n these pati ents i f l arger vol umes are removed.
After di agnosti c paracentesi s, fl ui d shoul d be sent to the l aboratory
for Gram stai n; cul ture; cytol ogy; protei n, gl ucose, and l actate
dehydrogenase l evel s; and bl ood cel l count wi th a di fferenti al cel l
count. A pol ymorphonucl ear cel l count of more than 500 cel l s/mm
3
i s hi ghl y suggesti ve of bacteri al peri toni ti s. An el evated peri toneal
fl ui d amyl ase l evel or a l evel greater than the serum amyl ase l evel
i s found i n pancreati ti s. Grossl y bl oody fl ui d i n the abdomen
(>100,000 red bl ood cel l s/mm
3
) i ndi cates more severe trauma or
perforati on of an abdomi nal organ.
P.45
The cl assi c posi ti ve test for hemoperi toneum i s the i nabi l i ty to read
newspaper type through the paracentesi s l avage fl ui d.
INDICATIONS
Eval uati on of asci tes
Eval uati on of bl unt or penetrati ng abdomi nal i njury
Rel i ef of respi ratory di stress due to i ncreased
i ntraabdomi nal pressure
Eval uati on of acute abdomen
Eval uati on of acute or spontaneous peri toni ti s
Eval uati on of acute pancreati ti s
CONTRAINDICATIONS
Acute abdomen requi ri ng i mmedi ate surgery (absol ute
contrai ndi cati on)
Coagul opathy or thrombocytopeni a (rel ati ve
Severe bowel di stenti on (use extra cauti on)
Mul ti pl e previ ous abdomi nal operati ons
Page 69
Pregnancy (absol ute to mi dl i ne procedure)
Di stended bl adder that cannot be empti ed wi th a Fol ey
catheter (rel ati ve contrai ndi cati on)
Obvi ous i nfecti on at the i ntended si te of i nserti on
(rel ati ve contrai ndi cati on)
Severe hypoprotei nemi a (rel ati ve contrai ndi cati on)
P.46
PROCEDURE
Pl ace the pati ent i n the hori zontal supi ne posi ti on, and ti l t the
pati ent sl i ghtl y to the si de of the col l ecti on (usual l y the l eft l ower
quadrant). Sl i ghtl y rotate the hi p down on the tabl e on the si de of
needl e i nserti on to make that quadrant of the abdomen more
dependent. The i nserti on si tes (Fi gure 1A) and abdomi nal wal l
anatomy (Fi gure 1B) are shown. Prep the ski n wi th povi done-i odi ne
sol uti on, and al l ow i t to dry whi l e appl yi ng steri l e gl oves and a
mask. Center the steri l e drape about one thi rd of the di stance from
the umbi l i cus to the anteri or i l i ac crest. Infi l trate the ski n and
subcutaneous ti ssues wi th a 1% sol uti on of l i docai ne wi th
epi nephri ne. A 2-i nch needl e i s then i nserted perpendi cul ar to the
ski n to i nfi l trate the deeper ti ssues and peri toneum wi th
anestheti c.
Page 70
(1) Inserti on si tes.
P.47
Insert an 18-gauge, 2-i nch angi ocatheter through the ski n. The
nondomi nant hand then stretches the ski n to one si de of the
puncture si te, and the needl e i s further i nserted to create a Z tract
(Fi gure 2A). Rel ease the pressure on the ski n after the needl e
enters the peri toneum. Advance the catheter unti l a pop i s
fel t and the catheter penetrates the peri toneum (Fi gure 2B).
Page 71
Remove the styl ette, attach to a Luer-l ock 20-mL syri nge, and
advance the catheter i nto the abdomi nal cavi ty (Fi gure 2C). Draw
the fl ui d i nto the syri nge. If no fl ui d returns, rotate, sl i ghtl y
wi thdraw, or advance the catheter unti l fl ui d i s obtai ned. If sti l l no
fl ui d returns, abort the procedure, and try an al ternati ve si te or
method. Use l arge Luer-ti pped syri nges or a syri nge and one-way
val ve or stopcock to remove addi ti onal fl ui d.
(2) Lateral si te.
P.48
If l avage i s desi red, such as for detecti ng hemoperi toneum after
trauma, make a 3- to 5-mm ski n i nci si on (i .e., l arge enough to
al l ow threadi ng a l avage catheter) i n the mi dl i ne 5 cm bel ow the
umbi l i cus. In a si mi l ar manner to that previ ousl y descri bed, i nsert
an 18-gauge needl e attached to a 20-mL syri nge i nto the
peri toneum whi l e appl yi ng sl i ght sucti on to the syri nge. Col l ect
fl ui d i n the syri nge as descri bed earl i er.
Page 72
(3) Mi dl i ne si te.
PITFALL: Maintain careful control over the depth of needle
penetration to help prevent accidental viscus perforation.
Introduce a gui de wi re through the needl e (Fi gure 4A). If there i s
any resi stance to the wi re's passage, wi thdraw the wi re, and
reposi ti on the needl e unti l the wi re feeds easi l y. Remove the
needl e after about one hal f of the wi re i s i nserted (Fi gure 4B).
Sl i de the peri toneal l avage catheter over the wi re usi ng a gentl e
twi sti ng moti on (Fi gure 4C). Remove the wi re after the catheter i s
i n the peri toneal cavi ty. Addi ti onal fl ui d may be aspi rated before
begi nni ng l avage. Connect the i ntravenous tubi ng, and i nfuse 700
to 1000 mL of Ri nger's l actate or normal sal i ne i nto the abdomi nal
cavi ty. Cl amp the tube, and gentl y rol l the pati ent from si de to
si de. Then uncl amp and connect the tubi ng to a 1-L vacuum bottl e
or a syri nge wi th stopcock, and remove the fl ui d. Adjust the
pati ent's posi ti on as necessary to get as much fl ui d as possi bl e
returned.
Page 73
(4) Peri toneal l avage.
PITFALL: Maintain careful control over the wire to prevent it
from slipping into the peritoneal cavity.
P.49
After the procedure, gentl y remove the catheter and appl y di rect
pressure to the wound. Observe the characteri sti cs of the fl ui d, and
send i t for the appropri ate studi es. If the i nserti on si te i s sti l l
l eaki ng fl ui d after 5 mi nutes of di rect pressure, suture the si te wi th
a verti cal mattress suture. Appl y a pressure dressi ng.
(5) Appl y di rect pressure to the wound after the catheter i s
removed.
PITFALL: Gauze dressing should be applied when rare,
persistent drainage occurs.
P.50
CODING INFORMATION
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Page 74
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ati on.
Instruments and materi al s are avai l abl e from Arrow Medi cal
Products Ltd.; 2400 Bernvi l l e Road, Readi ng, PA 19605 (phone:
800-233-3187; http://www.arrowi ntl .com/products/cri ti cal _care/).
Many ki ts and suppl i es from vari ous compani es (i ncl udi ng Baxter
and Ameri can Hospi tal Suppl y) can be obtai ned from Cardi nal
Heal th, Inc., 7000 Cardi nal Pl ace, Dubl i n, OH 43017 (phone:
800-234-8701; http://www.cardi nal .com/) and from Owens and
Mi nor, 4800 Cox Road, Gl en Al l en, VA 23060-6292 (phone:
804-747-9794; fax: 804-270-7281).
BIBLIOGRAPHY
Cappel l MS, Shetty V. A mul ti center, case-control l ed study of the
cl i ni cal presentati on and eti ol ogy of asci tes and of the safety and
cl i ni cal effi cacy of di agnosti c abdomi nal paracentesi s i n HIV
seroposi ti ve pati ents. Am J Gastroenterol 1994;89:21722177.
Guarner C, Sori ano G. Spontaneous bacteri al peri toni ti s. Semi n
Page 78
Li ver Di s 1997;17:203217.
Gupta S, Tal war S, Sharma RK, et al . Bl unt trauma abdomen: a
study of 63 cases. I ndi an J Med Sci 1996;50:272276.
Hal pern NA, McEl hi nney AJ, Greenstei n RJ. Postoperati ve sepsi s:
reexpl ore or observe? Accurate i ndi cati on from di agnosti c abdomi nal
paracentesi s. Cri t Care Med 1991;19:882886.
Mansoor T, Zubari S, Masi ul l ah M. Eval uati on of peri toneal l avage
and abdomi nal paracentesi s i n cases of bl unt abdomi nal traumaa
study of fi fty cases. J I ndi an Med Assoc 2000;98:174175.
Runyon BA. Management of adul t pati ents wi th asci tes caused by
ci rrhosi s. Hepatol ogy 1998;27:264272.
Stephenson J, Gi l bert J. The devel opment of cl i ni cal gui del i nes on
paracentesi s for asci tes rel ated to mal i gnancy. Pal l i at Med
2002;16:213218.
Thomson A, Cai n P, Kerl i n P, et al . Seri ous hemorrhage compl i cati ng
di agnosti c abdomi nal paracentesi s. J Cl i n Gastroenterol
1998;26:306308.
Watanabe A. Management of asci tes: a revi ew. J Med
1997;28:2130.
Webster ST, Brown KL, Lucey MR, et al . Hemorrhagi c compl i cati ons
of l arge vol ume abdomi nal paracentesi s. Am J Gastroenterol
1996;91:366368.
Page 79
> Table of Cont ent s > General Procedures > 6 - Ring Removal6
Ring Removal
Few pi eces of jewel ry carry the personal or soci etal i mportance and
meani ng of fi nger ri ngs. Unfortunatel y, di gi tal swel l i ng can l eave a
fi nger or toe ri ng ti ghtl y and pai nful l y trapped at the base of the
proxi mal phal anx. Swel l i ng can be caused by l ocal trauma,
i nfecti ons, arthri ti s, dermatol ogi c condi ti ons, and al l ergi c reacti ons.
As swel l i ng i ncreases, venous outfl ow from the di gi t i s i ncreasi ngl y
restri cted by the tourni quet-l i ke effects of the ri ng. If not promptl y
treated, possi bl e compl i cati ons i ncl ude nerve damage, i schemi a,
and di gi tal gangrene. Di fferent techni ques may be used to remove
the ri ng wi th no or mi ni mal damage to i t.
Before attempti ng ri ng removal , assess the i nvol ved di gi t for major
l acerati ons. Assess neurol ogi c compromi se usi ng a si mpl e test such
as the two-poi nt di scri mi nati on test. A Doppl er fl ow meter may al so
be used to moni tor di stal di gi tal pul ses. If there i s evi dence of
neurovascul ar compromi se (i .e., reduced sensory percepti on or
di mi ni shed pul ses), the ri ng shoul d be removed by the fastest
method: cutti ng. In the absence of neurovascul ar compromi se,
ri ng-spari ng techni ques may be attempted to preserve i ts i ntegri ty.
After removal of a ri ng, neurovascul ar i ntegri ty must be
re-eval uated by tacti l e sensati on and capi l l ary refi l l of the di gi t. If
defi ci ts are found i n ei ther area, prompt consul tati on wi th a hand
speci al i st i s warranted.
Instruct the pati ent to el evate the i nvol ved extremi ty to encourage
venous and l ymphati c drai nage. Lubri cate the di gi t wi th soap,
gl yceri n, or a water-sol ubl e l ubri cant. Someti mes, these measures
al l ow the ri ng to sl i de off wi th gentl e tracti on.
INDICATIONS
Removal of a ri ng from a swol l en di gi t
Page 80
CONTRAINDICATIONS
Use the ri ng-cutti ng techni que i f there are l acerati ons or
neurovascul ar compromi se.
P.52
PROCEDURE
When usi ng the stri ng techni que, after el evati ng the di gi t, wrap i t
i n a spi ral l i gature from the ti p of the di gi t to the ri ng.
Two-mi l l i meter umbi l i cal tape or 0-gauge or l arger brai ded suture
wi th a tapered needl e i s best, but other materi al s may be used.
Perform the wrappi ng wi th enough tensi on so that the i ntersti ti al
fl ui d gentl y moves under the ri ng but not so ti ghtl y as to obstruct
arteri al fl ow.
Page 81
(1) Wrap the el evated di gi t i n a spi ral l i gature wi th l arger brai ded
suture usi ng a tapered needl e from the ti p of the di gi t to the ri ng.
PITFALL: Avoid the use of monofilament or thin sutures because
they can tear through the skin.
P.53
In the stri ng techni que, the end i s then passed beneath the ri ng,
taki ng care not to pi erce the ski n. Grabbi ng the end of the tape or
the suture needl e wi th a smal l hemostat after i t passes under the
ri ng may faci l i tate thi s maneuver.
Page 82
(2) Pass the end of the suture beneath ri ng wi thout pi erci ng the
ski n.
The suture i s then sl owl y unwound from under the ri ng, pushi ng the
ri ng forward as i t unwraps. Lubri cati ng the suture can further
faci l i tate ri ng removal by thi s method.
Page 83
(3) Sl owl y unwi nd suture from under the ri ng, pushi ng the ri ng
forward as i t unwraps.
P.54
When usi ng the rubber gl ove techni que and the i nvol ved di gi t i s
markedl y swol l en, remove a fi nger from a smal l ,
powder-free, l atex surgi cal gl ove, and pul l i t onto the di gi t. When
the ri m of the gl ove fi nger nears the ri ng, pass a smal l , curved
forceps under the proxi mal si de of the ri ng to grasp the l atex, and
draw i t between the ri ng and the di gi t. Al l ow the l atex to compress
the swol l en di gi t uni forml y unti l the ri ng can be passed over the
l ubri cated gl ove and di gi t.
Page 84
(4) Rubber gl ove techni que.
PITFALL: Watch for latex allergy, which can worsen swelling.
Pi ck the thi nnest, l east ornate, or most accessi bl e porti on of the
ri ng for the cutti ng si te. The ri ng cutter i s i l l ustrated. The di gi t
guard of the ri ng cutter i s passed under the ri ng and protects the
di gi t from i njury.
Page 85
(5) Ri ng cutter.
P.55
If el evati on of the cutti ng si te on the ri ng i s necessary for passi ng
the di gi t guard, the ri ng may be compressed wi th pl i ers. Appl y
pressure to the ri ng wi th the jaws of the pl i ers pl aced 90 degrees
on ei ther si de of the cutti ng si te. Thi s converts the ri ng shape from
ci rcul ar to el l i pti cal , creati ng a space between the ri ng and
underl yi ng ti ssues. Compressi on from the si des tends to di spl ace
neurovascul ar bundl es to the l ess restri cted pal mar regi on and,
accordi ngl y, shoul d not compromi se them.
(6) Pi ck the thi nnest porti on of the ri ng as the cutti ng si te, and
use pl i ers i f necessary to compress the ri ng i f you cannot pass the
di gi t guard under the si te.
PITFALL: Avoid excessive pressure and trauma to the digit. Even
with mild pressure, the patient must be warned that that he or
Page 86
she may experience some discomfort.
When cutti ng the ri ng, rotate the l ever that turns the ci rcul ar saw
bl ade. Conti nued rotati on of the saw bl ade severs the ri ng wi thout
cutti ng the ski n.
(7) Conti nual l y rotate the saw bl ade usi ng the l ever to sever the
ri ng wi thout i njuri ng the ski n.
P.56
The two ends of the di vi ded ri ng are then grasped wi th pl i ers or
hemostats, and they are pul l ed apart to open the ri ng and al l ow i ts
removal .
(8) Grasp the two ends of the di vi ded ri ng wi th pl i ers, and pul l
Page 87
them apart to remove the ri ngs from the fi nger.
If the object i s too thi ck or tempered for removal by thi s
i nstrument (e.g., steel nuts), consi der use of motori zed, hand-hel d
cutters wi th a sharp-edged, ci rcul ar gri nder. It i s usual l y necessary
to make two cuts 180 degrees apart, because such ri ngs are usual l y
too hard to bend. Pl ace a Si l asti c band or a si mi l ar materi al
beneath the ri ng-cutti ng si tes to protect the fi nger.
(9) Use motori zed, hand-hel d cutters wi th sharp-edged, ci rcul ar
gri nders to remove thi cker objects from the di gi t.
P.57
CODING INFORMATION
There i s no speci fi c code for ri ng removal . Use the appropri ate
eval uati on and management (E/M) code for the vi si t.
Page 88
Ri ng cutters may be obtai ned at Chi ef Suppl y Co., 2468 West 11th
Avenue; P.O. Box 22610, Eugene, OR 97402 (phone: 800-824-4338;
http://www.chi efssuppl y.com/ri ng_cutter.phtml ) or from Transcon
Sal es and Mfg. (Mi l tex Brand Ri ng Cutter), 5725 South Mai n Street,
Los Angel es, CA 90037-4171 (Phone: 888-299-8830;
http://www.transconmfg.com).
BIBLIOGRAPHY
Edl i ch RF, Eggl eston JM. Ri ng tourni quet syndrome. In: Ti nti nal l i JE,
Rui z E, Krome RL, eds. Emergency medi ci ne: a comprehensi ve study
gui de. New York: McGraw-Hi l l , 1985:300301.
Fasano FJ, Hansen RH. Forei gn body granul oma and synovi ti s of the
fi nger: a hazard of ri ng removal by the sawi ng techni que. J Hand
Surg Am 1987;12:621623.
Greenspan L. Tourni quet syndrome caused by metal l i c bands: a new
tool for removal . Ann Emerg Med 1982;11:375378.
Hi ew LY, Juma A. A novel method of ri ng removal from a swol l en
fi nger. Br J Pl asti c Surg 2000;53:173174.
Huss CD. Removi ng a ri ng from a swol l en fi nger. In: Dri scol l CE,
Rakel RE, eds. Pati ent care procedures for your practi ce. Oradel l ,
NJ: Medi cal Economi cs, 1988.
Mi zrahi S, Lunski I. A si mpl i fi ed method for ri ng removal from an
edematous fi nger. Am J Surg 1986;151:412413.
Paterson P, Khanna A. A novel method of ri ng removal from a
swol l en fi nger. Br J Pl ast Surg 2001;54:182.
Thi l agarajah M. An i mproved method of ri ng removal . J Hand Surg Br
1999;24:118119.
Page 89
> Table of Cont ent s > General Procedures > 7 - Fishhook Removal7
Fishhook Removal
Persons wi th penetrati ng fi shhook i njuri es commonl y present to the
offi ce or emergency department. Most of these i njuri es occur to the
hand, face, head, or upper extremi ty. The pul l of the fi shi ng l i ne
tends to create a tangenti al entry and superfi ci al penetrati on.
Al though ocul ar i nvol vement shoul d prompt i mmedi ate referral to an
ophthal mol ogi st, most removal techni ques can be performed
wi thout ski n i nci si ons.
Three of the most commonl y empl oyed techni ques are demonstrated
i n thi s chapter. The retrograde techni que i s the si mpl est of the
removal techni ques, but i t frequentl y i s unsuccessful . The
retrograde techni que works wel l for barbl ess hooks or those i n very
superfi ci al l ocati ons. Thi s techni que does not requi re any addi ti onal
tool s.
The stri ng yank techni que i s a modi fi cati on of the retrograde
techni que. Thi s techni que i s rel ati vel y atraumati c and works wel l
wi th smal l to medi um-si zed hooks or those that are deepl y
embedded. The stri ng yank techni que i s rapi d and can be performed
wi thout the need for l ocal anesthesi a. The techni que cannot be
performed on hooks embedded i n mobi l e body parts such as
earl obes.
The advance and cut techni que i s al most uni versal l y successful ,
even when removi ng l arge, mul ti barbed hooks. The techni que i s
best performed wi th two tool s: needl e-nosed pl i ers for advanci ng
the hook and fi ne-poi nt wi re cutters to cut through the needl e.
These i nstruments are rel ati vel y i nexpensi ve and can be purchased
at most hardware stores. Local anesthesi a shoul d be admi ni stered
for thi s techni que. One major di sadvantage of the advance and cut
techni que i s the creati on of addi ti onal trauma and a second wound
si te on the ski n.
Page 90
After removal of the hook, the wound shoul d be expl ored for
possi bl e forei gn bodi es. Topi cal anti bi oti cs shoul d then be appl i ed
to the si te. Most wel l -conducted, control l ed studi es do not
demonstrate benefi t from systemi c anti bi oti c use.
P.59
INDICATIONS
Fi shhooks that are embedded i n the ski n and superfi ci al
ti ssues
CONTRAINDICATIONS
Ocul ar embedded fi shhooks
Obvi ous penetrati on through other deep, vi tal structures
such as hand extensor tendons
Fi shhooks i n mobi l e structures such as earl obes (i .e., for
stri ng yank techni que)
P.60
PROCEDURE
Appl y downward pressure to the shaft of the hook i n an attempt to
di sengage the barb. Back out the hook through the path of entry.
Page 91
(1) The retrograde techni que.
Fi shi ng l i ne or a stri ng i s ti ed to the mi dpoi nt of the bend i n the
hook (Fi gure 2A). Grasp thi s stri ng ti ghtl y onl y 3 to 4 i nches from
the hook, and then use the nondomi nant hand to stabi l i ze the
ti ssues around the embedded hook. Appl y downward pressure to the
shaft of the hook whi l e fi rml y and rapi dl y pul l i ng on the stri ng to
wi thdraw the hook (Fi gure 2B).
(2) The stri ng yank techni que.
P.61
After admi ni strati on of l ocal anesthesi a, grasp the upper shaft of
the hook usi ng a stabi l i zi ng i nstrument such as a needl e dri ver or
Page 92
needl e-nose pl i ers (Fi gure 3A). Advance the hook through the ski n,
fol l owi ng the curvature of the hook (Fi gure 3B). Usi ng fi ne-ti pped
wi re cutters, cut the upper shaft just bel ow the eye of the hook
(Fi gure 3C). Grasp the hook near the ti p, and pul l i t free from the
ski n (Fi gure 3D).
(3) The advance and cut techni que.
P.62
CODING INFORMATION
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Needl e-nose pl i ers and fi ne-ti pped wi re cutters can be purchased at
any hardware store. These i nstruments can be i nexpensi ve but
val uabl e addi ti ons to the pri mary care offi ce for unusual
emergenci es. A suggested anesthesi a tray that can be used for thi s
procedure i s l i sted i n Appendi x G.
BIBLIOGRAPHY
Brown JSB. Mi nor surgery: a text and atl as, 3rd ed. London:
Chapman & Hal l , 1997:335.
Cannava PE. Fi shhook removal s. Arch Ophthal mol
1999;117:16681669.
Doser C, Cooper WL, Edi ger WM, et al . Fi shhook i njuri es: a
prospecti ve eval uati on. Am J Emerg Med 1991;9:413415.
El dad S. Embedded fi shhook removal [Letter]. Am J Emerg Med
2000;18:736737.
Gammons M, Jackson E. Fi shhook removal . Am Fam Physi ci an
2001;63:22312236.
Lantsberg L, Bl i ntsovsky E, Hoda J. How to extract an i ndwel l i ng
fi shhook. Am Fam Physi ci an 1992;45:25892590.
Rudni tsky GS, Barnet RC. Soft ti ssue forei gn body removal . In:
Roberts JR, Hedges JR, eds. Cl i ni cal procedures i n emergency
medi ci ne, 3rd ed. Phi l adel phi a: WB Saunders, 1998:623624.
Suresh SD. Fi sh-hook removal . Lancet 1991;338:14631464.
Weber LE. Removi ng fi shhooks. In: Dri scol l CE, Rakel RE, eds.
Page 99
Pati ent care procedures for your practi ce. Los Angel es: Practi ce
Management Informati on Corporati on, 1991:331335.
Page 100
> Table of Cont ent s > General Procedures > 8 - Tick Removal8
Tick Removal
Many peopl e work and pl ay i n nonurban areas where they are
exposed to ti ck bi tes. The ti ck bi te i tsel f usual l y produces harml ess
effects, such as mi l d i nfl ammatory reacti on or estheti c di staste.
However, several medi cal l y i mportant i l l nesses may devel op from
mi croorgani sms transmi tted by the ti ck, i ncl udi ng Rocky Mountai n
spotted fever, Q fever, typhus, ti ck fever, tul aremi a, babesi osi s,
rel apsi ng fever, and Lyme di sease. Ti ck-borne di seases can be
transmi tted by carel ess handl i ng of i nfected ti cks and through
bi tes. The neurotoxi n secreted i n the sal i va of certai n ti cks may
al so resul t i n a progressi ve ascendi ng paral ysi s. To l i mi t exposure
to potenti al l y pathogeni c organi sms, expedi ent and effecti ve ti ck
removal i s recommended.
There are two major fami l i es of ti cks that bi te humans. The
Argasi dae fami l y (i .e., soft ti cks) tend to l i ve around burrows,
roots, and nests of bi rds or repti l es. They attach and feed for
mi nutes to hours and then fal l off the prey. The Ixodi dae fami l y
(i .e., hard ti cks) hi de i n grasses al ong the si des of ani mal trai l s
and attach themsel ves to a passi ng host. They remai n attached
unti l engorged, unti l they di e, or unti l they are physi cal l y removed.
In thei r l arval stage, i xodi d ti cks are known as seed ti cks and may
i nfest i n great numbers. One anecdotal report demonstrated
removal of seed ti cks wi th l i ndane shampoo.
Hard adul t ti cks are usual l y best removed mechani cal l y. A ti ck
attaches to i ts host wi th mouthparts equi pped wi th speci al i zed
structures desi gned to hol d i t embedded i n the ski n. Most speci es
secrete a cement from the sal i vary gl ands that toughens i nto a
hard col l ar around the mouthparts to hel p hol d i t i n pl ace. After
removal , assess whether the ti ck i s i ntact by i nspecti ng i t for the
mouthparts. If they are retai ned i n the ski n, i t may be necessary to
Page 101
perform a punch bi opsy to remove the remnants of the ti ck.
In the past, the appl i cati on of petrol eum jel l y, fi ngernai l pol i sh,
70% i sopropyl al cohol , or a hot ki tchen match was advocated to
i nduce the detachment of adul t ti cks. However, ti cks are extremel y
hard to suffocate because thei r respi ratory rate i s onl y 15 breaths
per hour, and studi es have shown that these methods rarel y work.
Some of these methods may al so i ncrease the l i kel i hood that the
ti ck wi l l regurgi tate i nto the si te, promoti ng di sease transmi ssi on.
These techni ques are not recommended. There i s one anecdotal
report of usi ng a 2% vi scous l i docai ne, whi ch caused the ti ck to
rel ease after about 5 mi nutes. It i s unknown whether thi s method
i ncreases the ri sk of di sease transmi ssi on.
P.64
Advi se pati ents about the possi bi l i ty of l ocal or systemi c i nfecti on,
and i nstruct them to watch for si gns of Lyme di sease (i .e.,
erythema margi natum). Excessi ve bl eedi ng from the removal si te i s
rare and usual l y easi l y control l ed wi th standard measures. In cases
of a parti cul arl y tenaci ous ti ck or retai ned mouthparts, a punch
bi opsy trephi ne may be used to remove the l ocal ski n and any part
of the ti ck that i s attached (see Chapter 10).
Instruct pati ents on ti ck i nfestati on preventi on methods. When
outdoors, protecti ve cl othi ng shoul d be tucked i n at the wri sts and
ankl es and sprayed wi th a ti ck repel l ant. Bare ski n shoul d have
repel l ant appl i ed every few hours.
INDICATIONS
Removal of ti cks embedded i n the ski n
P.65
PROCEDURE
Gentl y pai nt the surroundi ng area wi th povi done-i odi ne or a si mi l ar
sol uti on. Sl i de a pai r of curved hemostats between the ski n and the
Page 102
body of the ti ck. Strai ght forceps, tweezers, or gl oved fi ngers al so
may be used.
(1) After wi pi ng the surroundi ng area wi th povi done-i odi ne, sl i de a
pai r of curved hemostats between the ski n and the body of the
ti ck.
Pul l upward and perpendi cul arl y, wi th steady, even pressure. Pl ace
the ti ck i n a contai ner of al cohol , and ask the pati ent to pl ace the
contai ner i n a freezer i n case subsequent i denti fi cati on i s
warranted. Di si nfect the bi te si te wi th povi done-i odi ne scrub or
anti bacteri al soap.
(2) Pul l upward and perpendi cul arl y wi th steady, even pressure.
Page 103
PITFALL: Avoid leaving part or all of the arthropod' s head or
mouthparts. The further from the head traction is applied, the
greater is the chance parts will be broken off. When using
hemostats or other grasping devices, grasp the tick as close to
the skin surface as possible, and do not twist or jerk the tick.
PITFALL: Never squeeze, crush, or puncture the body of the
tick, because this may force infectious agents into the wound or
onto the examiner.
P.66
Al ternati vel y, a speci fi c ti ck removal devi ce, such as the TICKED
OFF devi ce, may be used i n pl ace of curved hemostats. Whi l e
hol di ng TICKED OFF verti cal to the ski n, pl ace the wi de part of the
notch on the ski n near the ti ck. Appl yi ng sl i ght pressure downward
on the ski n, sl i de the remover forward so the smal l part of the
notch i s up agai nst the ti ck. Use a sl ow, conti nuous,
forward-sl i di ng moti on of the remover to detach the ti ck (a moti on
si mi l ar to scoopi ng hard i ce cream from a bucket).
Page 104
(3) A speci fi c ti ck removal devi ce can be used i nstead of curved
hemostats.
P.67
CODING INFORMATION
There i s no speci fi c code for ti ck removal . Code an appropri ate
offi ce vi si t, wi th a punch bi opsy code i f a Keys punch i s used.
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Page 106
A standard offi ce surgi cal tray i s used for si mpl e surgi cal
procedures (see Appendi x A).
TICKED OFF may be purchased at Jeffers Pet Suppl i es (phone:
800-533-3377; http://www.jefferspet.com).
BIBLIOGRAPHY
Hal pern JS. Ti ck removal . J Emerg Nurs 1988;14:307309.
Jones BE. Human seed ti ck i nfestati on: Ambl yomma
ameri canum l arvae. Arch Dermatol 1981;117:812814.
Kammhol z LP. Vari ati on on ti ck removal . Pedi atri cs
1986;78:378379.
Karras DJ. Ti ck removal . Ann Emerg Med 1998;32:519.
Munns R. Punch bi opsy of the ski n. In: Dri scol l CE, Rakel RE, eds.
Pati ent care: procedures for your practi ce. Oradel l , NJ: Medi cal
Economi cs, 1988.
Needham G. Eval uati on of fi ve popul ar methods for ti ck removal .
Pedi atri cs 1985;75:9971002.
Oteo JA, Casas JM, Marti nez de Artol a V. Lyme di sease i n outdoor
workers: ri sk factors, preventi ve measures, and ti ck removal
methods. Am J Epi demi ol 1991;133:754755.
Patterson J, Fi tzwater J, Connel l J. Local i zed ti ck bi te reacti on.
Cuti s 1979;24:168169, 172.
Pearn J. Neuromuscul ar paral ysi s caused by ti ck envenomati on. J
Neurol Sci 1977;34:3742.
Shakman RA. Ti ck removal . West J Med 1984;140:99.
Page 107
> Table of Cont ent s > Dermat ology > 9 - Local Anest hesia Administ rat ion9
Local Anesthesia Administration
The techni ques for mi ni mi zi ng di scomfort duri ng l ocal anestheti c
admi ni strati on are often overl ooked i n modern cl i ni cal practi ce.
Most mi nor or offi ce operati ons are performed after i njecti on of
l ocal anesthesi a. Proper admi ni strati on techni que can reduce
pati ent di scomfort, i mprove pati ent sati sfacti on wi th the servi ce,
and i mprove the procedure's outcome.
The two mai n cl asses of i njectabl e l ocal anestheti cs are the ami des
and the esters. The ami des are more wi del y used and i ncl ude
l i docai ne (Xyl ocai ne) and bupi vacai ne (Marcai ne). The esters,
represented by procai ne (Novocai n), have a sl ower onset of acti on
than the ami des, and a hi gher rate of al l ergi c reacti ons. Indi vi dual s
wi th an al l ergy to one cl ass of anestheti cs general l y can recei ve
the other cl ass safel y. Admi ni strati on of the esters i s l i mi ted to
i ndi vi dual s wi th a pri or al l ergi c reacti on to ami de anestheti cs.
Many pati ents cl ai m al l ergy to cai ne drugs, but they
actual l y have experi enced a vagal response or other systemi c
response to recei vi ng an i njecti on. If the exact nature of the pri or
reacti on cannot be ascertai ned, admi ni strati on of di phenhydrami ne
hydrochl ori de (Benadryl ) can provi de suffi ci ent anesthesi a for smal l
surgi cal procedures. Between 1 and 2 mL of di phenhydrami ne (25
mg/mL) sol uti on i s di l uted wi th 1 to 4 mL of normal sal i ne for
i ntradermal (not subdermal ) i njecti on.
Epi nephri ne i n the l ocal anestheti c sol uti on prol ongs the durati on
of the anestheti c and reduces bl eedi ng by produci ng l ocal
vasoconstri cti on. The use of epi nephri ne al so permi ts use of l arger
vol umes of anestheti c. An average-si zed adul t (70 kg) can safel y
recei ve up to 28 mL (4 mg/kg) of 1% l i docai ne and up to 49 mL (7
mg/kg) of 1% l i docai ne wi th epi nephri ne.
Hi stori cal l y, physi ci ans have been taught to avoi d admi ni steri ng
Page 108
sol uti ons wi th epi nephri ne to body si tes served by si ngl e arteri es,
such as fi ngers, toes, peni s, and the end of the nose. The
safety of admi ni steri ng epi nephri ne to the ti p of the nose or to the
di gi ts has been documented i n some reports, but l i mi ti ng the use
of epi nephri ne i n these si tes i s prudent i n the current medi col egal
cl i mate.
Local anestheti cs can be i njected i ntradermal l y or subdermal l y.
Intradermal admi ni strati on produces a vi si bl e wheal i n the ski n,
and the onset of acti on of the anestheti c i s al most i mmedi ate.
Intradermal i njecti on of a l arge vol ume of sol uti on
P.72
can stretch pai n sensors i n the ski n, ai di ng i n the anestheti c effect.
Thi s vol ume effect i s bel i eved to expl ai n the benefi t of normal
sal i ne i njecti ons i nto tri gger poi nts. Intradermal i njecti on i s
especi al l y useful for shave exci si ons, because the anestheti c
sol uti on effecti vel y thi ckens the dermi s, el evates the l esi on, and
prevents i nadvertent penetrati on beneath the dermi s.
Subdermal i njecti ons take effect more sl owl y but general l y produce
much l ess di scomfort for the pati ent. Some physi ci ans recommend
i ni ti al admi ni strati on of an anestheti c i nto a subdermal (l ess
pai nful ) l ocati on and then wi thdrawi ng the needl e ti p for
i ntradermal i njecti on. The i ni ti al subdermal admi ni strati on often
reduces the di scomfort of the i ntradermal i njecti on.
RECOMMENDATIONS TO REDUCE THE
DISCOMFORT OF LOCAL ANESTHESIA
Stretch the ski n usi ng the nondomi nant hand duri ng
admi ni strati on.
Encourage the pati ent to tal k as a di stracti on and for
moni tori ng for vagal responses.
Tal k to the pati ent duri ng admi ni strati on; si l ence
i ncreases pati ent di scomfort.
Use the smal l est gauge needl e possi bl e (preferabl y 30
gauge).
Page 109
Consi der sprayi ng aerosol refri gerant onto the ski n
before needl e i nserti on.
Consi der vi brati ng nearby ski n or patti ng di stant si tes to
di stract duri ng admi ni strati on.
Admi ni ster anestheti c at room temperature (i .e.,
nonchi l l ed sol uti ons).
Insert the needl e through enl arged pores, scar, or hai r
fol l i cl es (i .e., l ess sensi ti ve si tes).
Pause after the needl e penetrates the ski n to al l ow for
pati ent recovery and rel axati on.
Inject a smal l amount of anestheti c and pause, al l owi ng
the anestheti c to take effect.
Empower the pati ent by temporari l y stoppi ng the
i njecti on when burni ng i s detected.
Inject anestheti cs sl owl y.
Begi n the i njecti on subdermal l y, and then wi thdraw the
needl e ti p for i ntradermal i njecti on.
Consi der addi ti on of bi carbonate to buffer the aci di ty of
the anestheti c.
Permi t adequate ti me for the anestheti c to take effect
before i ni ti ati ng a surgi cal procedure.
P.73
PROCEDURE
Stretch the ski n wi th the nondomi nant hand before i nserti on of the
needl e i nto the ski n. Pati ents dread havi ng the needl e i nserted;
the di scomfort i s reduced i f the pai n sensors i n the ski n are
stretched.
Page 110
(1) Reduce the pati ent's di scomfort by stretchi ng the ski n wi th your
nondomi nant hand before i nserti on of the needl e.
PITFALL: Replace the needle used for drawing the anesthetic
from the stock bottle with a smaller (30-gauge) needle before
injection into the patient.
P.74
The syri nge i s hel d i n the domi nant hand i n the posi ti on ready to
i nject (Fi gure 2A). The thumb shoul d be near (but not on) the
pl unger. after the needl e i s i nserted i nto ski n, some physi ci ans
prefer to wi thdraw the pl unger to ensure that the needl e ti p i s not
i n an i ntravascul ar l ocati on. The thumb can be sl i pped under the
back edge of the pl unger and pul l ed back (Fi gure 2B), l ooki ng for
bl ood to enter the syri nge to ensure that the needl e ti p i s not i n a
bl ood vessel . The thumb then sl i ps onto the pl unger for gentl e
i njecti on. However, i t i s very unl i kel y that a short, 30-gauge needl e
ti p wi l l enter a si gni fi cant vessel , and many physi ci ans prefer to
i nject wi thout wi thdrawi ng, because pul l i ng back on the pl unger
moves the needl e ti p and causes di scomfort for the pati ent.
Page 111
(2) To ensure that the needl e i s not i nserted i nto a bl ood vessel ,
hol d the syri nge wi th your domi nant hand, pl aci ng the thumb near
the pl unger; i nsert the needl e; and pul l the pl unger back wi th your
thumb, checki ng for the presence of bl ood.
PITFALL: Avoid movement of the needle after it enters the skin.
Many physicians hold the syringe like a pencil for needle
insertion. After insertion, they stop stretching the skin with the
nondominant hand and grab the syringe, shift the dominant
hand back onto the plunger, and pull back on the plunger to
check for vascular entry of the needle tip. They then shift the
hands again and move the dominant hand into a position for
injection. All of these shifts cause movement of the needle tip in
the skin and increase the discomfort for the patient
substantially. Insert the needle with the hand in a position ready
to inject.
Insert the needl e i nto ski n at a 15- or 30-degree angl e. The depth
of the needl e ti p i s more di ffi cul t to control at a 90-degree angl e of
entry.
Page 112
(3) The needl e shoul d be i nserted i nto the ski n at a 15- or
30-degree angl e.
P.75
When i njecti ng l acerati on si tes for repai r, i nsert the needl e i nto
the wound edge, rather than i ntact ski n. Inserti on of a needl e i nto
a wound edge produces l ess di scomfort.
(4) When i njecti ng l acerati on si tes for repai r, i nsert the needl e i nto
the wound edge rather than i ntact ski n.
Pause after the needl e enters the ski n. Try to make the pati ent
l augh. Pati ents fear the needl e entry; after they real i ze that the
di scomfort was l ess than anti ci pated, pati ents often rel ax. Mai ntai n
ski n stretch wi th the nondomi nant hand for the i njecti on.
Page 113
(5) Pausi ng after the needl e enters the ski n al l ows the pati ent to
rel ax, reduci ng anxi ety and di scomfort.
PITFALL: Plunging in anesthetic immediately after needle entry
causes continued discomfort and anxiety. Most vagal or syncopal
episodes are related to the catecholamine storm produced by
the patient' s anxiety. Pausing after needle insertion and slow
administration allow patients to relax, reducing their
catecholamine production, and reducing complications.
P.76
Intradermal i njecti on creates a wheal i n the ski n.
(6) A wheal i s created i n the ski n duri ng i ntradermal i njecti on.
Admi ni ster the l ocal anestheti c for a shave exci si on bel ow the
center of the l esi on to be removed (Fi gure 7A). The anestheti c fl ui d
effecti vel y i ncreases the depth of the dermi s, reduci ng chances for
subdermal penetrati on at shave exci si on. The fl ui d al so fl oats the
Page 114
l esi on upward, faci l i tati ng removal by shave techni que (Fi gure 7B).
(7) For a shave exci si on, l ocal anestheti c shoul d be admi ni stered
bel ow the center of the l esi on to be removed.
P.77
CODING INFORMATION
The work of l ocal anesthesi a admi ni strati on general l y i s i ncl uded i n
the codes for most offi ce surgi cal procedures and cannot be bi l l ed
as a separate procedure. The anesthesi a codes (0010001999) i n
the Current Procedural Termi nol ogy (CPT) book general l y refl ect
general , regi onal , or suppl ementati on of l ocal anesthesi a by an
anesthesi ol ogi st. The anesthesi a codes general l y are not bi l l ed for
offi ce procedures.
A suggested anesthesi a tray that can be used for thi s procedure i s
l i sted i n Appendi x G.
BIBLIOGRAPHY
Avi na R. Offi ce management of trauma: pri mary care l ocal and
regi onal anesthesi a i n the management of trauma. Cl i n Fam Pract
2000;2:533550.
Baker JD, Bl ackmon BB. Local anesthesi a. Cl i n Pl ast Surg
1985;12:2531.
Brown JS. Mi nor surgery: a text and atl as, 3rd ed. London: Chapman
Page 115
& Hal l Medi cal , 1997.
deJong RH. Toxi c effects of l ocal anestheti cs. JAMA
1978;239:11661168.
Di nehart SM. Topi cal , l ocal , and regi onal anesthesi a. In: Wheel and
RG, ed. Cutaneous surgery. Phi l adel phi a: WB Saunders,
1994:102112.
Greki n RC. Local anesthesi a i n dermatol ogi c surgery. J Am Acad
Dermatol 1988;19:599614.
Kel l y AM, Cohen M, Ri chards D. Mi ni mi zi ng the pai n of l ocal
i nfi l trati on anesthesi a for wounds by i njecti on i nto the wound
edges. J Emerg Med 1994;12:593595.
Scarfone RJ, Jasani M, Gracel y EJ. Pai n of l ocal anestheti cs: rate of
admi ni strati on and bufferi ng. Ann Emerg Med 1998;31:3640.
Smi th DW, Peterson MR, DeBerard SC. Local anesthesi a. Postgrad
Med 1999;106:5766.
Stegman SJ, Tromovi tch TA, Gl ogau RG. Basi cs of dermatol ogi c
surgery. Chi cago: Year Book Medi cal Publ i shers, 1982:2331.
Swanson NA. Atl as of cutaneous surgery. Boston: Li ttl e, Brown,
1987:156162.
Wi nton GB. Anesthesi a for dermatol ogi c surgery. J Dermatol Surg
Oncol 1988;14:4154.
Yagi el a JA. Oral -faci al emergenci es: anesthesi a and pai n
management. Emerg Med Cl i n North Am 2000;18:449470.
Zuber TJ, DeWi tt DE. The fusi form exci si on. Am Fam Physi ci an
1994;49:371376.
Zuber TJ. Admi ni strati on of l ocal anesthesi a. AAFP manual s and
vi deotapes of ski n surgery techni ques. Kansas Ci ty: Ameri can
Academy of Fami l y Physi ci ans, 1999.
Page 116
> Table of Cont ent s > Dermat ology > 10 - Punch Biopsy of t he Skin10
Punch Biopsy of the Skin
Punch bi opsy i s one of the most wi del y used dermatol ogi c
procedures i n pri mary care medi ci ne. Thi s techni que obtai ns a
ful l -thi ckness ski n speci men for hi stol ogi c assessment. A properl y
performed punch bi opsy frequentl y yi el ds useful di agnosti c
i nformati on. The techni que i s si mpl e, rapi d, and general l y resul ts i n
an acceptabl e fi nal cosmeti c appearance at the si te.
Punch bi opsy i s performed wi th a ci rcul ar bl ade known as a
trephi ne, whi ch i s attached to a penci l -l i ke handl e. The i nstrument
i s rotated usi ng downward pressure unti l the bl ade penetrates i nto
the subcutaneous fat. A cyl i ndri cal core of ti ssue i s then cut free
and pl aced i n formal i n for transfer to the l aboratory. Most 3- or
4-mm punch bi opsy si tes are cl osed wi th a si ngl e suture. The 2-mm
punch bi opsy si tes frequentl y do not requi re suture cl osure, and
Monsel 's sol uti on can be used for hemostasi s i f the wound i s
al l owed to granul ate.
Punch bi opsy i s general l y performed to eval uate l esi ons of
uncertai n ori gi n or to confi rm or excl ude the presence of
mal i gnancy. Thi s bi opsy techni que i s consi dered the method of
choi ce for many fl at l esi ons. Suspected mel anomas can be
eval uated by thi s techni que, especi al l y when the l esi on i s too l arge
for easy removal . The yi el d may be i mproved i f the most suspi ci ous
or abnormal -appeari ng area (darkest, most rai sed, or most i rregul ar
contour) i s bi opsi ed. If the suspi ci on for mel anoma i s hi gh, i t i s
preferabl e to perform exci si onal bi opsy to have the enti re l esi on
avai l abl e for eval uati on. Physi ci ans shoul d not fear performi ng
punch bi opsy on a mel anoma, because the bi opsy does not al ter the
natural course of the di sease, and a prompt bi opsy expedi tes
defi ni ti ve treatment.
Punch bi opsy used for basal and squamous cel l carci noma has one
Page 117
di sadvantage. After these cancers have been bi opsi ed usi ng punch
techni que, the physi ci an i s obl i gated to perform a defi ni ti ve
exci si onal techni que. Superfi ci al techni ques that are frequentl y
empl oyed for these l esi ons, such as curettage and
el ectrodesi ccati on, may mi ss cel l s that have been dri ven deeper by
the punch i nstrument.
Physi ci ans shoul d be aware of the underl yi ng anatomy when
performi ng a punch bi opsy. Certai n areas of the body where there i s
l i ttl e subcutaneous ti ssue pose the greatest threat of damagi ng
underl yi ng structures such as arteri es, tendons, or nerves. Punch
bi opsy on the upper cheek can damage the faci al or tri gemi nal
nerves, and punch bi opsy of the l ateral di gi ts or of the thi n eyel i ds
shoul d be approached wi th great cauti on.
P.79
INDICATIONS
Eval uati on of ski n tumors such as basal cel l carci noma
or Kaposi 's sarcoma
Di agnosi s of bul l ous ski n di sorders such as pemphi gus
vul gari s
Di agnosi s of i nfl ammatory ski n di sorders such as di scoi d
l upus
Removal of smal l ski n l esi ons such as i ntradermal nevi
Di agnosi s of atypi cal appeari ng l esi ons such as atypi cal
mycobacteri al i nfecti on
CONTRAINDICATIONS
Lesi ons overl yi ng anatomi c structures l i kel y to be
damaged by ful l -thi ckness ski n bi opsy: on the eyel i d
(gl obe), on the dorsum of the hand i n el derl y pati ents
(tendons), or on the upper cheek (faci al nerve) or
fi ngers (di gi tal nerves and arteri es) (rel ati ve
Subcutaneous l esi ons that cannot be reached wi th the
Page 118
punch i nstrument (erythema nodosum)
Foot and toe l esi ons i n el derl y pati ents or those wi th
peri pheral vascul ar di sease
P.80
PROCEDURE
The punch bi opsy i nstrument (i .e., trephi ne) has a pl asti c,
penci l -l i ke handl e and a ci rcul ar scal pel bl ade. The bl ade attaches
to the handl e at the hub of the i nstrument. Sel ect a punch bi opsy
i nstrument of suffi ci ent si ze (i .e., 4 or 5 mm) to obtai n adequate
ti ssue for hi stol ogi c assessment whi l e mi ni mi zi ng the si ze of the
scar (i .e., 3-mm i nstrument for bi opsy on the face.)
(1) The punch bi opsy i nstrument: trephi ne.
P.81
Sel ect the best si te for the bi opsy. Perform the punch bi opsy at the
most abnormal -appeari ng si te wi thi n the most abnormal -appeari ng
l esi on or at the edge of an acti vel y growi ng l esi on. Tumors of the
ski n shoul d be bi opsi ed i n the center of the l esi on (Fi gure 2A), and
bul l ous l esi ons shoul d be bi opsi ed at the edge (Fi gure 2B.)
Page 119
(2) Sel ect the best si te for the bi opsy.
PITFALL: Do not biopsy lesions that have been traumatized,
scratched, or significantly modified. Biopsy of a traumatized
lesion rarely provides useful information. Provide the pathologist
with information on the age and sex of the patient, current
medications, appearance of the lesion, and body location to
increase the chance of gaining useful clinical information from
the biopsy. Remember that biopsy of nonspecific rashes,
particularly in younger individuals, rarely provides additional
information that benefits the clinician.
P.82
Prepare for the cl osure of the punch bi opsy si te when performi ng
the techni que. A ci rcul ar defect i s not easi l y cl osed, but an oval or
el l i pti cal defect approxi mates wel l . After the admi ni strati on of l ocal
anesthesi a, stretch the ski n 90 degrees (i .e., perpendi cul ar) to the
l i nes of l east ski n tensi on usi ng the nondomi nant hand (Fi gure 3B.)
The l i nes of l east ski n tensi on for the arm are ci rcumferenti al (i .e.,
perpendi cul ar to the l ong axi s of the arm) (Fi gure 3A.) After the
punch bi opsy i s performed, rel ax the nondomi nant hand, and the
ci rcul ar defect becomes more oval . Cl ose the defect wi th a si ngl e,
smal l -cal i ber suture such as 5-0 nyl on (Fi gure 3C.)
Page 120
(3) Prepare for the cl osure of the punch bi opsy si te when
performi ng thi s techni que.
P.83
Rotate the punch bi opsy i nstrument wi th downward force when
performi ng the bi opsy. Turn the bl ade around i ts handl e wi th a
back-and-forth moti on unti l the i nstrument traverses the ful l
thi ckness of the ski n. Be prepared to stop the downward pressure
as soon as the i nstrument penetrates through the ski n. When the
trephi ne penetrates the ski n i nto the subcutaneous fat, the
operator often noti ces a gi ve.
Page 121
(4) Rotate the punch bi opsy i nstrument wi th downward force when
performi ng the bi opsy.
PITFALL: Historically, physicians were instructed to insert the
instrument up to the hub. With larger punch instruments, the
blade must penetrate 3/8 inch of the skin to reach the hub.
Going to the hub is appropriate where the skin is thick (e.g.,
upper back) but can damage underlying structures such as
nerves or tendons where the skin and subcutaneous tissue is
thin. Do not push the instrument to the hub when performing
punch biopsy on the upper cheek or dorsum of the hand.
Cut the speci men free from the subcutaneous fat after the
cyl i ndri cal cut i s made through ski n. Li ft the speci men wi th the
needl e used to anestheti ze the ski n si te, and then cut i t free at
the base (beneath dermi s) usi ng sharp i ri s sci ssors.
(5) Cut the speci men free from the subcutaneous fat after the
cyl i ndri cal cut i s made through the ski n.
PITFALL: Many pathologists refuse to examine a skin biopsy
specimen that has been crushed. Punch biopsy specimens often
are crushed when they are elevated using Adson forceps.
Elevate the specimen with the anesthesia needle to avoid crush
artifact.
P.84
CODING INFORMATION
Page 122
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Page 125
the
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Basi c setup for thi s procedure i ncl udes l ocal anesthesi a (1 to 3 mL
of anestheti c), the punch bi opsy i nstrument, and sharp i ri s sci ssors
to cut the speci men free. If the speci men cannot be l i fted usi ng the
anesthesi a needl e, Adson pi ckups wi thout teeth can l i ft the
speci men.
Punch bi opsy i nstruments (Fray Products Corporati on, Bai rd
Research Park, Amherst, NY) can be obtai ned through Del asco,
Counci l Bl uffs, IA (phone: 1-800-831-6273; http://www.del asco.com
).
Suggested suture removal ti mes are l i sted i n Appendi x C. A
suggested anesthesi a tray that can be used for thi s procedure i s
l i sted i n Appendi x G. Ski n preparati on recommedati ons appear i n
Appendi x H.
BIBLIOGRAPHY
Fewkes JL. Ski n bi opsy: the four types and how best to perform
them. Pri m Care Cancer 1993;13:3539.
Pari ser RJ. Ski n bi opsy: l esi on sel ecti on and opti mal techni que. Mod
Med 1989;57:8290.
Paver RD. Practi cal procedures i n dermatol ogy. Aust Fam Physi ci an
1990;19:699701.
Phi l l i ps PK, Pari ser DM, Pari ser RJ. Cosmeti c procedures we al l
perform. Cuti s 1994;53: 187191.
Si egel DM, Usati ne RP. The punch bi opsy. In: Usati ne RP, Moy RL,
Page 126
Tobi ni ck EL, Si egel DM, eds. Ski n surgery: a practi cal gui de. St.
Loui s: Mosby, 1998:101119.
surgery. Chi cago: Year Book Medi cal Publ i shers, 1982.
1987.
Wheel and RG, ed. Cutaneous surgery. Phi l adel phi a: WB Saunders,
1994.
Zuber TJ. Offi ce procedures. The academy col l ecti on qui ck
Wi l ki ns, 1999.
Zuber TJ. Punch bi opsy of the ski n. Am Fam Physi ci an
2002;65:11551158, 11611162, 1164, 11671168.
Zuber TJ. Ski n bi opsy techni ques: when and how to perform punch
bi opsy. Consul tant 1994; 34:14671470.
Page 127
> Table of Cont ent s > Dermat ology > 11 - Shave Biopsy11
Shave Biopsy
Shave bi opsy i s one of the most wi del y used procedures performed
i n pri mary care practi ce. The techni que i s used to obtai n ti ssue for
hi stol ogi c exami nati on and i s useful for removi ng superfi ci al l esi ons
i n thei r enti rety. Peduncul ated l esi ons above the ski n surface are
parti cul arl y wel l sui ted for thi s removal techni que, but fl at l esi ons
that are hi gh i n the dermi s and do not extend beneath the dermi s
can al so be removed by shave techni que. Hori zontal sl i ci ng i s
performed at the l evel of the dermi s, avoi di ng i njury to the
subcutaneous ti ssues. Cosmeti c resul ts general l y are good, wi th
the l east noti ceabl e scars occurri ng when l esi ons are removed from
concave surfaces such as the nasol abi al fol d.
Four techni ques are commonl y empl oyed for shave bi opsy. A no. 15
scal pel bl ade hel d hori zontal l y i n the hand can provi de good control
of depth. The ease of the scal pel techni que makes i t a frequent
choi ce by i nexperi enced physi ci ans. Hori zontal sl i ci ng wi th a fl exed
razor bl ade i s a ti me-honored method for shave bi opsy. Thi s
techni que i s used l ess frequentl y because of the potenti al for i njury
from the l arge, exposed cutti ng surface. Sci ssors (e.g., i ri s
sci ssors) can be effecti vel y used to remove el evated l esi ons.
Sci ssors removal of fl at l esi ons can be more di ffi cul t. Radi osurgi cal
l oop removal i s effecti ve, al though novi ce practi ti oners tend to
create deeper, scoop defects i n the dermi s beneath the
l esi on bei ng removed.
Shave bi opsy i s performed deep enough to remove the l esi on but
shal l ow enough to prevent si gni fi cant damage to the deep dermi s.
The deeper the damage i n the ski n, the more l i kel y scar formati on
wi l l l eave a noti ceabl e, hypopi gmented scar. If a scoop defect i s
created, the edges can be feathered (i .e., smoothed) to bl end the
col or change i nto the surroundi ng ski n (see Chapter 20). Depressed
Page 128
scars can resul t after thi s techni que, especi al l y from areas where
there i s extensi ve muscl e tensi on on the ski n, such as the chi n or
peri oral areas.
Many physi ci ans recommend not performi ng shave bi opsy on
pi gmented l esi ons. If a l esi on shoul d turn out to be a mel anoma on
bi opsy, usi ng a techni que that cuts through the mi ddl e of the
l esi on can create major probl ems for determi ni ng depth, prognosi s,
and therapy for the l esi on. Some cl i ni ci ans argue that the shave
techni que can be performed on mel anomas and that the ol d adage
of not shavi ng a pi gmented l esi on can be dropped. Most sti l l
recommend cauti on, and i t i s our recommendati on that exci si onal
bi opsy (see Chapter 12) shoul d be used for any pi gmented l esi on
that coul d potenti al l y represent a mel anoma.
P.86
INDICATIONS
Lesi ons amenabl e to shave exci si onal techni que i ncl ude
acrochordons (i .e., ski n tags), angi omas, fi bromas, basal
cel l carci nomas (i .e., wel l -defi ned, smal l , pri mary and
not recurrent, and i n l ow-ri sk si tes), dermatofi bromas,
keratoacanthomas, cutaneous horns, mol l uscum
contagi osum, nonpi gmented nevi (e.g., i ntradermal
nevi ), papi l l omas, warts, syri ngomas, venous l akes,
cherry angi omas, stucco keratoses, seborrhei c keratoses,
acti ni c keratoses, rhi nophymas, sebaceous hyperpl asi a,
porokeratosi s, neurofi bromas, and dermatosi s papul osa
ni gra.
RELATIVE CONTRAINDICATIONS: LESIONS
BEST CONSIDERED FOR ALTERNATE
TECHNIQUES
Pi gmented nevi (pathol ogy speci men shoul d be ful l
thi ckness of the ski n i n the event the l esi on i s a
Page 129
mel anoma)
Ski n appendage l esi ons (e.g., cyl i ndromas, epi dermoi d
cysts)
Subcutaneous l esi ons (pathol ogy often mi ssed by shave
techni que)
Epi dermal nevi (removal requi res ful l -thi ckness exci si on)
Lesi ons on si tes wi th extensi ve muscl e tensi on on the
ski n (e.g., chi n, peri oral si tes)
P.87
PROCEDURE
Smal l , peduncul ated l esi ons can be removed easi l y wi th the shave
techni que. Pi ctured i s a smal l angi oma that appears on a stal k. The
ski n i s stretched wi th the nondomi nant hand, and the l esi on i s
removed wi th sharp i ri s sci ssors. Smal l l esi ons can be removed
wi thout l ocal anesthesi a i f the pai n receptors wi thi n the ski n are
stretched.
(1) Smal l l esi ons can be removed wi th sharp i ri s sci ssors.
PITFALL: The scissors must be flush with the skin surface to
prevent leaving a residual stump, but no extra skin should be
included within the scissor blades to prevent unintentional
cutting of surrounding skin.
For removal of a fl at (sessi l e) l esi on, l ocal anestheti c i s pl aced
beneath the l esi on i n subdermal and i ntradermal l ocati ons (Fi gure
Page 130
2A). The fl ui d rai ses the l esi on upward, al l owi ng easi er removal
(Fi gure 2B). Admi ni strati on of l ocal anestheti c thi ckens the ski n,
maki ng i t l ess l i kel y that the shave wi l l penetrate the dermi s i nto
the subcutaneous fat (Fi gure 2C).
(2) Removal of a fl at l esi on.
PITFALL: Unintentional penetration into the fat (i.e., yellow fat
in the base of the wound) should prompt transforming the
biopsy site into a sterile surgical wound. The wound should have
the edges incised vertically, and the wound should be closed
with sutures.
P.88
Lesi on removal can be faci l i tated by el evati ng and squeezi ng the
surroundi ng ski n.
(3) El evati ng and squeezi ng the ski n surroundi ng a l esi on can make
Page 131
i ts removal easi er.
A no. 15 bl ade i s hel d hori zontal i n the domi nant hand whi l e the
nondomi nant hand stabi l i zes surroundi ng ski n (Fi gure 4A). The
bl ade i s brought across the base of the l esi on (Fi gure 4B) wi th a
strai ght movement or wi th a back-and-forth movement (Fi gure 4C).
(4) A no. 15 bl ade i s brought across the base of the l esi on wi th a
strai ght or back-and-forth movement.
P.89
Bi opsy can be performed wi th a razor bl ade hel d i n the hand, wi th
tensi on appl i ed to the two si des to create some curvature. The
sharp surface i s brought beneath the l esi on for removal wi thi n the
dermi s.
Page 132
(5) A razor bl ade al so can be used.
PITFALL: The large, exposed, cutting surface of the razor blade
and the hand tension required to maintain curvature of the
blade provide great potential for injury. Some surgeons no
longer advocate use of razor blades for shave biopsy because of
this potential for injury.
Radi osurgi cal l oop exci si on can be used to perform a shave bi opsy.
The l esi on i s grasped and el evated wi thi n the radi osurgi cal l oop
usi ng Adson forceps (Fi gure 6A). The l oop i s acti vated and moved
across the base of the l esi on (Fi gure 6B.) The radi osurgi cal current
can be set to provi de hemostasi s to the wound base.
(6) Radi osurgi cal l oop exci si on can be used to perform a shave
bi opsy.
PITFALL: Novice physicians tend to scoop with the loop. The loop
Page 133
must be brought under the lesion horizontally, and the lesion
must not be excessively elevated to prevent large scoop defects
from this technique.
P.90
The wound base can be treated wi th ferri c subsul fate (i .e., Monsel 's
sol uti on) for hemostasi s. Ferri c subsul fate shoul d be appl i ed to a
dry wound bed; the bl ood must be wi ped away wi th the sol uti on
appl i ed i mmedi atel y thereafter. Anti bi oti c oi ntment and a bandage
are then appl i ed.
(7) Treat the wound base wi th ferri c subsul fate for hemostasi s.
PITFALL: Ferric subsulfate can rarely produce permanent
discoloration or tattooing of the skin. Consider using a
35% to 85% aluminum chloride solution on the faces of
fair-skinned (light-complexioned) individuals to avoid this
complication.
P.91
CODING INFORMATION
The fol l owi ng codi ng i nformati on i s for shavi ng of epi dermal or
dermal l esi ons, i ncl udi ng l esi ons on mucous membranes (MM). The
codes are for si ngl e l esi on removal .
Page 134
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Number 15 scal pel bl ades, razor bl ades, sci ssors, and hemostati c
agents such as ferri c subsul fate are avai l abl e from surgi cal suppl y
houses or the resources l i sted i n Appendi x A. A suggested
Appendi x G. Ski n preparati on recommendati ons appear i n Appendi x
H. Radi osurgi cal i nstruments and machi nes are descri bed i n Chapter
20.
For practi ti oners wi shi ng to perform shave bi opsy wi th a razor
bl ade, the di sposabl e DermaBl ade (Personna Medi cal , Ameri can
Razor Company, Stauton, VA) enhances safety by al l owi ng the
operator to grasp the sure-gri p teeth to the si des i nstead of
di rectl y handl i ng the bl ade.
P.92
Page 145
BIBLIOGRAPHY
Fewkes JL, Sober AJ. Ski n bi opsy: the four types and how best to do
them. Pri m Care Cancer 1993;13:3639.
therapy, 3rd ed. St. Loui s: Mosby, 1996:815.
Huerter CJ. Si mpl e bi opsy techni ques. In: Wheel and RG, ed.
Phi l adel phi a: WB Saunders, 1994:159170.
Pari ser RJ. Ski n bi opsy: l esi on sel ecti on and opti mal techni que. Mod
Med 1989;57:8290.
Phi l l i ps PK, Pari ser DM, Pari ser RJ. Cosmeti c procedures we al l
perform. Cuti s 1994;53: 187191.
Russel l EB, Carri ngton PR, Smol l er BR. Basal cel l carci noma: a
compari son of shave bi opsy versus punch bi opsy techni ques i n
subtype di agnosi s. J Am Acad Dermatol 1999;41: 6971.
Ski n bi opsy. Avai l abl e at
http://www.mel anomacenter.org/di agnosi ng/typesski nbi opsi es.html
surgery. Chi cago: Year Book Medi cal , 1982.
1987:1415.
Usati ne RP, Moy RL, Tobi ni ck EL, et al . Ski n surgery: a practi cal
gui de. St. Loui s: Mosby, 1998;5576.
Zal l a MJ. Basi c cutaneous surgery. Cuti s 1994;53:172186.
Zi tel l i JA. Wound heal i ng by secondary i ntenti on: a cosmeti c
apprai sal . J Am Acad Dermatol 1983;9:407415.
Zuber TJ. Dermal el ectrosurgi cal shave exci si on. Am Fam Physi ci an
2002;65:18831886, 18891890, 1895, 18991900.
Zuber TJ. Ski n bi opsy techni ques: when and how to perform shave
and exci si onal bi opsy. Consul tant 1994;34:15151521.
Zuber TJ. Ski n bi opsy, exci si on and repai r techni ques. The AAFP
i l l ustrated manual s and vi deotapes of soft-ti ssue surgery
techni ques. Kansas Ci ty: Ameri can Academy of Fami l y Physi ci ans,
1998:1841.
Page 146
> Table of Cont ent s > Dermat ology > 12 - Fusiform Excision12
Fusiform Excision
The fusi form exci si on techni que i s one of the most versati l e offi ce
surgery procedures. The techni que i s used to remove beni gn and
mal i gnant l esi ons on or bel ow the ski n surface. The techni que can
be used to remove l esi ons enti rel y (i .e., exci si onal bi opsy) or to
remove a porti on of a l arge l esi on (i .e., i nci si onal bi opsy) for
hi stol ogi c assessment. The major advantage i s that the procedure
can often afford a one-stage di agnosti c and therapeuti c
i nterventi on.
The fusi form techni que hi stori cal l y has been mi snamed the
el l i pti cal exci si on. Properl y desi gned fusi form exci si ons resembl e a
bi concave l ens rather than an oval el l i pse. The corners of the
fusi form exci si on shoul d have angl es no greater than 30 degrees,
and the l ength of the fusi form exci si on i s three ti mes the wi dth.
The l ong axi s of the wound shoul d be al i gned wi th the resti ng ski n
tensi on l i nes to opti mi ze the cosmeti c and functi onal outcome.
The fusi form exci si on i ncorporates several i mportant dermatol ogi c
techni ques (Tabl e 12-1). The techni ques are combi ned to reduce
subcutaneous hematoma formati on, prevent devel opment of
seromas beneath the wounds, and produce good cosmeti c
outcomes. These vari ous techni ques are i l l ustrated i n thi s and
subsequent chapters.
TABLE 12-1. TECHNIQUES INCORPORATED INTO THE FUSIFORM EXCISION
Page 147

Exci si on al i gned wi th the l i nes of l east ski n tensi on
Local or fi el d bl ock anesthesi a
Steri l e drapi ng of the surgi cal si te
Smooth, conti nuous i nci si ons wi th the scal pel
Li fti ng ski n edges usi ng ski n hooks
Undermi ni ng of ski n edges
Pl acement of i nterrupted, deep, buri ed, subcutaneous sutures
Si mpl e, i nterrupted ski n sutures
Pl acement of sutures usi ng the hal vi ng techni que
Eversi on of wound edges
Moi st wound heal i ng usi ng anti bi oti c or other oi ntment

P.94
INDICATIONS
Removal of pi gmented mel anocyti c nevi to i denti fy
mel anoma and ascertai n the depth of the l esi on
Smal l tumors or ski n cancers that can be removed wi th
fusi form exci si on
Inci si onal bi opsy of a l arge l esi on when exci si on i s not
feasi bl e
Fl at l esi ons not readi l y amenabl e to shave exci si on
Lesi ons on convex surfaces that are not amenabl e to
shave exci si on
Removal of subcutaneous tumors
P.95
PROCEDURE
The fusi form exci si on shoul d paral l el the l i nes of l east ski n tensi on
(Fi gure 1A). These l i nes run perpendi cul ar to the l ong axi s of the
extremi ti es (Fi gure 1B) but are more compl ex on the face (Fi gure
1C). Wounds that fol l ow (paral l el ) these l i nes are l ess l i kel y to
Page 148
enl arge (i .e., hypertrophy or kel oi d) and heal faster.
(1) The fusi form exci si on shoul d paral l el the l i nes of l east ski n
tensi on.
P.96
Draw the fusi form exci si on on the ski n usi ng a ski n marki ng pen
before i ni ti ati ng the procedure. A properl y desi gned fusi form
exci si on i s three ti mes as l ong as i t i s wi de.
Page 149
(2) Draw the fusi form exci si on on the ski n usi ng a ski n marki ng pen
before i ni ti ati ng the procedure.
PITFALL: Many experienced physicians perform fusiform
excision without drawing out the skin incision lines. After the
sterile drapes are placed on the skin, the nearby landmarks may
be covered, causing the physician to incorrectly orient the
excision.
PITFALL: Many operators want to save as much tissue as
possible and draw the fusiform excision with the length only two
times the width. These so-called football excisions create
elevations of tissue at the ends (i.e., dog ears); the attempt to
excise less tissue produces inferior cosmetic results.
Perform l ocal (or fi el d bl ock) anesthesi a (see Chapters 9 and 23).
Insert the needl e wi thi n the fusi form i sl and of ski n to be exci sed.
The operator shoul d not create needl e tracts i nto the surroundi ng
ski n that wi l l remai n.
(3) Perform l ocal or fi el d bl ock anesthesi a.
Page 150
P.97
Create smooth, verti cal ski n i nci si ons usi ng a no. 15 scal pel . The
scal pel bl ade i s hel d verti cal l y at the corner of the wound and
punctures the ski n usi ng the poi nt of the bl ade. The bl ade handl e i s
then dropped down, and a smooth, conti nuous stroke i s used to
create the wound edge. The bl ade shoul d be passed fi rml y enough
to penetrate the enti re thi ckness of the dermi s wi th the fi rst pass.
(4) Create smooth, verti cal ski n i nci si ons usi ng a no. 15 scal pel .
PITFALL: Many inexperienced operators make a short pass with
the scalpel, stop to inspect the incision, and then make an
additional short pass. This creates cross-hatch marks and an
irregular skin edge. Smooth, confident passes with the scalpel
avoid jagged edges.
PITFALL: Create the incision with the blade vertical to the skin
surface. Novice surgeons often angle the blade under the lesion,
creating a wedge excision. Angled edges will not evert; create
wound edges that are vertical.
Grasp the corner of the central fusi form i sl and of ski n wi th Adson
forceps, and el evate the i sl and as the scal pel passes hori zontal l y
beneath the l esi on i n the l evel of the subcutaneous fat. After the
l esi on i s cut free, i mmedi atel y pl ace the speci men i n a contai ner of
formal i n for hi stol ogi c assessment i n the l aboratory.
Page 151
(5) Grasp the corner of the central fusi form i sl and of ski n wi th
Adson forceps, and el evate the i sl and as the scal pel passes
hori zontal l y beneath the l esi on i n the l evel of the subcutaneous
fat.
P.98
Undermi ni ng can be performed wi th the scal pel bl ade,
ti ssue-cutti ng (Metzenbaum) sci ssors, or bl untl y usi ng a hemostat.
El evate the ski n edges usi ng ski n hooks, not forceps. The safest
l evel of undermi ni ng i s i n the fat, just bel ow the dermal -fat
juncti on, to avoi d damagi ng nerves that traverse the deeper l evel s
of the fat. To create 1 cm of wound edge rel axati on, 3 cm of
undermi ni ng i s requi red. Undermi ne the wound corners to rel ease
any tetheri ng at these l ocati ons.
(6) Undermi ni ng can be performed wi th the scal pel bl ade,
ti ssue-cutti ng (Metzenbaum) sci ssors, or bl untl y usi ng a hemostat.
Page 152
PITFALL: Novice physicians frequently are distracted by the
bleeding (especially from facial wounds) produced by
undermining. The closure of the deeper tissues using the deep,
buried sutures almost always stops the bleeding. Physicians
should move quickly to perform the deep buried closure, rather
than waste time applying gauze to the wound.
PITFALL: Elevating skin edges using skin hooks prevents the
damage and subsequent scarring that often result from handling
the edges with forceps. A cheap, disposable skin hook can be
created by bending the tip of a 1-inch, 20-gauge needle with the
needle driver.
P.99
The deepl y buri ed subcutaneous sti tch cl oses dead space, stops
subcutaneous bl eedi ng, reduces hematoma and seroma formati on,
and takes al l tensi on off the ski n sutures. The suture begi ns i n the
center of the wound and passes beneath the l eft wound edge to
pass back i nto the center of the wound through the dermi s (Fi gure
7A). The needl e i s pl aced upsi de-down and backward i nto the
needl e hol der. It passes through the dermi s i nto the ri ght wound
edge and passes down to the base of the wound (Fi gure 7B). The
needl e then grabs a smal l bi t of the ti ssue i n the base of the
wound (Fi gure 7C). The suture threads need to be on the same si de
(i .e., toward the operator or away from the operator) compared wi th
the suture thread passi ng across the top of the wound. The two
ends of the suture are pi ctured on the near si de (Fi gure 7D). The
knot i s ti ed, and the suture cut free just above the knot. The knot
buri es i nto the base of the wound. (Fi gure 7E). Usual l y, a deepl y
buri ed suture i s pl aced i n the center and two ends of the wound.
Page 153
(7) The deepl y buri ed subcutaneous sti tch cl oses the dead space,
stops subcutaneous bl eedi ng, reduces hematoma and seroma
formati on, and takes al l tensi on off the ski n sutures.
P.100
The deepl y buri ed sutures do not evert the ski n edges. Eversi on can
be achi eved by proper pl acement of si mpl e, i nterrupted sutures. By
pushi ng down on ski n edges wi th the nondomi nant hand when
pl aci ng the ski n sti tches (Fi gure 8A), more of the deep ti ssue i s
grasped wi th the verti cal entry and exi t of the suture needl e
(Fi gure 8B). Thi s Erl enmeyer fl ask pass of the suture
faci l i tates eversi on when the knot i s ti ed (Fi gure 8C). Eversi on at
the ti me of wound repai r resul ts i n a better cosmeti c outcome,
Page 154
because al l scars retract wi th heal i ng and the everted edges wi l l
become fl at (Fi gure 8D).
(8) Eversi on can be achi eved by proper pl acement of si mpl e,
i nterrupted sutures.
P.101
The pri nci pl e of hal vi ng states that sutures shoul d be pl aced i n the
center of a wound edge fi rst and the next sutures pl aced i n the
center of the remai ni ng wound edges. Thi s prevents uneven edges
(i .e., dog ears), whi ch can be produced when suturi ng from one end
of the wound to the other.
Page 155
(9) The pri nci pl e of hal vi ng states that sutures shoul d be pl aced i n
the center of a wound edge fi rst, and the next sutures shoul d be
pl aced i n the center of the remai ni ng wound edges.
Anti bi oti c or other oi ntments appl i ed to the wound i mmedi atel y
after the procedure hel p to bathe the wound wi th heal i ng
jui ces that promote more rapi d and i mproved repai r at the si te.
(10) Appl y anti bi oti c or other oi ntments to wound i mmedi atel y after
the procedure to promote rapi d and i mproved repai r at the si te.
P.102
CODING INFORMATION
The codi ng of exci si on of l esi ons i s determi ned by the si ze and
l ocati on of the l esi on. Exci si on of mal i gnant l esi ons often yi el ds
hi gher rei mbursement than the exact same procedure performed on
beni gn l esi ons. When a l esi on of uncertai n nature i s exci sed, i t i s
Page 156
often benefi ci al to wai t unti l the pathol ogy report returns before
sel ecti ng the proper bi l l i ng code. The codes l i sted bel ow i ncl ude
ful l -thi ckness exci si on and si mpl e, one-l ayer cl osure. If two l ayers
of cl osure are requi red (i .e., deepl y buri ed subcutaneous suture
pl acement), i ntermedi ate cl osure can al so be bi l l ed. Exci si on of
hi dradeni ti s or ski n tags and exci si on associ ated wi th
reconstructi ve or fl ap cl osure are bi l l ed usi ng al ternate codes. The
bi l l i ng chart ci tes the fol l owi ng l ocati ons: trunk, arms, and l egs
(TAL); scal p, neck, hands, feet, and geni tal i a (SNHFG); and face,
ears, eyel i ds, nose, l i ps, and mucous membranes (FEENLMM).

Benign Lesions

Malignant Lesions
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Page 157
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Page 158
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Page 159
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Page 160
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P.103
The recommended surgi cal tray for offi ce surgery i s l i sted i n
Appendi x A. Suggested suture removal ti mes are l i sted i n Appendi x
C. A suggested anesthesi a tray that can be used for thi s procedure
i s l i sted i n Appendi x G. Ski n preparati on acommodati ons appear i n
Appendi x H.
BIBLIOGRAPHY
Borges AF, Al exander JE. Rel axed ski n tensi on l i nes, Z-pl asti es on
scars, and fusi form exci si on of l esi ons. Br J Pl ast Surg
1962;15:242254.
Jobe R. When an el l i pse i s not an el l i pse [Letter]. Pl ast
Reconstr Surg 1970;46:295.
Leshi n B. Proper pl anni ng and executi on of surgi cal exci si ons. In:
Wheel er RG, ed. Cutaneous surgery. Phi l adel phi a: WB Saunders,
1994:171177.
Moy RL, Lee A, Zal ka A. Commonl y used suturi ng techni ques i n ski n
surgery. Am Fam Physi ci an 1991;44:16251634.
Page 161
surgery. Chi cago: Year Book Medi cal Publ i shi ng, 1982:6068.
Stevenson TR, Jurki ewi cz MJ. Pl asti c and reconstructi ve surgery. In:
Schwartz SI, Shi res GT, Spencer FC, Husser WC, eds. Pri nci pl es of
surgery, 5th ed. New York: McGraw-Hi l l , 1989:20812132.
1987.
Vi stnes LM. Basi c pri nci pl es of cutaneous surgery. In: Epstei n E,
Epstei n E Jr, eds. Ski n surgery, 6th ed. Phi l adel phi a: WB Saunders,
1987:4455.
Zal l a MJ. Basi c cutaneous surgery. Cuti s 1994;53:172186.
Zi tel l i J. TIPS for a better el l i pse. J Am Acad Dermatol
1990;22:101103.
Zuber TJ, DeWi tt DE. The fusi form exci si on. Am Fam Physi ci an
1994;49:371376.
Zuber TJ. Offi ce procedures. The academy col l ecti on of qui ck
Wi l ki ns, 1999.
Zuber TJ. The AAFP i l l ustrated manual s and vi deotapes of
soft-ti ssue surgi cal techni ques. Kansas Ci ty: Ameri can Academy of
Fami l y Physi ci ans, 1999.
Page 162
> Table of Cont ent s > Dermat ology > 13 - Skin Tag Removal13
Skin Tag Removal
Ski n tags, or acrochordons, are 1- to 2-mm ski n growths commonl y
encountered on the neck, axi l l a, groi n, or i nframammary areas. The
l esi ons devel op on ski n surfaces that rub together or that
chroni cal l y rub agai nst cl othi ng. Ski n tags are hi stol ogi cal l y
cl assi fi ed as fi bromas, wi th hyperpl asti c epi dermi s connected to the
ski n on a connecti ve ti ssue stal k. At l east one fourth of al l adul ts
exhi bi t tags, wi th one hal f of these occurri ng i n the axi l l a. The
l esi ons usual l y begi n as ti ny, fl esh-col ored or l i ght brown
excrescences. As the l esi ons enl arge, they can rub on cl othi ng and
commonl y devel op added pi gmentati on. Not al l pol ypoi d l esi ons are
ski n tags; nevi , angi omas, and even mel anomas can appear
pol ypoi d.
Ski n tags are rare i n chi l dhood, and when found, they may i ndi cate
the presence of other di sorders such as nevoi d basal cel l carci noma
syndrome. Ski n tags i ncrease i n frequency from the second to fi fth
decade, but general l y do not i ncrease si gni fi cantl y i n number unti l
after 50 years of age. Ski n tags i n adul ts hi stori cal l y have been
associ ated wi th the presence of adenomatous col oni c pol yps, but
some studi es suggest that the associ ati on i s uncl ear. Some
cl i ni ci ans recommend routi ne screeni ng wi th occul t bl ood testi ng
and fl exi bl e si gmoi doscopy for i ndi vi dual s whose onl y ri sk for col on
pathol ogy i s the presence of ski n tags.
Fi broepi thel i omatous pol yps are l arger, si mi l ar l esi ons commonl y
found on the trunk, eyel i ds, neck, and peri neum.
Fi broepi thel i omatous pol yps often have a bagl i ke end on a narrow
stal k and can grow qui te l arge. Both acrochordons and
fi broepi thel i omatous pol yps can be easi l y removed wi th the offi ce
techni ques descri bed l ater. Commonl y used opti ons for removal of
ski n tags i ncl ude sci ssori ng, sharp exci si on, l i gature strangul ati on,
Page 163
el ectrosurgi cal destructi on, or a combi nati on of treatment
modal i ti es, i ncl udi ng chemi cal or el ectrocauteri zati on of the wound.
These methods may empl oy l ocal anesthesi a, especi al l y i f the
l esi on i s broad based.
El ectrosurgi cal destructi on i s commonl y empl oyed for ski n tags. The
techni que i s hemostati c and i s benefi ci al for removal of l esi ons,
especi al l y i n noncosmeti c areas (e.g., groi n, axi l l a) or on the
eyel i ds, where chemi cal hemostati c agents usual l y are avoi ded. The
downsi de of el ectrosurgery for ski n tags i s the ti me requi red for
equi pment setup, the odor created duri ng the procedure, and the
need for anesthesi a when usi ng thi s techni que. Cryosurgery can be
empl oyed, and i t avoi ds the need for anesthesi a. However, the ti me
requi red to perform cryosurgi cal destructi on i s greater than wi th
other methods, and thi s method may be more pai nful .
P.105
Sci ssor exci si on i s consi dered by many authori ti es to be the opti mal
removal techni que for ski n tags. Most smal l tags can be removed
wi thout the need for anesthesi a, and sci ssors removal al l ows for
rapi d removal of numerous l esi ons. It i s not uncommon to remove
100 or more l esi ons at a si ngl e sessi on, al though some i nsurance
compani es cap payment at 4565 tags per sessi on. Because
resi dual scarri ng depends on the depth of dermal i njury, scarri ng
can be mi ni mi zed wi th sci ssors removal . Hi stol ogi c assessment i s
offered to pati ents but may not al ways be necessary i f the
experi enced cl i ni ci an removes smal l , characteri sti c tags. Appl i cati on
of anti bi oti c oi ntment usual l y promotes rapi d (moi st) heal i ng of the
si te.
INDICATIONS
Removal of superfi ci al , pol ypoi d growths on
characteri sti c surfaces on the neck, groi n, and eyel i ds
CONTRAINDICATIONS
Pi gmented ski n l esi ons (especi al l y fl at l esi ons) general l y
Page 164
shoul d not be shaved or destroyed because of the
possi bi l i ty of the l esi on bei ng a mel anoma, whi ch
requi res assessment of depth for accurate stagi ng and
treatment. If there i s any concern about an unusual
appearance of a l esi on or confusi on about whether a
l esi on i s a ski n tag, the l esi on shoul d have a
ful l -thi ckness bi opsy and hi stol ogi c assessment.
P.106
PROCEDURE
Most l esi ons can be rapi dl y removed wi thout anestheti c. When
l esi ons have a wi de base (>2 mm), consi der admi ni steri ng a smal l
bl eb of 1% l i docai ne wi th epi nephri ne beneath the l esi on.
(1) Consi der admi ni steri ng a smal l bl eb of 1% l i docai ne wi th
epi nephri ne beneath a l esi on i f i t has a base wi der than 2 mm.
Use the nondomi nant hand. Most ski n tags can be removed wi thout
anesthesi a and wi th l i mi ted di scomfort i f the removal i s performed
rapi dl y from stretched ski n. The nondomi nant thumb and i ndex
fi nger shoul d forceful l y stretch the ski n surface to provi de
countertracti on and to stretch pai n fi bers.
Page 165
(2) The nondomi nant thumb and i ndex fi nger shoul d forceful l y
stretch the ski n surface to provi de countertracti on and to stretch
pai n fi bers.
PITFALL: It is easier to remove tags that are elevated with
forceps. However, forceps pull up normal tissue beneath the
tag, producing more scarring due to deeper dermal injury.
Dark-skinned individuals develop much more hypopigmentation
and even keloid formation at skin tag removal sites when
forceps are used. Avoid the use of forceps, and learn to elevate
the lesions in the blades of the scissors.
P.107
Use sharp, new, curved i ri s sci ssors. The ti ps of i ri s sci ssors are
not best for cutti ng. Pl ace the l esi on i nto the bl ades of the
sci ssors, at l east one fourth of the way back from the ti ps (Fi gure
3A). Wedge the cl osi ng bl ades of the sci ssors beneath the l esi on,
maki ng sure no surroundi ng ski n i s caught between the bl ades
(Fi gure 3B). Tal k to the pati ent; verbal anesthesi a hel ps. Tel l the
pati ent to take a deep breath, and rapi dl y cut the tag free (Fi gure
3C). Appl y Monsel 's sol uti on (i .e., ferri c subsul fate) or al umi num
Page 166
chl ori de sol uti on to the wound base for hemostasi s.
(3) Use sharp, new, curved i ri s sci ssors.
PITFALL: Straight iris scissors can be used by experienced
clinicians but often inadvertently pull surrounding tissue into the
blades of the scissors. Use a side-to-side rocking motion to
wedge the lesion beneath the blades of the scissors to prevent
trauma to surrounding skin.
The base of the l esi on i s anestheti zed, and cautery current i s
appl i ed to the l esi on. Wi pe away the necroti c ti ssue wi th gauze
after the destructi on.
(4) El ectrocautery destructi on.
PITFALL: Avoid full-thickness or deep burns, because greater
scarring is produced.
P.108
Page 167
CODING INFORMATION
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Page 168
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o
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CPT
i s a
tradem
ark of
the
Ameri c
an
Medi ca
l
Associ
ati on.
Requi red i nstruments depend on method sel ected for removal . If
sci ssors removal i s chosen, a pai r of new, sharp, curved i ri s
sci ssors shoul d be avai l abl e. If cryosurgery or el ectrosurgi cal
destructi on i s performed, see Chapters 19, 20, 38 and 39 for a
descri pti on of the needed equi pment. Ski n preparati on
Page 170
recommendati ons appear i n Appendi x H.
BIBLIOGRAPHY
Bennett RG. Fundamental s of cutaneous surgery. St. Loui s: Mosby,
1988:692.
Chi ri tescu E, Mal oney ME. Acrochordons as a presenti ng si gn of
nevoi d basal cel l carci noma syndrome. J Am Acad Dermatol
2001;44:789794.
Col eman WP, Hanke CW, Al t TH, Asken S. Cosmeti c surgery of the
ski n: pri nci pl es and techni ques. St. Loui s: Mosby, 1997.
therapy, 3rd ed. St. Loui s: Mosby, 1996.
Kuwahara RT, Huber JD, Ray SH. Surgi cal pearl : forceps method for
freezi ng beni gn l esi on. J Am Acad Dermatol 2000;43:306307.
Kwan TH, Mi hm MC. The ski n. In: Robbi ns SL, Cotran RS, eds.
Pathol ogi c basi s of di sease, 2nd ed. Phi l adel phi a: WB Saunders,
1979:14171461.
Parry EL. Management of epi dermal tumors. In: Wheel and RG, ed.
Cutaneous surgery. Phi l adel phi a: WB Saunders, 1994:683687.
Usati ne RP, Moy RL, Tobni ck EL, et al . Ski n surgery: a practi cal
gui de. St. Loui s: Mosby, 1998.
Zuber TJ. The i l l ustrated manual s and vi deotapes of soft-ti ssue
surgery techni ques. Kansas Ci ty: Ameri can Academy of Fami l y
Physi ci ans, 1998.
Page 171
> Table of Cont ent s > Dermat ology > 14 - Simple, Int errupt ed Skin Sut ure
Placement 14
Simple, Interrupted Skin Suture
Placement
The si mpl e, i nterrupted ski n suture has been one of the most
commonl y empl oyed wound cl osure techni ques i n the l ast century.
The si mpl e suture can be used al one or i n conjuncti on wi th deep
sutures to provi de opti mal wound heal i ng and cosmesi s. Properl y
pl aced i nterrupted ski n sutures i ncorporate symmetri c amounts of
ti ssue from each wound edge, evert the ski n edges, and provi de
wound edge opposi ti on wi thout ti ssue strangul ati on. Interrupted
ski n sutures al l ow preci se adjustments between sti tches. Proper
ti mi ng for suture removal al l ows for adequate heal i ng (i .e.,
strength to the devel opi ng scar) and mi ni mi zes the devel opment of
suture marks (i .e., rai l road or Frankenstei n marks.) Interrupted ski n
sutures al so permi t removal of sel ected sti tches (e.g., every other
sti tch) to i ndi vi dual i ze the ti me sutures are present.
Wound edge eversi on i s an i mportant goal when pl aci ng i nterrupted
ski n sutures. Heal i ng wounds have a natural tendency to become
i nverted wi th the retracti on that occurs wi thi n scars. Indented or
i nverted scars can cast a shadow on adjacent surfaces, and the
shadow magni fi es the appearance of the scar. Everted wounds are
created so that the fi nal scar i s fl at and not i nverted. Eversi on i s
accompl i shed by i ncorporati ng a greater amount of deep ti ssue i n
the needl e path, whi ch pushes together the deep ti ssue, causi ng
upward l i ft to the wound edges.
The si mpl e, i nterrupted ski n suture i s used i n a vari ety of cl i ni cal
setti ngs. The techni que i s used for superfi ci al wounds when
si ngl e-l ayer cl osure i s i ndi cated. Suture pl acement permi ts
functi onal movement of an area after cl osure and i s especi al l y
val uabl e over the dorsum of the fi ngers. Al though si mpl e sutures
Page 172
can be used to cl ose wi de surgi cal wounds, the di stri buti on of
tensi on to approxi mate the ski n edges may be better handl ed wi th
verti cal or hori zontal mattress ski n sutures or by pl acement of
deepl y buri ed subcuti cul ar sutures.
Nonabsorbabl e suture materi al s such as nyl on general l y are
sel ected for i nterrupted suture pl acement. Smal l er-cal i ber sutures
(5-0 and 6-0) tend to produce l ess ski n marki ng and scarri ng than
l arger-cal i ber sutures (3-0 and 4-0). Pl acement of ti ghtl y cl ustered
sutures cl ose to the wound edge di stri butes the ski n edge tensi on
better than pl acement of wi del y spaced sutures pl aced back from
the wound edge. Suggested suture removal ti mes are l i sted i n
Appendi x C.
Wound adhesi ves are an al ternate means for wound cl osure. Some
practi ti oners bel i eve that wound edge eversi on i s superi or wi th
suture cl osure, but adhesi ves
P.110
can produce good cosmeti c resul ts for wounds wi th cl osel y
approxi mated edges. Wound adhesi ves are costl y (more than $40
for si ngl e appl i cati ons) and probabl y wi l l not el i mi nate the need for
si mpl e i nterrupted cl osures.
INDICATIONS
Superfi ci al wounds that can be cl osed i n a si ngl e l ayer
Eversi on of wound edges after approxi mati on wi th
mattress or buri ed sutures
Marki ng of ski n for correct anatomi c approxi mati on (e.g.,
vermi l i on border)
Cl osure of wounds over areas of movement such as
fl exor creases or on the dorsum of the fi ngers
Cl osure of defects on breast ti ssue (use a runni ng
i ntracutaneous suture cl osure)
Wi del y separated wound edges that are better
approxi mated wi th deepl y buri ed sutures
Page 173
Presence of cel l ul i ti s, bacteremi a, or other acti ve
i nfecti on
P.111
PROCEDURE
A retracted scar on a verti cal surface, such as the face, produces a
shadow that magni fi es the appearance of the scar (Fi gure 1A).
Wound edges shoul d be everted at cl osure (Fi gure 1B) so that
subsequent scar retracti on wi l l produce a fi nal scar that i s fl at
(Fi gure 1C).
(1) A retracted scar on a verti cal surface produces a shadow that
magni fi es the appearance of the scar.
The poorl y performed, scooped passage of a suture needl e
across both wound edges (Fi gure 2A) wi l l fai l to create proper
cl osure. The sti tch shoul d be deeper than i t i s wi de. The needl e
shoul d enter the ski n verti cal l y (Fi gure 2B) and exi t the ski n
verti cal l y.
Page 174
(2) To create proper cl osure, make a sti tch that i s deeper than i t i s
wi de.
P.112
Symmetri c amounts of ti ssue from each wound edge shoul d be
i ncl uded i n the passage of the suture. Uneven bi tes of ti ssue i n the
di stance from the edge or the depth of passage (Fi gure 3A) produce
a cl osure wi th uneven edges (Fi gure 3B). The resul ti ng scar wi l l
cast a shadow and be cosmeti cal l y i nferi or.
(3) Equal amounts of ti ssue from each edge of the wound shoul d be
i ncl uded i n the passage of the suture.
PITFALL: Forcefully pushing or twisting the needle when passing
it through the tissue will cause the body of the needle to bend or
break. Follow the curve of the needle; do not apply twisting or
Page 175
torquing forces to the needle. Regrasp (remount) the needle in
the center of the wound rather than force a small needle
through both wound edges. If the needle bends, remove it, and
open another suture pack. Broken needle tips can result in hours
of frustrating searching to find the broken piece.
P.113
The proper needl e path to produce wound edge eversi on i s i n the
shape of a fl ask (Fi gure 4A). The nondomi nant hand i s used to push
down on both wound edges (Fi gure 4B), causi ng the ti ssue i n the
deep porti on of the wound to move toward the center of the wound
(Fi gure 4C). The needl e enters the ski n verti cal l y and exi ts the ski n
verti cal l y. When the nondomi nant hand rel axes, the ti ssue returns
to i ts natural posi ti on. The suture path i s fl ask shaped, and wi th
tyi ng, the suture produces eversi on.
(4) To produce wound edge eversi on, the needl e shoul d fol l ow a
Page 176
path that i s i n the shape of a fl ask.
PITFALL: Pushing down on the wound edges with the fingers
increases the risk for an inadvertent needlestick. Instruments
can be used to push down on the wound edges. If the fingers
are used, exert added care to minimize the risk of a needle
injury.
P.114
An al ternati ve method to produce a fl ask-shaped path i s techni cal l y
more di ffi cul t. As the needl e enters the ri ght wound edge, the
nondomi nant hand grasps ti ssue beneath the wound edge usi ng
Adson forceps and pul l s ti ssue to the center of the wound (Fi gure
5A). Before the needl e passes through the opposi te wound edge,
the deep ti ssue i s pul l ed to the center of the wound wi th a
backhanded techni que usi ng Adson forceps (Fi gure 5B).
(5) Al ternati ve method to produce a fl ask-shaped needl e path.
PITFALL: Avoid traumatizing the skin or deep tissue with the
forceps. Traumatized tissue may necrose, creating excessive
time to healing and inferior cosmetic results.
Anti bi oti c oi ntment i s pl aced over the sutured wound, and a
pressure dressi ng i s appl i ed.
Page 177
(6) Fi nal appearance of the sutured wound.
P.115
CODING INFORMATION
Al l codes l i sted are for superfi ci al wound cl osure usi ng sutures,
stapl es, or ti ssue adhesi ves wi th or wi thout adhesi ve stri ps on the
ski n surface. If a l ayered cl osure i s requi red, use al ternate codes:
i ntermedi ate cl osure codes 1203112057 or compl ex repai r codes
1310013160.
Add together the l engths of wounds i n the same cl assi fi cati on and
anatomi c si tes. Dbri dement i s consi dered a separate procedure
onl y when gross contami nati on requi res prol onged cl eansi ng or
when appreci abl e amounts of devi tal i zed or contami nated ti ssue
are removed.
Si mpl e repai r i s i ncl uded i n the codes reported for beni gn and
mal i gnant l esi on exci si on (see Chapter 12). The bi l l i ng chart ci tes
the fol l owi ng wound l ocati ons: scal p, neck, axi l l ae, external
geni tal i a, trunk, extremi ti es, hands, and feet (SNAGTEHF) and face,
ears, eyel i ds, nose, l i ps, and mucous membranes (FEENLMM).
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Page 178
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Page 179
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Page 180
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Page 183
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Page 184
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Page 185
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Page 186
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Page 187
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Page 188
e
nc
e,
si
m
pl
e
cl
os
ur
e
CPT
i s a
tradem
ark of
the
Ameri c
an
Medi ca
l
Associ
ati on.
P.116
Instruments for si mpl e, i nterrupted, ski n suture pl acement are
found i n Appendi x A and can be ordered through l ocal surgi cal
suppl y houses. Suture materi al s can be ordered from Ethi con,
Somervi l l e, NJ (http://www.ethi coni nc.com) and from
Sherwood-Davi s & Geck, whi ch i s now part of Kendal l Heal thcare (
http://www.tyco.com). A suggested anesthesi a tray that can be
used for thi s procedure i s l i sted i n Appendi x G. Ski n preparati on
Page 189
BIBLIOGRAPHY
Bennett RG. Fundamental s of cutaneous surgery. St. Loui s: CV
Mosby, 1988:384394.
Brown JS. Mi nor surgery a text and atl as, 3rd ed. London: Chapman
& Hal l , 1997:7096.
Ethi con wound cl osure manual . Somervi l l e, NJ: Ethi con, 1994.
Lammers RL, Trott AT. Methods of wound cl osure. In: Roberts JR,
Hedges JR, eds. Cl i ni cal procedures i n emergency medi ci ne, 3rd ed.
McCarthy JG. Pl asti c surgery. Phi l adel phi a: WB Saunders,
1990:168.
Moy RL. Suturi ng techni ques. In: Usati ne RP, Moy RL, Tobni ck EL,
Si egel DM, eds. St. Loui s: Mosby, 1998:88100.
Odl and PB, Murakami CS. Si mpl e suturi ng techni ques and knot
tyi ng. In: Wheel and RG, ed. Cutaneous surgery. Phi l adel phi a: WB
Saunders, 1994:178188.
Spi cer TE. Techni ques of faci al l esi on exci si on and cl osure. J
Dermatol Surg Oncol 1982;8: 551556.
surgery. Chi cago: Year Book Medi cal Publ i shers, 1984:4142.
1987:2628.
Zi tel l i JA. TIPS for a better el l i pse. J Am Acad Dermatol
1990;22:101103.
Zuber TJ. Basi c soft-ti ssue surgery. The AAFP i l l ustrated manual s
and vi deotapes of soft-ti ssue surgery techni ques. Kansas Ci ty:
Ameri can Academy of Fami l y Physi ci ans, 1998:3438.
Page 190
> Table of Cont ent s > Dermat ology > 15 - Running Cut aneous and Int racut aneous
Sut ures15
Running Cutaneous and
Intracutaneous Sutures
The runni ng (conti nuous) cutaneous suture provi des a rapi d and
conveni ent means for wound cl osure. Thi s techni que i s si mi l ar to
si mpl e i nterrupted sutures, except that the suture materi al i s not
cut and ti ed wi th each succeedi ng suture pl acement. The suture
evenl y di stri butes tensi on al ong the l ength of a wound, thereby
preventi ng damage to the ski n edges from excessi ve ti ghtness i n
i ndi vi dual sutures. Because suture materi al i s not consumed i n
creati ng repeti ti ve knots and cutti ng ends, thi s techni que can
provi de cost savi ngs i n l i mi ti ng the use of suture materi al . Thi s
suture method i s used pri mari l y i n wounds that are wel l
approxi mated and that are not under much tensi on.
The runni ng cutaneous suture may not provi de much ski n edge
eversi on and i s general l y avoi ded i n cosmeti cal l y i mportant areas
such as the face. One di sadvantage of a runni ng cutaneous suture
i s that, i f the suture thread breaks, the enti re wound may dehi sce.
A conti nuous suture does not permi t sel ecti ve removal of sutures i n
response to heal i ng. Because the enti re suture i s removed at one
ti me, sl i ghtl y l onger ti mes to removal are recommended (see
Appendi x C).
The runni ng i ntracutaneous (i ntradermal ) suture i s an el egant but
techni cal l y di ffi cul t and ti me-consumi ng techni que for wound
cl osure. Thi s suture i s pl aced when ski n suture marks must be
avoi ded. Certai n body l ocati ons such as the neck and breast favor
the pl acement of runni ng i ntracutaneous sutures. Thi s suture al so
i s i ndi cated when cl osi ng erythematous forehead ski n or faci al ski n
wi th extensi ve sebaceous gl and acti vi ty, whi ch can devel op
promi nent suture marks. Thi s techni que i s best appl i ed to shal l ow
Page 191
wounds or to wounds wi th the edges narrowed by pl acement of
deepl y buri ed sutures.
The runni ng i ntracutaneous suture i s pl aced wi thi n the dermi s usi ng
a hori zontal l oopi ng acti on. Al though an absorbabl e suture may be
used i n chi l dren, nonabsorbabl e suture general l y i s chosen.
Intradermal sutures remai n i n pl ace for 2 to 4 weeks; a sl i ppery
suture materi al such as pol ypropyl ene (Prol ene) i s often sel ected to
faci l i tate suture removal . Because l ong sutures can be di ffi cul t to
extract after several weeks, pl acement of extracutaneous l oops of
suture i n the center of a l ong suture can ai d i n removal .
P.118
INDICATIONS
Running Cutaneous Suture
Cl osure of l ong wounds i n l ess cosmeti cal l y i mportant
(nonfaci al ) areas
Cl osure of wounds where speed of cl osure i s i mportant
(e.g., i n the emergency department)
Shal l ow wounds wi th l oose ski n nearby, such as the
scrotum or dorsum of the hand
Running Intracutaneous Suture
Cl osure of wounds on hi ghl y vascul ar, ruddy, or pl ethori c
ski n
Cl osure of wounds on ski n subject to i ncreased moti on,
such as the neck
Cl osure of breast wounds or surgi cal si tes that are
subject to expansi on and suture marks
Cl osure of cosmeti cal l y sensi ti ve areas where suture
marks must be avoi ded, such as the head and neck
Unrel i abl e pati ent (i .e., unl i kel y to provi de necessary
Page 192
postoperati ve care for a runni ng suture)
Wounds best cl osed by other methods
Wi del y separated wounds that cl ose under si gni fi cant
tensi on
Presence of cel l ul i ti s, bacteremi a, or acti ve i nfecti on
P.119
PROCEDURE
The cl osure begi ns wi th pl acement of a si mpl e i nterrupted suture at
one end of the wound. The free end i s cut, but the l ong end (wi th
the needl e attached) i s not cut (Fi gure 1A). Mul ti pl e l oops are
made strai ght across the wound, movi ng down the wound edge
about 4 to 5 mm to i ni ti ate each pass, wi th the suture thread at a
60-degree angl e to the wound (Fi gure 1B). The suture thread
beneath the wound i s perpendi cul ar to the l ong axi s of the wound.
At the far end of the wound, the suture i s ti ed by l oopi ng suture
over the needl e dri ver and reachi ng back to grasp the fi nal l oop
across the wound (Fi gure 1C).
(1) The runni ng cutaneous suture.
PITFALL: Do not tie the suture too tightly. The wound edges will
bunch up if the final knot is too tight.
Some practi ti oners prefer not to have the suture angl ed across the
top of the wound. An al ternate techni que causes the suture thread
to appear perpendi cul ar to the wound above the ski n surface. Angl e
the needl e beneath the wound to exi t the ski n 4 to 5 mm down the
Page 193
wound edge (Fi gure 2A). The fi nal resul t appears i n Fi gure 2B.
(2) Instead of angl i ng the suture across the wound, some prefer to
angl e the needl e beneath the wound to exi t the ski n 4 to 5 mm
down the wound edge.
P.120
The most commonl y empl oyed method to i ni ti ate thi s suture i s to
percutaneousl y enter the wound 1 cm from the end of the wound
(Fi gure 3A). A hemostat can be pl aced on the free end of the suture
to prevent i t from sl i ppi ng i nto the wound (Fi gure 3B). A hori zontal ,
i ntracutaneous l oop i s created on each si de of the wound (Fi gure
3C). The suture comes strai ght across the wound wi th each
successi ve pass and does not pass back to the pri or exi t si te of the
l ast l oop on that si de of the wound (Fi gure 3D). The suture then
exi ts the wound wi th a percutaneous pass 1 cm from the end of the
wound (Fi gure 3E).
Page 194
(3) The runni ng i ntradermal suture.
PITFALL: Smaller loops create much less bunching of the skin
edges. Even experiences physicians may observe some edge
bunching, and placement of a few simple, interrupted sutures
may be needed to refine the skin edge.
P.121
After cutti ng the needl e free, the free ends of suture are secured
wi th tape at the ends of the wound (Fi gure 4A). Al ternatel y, a knot
can be ti ed by reachi ng back onto the thread (Fi gure 4B). Thi s knot
tyi ng frequentl y causes excess pul l and bunchi ng of the ski n edges,
and i t i s di scouraged because of i ts techni cal di ffi cul ty.
(4) After the needl e has been cut free, the ends of the suture are
Page 195
secured wi th tape at the ends of the wound.
To faci l i tate suture removal , an extracutaneous l oop may be pl aced
i n l ong suture l i nes. The extracutaneous l oop i s cut, creati ng two
smal l er threads that are easi er to extract than one l ong thread.
(5) Pl acement of an extracutaneous l oop.
P.122
CODING INFORMATION
Use the codes l i sted i n Chapter 12 for fusi form exci si on and i n
Chapter 14 for si mpl e, i nterrupted ski n sutures.
The basi c ski n-suturi ng i nstruments used are l i sted i n Appendi x A.
Suggested suture removal ti mes are l i sted i n Appendi x C. A
suggested anesthesi a tray that can be used for thi s procedure i s
l i sted i n Appendi x G. Ski n preparati on recommendati ons appear i n
Appendi x H. Ski n preparati on recommendati ons appear i n Appendi x
H.
BIBLIOGRAPHY
1988:464465.
Boutros S, Wei nfel d AB, Fri edman JD. Conti nuous versus i nterrupted
suturi ng of traumati c l acerati ons: a ti me, cost, and compl i cati on
rate compari son. J Trauma 2000;48:495497.
Page 196
Brown JS. Mi nor surgery a text and atl as, 3rd ed. London: Chapman
& Hal l , 1997:7096.
Lammers RL, Trott AL. Methods of wound cl osure. In: Roberts JR,
Moy RL. Suturi ng techni ques. In: Usati ne RP, Moy RL, Tobni ck EL,
Si egel DM, eds. Ski n surgery: a practi cal gui de. St. Loui s: Mosby,
1998:88100.
Stasko T. Advanced suturi ng techni ques and l ayered cl osures. In:
Wheel and RG, ed. Phi l adel phi a: WB Saunders, 1994:304317.
1987:4245.
Wong NL. Revi ew of conti nuous sutures i n dermatol ogi c surgery. J
Dermatol Surg Oncol 1993; 19:923931.
Zuber TJ. Basi c soft-ti ssue surgery. The AAFP i l l ustrated manual s
Zuki n DD, Si mon RR. Emergency wound care: pri nci pl es and
practi ce. Rockvi l l e, MD: Aspen Publ i shers, 1987:5154.
Page 197
> Table of Cont ent s > Dermat ology > 16 - Vert ical Mat t ress Sut ure Placement
16
Vertical Mattress Suture Placement
The verti cal mattress suture i s unsurpassed i n i ts abi l i ty to evert
ski n wound edges. The verti cal mattress suture i s commonl y
empl oyed where wound edges tend to i nvert, such as on the
posteri or neck, behi nd the ear, i n the groi n, i n the i nframammary
crease, or wi thi n concave body surfaces. Because l ax ski n may al so
i nvert, the verti cal mattress sti tch has been advocated for cl osure
on the dorsum of the hand and over the el bow.
The verti cal mattress suture i ncorporates a l arge amount of ti ssue
wi thi n the passage of the suture l oops and provi des good tensi l e
strength i n cl osi ng wound edges over a di stance. The verti cal
mattress suture can be used as the anchori ng sti tch when movi ng a
ski n fl ap or at the center of a l arge wound. The suture al so can
accompl i sh deep and superfi ci al cl osure wi th a si ngl e suture. The
verti cal mattress suture can provi de deeper wound support i n
si tuati ons when buri ed subcutaneous cl osure i s not advi sabl e (e.g.,
faci al ski n fl aps). Earl y removal of verti cal mattress sutures i s
advocated, especi al l y i f nearby si mpl e i nterrupted sutures can
remai n i n pl ace for the normal durati on.
A major drawback to the routi ne use of verti cal mattress sutures on
cosmeti cal l y i mportant areas i s the devel opment of crosshatch
marks (i .e., rai l road marks or Frankenstei n marks) from the suture
l oops on the ski n surface. After pl acement of a verti cal mattress
suture, the natural process of wound i nfl ammati on and scar
retracti on pul l s the external i zed l oops i nward. The resul ti ng
pressure necrosi s and scarri ng i s worsened i f the verti cal mattress
suture i s ti ed too ti ghtl y or i f a l arge-cal i ber suture (3-0 or 4-0
USP) materi al i s used.
A vari ati on of the verti cal mattress suture, known as the shorthand
Page 198
techni que or near-near/far-far techni que, has been advocated by
some physi ci ans. The vari ati on pl aces the near-near pass of suture
fi rst, al l owi ng the cl i ni ci an to pul l up the suture stri ngs to el evate
the ski n for pl acement of the far-far l oop. The vari ati on i s
advocated because i t can be pl aced more rapi dl y than the cl assi c
techni que. Unfortunatel y, the ski n can tear when l i fti ng the ski n
after the i ni ti al pass. Thi s tendency for wound edge teari ng causes
some cl i ni ci ans to pass the near-near l oop deeper and wi der,
di mi ni shi ng some of the eversi on benefi t of the standard verti cal
mattress techni que. Onl y the cl assi c techni que i s demonstrated i n
thi s chapter.
P.124
INDICATIONS
Cl osure of wounds that tend to i nvert (e.g., back of the
neck, groi n, i nframammary crease, behi nd the ear)
Cl osure of l ax ski n (e.g., dorsum of the hand, over the
el bow)
Anchori ng sti tch when movi ng a ski n fl ap
P.125
PROCEDURE
The far-far pass i s made wi th the suture needl e enteri ng and
exi ti ng the anestheti zed ski n 4 to 8 mm from the wound edge
(Fi gure 1A). The suture needl e shoul d pass verti cal l y through the
ski n surface. The far-far suture must be pl aced at the same
di stance and the same depth from the wound edge (Fi gure 1B).
Page 199
(1) The far-far pass i s made wi th the suture needl e enteri ng and
exi ti ng the anestheti zed ski n 4 to 8 mm from the wound edge.
PITFALL: Pass the suture needle symmetrically through the
tissue. Asymmetric bites through the wound edge cause one
edge to be higher than the other. The creation of a shelf, with
one wound edge higher, produces cosmetically inferior scars
that are prominent because they cast a shadow.
Pl ace the needl e backwards i n the needl e dri ver. The near-near
pass i s made shal l ow, wi thi n 1 to 2 mm of the wound edge, usi ng a
backhand pass. The near-near pass shoul d be wi thi n the dermi s.
(2) Pl ace the needl e backwards i n the needl e dri ver.
Page 200
P.126
Ti e the suture snugl y but gentl y (Fi gure 3A). Ti ght sutures produce
crosshatch marks (Fi gure 3B).
(3) Ti e the suture snugl y but gentl y.
PITFALL: Novice physicians often tie the suture tightly to
produce additional eversion. Avoid this temptation, because it
results in increased wound scarring.
The verti cal mattress suture can act as the anchori ng suture when
movi ng a ski n fl ap i nto pl ace.
(4) The verti cal mattress suture can act as the anchori ng suture
when movi ng a ski n fl ap i nto pl ace.
P.127
Page 201
CODING INFORMATION
The mattress suture cl osures are consi dered a vari ati on of
si ngl e-l ayered cl osure, and the codes 1200112021 appl y for
wound repai r. Chapter 14 l i sts the codes for si mpl e ski n suture
pl acement.
The standard i nstruments used for offi ce surgery are al so used for
mattress suture cl osure (see Appendi x A). Suggested suture
removal ti mes are l i sted i n Appendi x C, and a suggested anesthesi a
tray that can be used for thi s procedure i s l i sted i n Appendi x G.
Ski n preparati on recommendati ons appear i n Appendi x H.
BIBLIOGRAPHY
Chernosky ME. Scal pel and sci ssors surgery as seen by the
dermatol ogi st. In: Epstei n E, Epstei n E Jr, eds. Ski n surgery, 6th
ed. Phi l adel phi a: WB Saunders, 1987:88127.
Gaul t DT, Brai n A, Sommerl ad BC, et al . Loop mattress suture. Br J
Surg 1987;74:820821.
Jones JS, Gartner M, Drew G, et al . The shorthand verti cal mattress
sti tch: eval uati on of a new suture techni que. Am J Emerg Med
1993;11:483485.
Snow SN, Goodman MM, Lemke BN. The shorthand verti cal mattress
sti tcha rapi d everti ng ski n everti ng suture techni que. J Dermatol
Surg Oncol 1989;15:379381.
1994:304317.
surgery. Chi cago: Year Book Medi cal Publ i shi ng, 1982.
1987:3035.
Usati ne RP, Moy RL, Tobi ni ck EL, et al . Ski n surgery: a practi cal
gui de. St. Loui s: Mosby, 1998.
Page 202
Zuber TJ. The academy i l l ustrated manual s and vi deotapes of
soft-ti ssue surgery techni ques. Kansas Ci ty: Ameri can Academy of
Fami l y Physi ci ans, 1998.
Zuber TJ. The mattress sutures: verti cal , hori zontal , and corner
sti tch. Am Fam Physi ci an 2002; 66:22312236.
Page 203
> Table of Cont ent s > Dermat ology > 17 - Horizont al Mat t ress Sut ure Placement
17
Horizontal Mattress Suture
Placement
The hori zontal mattress suture i s an everti ng suture techni que that
al l ows for separated wound edges to be approxi mated. The
hori zontal mattress suture spreads the cl osure tensi on al ong the
wound edge by i ncorporati ng a l arge amount of ti ssue wi thi n the
passage of the suture thread. The techni que i s commonl y empl oyed
for pul l i ng wound edges over a di stance or as the i ni ti al suture to
anchor two wound edges (e.g., hol di ng a ski n fl ap i n pl ace).
Thi n ski n tends to tear wi th pl acement of si mpl e, i nterrupted
sutures. The hori zontal mattress suture i s effecti ve i n the cl osure
of fragi l e, el derl y ski n or the ski n of i ndi vi dual s recei vi ng chroni c
steroi d therapy. The hori zontal mattress suture techni que al so i s
effecti ve i n cl osi ng defects of thi n ski n on the eyel i d and the fi nger
and toe web spaces. Control of bl eedi ng i s another advantage of
thi s suture. Hemostasi s devel ops when a l arge amount of ti ssue i s
i ncorporated wi thi n the passage of a suture. The techni que can
produce effecti ve bl eedi ng control on vascul ar ti ssues such as the
scal p.
Certai n ski n defects tend to have the ski n edges rol l i nward.
Inversi on of the wound edge can retard heal i ng and promote wound
compl i cati ons. The hori zontal mattress suture produces strong
everti ng forces on the wound edge and can prevent i nversi on i n
suscepti bl e wounds i n the i ntergl uteal cl eft, groi n, or posteri or
neck.
After pl acement of hori zontal mattress sutures, the l oops of suture
thread that remai n above the ski n surface can compress the ski n
and produce pressure necrosi s and scarri ng. Thi s scarri ng potenti al
l i mi ts the use of the hori zontal mattress sutures on the face.
Page 204
Pressure i njury commonl y devel ops when the sutures are ti ed too
ti ghtl y. Bol sters are compressi bl e cushi ons pl aced wi thi n the
extracutaneous l oops of suture to prevent pressure i njury to the
ski n. Some of the commonl y used materi al s i n bol sters i ncl ude
pl asti c tubi ng, cardboard, and gauze.
Ski n compressi on i njury can be reduced by earl y removal of
hori zontal mattress sutures. Some authori ti es recommend removal
i n 3 to 5 days, wi th the surroundi ng i nterrupted sutures l eft i n
pl ace l onger. Earl y suture removal i s especi al l y val uabl e when the
hori zontal mattress techni que i s empl oyed i n cosmeti cal l y
i mportant body l ocati ons such as the head and neck.
P.129
INDICATIONS
Cl osure of thi n or atrophi c ski n (e.g., el derl y ski n,
eyel i ds, i ndi vi dual s on chroni c steroi d therapy)
Eversi on of ski n defects prone to i nversi on (e.g.,
posteri or neck, groi n, i ntergl uteal ski n defects)
Cl osure of bl eedi ng scal p wounds
Cl osure of web space ski n defects (e.g., fi nger or toe
web spaces)
P.130
PROCEDURE
The suture needl e i s passed from the ri ght si de of the wound to the
l eft si de of the wound (Fi gure 1A). The entry and exi t si tes of the
wound general l y are 4 to 8 mm from the wound edge. Do not ti e the
suture! The needl e i s pl aced backward i n the needl e dri ver (Fi gure
1B), and then the suture i s passed back from the l eft si de to the
ri ght si de (Fi gure 1C). The second pass of the suture i s 4 to 8 mm
down the wound edge (Fi gure 1D).
Page 205
(1) The hori zontal mattress suture.
P.131
The hori zontal mattress suture i s ti ed, produci ng ski n edge
eversi on (Fi gure 2A). Tyi ng the suture ti ghtl y produces extra
eversi on (Fi gure 2B).
Page 206
(2) Avoi d the temptati on to ti e the hori zontal mattress suture
ti ghtl y, because ti ght knots often produce ski n pressure necrosi s.
PITFALL: Although the added eversion may appear beneficial at
the time of wound closure, tight knots often produce skin
pressure necrosis. Avoid the temptation to tie the horizontal
mattress suture tightly.
Bol sters can cushi on the ski n from the pressure produced by the
extracutaneous l oops of a hori zontal mattress suture. Gauze i s
used i n these bol sters.
(3) Use bol sters to cushi on the ski n from the pressure produced by
the extracutaneous l oops of a hori zontal mattress suture.
P.132
Page 207
Mul ti pl e hori zontal mattress sutures are used to cl ose a fi nger web
wound (Fi gures 4A and 4B).
(4) Use mul ti pl e hori zontal mattress sutures to cl ose a fi nger web
wound.
Thi s wound i n the groi n i s prone to i nversi on (Fi gure 5A). The
hori zontal mattress suture can effecti vel y evert the edges (Fi gure
5B).
(5) Cl osure of ski n defects prone to i nversi on.
P.133
CODING INFORMATION
The mattress suture cl osures are consi dered a vari ati on of
si ngl e-l ayered cl osure, and the codes 1200112021 appl y for
wound repai r. Chapter 14 provi des a l i st of these codes.
Page 208
mattress suture cl osure (see Appendi x A). A suggested anesthesi a
BIBLIOGRAPHY
Col di ron BM. Cl osure of wounds under tensi on: the hori zontal
mattress suture. Arch Dermatol 1989;125:11891190.
Ethi con wound cl osure manual . Somervi l l e, NJ: Ethi con, 1994.
1994:304317.
1987:3035.
Physi ci ans, 1998.
Zuber TJ. The mattress sutures: verti cal , hori zontal , and corner
sti tch. Am Fam Physi ci an 2002;66:22312236.
Page 209
> Table of Cont ent s > Dermat ology > 18 - Minimal Excision Technique for
Removing Epidermal Cyst s18
Minimal Excision Technique for
Removing Epidermal Cysts
Epi dermal or sebaceous cysts are frequentl y encountered i n cl i ni cal
practi ce, and the sl owl y enl argi ng l esi ons are commonl y appear on
the trunk, neck, face, scrotum, and behi nd the ears. The term
epi dermal cyst i s preferred over the hi stori cal l y used term
sebaceous cyst. The cysts usual l y ari se from ruptured
pi l osebaceous fol l i cl es or the l ubri cati ng gl ands associ ated wi th
hai rs or other ski n adnexal structures. Wi thi n the cyst i s a yel l ow,
cheesel i ke substance commonl y (but i ncorrectl y) referred to as
sebum. The ranci d odor associ ated wi th some cysts refl ects the
l i pi d content of the cyst materi al and any decomposi ti on of cyst
contents by bacteri a.
Cl i ni cal l y, the cysts can vary i n si ze from a few mi l l i meters to 5 cm
i n di ameter. Cysts general l y have a doughy or fi rm consi stency;
stony hard l esi ons suggest the possi bi l i ty of al ternate di agnoses.
The cysts usual l y are mobi l e wi thi n the ski n, unl ess the cysts have
surroundi ng scar and fi brous ti ssue after a pri or epi sode of
i nfl ammati on.
The cyst contents i nduce a tremendous i nfl ammatory response from
the body after l eaki ng from cysts. Epi dermal cysts can have a
tremendous amount of associ ated pus when i nfl amed, but cul turi ng
these i nfl ammatory cel l s often reveal s a steri l e i nfl ammatory
response. Because of the di scomfort, redness, and swel l i ng
associ ated wi th an i nfl amed cyst, many i ndi vi dual s prefer to have
cysts removed before they have the opportuni ty to l eak and become
i nfl amed.
Infl amed cysts usual l y requi re i nci si on and drai nage of the pus and
sebaceous materi al , wi th removal of the cyst wal l at a l ater date.
Page 210
Attempts at defi ni ti ve surgi cal care of acti vel y i nfl amed cysts are
often unsuccessful . Infl amed ti ssues bl eed extensi vel y and are
unabl e to hol d sutures for proper cl osure.
After the i nfl ammati on resol ves, standard i nci si on and removal
techni ques hi stori cal l y have been empl oyed to remove the enti re
cyst. Cyst recurrences are prevented by compl ete removal of the
cyst wal l . Unfortunatel y, previ ous exci si on techni ques produced
l arge ski n defects and scars i n removi ng the enti re l esi on i ntact.
The mi ni mal exci si onal techni que was devel oped to remove the cyst
wal l s wi th a mi ni mal ski n scar.
Most cysts are si mpl e, sol i tary l esi ons. However, some cl i ni cal
si tuati ons warrant added care. Mul ti pl e epi dermal cysts that are
associ ated wi th osteomas and mul ti pl e ski n l i pomas or fi bromas
may represent Gardner's syndrome. Gardner's syndrome i s
associ ated wi th premal i gnant col oni c and gastri c pol yps. Dermal
P.135
cysts of the nose, head, and neck often appear si mi l ar to epi dermal
cysts. However, a dermal cyst can have a thi n stal k that connects
di rectl y to the subdermal space, and surgery can produce central
nervous system i nfecti on. Mul ti pl e cysts, such as i n the fol d behi nd
the ear, can be treated al ternatel y wi th medi cal therapy (i .e.,
i sotreti noi n). When a cyst i s removed wi th any techni que, the
medi cal provi der shoul d pal pate the surgi cal si te to ensure that no
ti ssue or l esi ons remai n. Rarel y, the cl i ni ci an may encounter basal
cel l carci noma or squamous cel l carci noma associ ated wi th
epi dermal cysts, and hi stol ogi c exami nati on of cyst wal l s i s
recommended whenever unusual or unexpected cl i ni cal fi ndi ngs are
encountered.
INDICATIONS
Lesi ons wi th the cl i ni cal fi ndi ngs or appearance of
sebaceous cysts, preferabl y those that have not
previ ousl y been i nfl amed or scarred
Fl uctuant or compressi bl e l esi ons i n common areas for
sebaceous cysts (e.g., face, neck, scal p, behi nd the
Page 211
ears, trunk, scrotum)
P.136
PROCEDURE
Anesthesi a i s accompl i shed wi th a two-step procedure. Begi n by
pl aci ng a smal l (30-gauge, -i nch l ong) needl e i nto the ski n
overl yi ng the cyst. Pl ace the needl e ti p i n an i ntradermal l ocati on,
preferabl y near the pl ugged pore (i .e., comedone) that may be
vi si bl e overl yi ng the cyst (Fi gure 1A). When the needl e ti p i s
correctl y pl aced, there i s resi stance to i njecti ng the anestheti c
wi thi n the ski n, and a bl eb devel ops i n the ski n. In the second
step, pl ace a l onger (25-gauge, 1-i nch l ong) needl e on the syri nge.
Insert the needl e l ateral l y, angl i ng the needl e 45 degrees down to
bel ow (behi nd) the cyst (Fi gure 1B). Pl ace an adequate amount of
anestheti c (usual l y 3 to 6 mL) beneath the cyst, thereby ful l y
anestheti zi ng the posteri or wal l of the cyst.
(1) Anestheti ze the ski n overl yi ng the cyst and the posteri or wal l .
Avoi d pl aci ng needl e ti p i nto the cyst, because the anestheti c
i ncreases the pressure and causes the cyst to expl ode.
PITFALL: If the needle tip is placed inadvertently within the cyst,
the anesthetic will increase pressure and cause the cyst to
explode, often shooting the sebaceous material across the
room.
P.137
Page 212
Create an entry i nto the cyst by verti cal l y stabbi ng a no. 11
(sharp-poi nted) scal pel bl ade i nto the cyst. Usual l y, a si ngl e
up-and-down moti on i s suffi ci ent to create the passage i nto the
cyst. Someti mes, the cyst can be squeezed from the si des, and
sebaceous materi al i mmedi atel y comes up. However, the openi ng
can be gentl y stretched wi th i nserti on of a strai ght hemostat down
i nto the cyst.
(2) Create an entry i nto the cyst by verti cal l y stabbi ng a no. 11
scal pel i nto the cyst.
PITFALL: Many operators fail to enter the cyst with the scalpel
blade. By directing the blade toward the center of the cyst and
inserting until a give is felt as the blade tip enters the
cyst, the pass of the blade usually will be successful.
PITFALL: The clinician should not be positioned directly over the
cyst. Opening a cyst that is under pressure can result in upward
spraying of the cyst' s contents. Hold some gauze in the
nondominant hand to act as a shield when opening the cyst.
Al ternatel y, some practi ti oners prefer the ease that i s afforded by
Page 213
creati ng a l arger openi ng. A 3- 4-mm bi opsy punch can be i nserted
di rectl y down i nto the cyst. The comedone or pore usual l y i s
i ncl uded i n the ski n that i s removed wi th the bi opsy punch. Thi s
openi ng al l ows much easi er emptyi ng of the cyst, but i t has the
di sadvantage of requi ri ng suture cl osure after the procedure.
(3) Al ternati vel y, a 3- or 4-mm bi opsy punch can be i nserted
di rectl y down i nto the cyst.
P.138
The cyst contents must be empti ed before attempti ng removal of
the cyst wal l . Usi ng the thumbs to squeeze the cyst general l y
provi des the greatest possi bl e hand strength (Fi gure 4A). Pl ace the
thumbs on opposi te si des of the cyst openi ng. Press strai ght down
wi th the greatest possi bl e force, and fi rml y rotate the thumbs
toward each other and then up toward the openi ng (Fi gure 4B).
Page 214
(4) The cyst contents must be empti ed before attempti ng removal
of the cyst wal l .
P.139
Squeezi ng out the cyst's contents can cause the sebaceous materi al
to erupt i nto the face of the practi ti oner. A more control l ed process
i nvol ves pl aci ng a hemostat i nto the cyst's openi ng and squeezi ng
the sebaceous materi al up i nto the open hemostat bl ades.
Squeezi ng i s accompl i shed usi ng fi ngers on the nondomi nant hand.
After the hemostat fi l l s wi th materi al , i t i s wi thdrawn wi th the
bl ades sti l l open, and the sebaceous materi al i s wi ped away usi ng
Page 215
gauze. The hemostat i s rei nserted and the process repeated.
(5) A more control l ed process of emptyi ng the cysts contents
i nvol ves pl aci ng a hemostat i nto the cyst openi ng and squeezi ng
the sebaceous materi al up i nto the open hemostat bl ades.
Use gauze to wi pe away sebaceous materi al on the ski n surface
(Fi gure 6A). Conti nue vi gorousl y squeezi ng unti l al l materi al i s
removed. The kneadi ng produced from the rocki ng moti on
of the thumbs toward the cyst openi ng hel ps to l oosen the cyst
from al l surroundi ng subcutaneous and cutaneous attachments.
Move the thumbs around the openi ng so that the vi gorous
massagi ng i s performed on al l si des of the cyst (Fi gure 6B).
(6) Use gauze to wi pe away sebaceous materi al on the ski n
surface, and conti nue squeezi ng vi gorousl y unti l al l materi al i s
removed.
P.140
Page 216
After the enti re si te has been vi gorousl y kneaded and the cyst i s
compl etel y empti ed, reach strai ght down through the openi ng usi ng
strai ght hemostats. Grasp the posteri or wal l of the cyst, and gentl y
el evate toward the ski n surface.
(7) Usi ng strai ght hemostats, reach strai ght down i nto the openi ng,
grasp the posteri or wal l of the cyst, and gentl y el evate i t toward
the ski n surface.
If resi stance i s encountered, grasp the cyst wal l wi th a second
hemostat just bel ow the i ni ti al hemostat appl i cati on, comi ng from
a hori zontal pl ane. Conti nue to el evate wi th both hemostats. If
more of the cyst wal l sl i des through the ski n openi ng, the fi rst
hemostat can be rel eased and used to regrasp the cyst wal l bel ow
the second hemostat.
(8) If resi stance i s encountered, grasp the cyst wal l wi th a second
Page 217
hemostat just bel ow the i ni ti al hemostat appl i cati on, comi ng from
a hori zontal pl ane.
P.141
An attempt i s made to remove the enti re cyst wal l i ntact. If the
cyst wal l breaks, enter the ski n openi ng and vi gorousl y grasp i n al l
di recti ons unti l addi ti onal cyst wal l i s grasped and pul l ed out.
(9) If the cyst wal l breaks, enter the ski n openi ng, and vi gorousl y
grasp i n al l di recti ons unti l addi ti onal cyst wal l i s grasped and
pul l ed out, because no part of the cyst wal l can remai n i n the
wound.
PITFALL: If any cyst wall remains in the wound, the cyst will
recur. It is critical that all of the cyst wall be removed. The
operator should vigorously search all sides and the depth of the
wound. It is critical that sufficient preprocedure anesthesia be
administered to permit this vigorous tugging within the wound.
Occasi onal l y, previ ous i nfl ammati on of the cyst causes scarri ng and
tetheri ng of the cyst wal l to surroundi ng ti ssues. Thi s usual l y
prevents removal of the cyst wal l by the mi ni mal techni que. If the
operator i s unabl e to remove the cyst wal l usi ng the mi ni mal
techni que, the operator shoul d make a fusi form exci si on
surroundi ng the ski n openi ng (Fi gure 10A) and cut down i nto the
subcutaneous ti ssues wi th a no. 15 bl ade to al l ow removal of the
enti re cyst wal l (Fi gure 10B). The si te i s then cl osed wi th sutures
(see Chapter 12).
Page 218
(10) If i t i s not possi bl e to remove the cyst wal l usi ng the mi ni mal
techni que, make a fusi form exci si on surroundi ng the ski n openi ng,
and cut down i nto the subcutaneous ti ssues wi th a no.15 bl ade to
al l ow removal of the enti re cyst wal l .
P.142
CODING INFORMATION
Use the beni gn exci si on codes (1140011446) for removal of
these l esi ons. The code sel ected i s determi ned by si ze and l ocati on
of the l esi on. The codes i ncl ude l ocal anesthesi a and si mpl e
(one-l ayer) cl osure, al though the codes can be used i f the mi ni mal
i nci si on techni que i s used and no suturi ng i s requi red. The si tes for
these codes i ncl ude the fol l owi ng: trunk, arms, or l egs (TAL); scal p,
neck, hands, feet, or geni tal i a (SNHFG); and face, ears, eyel i ds,
nose, l i ps, or mucous membrane (FEENLMM).
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CPT
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The basi c offi ce surgery i nstruments are used for the standard
Page 226
exci si on techni que (see Appendi x A.) The mi ni mal sebaceous cyst
removal techni que can be performed wi th a no. 11 scal pel bl ade,
two or three smal l mosqui to hemostats, and 1 i nch of steri l e gauze.
A suggested anesthesi a tray that can be used for thi s procedure i s
l i sted i n Appendi x G. Ski n preparati on recommendati ons appear i n
Appendi x H.
BIBLIOGRAPHY
Avakoff JC. Mi croi nci si on for removi ng sebaceous cysts [Letter].
Pl ast Reconstr Surg 1989;84: 173174.
Domonkos AN, Arnol d HL, Odom RB. Andrew di seases of the ski n:
cl i ni cal dermatol ogy, 7th ed. Phi l adel phi a: WB Saunders, 1982.
Johnson RA. Cyst removal : punch, push, pul l . Ski n 1995;1:1415.
P.143
Kl i n B, Ashkenazi H. Sebaceous cyst exci si on wi th mi ni mal surgery.
Am Fam Physi ci an 1990;41:17461748.
Li ebl i ch LM, Geronemus RG, Gi bbs RC. Use of a bi opsy punch for
removal of epi thel i al cysts. J Dermatol Surg Oncol
1982;8:10591062.
Lopez-Ri os F. Squamous cel l carci noma ari si ng i n a cutaneous
epi dermal cyst: case report and l i terature revi ew. Am J
Dermatopathol 1999;21:174177.
Nakamura M. Treati ng a sebaceous cyst: an i nci si onal techni que.
Aestheti c Pl ast Surg 2001;25: 5256.
Ri chards MA. Trephi ni ng l arge sebaceous cysts. J Pl ast Surg
1985;38:583585.
Vogt HB, Nel son RE. Exci si on of sebaceous cysts: a nontradi ti onal
method. Postgrad Med 1986; 80: 128334.
Zuber TJ. Mi ni mal exci si on techni que for epi dermoi d (sebaceous)
cysts. Am Fam Physi ci an 2002;65:14091412, 14171418, 1420,
14231424.
Zuber TJ. Offi ce procedures. The Academy col l ecti onqui ck
Wi l ki ns, 1999:97105.
Page 227
Zuber TJ. Ski n bi opsy, exci si on and repai r techni ques. The
1998: 9499.
Page 228
> Table of Cont ent s > Dermat ology > 19 - Skin Cryosurgery19
Skin Cryosurgery
Cryosurgery i s a frequentl y performed abl ati ve procedure that i s
used i n the treatment of beni gn, premal i gnant, and mal i gnant ski n
growths. Cryosurgery produces control l ed destructi on of ski n l esi ons
by wi thdrawi ng heat from the target ti ssue. Hi stori cal l y, physi ci ans
have used l i qui d ni trogen appl i ed wi th cotton-ti pped swabs,
al though modern appl i cati ons general l y use a probe ti p contai ni ng a
refri gerant l i qui d. Human ti ssue freezes at -2.2C, wi th ti ssue
destructi on occurri ng between -10C and -20C. Cl osed probe
systems usi ng ni trous oxi de can produce probe ti p temperatures i n
the range of -65C to -89C.
Cryosurgery produces an i ce bal l i n the target ti ssue. The edge of
the i ce bal l onl y achi eves a temperature of 0C, and thi s area
usual l y recovers. Cryosurgery shoul d be performed so that the i ce
bal l extends at l east 2 mm to 5 mm beyond the edge of the l esi on
bei ng destroyed. Because i ce bal l formati on i s geometri c i n al l
di recti ons, the l ateral extensi on of the i ce bal l from the appl i cator
ti p gi ves a good esti mati on of the depth of i ce penetrati on i nto the
ti ssue.
Many cl i ni ci ans advocate the performance of mul ti pl e freezes when
cryosurgery i s performed. The mai n advantage of
freeze-thaw-freeze techni que i s that greater cel l death i s achi eved
i n ti ssue that has been previ ousl y frozen (but woul d otherwi se
recover). Thi s advantage can be si gni fi cant when treati ng
premal i gnant or mal i gnant l esi ons or l esi ons that resi st freezi ng.
Cauti on shoul d be exerted duri ng the thaw phase, because vascul ar
l esi ons may bl eed on thawi ng.
Cryosurgery general l y produces a burni ng sensati on duri ng the
treatment, al though the di scomfort of i njected anestheti c often
exceeds the di scomfort of the procedure. After the procedure,
Page 229
cryosurgery produces anesthesi a i n the treated ti ssues. Frozen
ti ssue reacts wi th peri pheral edema i mmedi atel y after thawi ng.
Subsequent bul l a formati on and exudati on occur before the area
heal s i n a fi ne atrophi c scar wi thi n 4 weeks. The techni que
produces hi gh cure rates wi th good cosmeti c resul ts.
Certai n medi cal condi ti ons can produce an exaggerated ti ssue
response to the freezi ng of the ski n (l i sted i n the Rel ati ve
Contrai ndi cati ons secti on). Pati ents wi th condi ti ons that produce
serum col d-i nduced anti bodi es (i .e., cryogl obul i ns) are at greatest
ri sk for marked ski n necrosi s.
P.145
INDICATIONS
Acti ni c keratosi s
Leukopl aki a
Mi l i a
Mucocel e of the l i p
Pyogeni c granul oma
Seborrhei c keratosi s
Sebaceous hyperpl asi a
Superfi ci al basal cel l carci noma
Si mpl e l enti go
Cherry angi oma
Verrucae vul gari s
Hypertrophi c scars
Mol l uscum contagi osum
Capi l l ary hemangi oma of the newborn
Granul oma annul are
Sol ar i nduced pi gmentati on and wri nkl i ng
Fl at warts
Acti ve, severe col l agen vascul ar di sease
Acti ve, severe subacute bacteri al endocardi ti s
Page 230
Acti ve, severe ul cerati ve col i ti s
Acti ve syphi l i s i nfecti on
Acti ve, severe Epstei n-Barr vi rus i nfecti on
Acti ve, severe cytomegal ovi rus i nfecti on
Hi gh serum l evel of ci rcul ati ng cryogl obul i ns
Macrogl obul i nemi a
Immunoprol i ferati ve neopl asms, myel omas, l ymphomas
Hi gh-dose steroi d treatment
Acute poststreptococcal gl omerul onephri ti s
Chroni c, severe hepati ti s B i nfecti on
Col d-i nduced urti cari a
Raynaud's di sease (especi al l y for procedures on the
di gi ts)
Lesi ons on darkl y pi gmented i ndi vi dual s (due to
depi gmentati on from procedure)
P.146
PROCEDURE
Pare down thi ck, hyperkeratoti c l esi ons that resi st cryosurgi cal
treatment. Perform pari ng wi th a hori zontal l y hel d no. 15 scal pel
bl ade usi ng a sawi ng moti on or di rect pass through the l esi on.
Achi eve topi cal hemostasi s wi th an agent such as ferri c subsul fate
(Monsel 's sol uti on) before cryotherapy.
(1) Pare down thi ck, hyperkeratoti c l esi ons wi th a hori zontal l y hel d
no. 15 scal pel bl ade usi ng a sawi ng moti on or di rect pass through
Page 231
the l esi on.
PITFALL: Blood at the surface of the skin acts like an insulator
against cryosurgical destruction. Do not perform cryosurgery on
an actively bleeding lesion.
Sel ect a cryosurgi cal ti p for the procedure that approxi mates the
si ze of the l esi on bei ng treated.
(2) Sel ect a cryosurgi cal ti p that i s approxi matel y the same si ze of
the l esi on bei ng treated.
PITFALL: Avoid mismatched cryosurgical tips that can result in
inadequate or excessive treatment.
A l arge, fl at ti p appl i ed over a smal l l esi on produces excessi ve
ti ssue destructi on and potenti al scarri ng.
(3) A l arge, fl at ti p appl i ed over a smal l l esi on produces excessi ve
ti ssue destructi on and may cause scarri ng.
P.147
Page 232
Inadequate treatment of warts usi ng a ti p that i s too smal l may
resul t i n the formati on of a ri ng wart. Formati on of a ri ng wart does
not al ways i mpl y i nadequate treatment, because 5% of properl y
treated warts resul t i n ri ng wart formati on.
(4) Ri ng wart.
Appl y water-sol ubl e gel to the cryoti p, and pl ace the ti p on the
target ti ssue at ambi ent (room) temperature. Acti vate the cryogun,
causi ng the gel to turn whi te. The durati on of the freeze depends
on the ti me requi red to produce a proper-si zed i ce bal l . The edge of
the i ce bal l wi l l recover.
(5) The durati on of the freeze depends on the ti me requi red to
produce a proper-si zed i ce bal l .
PITFALL: Use the size of the ice ball to guide the duration of the
procedure. Physicians often desire to use freeze times to guide
therapy. Freeze times vary substantially because of factors such
as the pressure (amount of refrigerant) in the tank, skin or
lesion temperature, and thickness of the lesion.
Page 233
After an adequate freeze has been obtai ned, deacti vate the
cryogun, and al l ow the probe ti p to defrost before di sengagi ng the
ti p from the target ti ssue.
(6) After an adequate freeze has been obtai ned, deacti vate the
cryogun, and al l ow the probe ti p to defrost before di sengagi ng the
ti p from the target ti ssue.
PITFALL: Do not pull the cryotip off the target tissue before it
has defrosted or pull a cotton swab with liquid nitrogen off a
mucosal surface before it has thawed. Withdrawal of applicator
tips before defrosting often results in the removal or denuding
of the tissue surface.
P.148
Al l ow adequate ti me for the l esi on to thaw before the reappl yi ng
cryotherapy. As the ti ssue thaws, the whi te i ce bal l becomes red.
An adequate thaw permi ts fl ui d and el ectrol yte shi fts i n the
l esi onal ti ssue that enhance subsequent appl i cati ons of
cryotherapy.
Page 234
(7) As ti ssue thaws, the whi te i ce bal l becomes red.
PITFALL: Thawing of vascular lesions, such as cherry angiomas
or pyogenic granulomas, may bleed extensively on thawing. Be
prepared for this potential bleeding; gauze can be applied using
direct pressure, or Monsel' s solution can be applied to control
bleeding.
P.149
CODING INFORMATION
Destructi on performed i n certai n l ocati ons such as peni s and vul va
can be bi l l ed usi ng a speci fi c si te destructi on code. Speci fi c si te
codes general l y rei mburse more than the general codes. Mal i gnant
l esi on destructi on (1726017286) provi des addi ti onal
rei mbursement when cancerous l esi ons are abl ated.
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Page 238
ns
CPT
i s a
tradem
ark of
the
Ameri c
an
Medi ca
l
Associ
ati on.
Offi ce gun appl i cators, tank uni ts, and hand-hel d devi ces can be
obtai ned from Wal l ach Surgi cal , 235 Edi son Road, Orange, CT 06477
(phone: 203-799-2000; http://www.wal l achsd.com) and from Brymi l l
Cryogeni c Systems, 105 Wi ndermere Avenue, El l i ngton, CT
06029-3858 (phone: 800-777-2796; http://www.brymi l l .com).
BIBLIOGRAPHY
Cryomedi cs. Gui del i nes for cryosurgery. Langhorne, PA: Cabot
Medi cal , 1989.
Di nehart SM. Acti ni c keratoses: sci enti fi c eval uati on and publ i c
heal th i mpl i cati ons. J Am Acad Dermatol 2000;42:S25-S28.
Graham GF. Advances i n cryosurgery i n the past decade. Cuti s
1993;52:365372.
Greal i sh RJ. Cryosurgery for beni gn ski n l esi ons. Fam Pract
Recerti fi cati on Journal 1989;11: 2124.
Hocutt JE. Ski n cryosurgery for the fami l y physi ci an. Am Fam
Physi ci an 1993;48:445452.
Kufl i k EG. Cryosurgery for cutaneous mal i gnancy: an update.
Dermatol Surg 1997;23: 10811087.
Kuwahara RT, Huber JD, Shel l ey HR. Surgi cal pearl : forceps method
for freezi ng beni gn l esi on. J Am Acad Dermatol 2000;43:306307.
Page 239
Torre D. Cryosurgery of basal cel l carci noma. J Am Acad Dermatol
1986;15:917929.
Torre D. Cutaneous cryosurgery: current state of the art. J Dermatol
Surg Oncol 1985;11: 292293.
Torre D. The art of cryosurgery. Cuti s 1994;54:354.
Zal l a MJ. Basi c cutaneous surgery [Revi ew]. Cuti s
1994;53:172186.
Zouboul i s CC. Cryosurgery i n dermatol ogy. Eur J Dermatol
1998;8:466474.
Wi l ki ns, 1999.
Page 240
> Table of Cont ent s > Dermat ology > 20 - Dermal Radiosurgical Feat hering and
Ablat ion20
Dermal Radiosurgical Feathering
and Ablation
Radi osurgery uses hi gh-frequency current i n a vari ety of
dermatol ogi c appl i cati ons. The generators used i n radi osurgery
(e.g., El l man Surgi tron, El l man Internati onal , Hewl ett, NY)
transform 60 cycl es per second wal l el ectri ci ty i nto currents that
exceed 3 mi l l i on cycl es per second. The hi gh-frequency currents
operate i n the real m of AM radi o si gnal s (hence, the name
radi osurgery). Radi osurgery i s used i n cosmeti c surgery procedures
because the hi gh-frequency currents permi t cutti ng through ti ssue
wi thout di ssi pati ng heat i nto surroundi ng ti ssues, thereby l i mi ti ng
i njury and scarri ng.
Abl ati on or thermal ti ssue destructi on al so i s possi bl e wi th
radi osurgery uni ts. By changi ng the radi osurgi cal waveforms,
addi ti onal heat can be created to i ncrease ti ssue destructi on. Ol der
el ectrosurgery uni ts were l i mi ted to abl ati ve currents because of
thei r l ower current frequenci es (e.g., Hyfrecator, ConMed
Corporati on, Uti ca, NY). Spark-gap or ti ssue ful gurati ng procedures
are not consi dered cosmeti c, but they are effecti ve i n destroyi ng
warts or other growths i n non-cosmeti cal l y i mportant body areas. A
smal l , metal bal l el ectrode can be used for abl ati on of superfi ci al
ski n l esi ons. Fl at el ectrodes are used for matri cectomy destructi on
duri ng surgery for i ngrown toenai l s. Abl ati on of unwanted vei ns and
tel angi ectasi as can be performed wi th fi ne wi res i nserted i nto the
vei ns.
A major appl i cati on for dermal radi osurgery i s the featheri ng of
wound edges after shave exci si on of l esi ons (see Chapter 11). After
a l esi on has been removed by the shave techni que, a scooped-out
ski n defect usual l y exi sts. If thi s defect i s al l owed to heal wi thout
Page 241
al terati on, a ci rcul ar, depressed scar often resul ts. The shadow
produced by the edges of the depressi on creates an i nferi or
cosmeti c resul t and draws the attenti on of an observer's eye. The
fi nal cosmeti c outcome can be i mproved by smoothi ng or featheri ng
the wound edges. Featheri ng bl ends the fi nal l i ght col or of the scar
i nto the surroundi ng ski n and el i mi nates any sharp wound edges
that can cast shadows on verti cal ski n surfaces.
Featheri ng i s performed onl y usi ng a hi gh-frequency cutti ng current.
The techni que uses superfi ci al passes of an el ectrosurgi cal wi re
l oop over the ski n surface. The techni que can be used to smooth
any i rregul ari ty to the ski n surface. Because the techni que i s
desi gned to affect onl y the ski n surface, scarri ng that resul ts from
deeper dermal i njury i s prevented.
P.151
INDICATIONS
Featheri ng of shave exci si on si tes
Featheri ng of ski n surface i rregul ari ti es
Abl ati on of ski n l esi ons
Abl ati on of tel angi ectasi as
Hemostasi s i n wounds
Exci si on of ski n l esi ons
Creati on of ski n fl aps to cl ose ski n defects
Rhi nophyma pl ani ng
Removal of eyel i d l esi ons
Matri cectomy for i ngrown nai l s
CONTRAINDICATIONS
Appl i cati on of radi osurgery for treatment of a l esi on
di rectl y over or near a pacemaker
Pati ents i n di rect contact wi th metal i nstruments or
metal tabl es or exami nati on tabl es
Ungrounded pati ents
Improperl y functi oni ng equi pment
Page 242
P.152
PROCEDURE
Admi ni ster l ocal anesthesi a for most exci si onal , destructi ve, or
featheri ng radi osurgi cal procedures. To i l l ustrate the techni que of
featheri ng, fi rst perform a shave exci si on (see Chapter 11) such as
the radi osurgi cal techni que i l l ustrated here. When usi ng a dermal
l oop to remove a superfi ci al l esi on, the l esi on can be grasped and
el evated usi ng Adson forceps. El evate the l esi on upward through
the l oop, acti vate the el ectrode, and move the el ectrode
hori zontal l y to free the l esi on from the underl yi ng ti ssue. Use a
bl ended (i .e., cutti ng and coagul ati on) or cutti ng-current (i .e.,
i ni ti al machi ne setti ng of 3, approxi matel y 30 watts) for the
exci si on.
(1) When usi ng a dermal l oop to remove a superfi ci al l esi on, the
l esi on can be grasped and el evated usi ng Adson forceps.
PITFALL: With greater upward pull on a lesion, the loop
electrode passes deeper in the dermis, and greater scarring
results. To avoid excessive upward pull, many physicians shave
off lesions without using forceps to elevate the lesion.
PITFALL: Do not use nondermal loop electrodes for excision of
skin lesions. Use of larger loop electrodes, such as cervical
loops, produces larger defects. Use small, short-shafted dermal
loops for better control of the depth of excision and feathering.
After a shave exci si on, a ci rcul ar, crater-l i ke defect often exi sts
Page 243
(Fi gure 2A.) To perform featheri ng, the machi ne setti ng i s set to
cutti ng current onl y, and the power setti ng usual l y starts at 1 to
2 (15 to 20 watts). Stretch the ski n surroundi ng the treatment si te
usi ng the fi ngers on the nondomi nant hand. Pass the l oop over the
ski n surface wi th short, back-and-forth moti ons, el i mi nati ng sharp
edges and bl endi ng the wound edges i nto surroundi ng ski n (Fi gure
2B.) The fi nal wound i s smoothed and produces superi or cosmeti c
resul ts (Fi gure 2C.)
(2) Radi osurgi cal featheri ng.
PITFALL: Novice physicians often produce additional scoop
defects when initially performing radiosurgical feathering. To
prevent additional scooping defects, stretch the skin around the
treatment site tightly, and pass the loop in the air just above the
treatment site. Gently lower the loop to the skin surface, and do
not drag the loop on the surface during feathering to avoid
additional defects and deeper scars.
P.153
Perform abl ati on of superfi ci al ski n l esi ons usi ng coagul ati on
current wi th a power setti ng of 3 to 4 (30 to 45 watts). Hol d the
el ectrode di rectl y onto the ti ssue surface to produce a burn (i .e.,
thermal i njury).
Page 244
(3) Duri ng abl ati on, hol d the el ectrode di rectl y onto the ti ssue
surface to produce a thermal i njury.
Hol d the el ectrode just above the ti ssue surface, and a spark wi l l
travel from the el ectrode ti p to the surface of the ski n. The
el ectrode can be gentl y bounced on the ski n surface to
faci l i tate thi s spark-gap or ful gurati on techni que. Ful gurati on
produces an eschar (i .e., dry, burn scab) that l i mi ts the depth of
thermal i njury.
(4) Ful gurati on techni que.
PITFALL: The higher the current setting, the greater the heat
applied to the target tissue. Use lower current settings to avoid
excessive tissue burns and scarring.
Radi osurgery effecti vel y removes unwanted vei ns. The machi ne i s
set on coagul ati on current, wi th a setti ng of 2 to 3 (20 to 35
watts). Insert the fi ne tungsten wi re i nto the vei n by puncturi ng
the wi re through stretched ski n. Appl y a bri ef (hal f-second) burst of
cautery current. Local anesthesi a usual l y i s not admi ni stered before
Page 245
tel angi ectasi a abl ati on, because the fl ui d di storts the l ocal ti ssues
and vessel . Many pati ents tol erate wel l the bri ef appl i cati on of
l ow-vol tage current; oral di azepam or superfi ci al l y appl i ed
anestheti c creams al so can be used.
(5) Insert the fi ne tungsten wi re i nto the vei n by puncturi ng the
wi re through stretched ski n.
P.154
CODING INFORMATION
No addi ti onal rei mbursement i s provi ded for featheri ng. The CPT
codes for shave exci si on (1130011313) are appl i ed (see Chapter
11). The mai n reasons for performi ng featheri ng are the superi or
cosmeti c and functi onal outcomes. Destructi on codes
(1700017111) can be appl i ed for abl ati on procedures (see
Chapter 19).
Radi osurgi cal generators; el ectrodes for dermatol ogi c, gynecol ogi c,
pl asti c surgery, or ear, nose, and throat uses; smoke evacuators;
and other accessori es are avai l abl e from El l man Internati onal , 1135
Rai l road Avenue, Hewl ett, NY 11557-2316 (phone: 800-835-2316;
http://www.el l man.com) and from Wal l ach Surgi cal Devi ces, 235
Edi son Road, Orange, CT 06477 (phone: 203-799-2002;
http://www.wal l achsd.com). An anesthesi a tray that can be used
for thi s procedure i s l i sted i n Appendi x G. Ski n preparati on
Page 246
BIBLIOGRAPHY
Acl and KM, Cal onje E, Seed PT, et al . A cl i ni cal and hi stol ogi c
compari son of el ectrosurgi cal and carbon di oxi de l aser peel s. J Am
Acad Dermatol 2001;44:492496.
Bader RS, Scarborough DA. Surgi cal pearl : i ntral esi onal
el ectrodesi ccati on of sebaceous hyperpl asi a. J Am Acad Dermatol
2000;42:127128.
Bri densti ne JB. Use of ul tra-hi gh frequency el ectrosurgery
(radi osurgery) for cosmeti c surgi cal procedures [Edi tori al ]. Dermatol
Surg 1998;24:397400.
Hai ner BL. El ectrosurgery for cutaneous l esi ons. Am Fam Physi ci an
1991;445 (Suppl ): 81S90S.
Hai ner BL. Fundamental s of el ectrosurgery. J Am Board Fam Pract
1991;4:419426.
Harri s DR, Noodl eman R. Usi ng a l ow current radi osurgi cal uni t to
obl i terate faci al tel angi ectasi as. J Dermatol Surg Oncol
1991;17:382384.
Hetti nger DF, Val i nsky MS, Nucci o G, et al . Nai l matri xectomi es
usi ng radi o wave techni que. J Am Podi atr Med Assoc
1991;81:317321.
Pol l ack SV. El ectrosurgery of the ski n. New York: Churchi l l
Li vi ngstone, 1991.
Sebben JE. El ectrodes for hi gh-frequency el ectrosurgery. J Dermatol
Surg Oncol 1989;15: 805810.
Wri ght VC. Contemporary el ectrosurgery: physi cs for physi ci ans
[Edi tori al ]. J Fam Pract 1994; 39: 119122.
Wyre HW, Stol ar R. Exti rpati on of warts by a l oop el ectrode and
cutti ng current. J Dermatol Surg Oncol 1977;3:520522.
Zuber TJ. Dermal el ectrosurgi cal shave exci si on. Am Fam Physi ci an
2002;65:18831886, 18891890, 1895, 1899900.
Wi l ki ns, 1999.
Page 247
> Table of Cont ent s > Dermat ology > 21 - Scalp Repair Techniques21
Scalp Repair Techniques
The scal p contai ns one of the ri chest vascul ar suppl i es i n the body.
Traumati c or surgi cal wounds to the scal p present speci al
chal l enges for bl eedi ng control . Medi cal personnel are often asked
to i ntervene i n emergency si tuati ons i n whi ch scal p bl eedi ng cannot
be control l ed wi th pressure. Immedi ate acti on may be requi red
away from medi cal servi ces or equi pment such as on an athl eti c
fi el d. Two emergent fi el d methods to control scal p bl eedi ng and to
approxi mate ti ssues are presented i n thi s chapter: the hai r-tyi ng
techni que and the fi shi ng l i ne techni que. A rapi d hemostati c suture
techni que i s descri bed for management i n control l ed setti ngs.
The scal p i ncl udes fi ve l ayers: the ski n, subcutaneous ti ssue,
muscul oaponeuroti c l ayer (i .e., gal ea), l oose aponeuroti c ti ssue,
and peri osteum. Hai r fol l i cl e bul bs often are found i n the
subcutaneous l ayer; these hai r roots must not be damaged when
movi ng scal p wound edges. Undermi ni ng of the scal p shoul d be
performed cl ose to the fat-gal ea juncti on, not near the l ower
dermi s. The subcutaneous l ayer contai ns fi brous bands cal l ed
reti nacul a. The reti nacul a connect the ski n to deeper scal p l ayers
and provi de support for bl ood vessel s. The reti nacul a hel p to keep
bl ood vessel s open when they are cut, addi ng to the bl eedi ng from
scal p wounds.
Cl osure of scal p l acerati ons i n an offi ce or emergency room setti ng
i s usual l y performed i n one l ayer, because the deep scal p ti ssues
often are adherent to the ski n. Large needl es and l arge-di ameter
suture materi al s (e.g., 3-0 Prol ene) are sel ected for use on the
scal p. The l arge needl es can grasp a greater amount of ti ssue, and
the l arger-di ameter suture can be ti ed fi rml y to assi st i n
hemostasi s. Mi ni mal tri mmi ng of macerated wound edges i s
recommended, because excessi ve tri mmi ng can create wi der wounds
Page 248
and excessi ve tensi on at cl osure.
The scal p suturi ng techni que demonstrated i n thi s chapter i nvol ves
pl acement of a ski n suture that crosses. Many physi ci ans have been
i nstructed not to pl ace crossi ng or l ocki ng sti tches i n ski n.
Thi s i nstructi on i s based i n a concern for avascul ar necrosi s i nduced
by the crossi ng suture materi al . Al though crossi ng sutures are
appropri atel y avoi ded i n many body l ocati ons, the hi ghl y vascul ar
scal p rarel y experi ences bl ood fl ow probl ems and necessi tates a
hemostati c suture.
The muscul oaponeuroti c l ayer contai ns muscl e between two faci al
l ayers i n the forehead and occi pi tal regi ons. The muscl e i s absent
on the top of the head, and the two fasci al l ayers fuse i nto the
fi brous sheet known as the gal ea. The space beneath the gal ea i s
known as the danger space; hematomas or i nfecti ons can
P.156
accumul ate beneath the gal ea. Anesthesi a i s al ways admi ni stered
above the gal ea because the nerves are l ocated above, and fl ui d
beneath can di ssect to other areas such as the peri orbi tal ti ssues.
If defects are found i n the gal ea, they shoul d be cl osed wi th
i nterrupted absorbabl e sutures. Fai l ure to cl ose the gal ea i n l arge
scal p l acerati ons often resul ts i n wounds wi th retracted ski n edges
and l arger, thi cker fi nal scars. Ti ssue l oss i n the gal ea often
precl udes di rect cl osure and may requi re speci al i nterventi on. One
techni que used for thi s probl em i s to score the surroundi ng gal ea to
provi de some stretch to hel p cover the defect. Pressure bandages
or drai ns can be used to mi ni mi ze subgal eal fl ui d accumul ati on.
It i s recommended that hai r not be removed when performi ng scal p
repai r. Shavi ng the scal p i s associ ated wi th hi gher ski n i nfecti on
rates, and pati ents often are unhappy when cl i ppi ng l eaves l arge
hai rl ess areas. The hai r can be taped away from a wound, or
common agents i n the physi ci an's offi ce (e.g., ti ncture of benzoi n)
can be used to chemi cal l y remove hai r from a surgi cal si te.
The hai r apposi ti on techni que (HAT) study demonstrated good
cosmeti c and functi onal outcomes wi th scal p cl osure usi ng ti ssue
Page 249
gl ue. Pati ents had the si des of the wound brought together usi ng a
si ngl e twi st of hai r, and then the hai r was secured wi th the gl ue.
The study demonstrated superi or pati ent acceptance and l ess
scarri ng wi th thi s cl osure techni que.
INDICATIONS
Scal p l acerati ons or surgi cal wounds
P.157
PROCEDURE
On-fi el d fi rst ai d can be performed for bl eedi ng scal p wounds by
twi sti ng nearby hai r (Fi gure 1A) and then tyi ng the hai r over the
top of the wound (Fi gure 1B). If a spectator or observer has hai r
spray, vi gorousl y spray the ti ed hai r to mai ntai n the knot unti l
arri val at a medi cal faci l i ty.
(1) The emergent fi el d techni que of hai r tyi ng.
Keep a l arge hypodermi c needl e i n the tackl e box. If a l acerati on
occurs i n the fi el d, the needl e can be threaded through both wound
edges and fi shi ng l i ne threaded through the needl e (Fi gure 2A). The
needl e i s wi thdrawn wi th the l i ne remai ni ng wi thi n both wound
edges. The fi shi ng l i ne i s ti ed (Fi gure 2B). Thi s techni que usual l y
provi des very sati sfactory cl osure wi th few i nfecti ons because of
Page 250
the hi ghl y vascul ar scal p.
(2) The emergent fi el d techni que of fi shi ng l i ne cl osure.
P.158
The hemostati c scal p suture i s a si mpl e, fi gure-of-ei ght cl osure.
The suture i s passed from the ri ght si de of the wound to the l eft
si de but not ti ed (Fi gure 3A). Move down the wound edge, and
agai n pass the suture from the ri ght si de to the l eft si de (Fi gure
3B). Ti e the suture, wi th the suture stri ngs crossi ng over the top of
the wound i n an X-shape confi gurati on (Fi gure 3C).
(3) The hemostati c scal p suture.
Page 251
If the cl i ni ci an does not l i ke the suture crossi ng over the top of the
wound, the suture can be made to cross beneath the surface. Pass
from the ri ght si de of the wound to far down the l eft si de of the
wound (Fi gure 4A). Do not ti e the suture ends. Then pass from far
down the ri ght si de of the wound to the near poi nt on the l eft si de
(Fi gure 4B). The suture shoul d exi t the ski n on the l eft si de across
from where i t fi rst entered on the ri ght si de. Ti e the suture, wi th
the crossi ng of the suture threads beneath the wound (Fi gure 4C).
(4) A vari ati on of the hemostati c scal p suture.
P.159
Cl osure of a gal eal defect i n the base of a scal p wound i s achi eved
wi th a fi gure-of-ei ght pattern usi ng absorbabl e suture.
(5) A fi gure-of-ei ght, absorbabl e suture cl osure of a gal eal defect
i n the base of a scal p wound.
Page 252
If there i s ti ssue l oss of the gal ea (Fi gure 6A), consi der scori ng the
gal ea to provi de rel axati on.
(6) If there i s ti ssue l oss of the gal ea, consi der scori ng the gal ea
to provi de rel axati on.
P.160
CODING INFORMATION
The repai r codes used for these techni ques are found i n Chapter 14.
scal p repai r techni ques (see Appendi x A). Suggested suture removal
ti mes are l i sted i n Appendi x C, and a suggested anesthesi a tray
that can be used for thi s procedure i s l i sted i n Appendi x G. Ski n
preparati on recommendati ons appear i n Appendi x H.
BIBLIOGRAPHY
Al exander JW, Fi scher JE, Boyaji an M, et al . The i nfl uence of
hai r-removal methods on wound i nfecti ons. Arch Surg
Page 253
1983;118:347352.
Mosby, 1988:113115.
Bernstei n G. The far-near/near-far suture. J Dermatol Surg Oncol
1985;11:470.
& Hal l , 1997:7677.
Davi es MJ. Scal p wounds. An al ternati ve to suture. I njury
1988;19:375376.
Howel l JM, Morgan JA. Scal p l acerati on repai r wi thout pri or hai r
removal . Am J Emerg Med 1988;6: 710.
Hock MO, Ooi SB, Saw SM, Li m SH. A randomi zed control l ed tri al
compari ng the hai r apposi ti on techni que wi th ti ssue gl ue to
standard suturi ng i n scal p l acerati ons (HAT study). Ann Emerg Med
2002;40:1926.
Wardrope J, Smi th JAR. The management of wounds and burns.
Oxford: Oxford Uni versi ty Press, 1992:162163.
Physi ci ans, 1998.
Page 254
> Table of Cont ent s > Dermat ology > 22 - Tangent ial Lacerat ion Repair22
Tangential Laceration Repair
Some soft ti ssue i njuri es are caused by tangenti al forces that
produce obl i que, nonverti cal , or bevel ed wound edges. If these
bevel ed edges are sutured i n standard fashi on, an unsi ghtl y l edge
of ti ssue often resul ts. Uneven edges cast a shadow on verti cal
surfaces, and the shadow magni fi es the appearance of the scar.
Proper management of tangenti al l acerati ons, especi al l y on
cosmeti cal l y i mportant areas such as the face, i s essenti al for
opti mal resul ts.
Angl ed or bevel ed wounds have a broad edge (base si de) and a
shal l ow edge. The shal l ow edge may heal wi th mi ni mal ti ssue l oss
i f the wound angl e i s near verti cal . The di stal porti on (i .e., nearest
the center of the wound) of the shal l ow edge often necroses wi th
more pronounced wound edge angul ati on because of i nadequate
bl ood suppl y to the epi dermi s and upper dermi s. If the shal l ow
edge i s so thi n as to appear transparent at the ti me of i njury,
subsequent necrosi s i s al most guaranteed. A markedl y shal l ow edge
contracts and rol l s i nward i f taped or sutured wi thout modi fi cati on.
Tangenti al l acerati ons on the hand are commonl y produced by gl ass
fragments resul ti ng from a gl ass breaki ng whi l e bei ng washed i n
the si nk. Tangenti al l acerati ons on the head and face frequentl y
resul t from gl anci ng bl ows or col l i si ons. El derl y i ndi vi dual s often
experi ence tangenti al ski n wounds (i .e., ski n tears) on the
extremi ti es from even mi ni mal contact. Ski n tears i n the el derl y
represent a speci al management si tuati on; because suturi ng ski n
tears on the extremi ti es does not appear to i mprove outcomes,
tapi ng i s recommended.
A si mpl e repai r techni que for tangenti al wounds i nvol ves taki ng a
l arge, deep bi te from the broad edge and a smal l bi te from the
shal l ow edge. Hi stori cal l y, tangenti al l acerati ons have been treated
Page 255
by transformi ng the bevel ed edges to verti cal edges. Dbri dement
of the wound edges i s tedi ous and ti me consumi ng, and extensi ve
removal of ti ssue on the face shoul d be approached wi th cauti on.
Despi te these negati ve factors, the effort to transform wound
edges can provi de grati fyi ng cosmeti c and functi onal resul ts.
P.162
INDICATIONS
Wounds wi th bevel ed (nonverti cal ) edges
CONTRAINDICATIONS
Ski n tears i n el derl y i ndi vi dual s
P.163
PROCEDURE
An angul ated ski n wound can reduce bl ood suppl y to the di stal
porti on of the shal l ow wound edge, resul ti ng i n necrosi s of the
shal l ow edge (Fi gure 1A). If a tangenti al wound i s approxi mated
wi th a si mpl e suture (i .e., equal bi tes through each wound edge)
(Fi gure 1B), the shal l ow edge tends to rol l under. The greater
di stance of a tangenti al wound through ski n compared wi th a
verti cal wound al l ows more opportuni ty for subsequent scar
retracti on (Fi gure 1C), produci ng a fi nal i nverted or depressed scar
(Fi gure 1D).
Page 256
(1) An angul ated ski n wound can reduce bl ood suppl y to the di stal
porti on of the shal l ow wound edge, resul ti ng i n necrosi s of the
shal l ow edge.
A l arge, deep bi te i s taken wi th the suture needl e through the
broad edge, and a smal l (2-mm) bi te i s taken on the shal l ow edge
(Fi gure 2A). Thi s path of the suture thread promotes eversi on of
the shal l ow edge and hel ps wi th the fi nal appearance of the wound
(Fi gure 2B).
(2) The si mpl e suture repai r techni que for tangenti al wounds.
P.164
A C-shaped wound wi th bevel ed edges (Fi gure 3A) i s produced by a
Page 257
tangenti al i njury. Use a scal pel to create verti cal wound edges
(Fi gure 3B) that wi l l then be undermi ned and approxi mated (Fi gure
3C). Wi der exci si on of ti ssue i s performed wi th a verti cal l y hel d
scal pel on the shal l ow edge compared wi th the broad edge (Fi gure
3D). It i s di ffi cul t to debri de the ski n edge unl ess fi rm
countertracti on i s appl i ed to the ti ssues. Pul l fi rml y out from the
corners of the wound wi th the fi rst two fi ngers of the nondomi nant
hand when performi ng scal pel debri dement of the wound edge
(Fi gure 3E).
(3) The tangenti al i njury has produced a C-shaped wound wi th
bevel ed edges.
Before cl osi ng the wound wi th sutures, further undermi ne the
wound edges (Fi gure 4A). Pl ace the fi rst suture i n the mi ddl e of the
wound (Fi gure 4B) and the next two i n the mi ddl e of the remai ni ng
wound edges (i .e., hal vi ng techni que) unti l the wound i s cl osed
(Fi gure 4C).
Page 258
(4) Further undermi ne the wound edges before cl osi ng the wound
wi th sutures.
P.165
CODING INFORMATION
The si mpl e repai r codes (1200112020) are provi ded i n Chapter
14. Intermedi ate (l ayered) cl osure codes (1203112057) are
provi ded i n Chapter 24. The 2002 Current Procedural Termi nol ogy
(CPT) descri bes compl ex repai r as the repai r of wounds that
requi res more than l ayered cl osure, such as scar revi si on,
dbri dement of traumati c l acerati ons or avul si ons, extensi ve
undermi ni ng, stents, or retenti on sutures. The necessary
preparati on of compl ex wounds i ncl udes the creati on of a defect for
repai r. Compl ex repai r shoul d not be used wi th exci si on of beni gn
or mal i gnant l esi ons.
The compl ex repai r code reported shoul d descri be the sum of the
l engths of repai r for each group of anatomi c si tes. The si tes for
these codes i ncl ude the fol l owi ng: scal p, arms, or l egs (SAL);
forehead, cheeks, chi n, mouth, neck, axi l l a, geni tal i a, hands, or
feet (FCCMNAGHF); and eyel i ds, nose, ears, or l i ps (ENEL).
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Page 261
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Page 264
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Page 266
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Page 267
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ati on.
Instruments for tangenti al l acerati on repai r are i ncl uded i n the
offi ce surgi cal tray l i sted i n Appendi x A, and suggested suture
removal ti mes are l i sted i n Appendi x C. A suggested anesthesi a
P.166
Page 268
BIBLIOGRAPHY
Mosby, 1988:355444.
Dushoff IM. A sti tch i n ti me. Emerg Med 1973;5:2143.
Lammers RL, Trott AL. Methods of wound cl osure. In: Roberts JR,
Perry AW, McShane RH. Fi ne tuni ng of the ski n edges i n the cl osure
of surgi cal wounds: control l i ng i nversi on and eversi on wi th the path
of the needl ethe ri ght sti tch at the ri ght ti me. J Dermatol Surg
Oncol 1981;7:471476.
Stei n A, Wi l l i amson PS. Repai r of si mpl e l acerati ons. In: Dri scol l
CE, Rakel RE, eds. Pati ent care procedures for your practi ce. Los
Angel es: Practi ce Management Informati on Corporati on,
1991:299306.
Wi l l i amson P. Offi ce procedures. Phi l adel phi a: WB Saunders,
1955:215223.
Wi l son JL, Kocurek K, Doty BJ. A systemi c approach to l acerati on
repai r. Postgrad Med 2000;107:7788.
Physi ci ans, 1998.
Zuber TJ. Wound management. In: Rakel RE, ed. Saunders manual
of medi cal practi ce. Phi l adel phi a: WB Saunders, 1996:10071008.
Page 269
> Table of Cont ent s > Dermat ology > 23 - Field Block Anest hesia23
Field Block Anesthesia
Fi el d bl ock anesthesi a descri bes the i nfi l trati on of l ocal anestheti c
i n a ci rcumferenti al pattern around a surgi cal si te. Li ke nerve
bl ocks, fi el d bl ocks are used to anestheti ze l arge areas of ski n.
Fi el d bl ocks di ffer from nerve bl ocks i n that more than one nerve
experi ences i nterrupti on of the nerve transmi ssi on. The techni que
permi ts l arge areas to be anestheti zed, and i t i s useful for l arge
dermatol ogi c procedures. The fi el d bl ock does not di srupt the
archi tecture of the surgi cal si te and often i s admi ni stered for faci al
or cosmeti c repai rs.
Infected ti ssues such as areas of cel l ul i ti s or abscesses can prove
di ffi cul t to anestheti ze because the aci di c envi ronment of an
abscess can hydrol yze the anestheti c and render i t i neffecti ve.
Fi el d bl ock provi des adequate anesthesi a around an abscess by
worki ng i n the normal surroundi ng ti ssue. Local i zed structures are
often amenabl e to fi el d bl ock techni que. Faci al (e.g., cheek, eyel i d,
nose, pi nnae) and geni tal structures (e.g., peni s, peri neum) are
parti cul arl y wel l sui ted for thi s techni que. The admi ni strati on of
anestheti c i nto di stensi bl e ski n surroundi ng taut ski n (e.g., ti ssues
surroundi ng the nose or ear) permi ts more comfortabl e i njecti ons
for the pati ent.
Epi nephri ne can be added to l i docai ne for some fi el d bl ocks i f the
vasoconstri cti ve or anestheti c-prol ongi ng acti on of epi nephri ne i s
desi red. Epi nephri ne permi ts safe use of l arger amounts of
l i docai ne because i t prevents cl earance of the anestheti c from the
ti ssue. Epi nephri ne shoul d be avoi ded i n areas where vascul ar
compromi se coul d prove probl emati c, especi al l y i n i ndi vi dual s wi th
vascul i ti s or vasoconstri cti ve di sorders such as Raynaud's
phenomenon. Many authori ti es di scourage the addi ti on of
epi nephri ne for fi el d bl ocks on di gi ts, around the ear, on the nasal
Page 270
ti p, or surroundi ng the peni s.
INDICATIONS AND COMMON LOCATIONS
FOR FIELD BLOCKS
Surroundi ng l arge l esi ons to provi de a l arge area of
anesthesi a
Around i nfected cysts or abscesses
To prevent di storti on of ski n l andmarks from
admi ni strati on of l ocal anesthesi a
Around faci al structures (e.g., nose, pi nnae, forehead,
cheek, eyel i ds, upper l i p)
Di gi tal bl ocks (see Chapter 29)
Surroundi ng l ocal i zed structures (e.g., peni s, peri neu)
P.168
PROCEDURE
The fi el d bl ock can be performed i n a square pattern around a
wound. Onl y two needl esti cks are requi red. The needl e passes
al ong one si de, anestheti c i s admi ni stered as the needl e i s
wi thdrawn, and the needl e then redi rected 90 degrees wi thout
comi ng out from the i ni ti al puncture si te. Thi s same techni que i s
used on the opposi te si te of the wound.
(1) The fi el d bl ock can be performed i n a square pattern
surroundi ng a wound.
Page 271
The nerve di stri buti on for the pi nna i s demonstrated (Fi gure 2A). A
fi el d bl ock i s performed around the enti re pi nna (Fi gure 2B). To
avoi d motor paral ysi s of the faci al nerve anteri or to the pi nna, the
needl e shoul d pass i n a superfi ci al pl ane (i .e., subdermal l y i n front
of the ear). Separate i njecti ons may be needed for the concha and
external audi tory canal (Fi gure 2C).
(2) Fi el d bl ock for the ear.
P.169
Tri angul ated i njecti ons provi de adequate ci rcumferenti al
anesthesi a. Addi ti onal l i docai ne wi thout epi nephri ne must be
admi ni stered to the ti p of the nose to anestheti ze the external
nasal nerve, whi ch ari ses from the deep ti ssues.
Page 272
(3) Fi el d bl ock for thenose
Admi ni strati on of anestheti c i n a l i near pattern through both
eyebrows produces anesthesi a of the supraorbi tal and
supratrochl ear nerves on each si de. A l ong (1-i nch) needl e
shoul d be used to provi de near-compl ete anesthesi a of the enti re
forehead to the scal p.
(4) Forehead anesthesi a.
P.170
The peni s i s l i fted upward (i nto the posi ti on of erecti on). Two ski n
wheal s can be admi ni stered near the i nternal i ngui nal ri ngs (Fi gure
5A). The l ong needl e i s pl aced subdermal l y to enci rcl e the base of
the peni s wi th l i docai ne wi thout epi nephri ne (Fi gure 5B). A si ngl e
Page 273
i njecti on method i s descri bed i n Chapter 45.
(5) Peni l e bl ock.
P.171
CODING INFORMATION
Anesthesi a codes (0010001999) are usual l y l i mi ted to
anesthesi ol ogi sts provi di ng pati ent servi ces for surgi cal procedures.
Local anesthesi a i s not reported i n addi ti on to the surgi cal
procedure. Some i nsurance provi ders permi t bi l l i ng of regi onal or
general anesthesi a by the physi ci an or surgeon performi ng the
procedure. If reporti ng addi ti onal anesthesi a servi ces, the -47
modi fi er i s attached to the surgi cal code. It i s unl i kel y that
addi ti onal rei mbursement wi l l be provi ded for fi el d bl ocks; the
servi ce i s consi dered part of the reporti ng of the surgi cal procedure.
Syri nges (5 or 10 mL), anestheti c sol uti ons, and needl es (18 or 20
gauge, 1 i nch l ong for drawi ng up anestheti c; 25 or 27 gauge, 1
i nch l ong for del i veri ng anestheti c) can be ordered from surgi cal
suppl y houses or pharmaci es. A suggested anesthesi a tray that can
be used for thi s procedure i s l i sted i n Appendi x G.
BIBLIOGRAPHY
Avi na R. Pri mary care l ocal and regi onal anesthesi a i n the
management of trauma. Cl i n Fam Pract 2000;2:533550.
Page 274
Bennett RG. Fundamental s of cutaneous surgery. Boston: Li ttl e,
Brown, 1987:156162.
1994:102112.
Gmyrek R. Local anesthesi a and regi onal nerve bl ock anesthesi a.
Emedi ci ne Avai l abl e at
http://www.emedi ci ne.com/DERM/topi c824.htm
Greki n RC, Aul etta MJ. Local anesthesi a i n dermatol ogi c surgery. J
Am Acad Dermatol 1988;19:599614.
1987:156162.
Usati ne RP, Moy RL. Anesthesi a. In: Usati ne RP, Moy RL, Tobi ni ck
EL, Si egel DM, eds. Ski n surgery a practi cal gui de. St. Loui s: Mosby,
1998:2030.
Wi l l i amson P Offi ce procedures. Phi l adel phi a: WB Saunders,
1957:325339.
Oncol 1988;14:4154.
Zuber TJ. Fi el d bl ock anesthesi a. In: Advanced soft-ti ssue surgery.
AAFP i l l ustrated manual s and vi deotapes of soft-ti ssue techni ques.
Kansas Ci ty: Ameri can Academy of Fami l y Physi ci ans,
1998:2226.
Page 275
> Table of Cont ent s > Dermat ology > 24 - Lipoma Removal24
Lipoma Removal
Li pomas are beni gn, adi pose ti ssue tumors that can ari se anywhere
on the body. Li pomas frequentl y are encountered on the upper hal f
of the body, wi th common si tes i ncl udi ng the head, neck,
shoul ders, and back. Most l esi ons are confi ned to the subcutaneous
ti ssues, but l esi ons occasi onal l y penetrate between fasci al pl anes
and even i nto muscl e. Subfasci al l i pomas are most commonl y found
i n the neck.
Li pomas can vary from the si ze of a pea to that of a soccer bal l .
The tumors are composed of l obul es of fat encased i n a thi ck,
fi brous capsul e. The adi pose ti ssue wi thi n l i pomas i s often
i ndi sti ngui shabl e from normal fat. Del i neati on of a l i poma may be
achi eved by searchi ng for the l i mi ts of the capsul e. Lobul es are
connected by a thi nner stroma or fi brous bands that can extend to
deep fasci a or the ski n and produce di mpl i ng. These bands may
prevent easy enucl eati on of an encapsul ated l i poma.
Li pomas often produce a rounded mass that protrudes above
surroundi ng ski n. On pal pati on, the l esi ons usual l y feel smooth,
l obul ated, and compressi bl e. Some cl i ni ci ans descri be a
characteri sti c doughy feel to the l esi ons. Li pomas are
general l y nontender, al though adi posi s dol orosa (i .e., Dercum's
di sease) i s a condi ti on wi th pai nful or tender truncal or extremi ty
l i pomas. Dercum's di sease i s most commonl y encountered i n women
i n the l ater reproducti ve years. Li pomas often grow sl owl y and can
i ncrease i n si ze i f the pati ent gai ns wei ght. Duri ng ti mes of wei ght
l oss or starvati on, l i pomas do not decrease i n si ze.
The presence of mul ti pl e l i pomas i s known as l i pomatosi s, and the
condi ti on i s more common i n men. Heredi tary mul ti pl e l i pomatosi s
i s an autosomal domi nant condi ti on that produces wi despread
l i pomas over the extremi ti es and trunk. Madel ung's di sease refers
Page 276
to beni gn symmetri c l i pomatosi s of the head, neck, shoul ders, and
proxi mal upper extremi ti es. It i s uncommon to fi nd mal i gnancy i n a
l i poma (i .e., l i posarcoma) when a pati ent di spl ays mul ti pl e
l i pomas. Li posarcoma i s found i n 1% of l i pomas and i s most
commonl y encountered i n l esi ons on the l ower extremi ti es,
shoul ders, and retroperi toneal areas. Other ri sk factors for
l i posarcoma i ncl ude l arge si ze (>5 cm), associ ated cal ci fi cati on,
rapi d growth, or i nvasi on i nto nearby structures or down through
fasci a and i nto muscl e.
Nonexci si onal techni ques for l i poma removal i ncl ude steroi d
i njecti on and l i posucti on. Steroi d i njecti ons produce fat atrophy and
are best performed on
P.173
smal l er l esi ons (<1 i nch i n di ameter). Often, mul ti pl e i njecti ons
gi ven over 1 to 3 months are requi red for an adequate response.
Li posucti on can be performed i n the offi ce usi ng l arge-gauge
needl es attached to 20-mL or l arger syri nges (after fi el d bl ock
anesthesi a usi ng di l uted l i docai ne) or i n the operati ng room usi ng
standard sucti on curettes. Compl ete eradi cati on of the l i poma cel l s
can be di ffi cul t to achi eve wi th l i posucti on, and rapi d regrowth of
the l esi on may resul t. Li posucti on i s an attracti ve opti on for
l i pomas l ocated i n areas where l arge scars shoul d be avoi ded (e.g.,
face).
Smal l l i pomas are often surrounded by a wel l -devel oped and easi l y
i denti fi ed capsul e. After the creati on of a smal l i nci si on, these
l esi ons may be extruded through the wound wi th the appl i cati on of
pressure to surroundi ng ski n. Enucl eati on can al so be achi eved by
combi ni ng the use of a dermal curette wi th pressure. Larger
l i pomas often do not di spl ay such a wel l -defi ned capsul e, and
di sti ngui shi ng normal from l i pomatous fat can be a chal l enge.
Large l i pomas can be removed by l eavi ng the top of the tumor
attached to a smal l i sl and of overl yi ng ski n. Thi s ski n can be
grasped and retracted when di ssecti ng around the l i poma. The
deeper yel l ow col or (due to i ncreased densi ty) often seen i n
Page 277
l i pomas can hel p vi sual l y i denti fy the tumor. Ski n marki ngs made
before the procedure al so ai d i n i denti fyi ng the extent of the
tumor. Care must be exerted when di ssecti ng the base of the
wound to avoi d creati ng trauma to deep structures such as arteri es,
nerves, or muscl e. After the tumor i s removed, i nspect the base of
the wound careful l y to i denti fy any l obul es of tumor that may have
been l eft.
Smal l bl eedi ng vessel s at the base of the wound can be cl amped
wi th hemostats or ti ed off wi th absorbabl e sutures i n a
fi gure-of-ei ght pattern. The wound bed shoul d be dry (i .e., bl eedi ng
control l ed) before cl osure i s attempted. Deep wounds often requi re
the use of l arger-gauge absorbabl e sutures, because si gni fi cant
tensi on may be requi red to cl ose the dead space created by
removal of a l arge tumor. Hi stori cal l y, Penrose drai ns were used to
faci l i tate bl ood and fl ui d drai nage from these deep wounds. Drai ns
i ncrease bacteri al counts i n wounds and often are not needed i f
meti cul ous hemostasi s and suture cl osure of the deep wound are
properl y performed.
INDICATIONS
Removal of tumors that are symptomati c (i .e., produci ng
pai n or di scomfort)
Removal to i mprove body contour and appearance
Removal to rel i eve anxi ety regardi ng the di agnossi
CONTRAINDICATIONS
Uncooperati ve i ndi vi dual
Tumors at i ncreased ri sk for mal i gnancy (i .e., l arger than
5 cm i n di ameter, di spl ayi ng associ ated cal ci fi cati on,
i nvadi ng nearby structures, growi ng rapi dl y, i nvadi ng
deeper structures such as fasci a, or i n hi gh-ri sk si tes
such as the l ower l egs or shoul ders) wi thout a pri or
bi opsy resul t to document the beni gn nature of the
l esi on (rel ati ve contrai ndi cati on)
P.174
Page 278
PROCEDURE
Pal pate the tumor, and draw an outl i ne of the tumor on the ski n
wi th a ski n marki ng pen. Draw a fusi form exci si on that overl i es the
center of the tumor, that i s smal l er than the underl yi ng l i poma, and
whose l ong axi s coi nci des wi th the nearby l i nes of l east ski n
tensi on. The fusi form i nci si on shoul d be desi gned to be about two
thi rds of the di ameter of the underl yi ng l i poma.
(1) Pal pate the tumor, and draw an outl i ne of the tumor on the ski n
wi th a ski n marki ng pen.
PITFALL: Do not draw on the skin using ballpoint pens. Ballpoint
pens can traumatize skin, and the ink tends to wash off when
the skin preparation is performed. Using a surgical skin marking
pen is likely to provide an outline of the tumor that will guide the
excision and last throughout the surgery.
Fi el d bl ock anesthesi a can be achi eved by i njecti ng beneath and
l ateral to the outl i ned l esi on usi ng l ong (1 or 1 i nch)
needl es. A suffi ci ent vol ume of 1% l i docai ne shoul d be
admi ni stered around the peri phery of the l esi on to surround the
tumor.
Page 279
(2) Inject 1% l i docai ne beneath and l ateral to the outl i ned l esi on
usi ng l ong needl es.
P.175
Inci se the ski n through the fusi form marki ngs, but do not
undermi ne the central fusi form i sl and of ski n. Carry the verti cal
i nci si on down to the l evel of the fat or to the l i poma capsul e. Use
an Al l i s cl amp or l arge Kel l y cl amp to grasp the center of the i sl and
of ski n, whi ch remai ns attached to the underl yi ng l i poma. Use the
cl amp to provi de tracti on to undermi ne l ateral ski n and to di ssect
around the l i poma.
(3) Inci se the ski n through the fusi form marki ngs, but do not
undermi ne the central fusi form i sl and of ski n.
PITFALL: Some physicians prefer to make a simple incision
through skin rather than create a fusiform island of skin.
Page 280
Traction applied directly on the lipoma produces tearing through
the tissue, and closure after large lipoma removal leaves
redundant skin unless a fusiform section of skin is removed.
Use the gl oved fi nger, sci ssors, or scal pel bl ade to careful l y di ssect
around the enti re l esi on. The ori gi nal ski n marki ngs shoul d be used
to gui de the di ssecti on.
(4) Use the gl oved fi nger, sci ssors, or scal pel bl ade to careful l y
di ssect around the enti re l esi on.
PITFALL: Care must be taken to avoid damaging structures
beneath the lipoma, such as nerves, arteries, or muscle.
Because visualization may be poor beneath the lesion, blunt
dissection is often advocated for freeing the underside of the
lipoma. A finger is often a sensitive and effective tool for this
part of the operation.
P.176
The enti re l i poma can often be del i vered through the smal l er
fusi form ski n i nci si on.
Page 281
(5) The l i poma can often be removed i n i ts enti rety through the
smal l er fusi form ski n i nci si on.
PITFALL: Bleeding may occur during dissection and delivery of
the tumor. Bleeding vessels can be briefly clamped with small
hemostats to provide adequate hemostasis before wound
closure.
Mul ti pl e, i nterrupted, deepl y buri ed sutures are pl aced to cl ose the
l arge defect after removal of the l i poma. Large-cal i ber absorbabl e
suture (e.g., 3-0 or 4-0 pol ygl ycan) i s used and shoul d grasp a
si gni fi cant porti on of l ateral ti ssue so that i t wi l l not tear when
cl osi ng the deep space. Si gni fi cant tensi on may be pl aced on these
sutures when cl osi ng l arge spaces.
(6) Mul ti pl e, i nterrupted, deepl y buri ed, l arge-cal i ber, absorbabl e
sutures are pl aced to cl ose the l arge defect.
Page 282
P.177
Standard ski n cl osure i s performed for the fusi form ski n defect.
(7) Standard ski n cl osure i s performed for the fusi form ski n defect.
Smal l l i pomas (<3 cm i n di ameter) can be treated wi th steroi d
i njecti ons that produce atrophy i n the adi pose ti ssue. A 1:1 mi xture
of 1% l i docai ne and tri amci nol one acetoni de (10 mg/mL) can be
i njected i nto the center of the l esi on.
(8) Smal l l i pomas can be treated wi th steroi d i njecti ons that
produce atrophy i n the adi pose ti ssue.
Smal l l i pomas al so can be treated wi th enucl eati on. A 4-mm bi opsy
punch creates a ski n defect over the top of the l esi on. A ski n
curette i s used to free the l esi on from surroundi ng ti ssue and then
used to del i ver (i .e., enucl eate) the tumor through the smal l ski n
openi ng. Suturi ng general l y i s not needed, and a pressure dressi ng
i s appl i ed.
Page 283
(9) Smal l l i pomas can al so be treated wi th enucl eati on.
P.178
CODING INFORMATION
Li poma removal can be reported usi ng the beni gn exci si on codes
(1140011446), whi ch are l i sted i n Chapter 12. The beni gn
exci si on codes i ncl ude removal of the beni gn subcutaneous l esi on
wi th si mpl e ski n cl osure. Enucl eati on i s usual l y reported wi th these
codes. Intral esi onal i njecti on i s reported usi ng the 11900 code.
Intermedi ate cl osure codes can be added to an exci si on code i f
deepl y buri ed subcutaneous sutures are pl aced. Intermedi ate codes
are ci ted for the fol l owi ng areas: scal p, axi l l a, trunk, arms, or l egs
(excl udi ng hands and feet) (SATAL); neck, hands, feet, or external
geni tal i a (NHFG); and face, ears, eyel i ds, nose, l i ps, or mucous
membranes (FEENLMM).
Intermediate Repair: Layered Closure
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Page 291
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Page 292
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l esi ons may be more appropri atel y reported usi ng tumor exci si on
codes.
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Page 294
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Page 298
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Page 303
ati on.
P.179
A standard surgery tray can be used for removal of l i pomas (see
Appendi x A). Consi der addi ng two or three l arger hemostats (e.g.,
Kel l y cl amps) to the surgery tray to al l ow easi er graspi ng of the
l i poma. Suggested suture removal ti mes are l i sted i n Appendi x C,
and a suggested anesthesi a tray that can be used for thi s
procedure i s l i sted i n Appendi x G. Ski n preparati on
BIBLIOGRAPHY
Benjami n RB. Atl as of outpati ent and offi ce surgery, 2nd ed.
Phi l adel phi a: Lea & Febi ger, 1994:385392.
1988:726731.
& Hal l Medi cal , 1997: 222223.
Campen R, Manki n H, Loui s DN, et al . Fami l i al occurrence of
adi posi s dol orosa. J Am Acad Dermatol 2001;44:132136.
Chri stenson L, Patterson J, Davi s D. Surgi cal pearl : use of the
cutaneous punch for the removal of l i pomas. J Am Acad Dermatol
2000;42:675676.
Di gregori o F, Barr RJ, Fretzi n DF. Pl eomorphi c l i poma: case reports
Page 304
and revi ew of the l i terature. J Dermatol Surg Oncol
1992;18:197202.
Eskey CJ, Robson CD, Weber AL. Imagi ng of beni gn and mal i gnant
soft ti ssue tumors of the neck. Radi ol Cl i n North Am
2000;38:10911104.
P.180
Humeni uk HM, Lask GP. Treatment of beni gn cutaneous l esi ons. In:
Pari sh LC, Lask GP, eds. Aestheti c dermatol ogy. New York:
McGraw-Hi l l , 1991:3949.
Makl ey JT. Beni gn soft ti ssue l esi ons. In: Evarts CM, ed. Surgery of
the muscul oskel etal system, 2nd ed. New York: Churchi l l
Li vi ngstone, 1990:47954818.
Moraru RA. Li pomas. Emedi ci ne November 7, 2001. Avai l abl e at
http://www.emedi ci ne.com/DERM/topi c242.htm
Sal am GA. Li poma exci si on. Am Fam Physi ci an 2002;65:901905.
Sanchez MR, Gol omb FM, Moy JA, et al . Gi ant l i poma: case report
and revi ew of the l i terature. J Am Acad Dermatol
1993;28:266268.
Zuber TJ. Ski n bi opsy, exci si on, and repai r techni ques. The AAFP
i l l ustrated manual s of soft-ti ssue surgery techni ques. Kansas Ci ty:
Ameri can Academy of Fami l y Physi ci ans, 1999: 100106.
Page 305
> Table of Cont ent s > Dermat ology > 25 - Basic Z- Plast y25
Basic Z-Plasty
Hi stori cal l y, Z-pl asty has been a commonl y taught and used
techni que i n pl asti c surgery. Many vari ati ons of Z-pl asty have been
devel oped, but thi s chapter focuses on the basi c (60-degree)
Z-pl asty techni que. The procedure uses the transposi ti on of two
tri angul ar fl aps to produce a Z-shaped wound. The mai n i ndi cati on
for performi ng Z-pl asty i s to change the di recti on of a wound so
that i t al i gns more cl osel y wi th the resti ng ski n tensi on l i nes.
Because the techni que i ncreases the l ength of ski n avai l abl e i n a
desi red di recti on, Z-pl asty al so i s used to correct contracted scars
across fl exor creases. The 60-degree Z-pl asty l engthens the scar
(or avai l abl e l ength i n a certai n di recti on) by 75%.
When consi deri ng the performance of a Z-pl asty, some physi ci ans
theoreti cal l y object to the creati on of a wound that i s three ti mes
as l ong as the ori gi nal wound (i .e., the two di agonal arms are as
l ong as the central wound). Al though the creati on of l ong wounds i s
general l y di scouraged, a wel l -desi gned Z-pl asty can si gni fi cantl y
i mprove the cosmeti c and functi onal outcome. Z-pl asty can be
performed on a fresh wound that i s counter to the resti ng ski n
tensi on l i nes, al though some experts recommend si mpl e cl osure of
the wound and then Z-pl asty at a l ater date to revi se scars that are
probl emati c.
The techni que of Z-pl asty i s easy to understand, but i t requi res
some ski l l and practi ce. Physi ci ans wi th the opportuni ty to
frequentl y perform Z-pl asty observe general l y favorabl e functi onal
and cosmeti c outcomes.
INDICATIONS
Revi si on of contractures or scars that cross fl exor
creases and resul t i n bowstri ng-type scars (e.g., verti cal
scars over the fl exor creases of the proxi mal
Page 306
i nterphal angeal joi nts of the hands)
Revi si on of scars that transverse across concavi ti es
(e.g., across a deep nasol abi al fol d, a verti cal scar that
transverses between the l ower l i p and the chi n)
Redi recti on of wounds that are perpendi cul ar to the l i nes
of l east ski n tensi on (i .e., reori ent to a di recti on that
wi l l produce a cosmeti cal l y superi or resul t)
Creati on of wound i rregul ari ty (i .e., i mproved cosmeti c
resul ts from a l i ne that i s broken-up or zi g-zag
versus a l ong, strai ght l i ne that i s l ess appeal i ng)
Reposi ti oni ng of poorl y posi ti oned ti ssues that produce
a trap-door effect (i .e., rearrangi ng a ci rcul ar scar that
i s causi ng the central ti ssue to rai se upward)
P.182
PROCEDURE
The ori gi nal (verti cal ) wound or scar (AB) i s perpendi cul ar to the
l i nes of l east ski n tensi on.
(1) The verti cal wound or scar (AB) i s perpendi cul ar to the l i nes of
l east ski n tensi on.
Draw and i nci se the di agonal l i nes, wi th one arm on each si de of
the ori gi nal wound. The di agonal l i nes AC and BD are the same
l ength as the ori gi nal l i ne AB, and they are 60 degrees away from
the center l i ne. The l eft tri angul ar fl ap i s l abel ed F1, and the ri ght
fl ap i s l abel ed F2.
Page 307
(2) Draw and i nci se di agonal l i nes, AC and BD, whi ch are the same
l ength as the ori gi nal scar (AB) and are 60 degrees away from the
center l i ne.
PITFALL: Place the side arms on opposite sides of the central
wound. Novice physicians occasionally make the error of
performing their first Z-plasty with the arms on the same side of
the central wound.
PITFALL: Many physicians unintentionally incise the diagonal
lines at 45-degree angles, rather than 60-degree angles. Flaps
in a 45-degree Z-plasty are easier to transpose but only rotate
the direction of the original defect by 60 to 70 degrees (rather
than 90 degrees with a 60-degree Z-plasty).
Undermi ne the fl aps and the surroundi ng ski n i n the l evel of the
upper fat (i .e., bel ow the dermi s).
(3) Undermi ne the fl aps and the surroundi ng ski n i n the l evel of the
upper fat bel ow the dermi s.
PITFALL: Failure to undermine extensively makes the
Page 308
transposition very difficult. Liberal undermining is beneficial.
P.183
Transpose the fl aps. F2 now appears on top, and F1 now appears on
the bottom. The new l i ne i n the center (CD or FE) al i gns wi th the
resti ng ski n tensi on l i nes.
(4) Transpose the fl aps so that F2 appears on the top and F1
appears on the bottom.
PITFALL: Handle the flaps gently, grasping the skin with skin
hooks or Adson forceps without teeth. Many physicians
transpose the flaps with toothed forceps, causing tears or
damage to the flaps and adding unnecessary scarring.
Pl ace a central anchori ng sti tch hol di ng the two fl aps i n posi ti on.
Page 309
(5) Pl ace a central anchori ng sti tch hol di ng the two fl aps i n
posi ti on.
Pl ace corner sti tches i n the corners of each fl ap, and then pl ace the
sti tches on the ends of the di agonal s (AC and BD). Keep the
sti tches on the di agonal s to a mi ni mum, and do not pl ace the
di agonal sti tches near the corner.
(6) Pl ace corner sti tches i n the corners of each fl ap, and pl ace
sti tches on the ends of the di agonal s (AC, BD).
PITFALL: Almost all 60-degree Z-plasties performed on human
skin result in some pouching upward at the base of the flap after
transposition. This upward bunching of tissue, or dog-ear
formation, occurs almost universally, and should not be of great
concern. Most dog-ear formations are caused by the marked
rotation of the tissue, and they will flatten with time, resulting in
a good cosmetic outcome.
P.184
A contracted scar commonl y resul ts from wounds that traverse the
fl exor creases on the fi ngers (Fi gure 7A). Exci se the scar, and then
draw and exci se the l ateral arms (Fi gure 7B). The center of the
fi nal wound now runs paral l el to the resti ng ski n tensi on l i nes
(Fi gure 7C).
Page 310
(7) Basi c Z-pl asty of a contracted scar.
A wound that crosses the nasol abi al fol d (Fi gure 8A) may resul t i n
an unsi ghtl y, contracted, bowstri ng scar. The wound can be
redi rected wi th a Z-pl asty. Draw and exci se the l ateral arms (Fi gure
8B). The center of the fi nal wound fol l ows the center of the
nasol abi al fol d (Fi gure 8C). F1 and F2 represent the fl aps before
and after transposi ti on, respecti vel y.
(8) Basi c Z-pl asty of a wound that crosses the nasol abi al fol d.
P.185
CODING INFORMATION
See codi ng l i st i n Chapter 26.
Page 311
Instruments are l i sted i n Appendi x A. Suggested suture removal
ti mes are l i sted i n Appendi x C, and a suggested anesthesi a tray
that can be used for thi s procedure i s l i sted i n Appendi x G.
BIBLIOGRAPHY
Borges AF, Al exander JE. Rel axed ski n tensi on l i nes, Z-pl asti es on
scars, and fusi form exci si on of l esi ons. Br J Pl ast Surg
1962;15:242254.
Dzubow LM. Z-pl asty mechani cs [Comment]. J Dermatol Surg Oncol
1994;20:108.
Gahankari D. Z-pl asty templ ate: an i nnovati on i n Z-pl asty
fashi oni ng. Pl ast Reconstr Surg 1996;97:11961199.
Hudson DA. Some thoughts on choosi ng a Z-pl asty: the Z made
si mpl e. Pl ast Reconstr Surg 2000;106:665671.
Johnson SC, Bennett RG. Doubl e Z-pl asty to enhance rhombi c fl ap
mobi l i ty. J Dermatol Surg Oncol 1994;20:128132.
Lesavoy MA, Weatherl ey-Whi te RCA. The i ntegument. In: Hi l l GJ,
ed. Outpati ent surgery, 3rd ed. Phi l adel phi a: WB Saunders,
1988:123148.
McCarthy JG. Introducti on to pl asti c surgery. In: McCarthy JG, ed.
Pl asti c surgery. Phi l adel phi a: WB Saunders, 1990:168.
Mi cal i G, Real i UM. Scars: traumati c and facti ti al . In: Pari sh LC,
Lask GP, eds. Aestheti c dermatol ogy. New York: McGraw-Hi l l ,
1991:8495.
Robson MC, Zachary LS. Repai r of traumati c cutaneous i njuri es
i nvol vi ng the ski n and soft ti ssue. In: Georgi ade GS, Georgi ade NS,
Ri efkohl R, Borwi ck WJ, eds. Textbook of pl asti c, maxi l l ofaci al , and
reconstructi ve surgery, 2nd ed. Bal ti more: Wi l l i ams & Wi l ki ns,
1987:129140.
Scl afi ni AP, Parker AJ. Z-pl asty. Emedi ci ne Avai l abl e at
http://www.emedi ci ne.com/ENT/topi c652.htm
Stegman SJ. Fi fteen ways to cl ose surgi cal wounds. J Dermatol Surg
Page 312
1975;1:2531.
Physi ci ans, 1999.
Page 313
> Table of Cont ent s > Dermat ology > 26 - Advancement Flap Placement 26
Advancement Flap Placement
Local ski n fl aps provi de a sophi sti cated approach to cl osi ng l arge
ski n defects produced by trauma or removal of l esi ons from the
ski n. The fusi form (el l i pti cal ) exci si on i s the techni que most
commonl y empl oyed for l esi on removal , but nearby structures (e.g.,
nose, ear) can precl ude use of thi s techni que. Nearby ski n general l y
better approxi mates the needed col or and texture to cl ose a defect
than ski n brought i n from a di stant si te (i .e., ski n graft). Local ski n
fl aps can provi de excel l ent functi onal and cosmeti c outcomes.
Advancement fl aps represent some of the si mpl est and most
commonl y used fl ap techni ques. Advancement fl aps move adjacent
ti ssue to cl ose a defect wi thout rotati on or l ateral movement. The
ski n i s stretched uni di recti onal l y (i .e., si ngl e advancement fl ap) or
bi di recti onal l y (i .e., bi l ateral advancement fl ap) to cl ose the
defect. Uni di recti onal pul l on ti ssue can be useful when a certai n
type of ski n i s needed for cl osure. For i nstance, after removal of a
tumor from the outer porti on of the eyebrow, the defect shoul d be
repl aced wi th hai r-beari ng ski n of the medi al eyebrow to prevent a
shortened and cosmeti cal l y abnormal -appeari ng eyebrow.
The bl ood suppl y for a si ngl e advancement fl ap comes from the
base of the fl ap. If a l ong advancement fl ap i s needed to stretch
ski n for cl osure, the bl ood suppl y may be compromi sed to the fl ap
ti p. When cl osi ng a 1-i nch di ameter defect on the face, the si ngl e
advancement fl ap shoul d be no l onger than 3 i nches. Si ngl e
advancement fl aps on l ess vascul ar areas of the body do better i f
l i mi ted to a l ength-to-wi dth rati o of 2.5 to 1. One way to avoi d
l ong si ngl e advancement fl aps i s to pul l ski n from both di recti ons;
the bi l ateral advancement fl ap general l y has l ess chance of fl ap ti p
necrosi s. The l ong arms for si ngl e or bi l ateral advancement fl aps
are desi gned to al i gn wi th the l i nes of l east ski n tensi on to
Page 314
i mprove the fi nal cosmeti c resul t.
When removi ng ski n cancer, i t i s best to ensure cl ear margi ns
before performance of fl ap cl osure. Wi de exci si on around a cancer
may provi de hi gh rates of cure, but the excessi ve removal of ti ssue
may l i mi t the cosmeti c outcome. Hi stol ogi c confi rmati on by Mohs'
surgery or frozen secti ons i s essenti al before cl osure, when
removi ng cancers at hi gh ri sk for recurrence (e.g., morpheaform or
scl erosi ng basal cel l carci nomas).
Preventi ng compl i cati ons i s an i mportant aspect of performi ng fl ap
surgery. Stri ct steri l e techni que i s necessary to avoi d wound
i nfecti ons. Excessi ve stretchi ng of ski n shoul d be avoi ded because
necrosi s wi l l ensue. Wi de undermi ni ng of
P.187
the l ateral ti ssue around a fl ap ai ds the cl osure. Do not pul l on the
ski n edges wi th forceps because careful handl i ng prevents
excessi ve scarri ng. Bl ood accumul ati ons beneath fl aps can i nterfere
wi th oxygen del i very to the ti ssue, and excel l ent hemostasi s i s
requi red. Bl eedi ng vessel s shoul d be cl amped or suture-l i gated
before the fl ap i s sutured, and pressure bandagi ng i s advocated
fol l owi ng the procedure.
INDICATIONS
Single Advancement Flap
Cl osure of l ateral eyebrow defects
Repai r of defects of the templ e area
Cl osure of forehead defects
Cl osure of cheek defects
Cl osure of upper arm defects
Cl osure of defects on the ti p of the nose
Bilateral Advancement Flap
Cl osure of defects on the trunk or abdomen
Cl osure of a mi ddl e eyebrow defect
Cl osure of forehead ski n defects
Page 315
Practi ti oner's unfami l i ari ty or i nexperi ence wi th
techni ques
Cel l ul i ti s i n the ti ssues
Ski n unabl e to be stretched to cover the defect
Chroni c steroi d use (and steroi d ski n effects)
P.188
PROCEDURE
The si ngl e advancement fl ap techni que i s performed after
admi ni strati on of anesthesi a (e.g., fi el d bl ock). The l esi on i s
removed wi th a ri m of normal -appeari ng ski n, and the defect i s
squared (Fi gure 1A). The fl ap arms are i nci sed, paral l el i ng the l i nes
of l est ski n tensi on, approxi matel y two ti mes the ori gi nal defect's
di ameter (Fi gure 1B). The fl ap and surroundi ng ski n are undermi ned
wi th a hori zontal l y hel d scal pel bl ade (Fi gure 1C).
Page 316
(1) The si ngl e advancement fl ap techni que.
Attempt to sl i de the fl ap to cover the defect usi ng ski n hooks on
the fl ap. If the defect cannot be covered by the fl ap, the fl ap can
be l engthened. Anchor the fl ap i n pl ace wi th one or two sutures
(Fi gure 2A). If there i s tensi on on the sutures, verti cal mattress
sutures can be pl aced (see Chapter 16). Noti ce that the ski n
bunches up (i .e., dog ears) near the base of the fl ap when the fl ap
i s moved. These dog ears are el i mi nated by exci si ng tri angul ar
pi eces of ski n (i .e., Burrow's tri angl es) (Fi gure 2B).
Page 317
(2) Usi ng ski n hooks, attempt to sl i de the fl ap to cover the defect.
P.189
After removal of redundant ti ssue, the corners l i e fl at. Corner
sutures can be pl aced for the four corners, and i nterrupted suture i s
used to compl ete the fl ap.
(3) Pl ace corner sutures on the four corners and i nterrupted sutures
al ong the si des of the fl ap.
After removal of a tumor i n the l ateral eyebrow, hai r-beari ng ski n i s
used to cl ose the defect (Fi gure 4A). After removal of a tumor i n
the templ e, hai r-beari ng ski n i s brought down from the scal p to
cl ose the defect (Fi gure 4B).
(4) Appl i cati ons of the si ngl e advancement fl ap.
A square defect i s created around the tumor, and the fl ap arms
Page 318
i nci sed to about 1.5 ti mes the di ameter of the defect.
(5) The bi l ateral advancement fl ap.
P.190
The centers of the fl aps are joi ned wi th anchori ng sutures, and
corner sutures are used to joi n the fl ap corners (Fi gure 6A). The
dog ears formed are smal l er wi th bi l ateral advancement fl aps and
someti mes may not requi re exci si on. Smal l er tri angl es are exci sed
(Fi gure 6B), and the compl eted fl ap i s i l l ustrated (Fi gure 6C). A
pressure bandage can be appl i ed usi ng gauze and el asti c tape.
Page 319
(6) The centers of the fl aps are joi ned wi th anchori ng sutures, and
corner sutures are used to joi n the fl ap corners.
The mi ddl e eyebrow (Fi gure 7A) and the forehead (Fi gure 7B) can
be cl osed usi ng thi s techni que.
Page 320
(7) Appl i cati ons of the bi l ateral advancement fl ap.
P.191
CODING INFORMATION
These codes encompass exci si on or repai r, or both, by adjacent
transfer or rearrangement, i ncl udi ng Z-pl asty, W-pl asty, V-Y pl asty,
rotati on fl aps, advancement fl aps, and doubl e-pedi cl e fl aps. When
appl i ed to l acerati on repai r, the defect must be devel oped by the
surgeon, and these codes shoul d not be used for di rect cl osure of a
defect that i nci dental l y resul ts i n the confi gurati on of one of the
fl aps or pl asti es. If the confi gurati ons resul t i nci dental l y from the
l acerati on shape, cl osure shoul d be reported usi ng si mpl e repai r
codes (see Chapter 14). Al l of the fol l owi ng codes are for adjacent
ti ssue transfer or rearrangement, and they refer to defects i n the
trunk or the fol l owi ng si tes: scal p, arms, or l egs (SAL); forehead,
cheeks, chi n, mouth, neck, axi l l ae, geni tal i a, hands, or feet
(FCCMNAGHF); and eyel i ds, nose, ears, or l i ps (ENEL).
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Page 325
i s a
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ati on.
Surgery tray i nstruments are l i sted i n Appendi x A. Consi der addi ng
two ski n hooks to gentl y handl e the ski n fl aps. Have at l east three
fi ne (mosqui to) hemostats to assi st wi th hemostasi s whi l e
devel opi ng l arge ski n fl aps. Suggested suture removal ti mes are
l i sted i n Appendi x C, and a suggested anesthesi a tray that can be
used for thi s procedure i s l i sted i n Appendi x G. Al l i nstruments can
be ordered through l ocal surgi cal suppl y houses.
BIBLIOGRAPHY
Cook J. Introducti on to faci al fl aps. Dermatol Cl i n
2001;19:199212.
Grabb WC. Cl assi fi cati on of ski n fl aps. In: Grabb WC, Myers MB,
eds. Ski n fl aps. Boston: Li ttl e, Brown, 1975:145154.
Gri gg R. Forehead and templ e reconstructi on. Otol aryngol Cl i n North
Am 2001;34:583600.
Harahap M. The modi fi ed bi l ateral advancement fl ap. Dermatol Surg
2001;27:463466.
Shi m EK, Greenway HT. Surgi cal pearl : repai r of hel i cal ri m defects
wi th the bi pedi cl e advancement fl ap. J Am Acad Dermatol
2000;43:11091111.
Page 326
P.192
1975;1:2531.
1987:8691.
Tol l efson TT, Murakami CS, Kri et JD. Cheek repai r. Otol aryngol Cl i n
North Am 2001; 34: 627646.
Vural E, Key JM. Compl i cati ons, sal vage, and enhancement of l ocal
fl aps i n faci al reconstructi on. Otol aryngol Cl i n North Am
2001;34:739751.
Whi taker DC. Random-pattern fl aps. In: Wheel and RG, ed.
Zuber TJ. Advanced soft-ti ssue surgery. The AAFP i l l ustrated
manual s and vi deotapes of soft-ti ssue surgery techni ques. Kansas
Ci ty: Ameri can Academy of Fami l y Physi ci ans, 1999: 6272.
Page 327
> Table of Cont ent s > Dermat ology > 27 - O- To- Z Plast y27
O-To-Z Plasty
The O-to-Z pl asty i s a versati l e cl osure techni que used for l arge
defects that are not appropri atel y cl osed wi th a fusi form (el l i pti cal )
exci si on techni que. Because of the mul ti pl e cl i ni cal i ndi cati ons, the
O-to-Z pl asty can be readi l y l earned by general i st physi ci ans and
used frequentl y i n practi ce. Advantages of the techni que i ncl ude
the spari ng of ti ssue, cl osure al i gni ng wi th the l i nes of l east ski n
tensi on, and producti on of a broken l i ne (Z-shaped) fi nal scar. The
O-to-Z fl ap techni que general l y produces excel l ent cosmeti c
resul ts.
The O-to-Z pl asty i ncorporates advancement and rotati on
techni ques, and some authors characteri ze i t as a transposi ti on
fl ap. The O-to-Z fl ap can be envi si oned as a l arge fusi form
exci si on, wi th onl y the central ci rcul ar area around the l esi on
exci sed (see Fi gure 2.) On each si de of the central ci rcul ar area,
onl y one of the arms of the fusi form exci si on i s i nci sed. A fl ap i s
created on each si de, and these two fl aps are joi ned central l y to
create a fi nal Z-shaped scar.
Large fusi form exci si ons can resul t i n the removal of a l arge
amount of ti ssue and subsequent pul l on surroundi ng structures
wi th cl osure of the wound. For i nstance, a l arge fusi form exci si on
just above the eyebrow can produce permanent el evati on of the
eyebrow. Fusi form exci si ons on the upper l i p can el evate the
vermi l i on border. The O-to-Z pl asty can obvi ate the di ffi cul ty of
l ateral pul l on surroundi ng structures when cl osi ng the wound.
Ski n fl aps are most commonl y performed on the face, where the
bl ood suppl y i s extensi ve. The O-to-Z pl asty recei ves i ts bl ood
suppl y through l arge pedi cl e bases (i .e., porti on of the fusi form
i nci si ons that are not i nci sed) and can someti mes work wel l even
on nonfaci al si tes. As wi th al l ski n fl aps, meti cul ous attenti on to
Page 328
hemostasi s i s requi red.
When the O-to-Z pl asty i s performed after ski n cancer removal , i t i s
preferabl e to ensure cl ear margi ns usi ng frozen secti ons or Mohs'
surgery before performi ng wound cl osure. Because these opti ons
may not be avai l abl e to an offi ce physi ci an, a suffi ci ent margi n of
normal -appeari ng ski n must be removed around and beneath a
cancer (usual l y at l east 4 to 6 mm) before cl osure i s attempted.
Postprocedure pressure dressi ngs are recommended to reduce
hematoma formati on beneath the fl aps and the devel opment of
compl i cati ons.
P.194
INDICATIONS
Lesi on removal next to l i near structures that shoul d not
be pul l ed
Lesi on removal on the upper l i p
Cl osure of defects on the chi n or beneath the chi n
Cl osure of l arge forehead defects (especi al l y i f just
above the eyebrows or near the hai rl i ne)
Repai r of scal p defects
Cl osure of defects i n templ e regi on, l ateral face beneath
the ear, or al ong the mandi bl e
Practi ti oner's unfami l i ari ty or l ack of ski l l i n the
techni que
Cel l ul i ti s i n the ti ssues
Ski n unabl e to stretch to easi l y cl ose the defect
Chroni c steroi d use wi th steroi d ski n effects
P.195
PROCEDURE
The O-to-Z pl asty i s based on the fusi form exci si on. After removal
Page 329
of the ski n l esi on (Fi gure 1A), the fusi form exci si on i s desi gned so
that the l ength i s three ti mes the wi dth (Fi gure 1B). The fusi form
exci si on i s al i gned so that the l ong axi s i s paral l el to the l i nes of
l east ski n tensi on.
(1) After removal of a ski n l esi on, a fusi form exci si on i s desi gned
so that the l ength i s three ti mes the wi dth, and i t i s al i gned so
that the l ong axi s i s paral l el to the l i nes of l east ski n tensi on.
In the O-to-Z pl asty, onl y one i nci si on l i ne (i .e., arm) i s performed
on each si de of the central ci rcul ar exci si on. The i nci si on l i nes are
drawn to sl ope toward a theoreti cal central l i ne. One i nci si on arm i s
above the central l i ne, and one i nci si on arm i s bel ow the central
l i ne.
(2) One i nci si on arm i s drawn to sl ope toward a theoreti cal central
l i ne on each si de of the central ci rcul ar exci si on; one i nci si on l i ne
i s above, and the other i s bel ow the central l i ne.
PITFALL: Make sure the incision arms are on opposite sides of
the central line! Many novice practitioners have unintentionally
Page 330
incised both arms on the same side of the central line,
necessitating performance of a fusiform excision or an
advancement flap technique.
P.196
The central i sl and of ski n contai ni ng the tumor has been removed
and sent for hi stol ogi c anal ysi s (Fi gure 3A). Gentl e sl opi ng l i nes
are i nci sed that end at the theoreti cal central l i ne (Fi gure 3B). The
arms are approxi matel y 1.5 to 2 ti mes the di ameter of the central
ci rcul ar exci si on. The corners are squared to faci l i tate
approxi mati on of the fl aps (Fi gure 3C).
(3) Gentl e sl opi ng l i nes are i nci sed. They end at the theoreti cal
central l i ne, and each l i ne approxi matel y 1.5 to 2 ti mes the
di ameter of the central ci rcul ar exci si on.
The fl aps are gentl y el evated wi th ski n hooks, and hori zontal
undermi ni ng i s performed wi th a no. 15 scal pel bl ade or sci ssors.
The wi der the undermi ni ng around the enti re si te, the easi er i t i s to
move the ski n fl aps together.
Page 331
(4) Gentl y el evate the fl aps wi th ski n hooks, and perform
hori zontal undermi ni ng wi th a no. 15 scal pel bl ade or sci ssors.
The two fl aps are brought together and anchored wi th one or two
verti cal mattress sutures. Corner sti tches are pl aced i n the fl ap ti p
corners. The el evated ti ssue formati ons at the ends of the arms are
known as dog ears.
(5) Bri ng the two fl aps together, anchor them wi th one or two
verti cal mattress sutures, and pl ace corner sti tches i n the fl ap ti p
corners.
P.197
Tri angul ar pi eces of ski n are removed, el i mi nati ng the dog ears and
al l owi ng the corners to l i e fl at (Fi gure 6A). The fi nal cl osure i s
shown (Fi gure 6B).
Page 332
(6) Remove the dog ears of ski n.
Thi s cl osure can be performed on the forehead above the eyebrow
(Fi gure 7A), on the chi n (Fi gure 7B), or beneath the chi n (Fi gure
7C).
(7) Exampl es of cl i ni cal i ndi cati ons for the O-to-Z pl asty: the
forehead above the eyebrow, the chi n, and beneath the chi n.
P.198
CODING INFORMATION
Chapter 25 l i sts the codes used for reporti ng the adjacent ti ssue
transfer procedures.
Appendi x A l i sts the i nstruments i ncl uded i n a standard ski n
surgery pack. The comments on i nstruments i n Chapter 26 al so
appl y to the performance of O-to-Z pl asty. Suggested suture
Page 333
removal ti mes are l i sted i n Appendi x C, and a suggested anesthesi a
BIBLIOGRAPHY
Hammond RE. Uses of the O-to-Z-pl asty repai r i n dermatol ogi c
surgery. J Dermatol Surg Oncol 1979;5:205211.
1975;1:2531.
1987:102104.
Vural E, Key JM. Compl i cati ons, sal vage, and enhancement of l ocal
fl aps i n faci al reconstructi on. Otol aryngol Cl i n North Am
2001;34:739751.
Whi taker DC. Random-pattern fl aps. In: Wheel and RG, ed.
Zuber TJ. Advanced soft-ti ssue surgery. AAFP i l l ustrated manual s
Page 334
> Table of Cont ent s > Dermat ology > 28 - Sclerot herapy28
Sclerotherapy
Scl erotherapy i s an i nexpensi ve and general l y safe outpati ent
techni que for the removal of unwanted spi der (tel angi ectati c),
reti cul ar, and vari cose vei ns. A concentrated sal i ne or chemi cal
sol uti on i s i njected i nto the unwanted vessel usi ng a smal l (30- to
32-gauge) needl e. The sol uti on washes over the vessel 's
endothel i al cel l s, produci ng obl i terati on of the vessel and shi fti ng
bl ood i nto nearby heal thy vessel s.
Abnormal or di stended vei ns resul t from i ncreased vascul ar pressure
transmi tted to the superfi ci al vessel s. Val ves i n the deep vei ns of
the l ower extremi ty are thi n and fragi l e, and damage to these
val ves reduces the uni di recti onal fl ow of bl ood returni ng to the
heart. Many condi ti ons can render the val ves nonfuncti onal , such as
the i ncreased bl ood fl ow of pregnancy, deep venous thrombosi s,
venous i njury, and i ncreased abdomi nal pressure (i .e., excessi ve
si tti ng, l eg crossi ng, or obesi ty). Other i nfl uences, such as
hormonal changes i n the vei ns or congeni tal absence of vei n val ves,
can al so produce vari cosi ti es.
If hypertoni c sal i ne i s used as the scl erosi ng sol uti on, l i docai ne
usual l y i s mi xed wi th the sal i ne to l essen the di scomfort. Two
mi l l i l i ters of 1% l i docai ne hydrochl ori de (wi thout epi nephri ne) i s
added to a 30-mL bottl e of 23.4% hypertoni c sal i ne, creati ng a
fi nal concentrati on of 22%. Thi s sol uti on i s then pl aced i nto 10 to
20 tubercul i n syri nges, and 30-gauge needl es are attached to the
syri nges. Al ternatel y, physi ci ans may choose to perform
scl erotherapy wi th detergent sol uti ons such as sodi um tetradecyl
sul fate. The syri nges are onl y hal f fi l l ed (0.5 mL) wi th scl erosi ng
sol uti on so that the thumb i s not extended ful l y duri ng the
i njecti on and to l i mi t the amount i njected i nto any si ngl e vessel
and prevent deep venous i njecti on. The syri nges are pl aced on a
Page 335
tray for the procedure.
One to si x i njecti ons may be needed to effecti vel y treat any vei n.
When spi der vei ns are i njected, i nterconnecti ons among
subcutaneous vessel s may permi t treatment of a l arge network over
a wi de area of ski n. Wai t at l east 4 to 6 weeks before rei njecti ng
i ndi vi dual vessel s to permi t adequate heal i ng and to reduce
posti nfl ammatory compl i cati ons.
Pati ents desi ri ng scl erotherapy shoul d undergo a pretreatment
consul tati on (Tabl e 28-1). The consul tati on i s used to eval uate
potenti al candi dates, map or photograph the extent of thei r
di seased vessel s, and to educate them regardi ng the procedure.
Educati on i s parti cul arl y i mportant, because l ess than 90% of
pati ents of even the most experi enced practi ti oners report ful l
sati sfacti on wi th the outcome.
P.200
Photography can hel p remi nd pati ents of the severi ty of the di sease
before therapy.
TABLE 28-1. INITIAL CONSULTATION SESSION

1.
Assess the appropri ateness of the candi date. Has the pati ent undergone pri or therapy? A hi story of di ssati sfacti on wi th pri or
therapy may predi ct future di ssati sfacti on. Is there a hi story of si gni fi cant vei n i njury, cl ots, or predi sposi ng factors? Is the
pati ent taki ng medi cati ons (e.g., hormone therapy) that may exacerbate vei n di sease? Is the pati ent wi l l i ng to wear the support
hose after the procedure?
2.
Educate the pati ent regardi ng the major compl i cati ons of the procedure. Does the pati ent understand that he or she may
experi ence some di scomfort duri ng or after the procedure? See Tabl e 28.2
3.
Assess major pressure i nfl uence on the superfi ci al vei ns from i ncompetent perforator vei ns. Perform a cough test (i .e., pati ent
coughs whi l e exami ner hol ds the exami ni ng hand over the saphenofemoral juncti on; i f the perforator i s i ncompetent, a pul se i s
fel t). The Brodi e-Trendel enberg test uses two exami ners. The pati ent i s l ai d supi ne, wi th the l egs el evated to a verti cal posi ti on
to drai n al l the bl ood from the vei ns. The exami ners hol d pressure on the saphenofemoral juncti on whi l e the pati ent i s stood up;
the vei ns on the posteri or l ower l egs are observed. If there i s an i ncompetent perforator, the vei ns fi l l rapi dl y (<1520
seconds), and then a surge i s noted i n the fi l l i ng vei ns when the pressure over the juncti on i s rel eased.
Page 336
4.
To perform photopl ethysmography, the pati ent i s seated, and the sensor pl aced on the ski n 10 cm above the medi al mal l eol us.
The ankl e i s dorsi fl exed 10 ti mes by the exami ner over 10 to 15 seconds, effecti vel y emptyi ng the bl ood from the subdermal
pl exus. In a normal study, refi l l i ng occurs i n more than 25 seconds; i ntermedi ate refi l l i ng occurs i n 15 to 20 seconds, and severe
i ncompetence of the perforators al l ows the subdermal vei ns to refi l l i n l ess than 15 seconds.
5.
Record or chart the presence of abnormal vei ns. If photographs are obtai ned, perform them i n an area of the offi ce wi th a dark
background (e.g., mounted dark fel t).
6.
Wri te a prescri pti on for the pati ent to be fi tted for two pai rs of 30 to 40 mm Hg, thi gh-hi gh support hose. The pati ent must bri ng
a pai r of support hose to the fi rst scl erotherapy sessi on.

Scl erotherapy i s contrai ndi cated i f the procedure i s unl i kel y to
produce si gni fi cant benefi t. If a pati ent has si gni fi cant pressure
extendi ng to superfi ci al vei ns (e.g., produced by an i ncompetent
perforati ng vei n i n the saphenofemoral juncti on i n the groi n),
abnormal vei ns wi l l rapi dl y repl ace those that are abl ated.
Incompetent perforators can be eval uated by physi cal exami nati on
(e.g., cough test, Brodi e-Trendel enburg test) or confi rmatory
testi ng (e.g., photopl ethysmography, Doppl er studi es).
Photopl ethysmography i s easy to perform and gi ves an accurate
assessment of fi l l i ng ti me after the bl ood i s removed from the
l ower l eg usi ng the cal f muscl e pump.
After scl erotherapy, pati ents shoul d wear support hose for 3
consecuti ve days and 2 ni ghts. Support hose are pl aced on the
pati ent i mmedi atel y after the scl erotherapy sessi on. The use of
support hose l i mi ts the refi l l i ng of treated vessel s and si gni fi cantl y
reduces compl i cati ons after therapy (Tabl e 28-2). Pati ents are
fi tted for thi gh-hi gh, 30- to 40-mm Hg support hose at the i ni ti al
consul tati on. The fi rst scl erotherapy sessi on i s schedul ed for 2
weeks after the consul tati on to al l ow adequate ti me to obtai n the
fi tted hose. Pati ents wi th l eg hypostasi s are encouraged to wear
support hose l ong term to i mprove the heal th of the l eg ti ssues and
to reduce recurrences. Pati ents often prefer l ower-pressure
(over-the-counter, 10- to 20-mm Hg) support hose, but the
hi gher-pressure type of support hose i s needed to ensure adequate
venous drai nage and to prevent stasi s compl i cati ons.
Page 337
TABLE 28-2. COMPLICATIONS OF SCLEROTHERAPY

Complications Comments

Cutaneous hyperpi gmentati on Occurs i n about 30% of pati ents i f hypertoni c sal i ne i s the
scl erosi ng agent
Brui si ng Worsened i f l arger vessel s are i njected, when canal i zati on fai l s or
i f l ack of compressi on afterward
Temporary swel l i ng Between 2% and 5% of pati ents experi ence pedal and l eg edema
after the procedure
Tel angi ectati c matti ng New appearance of fi ne (bl ush) vessel s i n about 25% of pati ents
Pai n Hypertoni c sal i ne i s more uncomfortabl e than detergent sol uti ons
Local i zed urti cari a after Al l ergi c l ocal reacti on occurri ng i n the fi rst 30 mi nutes fol l owi ng
scl erotherapy
Tape compressi on bl i ster Common compl i cati on when gauze i s taped over i njecti on si tes
Recurrence of abnormal vei ns Most pati ents have some new vessel s i n the next 5 years
Cutaneous necrosi s Can resul t from extravasati on or i nadvertent i njecti on of an
arteri ol e; i s more common when i njecti ng bel ow the ankl e or on
the foot
Anaphyl axi s Uncommon systemi c reacti on
Al l ergi c reacti on to scl erosi ng agent Detergent sol uti ons can produce speci fi c reacti ons
Superfi ci al thrombophl ebi ti s weeks Up to 15% of pati ents experi ence thi s i n the fi rst 3 after i njecti on
Deep venous thrombosi s and pul monary embol us Rare but seri ous compl i cati on of the procedure
P.201
INDICATIONS
Abl ati on of unwanted spi der, reti cul ar, or vari cose vei ns
El i mi nati on of the symptoms of vari cosi ti es such as
achi ng, ni ght cramps, or i tchi ng
Improvement i n cosmeti c appearance of l egs or other
affected body si tes
Prevent the compl i cati on of l eg hypostasi s (e.g.,
dermati ti s, ul cerati on) by di verti ng bl ood to heal thy
Page 338
vessel s
Uncooperati ve pati ent (i ncl udi ng refusal to wear support
hose after the procedure)
Hi story of al l ergi c reacti on to scl erosi ng sol uti on (may
use al ternate sol uti ons)
Severe peri pheral arteri al di sease that may compromi se
heal i ng or precl ude use of support hose
Untreated i ncompetent saphenofemoral juncti on
perforator
Poorl y control l ed di abetes
P.202
PROCEDURE
The pati ent l i es fl at on the treatment tabl e (prone or supi ne,
dependi ng on the l ocati on of the vei ns bei ng treated.) Two l i ghts
are posi ti oned from opposi te di recti ons to hi ghl i ght the vessel s and
to l i mi t shadows that can i nterfere wi th vi sual i zati on of the
vessel s.
(1) The pati ent l i es fl at on the treatment tabl e.
Pour a col orl ess anti septi c sol uti on (i .e., benzal koni um chl ori de
[Zephi ran] or al cohol ) i nto a basi n contai ni ng cotton bal l s. Appl y
Page 339
the sol uti on wi th the cotton bal l s to render the ski n more
transparent and to make the vei ns easi er to vi sual i ze.
(2) Appl y a col orl ess anti septi c sol uti on wi th cotton bal l s to render
the ski n more transparent and to make the vei ns easi er to
vi sual i ze.
P.203
The i njecti on needl e i s bent wi th the bevel up before i ni ti ati ng an
i njecti on. Ini ti al l y i denti fy the bevel ; use magni fi cati on (1 to 3
di opter gl asses) i f needed. Posi ti on the bevel upward from the
hori zontal l y hel d crossbar (Fi gure 3A). Bend the needl e to a 30- to
45-degree angl e (Fi gure 3B) so that the needl e can enter next to a
vei n hori zontal to the ski n surface. Injecti ons shoul d onl y be
performed wi th the bevel up; thi s hel ps to prevent scl erosi ng fl ui d
from l eaki ng i nto the ti ssue. Injecti ons must be i ntral umi nal to
prevent compl i cati ons.
Page 340
(3) Perform i njecti ons wi th the bevel up to hel p prevent scl erosi ng
fl ui d from l eaki ng i nto the ti ssue.
PITFALL: The most common mistake made by novice
sclerotherapists is to attempt entry into small vessels with the
needle held at a angle to the surface of the skin. If the needle is
at an angle, the tip frequently passes through a small vessel and
deposits the solution in the tissues.
P.204
Posi ti on the hands to provi de three-poi nt tracti on before i njecti ng a
vei n. The nondomi nant hand appl i es tracti on usi ng the thumb and
i ndex (second) fi nger. The i njecti ng (domi nant) hand's fi fth fi nger
i s used to provi de the thi rd poi nt.
Page 341
(4) Hands shoul d be posi ti oned to provi de three-poi nt tracti on
before i njecti ng a vei n.
Injecti ons are admi ni stered sl owl y. If the needl e ti p i s i ntral umi nal ,
the sol uti on wi l l fl ow easi l y i nto the vessel . Observe the needl e ti p
and vessel cl osel y. If a smal l bl eb (or bubbl e) devel ops at the
i njecti on si te (Fi gure 5A), extravasati on i s l i kel y. The i njecti on
shoul d be termi nated i mmedi atel y and the bl eb mi l ked back to the
puncture si te to mechani cal l y attempt removal of any fl ui d i n the
ti ssue (Fi gure 5B). Some physi ci ans advocate i nfi l trati ng around
extravasati on si tes wi th normal sal i ne, but most mi ni mal
extravasati ons do not produce ski n necrosi s or other compl i cati ons.
(5) If a smal l bl eb devel ops at the i njecti on si te, the i njecti on
shoul d be termi nated i mmedi atel y, and the bl eb shoul d be mi l ked
back to the puncture si te to mechani cal l y attempt removal of any
fl ui d i n the ti ssue.
Page 342
P.205
Target l arger, strai ghter porti ons of vessel s to i mprove the rate of
successful canal i zati on (Tabl e 28-3). Proper i njecti on techni que
resul ts i n vi si bl e bl anchi ng of the vessel (i .e., washout effect).
Because vessel s can have si gni fi cant connecti ons beneath the
surface of the ski n, conti nue the i njecti on i f the sol uti on i s fl owi ng
easi l y and i f there i s no evi dence of extravasati on.
(6) Target l arger, strai ghter porti ons of vessel s to i mprove the rate of successful canal i zati on.
TABLE 28-3. PRINCIPLES GUIDING INJECTION DECISIONS DURING SMALL VESSEL SCLEROTHERAPY

Inject proxi mal to di stal vei ns.
Larger vei ns are treated before smal l er vei ns.
Treat an enti re vessel , i f possi bl e, at a gi ven treatment sessi on.
Inject the l argest feedi ng vessel (i .e., tree trunk) when treati ng a tel angi ectati c cl uster.
Empty l arger vei ns whenever possi bl e before i njecti on.
Adapted from Sadi ck N, Li C. Smal l -vessel scl erotherapy. Dermatol Cl i n 2001;19:475481.
Immedi atel y after the i njecti on, pl ace pressure on the si te wi th
gauze. The nurse can hol d pressure to the si te for 30 to 60 seconds
whi l e the physi ci an i njects another si te. The number of i njecti ons
performed duri ng any one sessi on depends on many factors,
Page 343
i ncl udi ng the extent of di sease, ti me avai l abl e for the procedure,
and the pati ent's tol erance.
(7) Immedi atel y after the i njecti on, pl ace pressure on the si te wi th
gauze for 30 to 60 seconds.
P.206
Fi tted support hose are appl i ed whi l e the pati ent i s supi ne, before
standi ng and refi l l i ng the vei ns. Do not tape gauze on the ski n. The
2 * 2 i nch gauze can be hel d over the i njecti on si tes as the support
hose are rol l ed up the l eg. Thi s techni que al l ows the gauze to
absorb drai nage, whi l e avoi di ng tape al l ergi es and tape bl i steri ng.
The pati ent i s i nstructed to ambul ate for 20 mi nutes after
appl i cati on of the support hose to prevent pool i ng of scl erosi ng
agents i nto the deep vei n ci rcul ati on.
(8) Appl y fi tted support hose whi l e the pati ent i s supi ne, and have
Page 344
pati ent ambul ate for 20 mi nutes to prevent any pool i ng of
scl erosi ng agents i nto the deep vei n ci rcul ati on.
P.207
CODING INFORMATION
If bi l ateral procedures are performed duri ng the sessi on, then add
the -50 modi fi er when reporti ng codes 36468, 36470, and 36471.
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Page 348
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Page 349
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Page 350
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Page 351
l
Associ
ati on.
Hypertoni c sal i ne, sodi um tetradecyl sul fate, and benzal koni um
chl ori de sol uti on can be obtai ned from l ocal surgi cal suppl y houses
or pharmaci es. The photopl ethysmography machi ne (Hemodynami cs
AV-1000 l i ght refl ecti on rheography), vei n l i ght (i .e.,
transi l l umi nati on devi ce for vei ns), and 30-gauge scl erotherapy
needl es can be ordered from Sam Wagner, Mi ddl ebourne, WV
(phone: 304-758-2370; http://www.vei nsonl i ne.com).
BIBLIOGRAPHY
Baccagl i ni U, Spreafi co G, Castoro C, et al . Scl erotherapy of
vari cose vei ns of the l ower l i mbs. Dermatol Surg
1996;22:883889.
Gol dman MP, Bergan JJ. Scl erotherapy: treatment of vari cose and
tel angi ectati c l eg vei ns, 3rd ed. St. Loui s: MosbyYear Book,
2001.
Gol dman MP, Wei ss RA, Brody HJ, et al . Treatment of faci al
tel angi ectasi as wi th scl erotherapy, l aser surgery, and/or
el ectrodesi ccati on: a revi ew. J Dermatol Surg Oncol
1993;19:899906.
Green D. Scl erotherapy for vari cose and tel angi ectati c vei ns. Am
Fam Physi ci an 1992;46:827837.
Hubner K. Is the l i ght refl ecti on rheography (LRR) sui tabl e as a
di agnosti c method for the phl ebol ogy practi ce? Phl ebol Proctol
1986;15:209212.
Page 352
Imperi o WA. Learn the l ogi c behi nd effecti ve scl erotherapy. Ski n
Al l ergy News 2002;33:32.
Pfei fer JR, Hawtof GD, Mi ni er JA. Sal i ne i njecti on scl erotherapy i n
the abl ati on of spi der tel angi ectasi a of the l ower extremi ti es.
Perspect Pl ast Surg 1990;2:165170.
P.208
Pfei fer JR, Hawtof GD. Injecti on scl erotherapy and CO2 l aser
scl erotherapy i n the abl ati on of cutaneous spi der vei ns of the l ower
extremi ty. Phl ebol ogy 1989;4:231240.
Pi achaud D, Weddel l JM. Cost of treati ng vari cose vei ns. Lancet
1972;11:11911192.
Sadi ck N, Li C. Smal l -vessel scl erotherapy. Dermatol Cl i n
2001;19:475481.
Sadi ck NS, Farber B. A mi crobi ol ogi c study of di l uted scl erotherapy
sol uti ons. J Dermatol Surg Oncol 1993;19:450454.
Sadi ck NS. Predi sposi ng factors of vari cose and tel angi ectati c l eg
vei ns. J Dermatol Surg Oncol 1992;18:883886.
Ti si PV, Beverl ey CA. Injecti on scl erotherapy for vari cose vei ns.
Cochrane Database Syst Rev 2002;CD001732.
Wei ss MA, Wei ss RA, Gol dman MP. How mi nor vari cosi ti es cause l eg
pai n. Contemp Obstet Gynecol 1991:113125.
Wei ss RA, Sadi ck NS, Gol dman MP, et al . Post-scl erotherapy
compressi on: control l ed comparati ve study of durati on of
compressi on and i ts effects on cl i ni cal outcome. Dermatol Surg
1999;25:105108.
Wei ss RA, Wei ss MA, Gol dman MP. Physi ci ans' negati ve percepti on
of scl erotherapy for venous di sorders: revi ew of a 7-year experi ence
wi th modern scl erotherapy. South Med J 1992;85:11011106.
Page 353
> Table of Cont ent s > Nail Procedures > 29 - Digit al Nerve Block29
Digital Nerve Block
Di gi tal nerve bl ock i s commonl y performed to provi de anesthesi a of
an enti re di gi t. Di gi tal nerve bl ock anestheti zes the four di gi tal
nerves that traverse the si des of the di gi t. Thi s techni que has the
advantage of provi di ng l onger durati on of anesthesi a over l ocal
i nfi l trati on, and i t does not di stort anatomi c l andmarks for di gi tal
surgery.
Because mul ti pl e nerves are affected duri ng the techni que, thi s
anesthesi a woul d be more appropri atel y l abel ed as di gi tal fi el d
bl ock rather than the commonl y used nerve bl ock. Admi ni strati on of
1 to 3 mL of 2% l i docai ne provi des adequate anesthesi a wi thout
use of a l arge vol ume. The great toe or thumb can al so recei ve
some addi ti onal superfi ci al i nnervati on proxi mal l y, and a sl i ghtl y
l arger vol ume of sol uti on (admi ni stered as a dorsal ski n wheal ) may
be needed for these di gi ts. Al l di gi tal bl ocks requi re some ti me for
the anestheti c to affect the nerve sheath; many novi ce and
i mpati ent physi ci ans conti nue to add vol ume when a few mi nutes of
ti me woul d produce the desi red effect.
Di gi tal bl ock techni que hi stori cal l y was cal l ed ri ng bl ock because of
the ci rcumferenti al i nfi l trati on of anestheti c. Increasi ng rates of
vascul ar compromi se can be observed wi th ci rcumferenti al
i nfi l trati on, especi al l y i f vol umes greater than 7 to 8 mL are
admi ni stered to the smal l er di gi ts. Use of 3- or 5-mL syri nges can
hel p avoi d the temptati on to del i ver l arger vol umes. Impai red
di gi tal ci rcul ati on can al so occur i f an i ndi vi dual suffers from
vasospasti c di sease such as Raynaud's phenomenon or i f the di gi t
i s markedl y swol l en before i nfi l trati on. Despi te evi dence for the
safety of the practi ce, i t i s sti l l advi sabl e to avoi d the addi ti on of
epi nephri ne to l i docai ne for use on the di gi ts.
Hi stori cal l y, physi ci ans were i nstructed to i nsert the needl e i nto
Page 354
the web space to perform di gi tal bl ock. The advantage of a web
space i njecti on i s that the nerve can be i njected at the si te of
bi furcati on between adjoi ni ng di gi ts. The bl ood vessel s of the web
space are l arger than on the di gi t, and i ntravascul ar i njecti on of
anestheti c can easi l y occur wi th the web space techni que.
Physi ci ans are encouraged to use the di gi tal techni ques descri bed
i n thi s chapter.
INDICATIONS
Repai r of di gi tal l acerati ons
Nai l procedures (e.g., i ngrown nai l surgery, nai l bed
bi opsy, nai l removal )
P.212
Inci si on and drai nage of abscesses (e.g., fel on surgery,
paronychi a surgery)
Anesthesi a for fracture or di sl ocati on mani pul ati on of
di gi tal orthopedi c i njuri es
Tumor or cyst removal or abl ati on (e.g., di gi tal mucous
cysts, gi ant cel l tumors of sheaths, warts)
CONTRAINDICATIONS AND PRECAUTIONS
Use of epi nephri ne added to l i docai ne
Use of vol umes greater than 7 mL, especi al l y i n
i ndi vi dual s wi th peri pheral vascul ar di sease, Raynaud's
di sease or phenomenon, di gi tal vascul i ti s, i mpai red
ci rcul ati on (e.g., di abetes, scl eroderma)
P.213
PROCEDURE
Cross secti on of the di gi t reveal s the nerves traversi ng l ateral l y on
each si de of the di gi t. One nerve appears to be pl antar or pal mar,
and one i s more dorsal .
Page 355
(1) Cross secti on of a di gi t showi ng the nerves traversi ng l ateral l y
on each si de of the di gi t.
One method of di gi tal bl ock i nserts the needl e l ateral l y i nto the
base (proxi mal porti on) of the di gi t, 1 cm di stal to the web space
(Fi gure 2A). Insert the needl e to the bone, and i nfuse anestheti c.
Angl e the needl e vol arl y and dorsal l y (Fi gure 2B). Repeat thi s
techni que on the opposi te si de.
(2) One techni que of di gi tal bl ock. Insert the needl e l ateral l y i nto
the base of the di gi t, 1 cm di stal to the web space, and i nject the
anestheti c. Angl e the needl e vol arl y and dorsal l y, and repeat the
techni que on the opposi te si de.
P.214
An al ternate techni que i nserts the needl e near the juncti on of the
Page 356
dorsal and l ateral surfaces of the di gi t. Sl i de the needl e al ong the
l ateral surface, i njecti ng as the needl e ti p i s wi thdrawn back to the
i nserti on si te (Fi gure 3A). Wi thout pul l i ng the needl e ti p out of the
ski n, redi rect the needl e ti p al ong the dorsum of the di gi t and
agai n admi ni ster the anestheti c as the needl e i s wi thdrawn (Fi gure
3B). Insert the needl e near the juncti on of the vol ar and l ateral
surfaces of the di gi t. Admi ni ster the anestheti c al ong the opposi te
si des of the di gi t (Fi gure 3C).
(3) Al ternati ve techni que. Insert the needl e near the juncti on of
the dorsal and l ateral surfaces of the di gi t, i njecti ng anestheti c as
the needl e ti p i s wi thdrawn al ong the l ateral surface back to the
i nserti on si te. Then redi rect the needl e ti p al ong the dorsum of
di gi t, and admi ni ster anestheti c as the needl e i s wi thdrawn.
Page 357
Repeat thi s techni que for the vol ar and l ateral surfaces of the
di gi t.
P.215
CODING INFORMATION
No Current Procedural Termi nol ogy (CPT) code exi sts for di gi tal
nerve bl ock. The servi ce i s i ncl uded i n the reporti ng for the
procedure for whi ch i t i s performed (e.g., l acerati on repai r, bi opsy
servi ce).
Syri nges (3 or 5 mL), 2% l i docai ne wi thout epi nephri ne, and 25- or
27-gauge, 1-i nch needl es can be obtai ned from l ocal surgi cal
suppl y houses or pharmaci es. A suggested anesthesi a tray that can
be used for thi s procedure i s l i sted i n Appendi x G. Ski n preparati on
BIBLIOGRAPHY
Avi na R. Pri mary care l ocal and regi onal anesthesi a i n the
management of trauma. Cl i n Fam Pract 2000;2:533550.
Bartfi el d JM, Ford DT, Homer PJ. Buffered versus pl ai n l i docai ne for
di gi tal nerve bl ocks. Ann Emerg Med 1993;22:216219.
& Hal l , 1997:5262.
1994:102112.
Greki n RC, Aul etta MJ. Local anesthesi a i n dermatol ogi c surgery. J
Am Acad Dermatol 1988; 19:599614.
Knoop K, Trott A, Syverud S. Compari son of di gi tal versus
metacarpal bl ocks for repai r of fi nger i njuri es. Ann Emerg Med
1994;23:12961300.
Randl e D, Dri scol l CE. Admi ni steri ng l ocal anesthesi a. In: Dri scol l
CE, Rakel RE, eds. Pati ent care procedures for your practi ce, 2nd
ed. Los Angel es: Practi ce Management Informati on Corporati on,
Page 358
1991:269282.
Usati ne RP, Moy RL. Anesthesi a. In: Usati ne RP, Moy RL, Tobi ni ck
EL, Si egel DM, eds. Ski n surgery: a practi cal gui de. St. Loui s:
Mosby, 1998:2030.
Val vano MN, Leffl er S. Compari son of bupi vacai ne and
l i docai ne/bupi vacai ne for l ocal anesthesi a/di gi tal nerve bl ock. Ann
Emerg Med 1996;27:490492.
Wal dbi l l i g DK. Randomi zed doubl e-bl i nd control l ed tri al compari ng
room-temperature and heated l i docai ne for di gi tal nerve bl ock. Ann
Emerg Med 1995;26:677681.
Wardrope J, Smi th JAR. The management of wounds and burns.
Oxford, UK: Oxford Uni versi ty Press, 1992:5052.
Oncol 1988;14:4154.
Woodsi de JR. Local and regi onal anesthesi a of the upper extremi ty.
In: Rakel RE, ed. Saunders manual of medi cal practi ce.
Zuber TJ. Di gi tal nerve bl ock. In: Advanced soft-ti ssue surgery. The
AAFP i l l ustrated manual s and vi deotapes of soft-ti ssue surgery
techni ques. Kansas Ci ty: Ameri can Academy of Fami l y Practi ce,
1998:3438.
Page 359
> Table of Cont ent s > Nail Procedures > 30 - Ingrown Nail Surgery30
Ingrown Nail Surgery
Ingrown nai l s, or onychocryptosi s, i s a common probl em
encountered i n pri mary care practi ce. Indi vi dual s wi th i ngrown nai l s
often present i n the second or thi rd decades of l i fe wi th pai n,
drai nage, and di ffi cul ty wal ki ng. Many causes have been associ ated
wi th the devel opment of i ngrown nai l s (Tabl e 30-1). Al l of these
causes al ter the normal fi t of the nai l pl ate i n the l ateral groove,
resul ti ng i n a forei gn body reacti on that produces edema, i nfecti on,
and granul ati on ti ssue. Many i ngrown nai l s exhi bi t a l ateral l y
poi nti ng spi cul e of nai l that di gs i nto the l ateral ti ssue.
TABLE 30-1. CAUSES OF INGROWN NAILS

Improperl y tri mmed nai l s or torn di stal nai l s
Hyperhi drosi s
Excessi ve external pressure from i mproperl y fi tti ng footwear or poor stance and gai t
Trauma to the nai l uni t
Subungual neopl asms or skel etal abnormal i ti es
Di abetes mel l i tus
Obesi ty
Nai l changes of the el derl y, i ncl udi ng onychogryphosi s and onychomycosi s

Three stages have been descri bed for the progressi on of i ngrown
nai l s. In stage I, the l ateral nai l fol d exhi bi ts erythema, mi l d
edema, and pai n when pressure i s appl i ed. In stage II, i ndi vi dual s
experi ence i ncreased symptoms, drai nage, and i nfecti on. Stage III
i s characteri zed by magni fi ed symptoms, the presence of
granul ati on ti ssue i n the l ateral nai l fol d, and l ateral wal l
hypertrophy.
Many management opti ons have been proposed for i ngrown nai l s.
Page 360
Soaks, topi cal or systemi c anti bi oti cs, and cotton wi ck i nserti on i n
the l ateral nai l groove have al l been used for grade I di sease.
Surgi cal i nterventi on i s advocated for grade II and more often for
grade III di sease. Hi stori cal l y, si mpl e nai l avul si on or wedge
resecti on of the di stal corner of the nai l has been performed.
Because i ngrown nai l s represent an abnormal l ateral nai l groove,
removal of more than the l ateral one fourth of the nai l i s
unnecessary. Hi gh recurrence rates are associ ated wi th these
si mpl e nai l exci si on procedures.
Matri cectomy of the l ateral nai l matri x i s requi red to permanentl y
abl ate l ateral nai l -formi ng ti ssue and to create a new l ateral nai l
fol d. Many physi ci ans prefer to perform chemi cal matri cectomy wi th
sodi um hydroxi de or more commonl y
P.217
wi th phenol . Phenol produces adequate nai l bed abl ati on, but i t i s
associ ated wi th a pungent odor, l ateral nai l fol d damage, excessi ve
wound di scharge, and i nfecti on. El ectrosurgi cal abl ati on of the nai l
bed i s a hi ghl y successful al ternati ve that produces l ess di scharge.
Speci al matri cectomy el ectrodes wi th one coated si de can be used
to avoi d i njury to the overl yi ng normal ti ssue of the proxi mal nai l
fol d (i .e., cuti cl e) whi l e abl ati ng the nai l bed. Laser matri cectomy
i s another opti on, but i t i s l ess attracti ve because of the hi gh
capi tal and upkeep costs for most pri mary care practi ces.
The granul ati on ti ssue produced by the forei gn body reacti on can
produce l ateral wal l hypertrophy. Because thi s ti ssue i s abnormal ,
many physi ci ans advocate removal at the ti me of nai l surgery.
Removal of l ateral wal l hypertrophy can be accompl i shed wi th
scal pel exci si on or wi th el ectrosurgi cal exci si on or abl ati on. Ti ssue
removal can produce a scooped-out defect i n the l ateral ti ssue at
the ti me of surgery. Thi s defect fi l l s i n over several weeks as the
remai ni ng normal l ateral ti ssue grows to the newl y formed l ateral
nai l edge.
INDICATIONS
Ingrown nai l , grade II or grade III
Page 361
Di abetes mel l i tus
Peri pheral vascul ar di sease, especi al l y i f di gi tal
i schemi a exi sts
Coagul opathy or bl eedi ng di athesi s
P.218
PROCEDURE
Noti ce the l ateral wal l hypertrophy wi th pus-fi l l ed drai nage.
(1) An i ngrown nai l .
After di gi tal bl ock, some physi ci ans prefer to pl ace a tourni quet to
l i mi t bl eedi ng duri ng the procedure. A rubber band can be pl aced
around the di gi t (toe) and hel d wi th a hemostat.
Page 362
(2) A tourni quet can be appl i ed to l i mi t bl eedi ng duri ng the
procedure.
PITFALL: Avoid pulling the rubber band too tightly and damaging
the tissues. Limit the amount of time that the tourniquet is
placed. It is advisable to withdraw the tourniquet after 10
minutes of application to limit vascular injury from interrupted
blood flow to the digit.
P.219
Free the l ateral nai l pl ate from the overl yi ng proxi mal nai l fol d
(i .e., cuti cl e.) A Freer septum el evator can be used to l i ft the
cuti cl e off the nai l pl ate.
(3) Li ft the cuti cl e off the nai l pl ate usi ng a Freer septum el evator.
Remove the l ateral one fi fth to one fourth of the nai l . Cut the nai l
Page 363
wi th nai l spl i tters or bandage sci ssors, pl aci ng the thi n bl ade
beneath the di stal (free) edge of the nai l (Fi gure 4A). Cut the nai l
strai ght back beneath the proxi mal nai l fol d (Fi gure 4B). As the
proxi mal edge of nai l i s cut, a gi ve i s fel t by the operator.
Grasp the l ateral nai l wi th strai ght hemostats, and l i ft the nai l out
usi ng a twi sti ng moti on that pul l s outward and l ateral l y (Fi gure
4C). After the nai l has been removed, exami ne the l ateral sul cus
beneath the proxi mal nai l fol d to ensure no pi eces of nai l remai n
wi thi n the corner (Fi gure 4D).
(4) Remove the l ateral one fi fth to one fourth of the nai l .
PITFALL: Grasp as much of the lateral nail in the hemostats
before attempting withdrawal. If just the end of the nail plate is
grasped, the nail frequently breaks on removal.
PITFALL: Avoid damaging the nail bed when cutting the nail
plate. If the scissors are used, the blade placed beneath the nail
plate can traumatize the nail bed. Advance the scissors by
cutting just with the tips of the scissors, and angle the tips of
the scissors upward away from the nail bed.
P.220
Matri cectomy can be performed chemi cal l y or el ectrosurgi cal l y, as
demonstrated here. Pl ace the el ectrode over the l ateral nai l bed
wi th the Tefl on-coated porti on upward (Fi gure 5A). Acti vate the
el ectrode for 3 to 10 seconds, gentl y bounci ng the el ectrode
agai nst the nai l bed to produce abl ati on of the ti ssue. Make sure
Page 364
the l ateral horn of the matri x i s abl ated by movi ng the el ectrode
l ateral l y beneath the proxi mal nai l fol d (Fi gure 5B). A properl y
treated nai l bed appears whi te after thermal abl ati on.
(5) Perform a matri cectomy.
PITFALL: Avoid prolonged activation of the electrode against the
nail bed. Prolonged burning can damage the deep tissues (i.e.,
extensor tendon insertion beneath the nail bed) and cause
excessive time (months) to healing.
PITFALL: If the lateral horn of the matrix is not destroyed, a
new spicule of nail will grow into the new lateral nail fold, with
recurrence of symptoms in the months after the procedure.
The hypertrophi ed l ateral ti ssue can be cut away or abl ated wi th
the el ectrode and scraped away wi th gauze (Fi gure 6A). After the
ti ssue i s removed, normal ti ssue remai ns. A l arge, scooped-out
defect (Fi gure 6B) wi l l rapi dl y fi l l i n over the next few weeks. Pl ace
anti bi oti c oi ntment i n the wound, and tape a bul ky gauze dressi ng
over the si te. Di sposabl e surgi cal sl i ppers can be worn by the
pati ent on l eavi ng the offi ce.
Page 365
(6) Remove the hypertrophi ed l ateral ti ssue.
P.221
CODING INFORMATION
Code 11750 i s most commonl y reported when parti al avul si on and
matri cectomy are performed for permanent nai l removal . Al though
si mpl e avul si on wi thout matri cectomy i s not advocated, some
practi ti oners conti nue to perform the techni que and shoul d report
11730 or 11730 and 11732.

CPT Code Description 2002 Average 50th Percentile Fee

11730* Avul si on of a si ngl e nai l pl ate, parti al or
compl ete, si mpl e
$120
11732 Avul si on of each addi ti onal nai l pl ate $75
11750 Exci si on of nai l and nai l matri x, parti al or
compl ete
$345
11765 Wedge exci si on of ski n of nai l fol d $189

CPT i s a trademark of the Ameri can
Medi cal Associ ati on.
The Freer septum el evator, bandage sci ssors or nai l spl i tters, and
hemostats are avai l abl e from surgi cal suppl y stores or i nstrument
deal ers. Di sposabl e surgi cal sl i ppers are avai l abl e from surgi cal
suppl y houses. Matri cectomy el ectrodes and el ectrosurgi cal
equi pment are avai l abl e from El l man Internati onal , Hewl ett, NY
(phone: 800-835-5355; http://www.el l man.com). A suggested
Appendi x G.
BIBLIOGRAPHY
Appenhei mer AT. Treatment of i ngrown toenai l . Pati ent Care
1987;21:119125.
Brown JS. Mi nor surgery: a text and atl as. London: Chapman & Hal l ,
Page 366
1997:224235.
Cei l l ey RI, Col l i son DW. Matri cectomy. J Dermatol Surg Oncol
1992;18:728734.
Cl ark RE, Madani S, Bettencourt MS. Nai l surgery. Dermatol Cl i n
1998;16:145164.
Cl ark RE, Tope WD. Nai l surgery. In: Wheel and RG, ed. Cutaneous
surgery. Phi l adel phi a: WB Saunders, 1994:375402.
Dani el CR 3rd. Basi c nai l pl ate avul si on. J Dermatol Surg Oncol
1992;18:685688.
Gi l l ette RD. Practi cal management of i ngrown toenai l s. Postgrad
Med 1988;84:145146, 151153, 156158.
Hetti nger DF, Val i nsky MS, Nucci o G, et al . Nai l matri xectomi es
usi ng radi o wave techni que. J Am Podi atr Med Assoc
1991;81:317321.
Leahy AL, Ti mon CI, Crai g A, et al . Ingrowi ng toenai l s: i mprovi ng
treatment. Surgery 1990;107:566567.
Onumah N, Scher RK. Nai l surgery. Emedi ci ne September 18, 2002.
Avai l abl e at http://www.emedi ci ne.com/derm/topi c818.htm
Qui l l G, Myerson M. A gui de to offi ce treatment of i ngrown
toenai l s. Hosp Med 1994; 30: 5154.
Zuber TJ, Pfenni nger JL. Management of i ngrown toenai l s. Am Fam
Physi ci an 1995;52: 181188.
Zuber TJ. Ingrown toenai l removal . Am Fam Physi ci an
2002;65:25472550, 25512552, 2554, 25572558.
Zuber TJ. Offi ce procedures. The AAFP col l ecti on of qui ck reference
gui des for fami l y physi ci ans. Kansas Ci ty: Ameri can Academy of
Fami l y Physi ci ans, 1998:123130.
Page 367
> Table of Cont ent s > Nail Procedures > 31 - Subungual Hemat oma Drainage31
Subungual Hematoma Drainage
The traumati c accumul ati on of bl ood beneath the nai l pl ate can
create an excruci ati ngl y pai nful i njury. The often pul sati l e pai n i s
caused by i ncreased pressure from the bl ood wi thi n a cl osed space
adjacent to the sensi ti ve nai l bed and matri x. Subungual
hematomas frequentl y mani fest wi th a bl ue-bl ack di scol orati on that
can extend beneath part or al l of the nai l surface. The pai n of a
subungual hematoma can be dramati cal l y and i nstantaneousl y
rel i eved after evacuati on.
Trephi nati on provi des a si mpl e techni que to evacuate hematomas.
Vari ous techni ques have been advocated, i ncl udi ng the use of
heated paper cl i ps, scal pel bl ades, dental burrs, and cautery uni ts.
Because the nai l pl ate has no sensati on, anesthesi a general l y i s
not requi red. Care shoul d be exerted wi th any trephi nati on
i nstrument, because downward pressure i ncreases pai n. The use of
a hot-ti pped cautery uni t i s advocated because i t burns a hol e
through nai l pl ate wi thout the need for much downward pressure or
mi ni ng. The exami ner must be prepared to l i ft up i mmedi atel y on
passage through the nai l pl ate to avoi d i njury to the sensi ti ve nai l
bed.
Over ti me, the ti ssues surroundi ng the hematoma stretch, and the
pai n subsi des. There appears to be l i ttl e pai n rel i ef obtai ned from
drai ni ng a hematoma after about 48 to 72 hours fol l owi ng the
i ni ti al i njury. The di scol orati on of a subungual hematoma wi l l grow
out wi th the nai l and be repl aced wi th normal -appeari ng ti ssues.
Up to 25% of al l subungual hematomas are associ ated wi th a
fracture of the di stal phal anx. The si ze of the subungual hematoma
does not correl ate wi th the presence of a fracture, and some
physi ci ans advocate routi ne x-ray exami nati on. If fracture i s
i denti fi ed, 60% of those nai l s have a l acerati on l arge enough to
Page 368
warrant cl osure wi th a smal l , absorbabl e suture. The major
i ncenti ve to nai l bed expl orati on and l acerati on repai r i s to prevent
permanent nai l dystrophy or deformi ty from a step-off or separated
l acerati on.
Appropri ate management of a subungual hematoma seeks to
provi de pai n rel i ef, recogni zes associ ated i njuri es, and promotes
regrowth of a functi onal l y normal and cosmeti cal l y acceptabl e nai l .
Hi stori cal l y, i t was recommended that hematomas i nvol vi ng more
than 25% to 50% of the nai l surface be expl ored. Nai l pl ate
removal and nai l bed expl orati on was advocated to opti mi ze the
cosmeti c outcome. The routi ne practi ce of nai l bed expl orati on has
been questi oned by several
P.223
studi es; i t appears that the practi ce i s justi fi ed onl y when a
l acerati on i s through the nai l pl ate or through ei ther of the l ateral
nai l fol ds. If no l acerati on i s detected, i t i s probabl y safe to
evacuate the hematoma, al though 1 i n 12 sti l l may experi ence
resi dual nai l change.
INDICATIONS
Severe pai n after acute traumati c i njury, wi th hematoma
i nvol vi ng >20% of nai l bed area.
Pati ent i s no l onger experi enci ng pai n at rest (after 48
to 72 hours).
Subungual ecchymosi s (pai n resol ves after 30 mi nutes;
onl y mi l d bl eedi ng occurs)
Bl ood col l ecti on wi thout trauma (tumors such as gl omus
tumors, keratoacanthomas, and Kaposi 's sarcoma may
mani fest i ni ti al l y as a subungual hematoma)
Subungual band of pi gmentati on (most l i kel y represents
nontraumati c beni gn or mal i gnant pi gmentati on)
P.224
Page 369
PROCEDURE
Evacuati on of the hematoma. Hol d the fi ne-ti pped cautery verti cal l y
over the center of the hematoma (Fi gure 1A). Acti vate the cautery,
and burn through the nai l pl ate. As the nai l pl ate i s traversed,
bl ood may spurt upward as the pressure i s rel eased (Fi gure 1B). As
soon as the subungual space i s entered, the operator must be
prepared to pul l up and not al l ow the hot ti p to touch down on the
hi ghl y sensi ti ve nai l bed (Fi gure 1C).
(1) Hol di ng a fi ne-ti pped cautery verti cal l y over the center of the
hematoma, burn through the nai l pl ate unti l the subungual space i s
reached.
Al ternatel y, a heated paper cl i p can al so accompl i sh the
evacuati on. The metal paper cl i p i s strai ghtened and grasped wi th a
hemostat for heati ng and nai l pl ate dri l l i ng.
Page 370
(2) Use of a heated paper cl i p for evacuati on.
PITFALL: Avoid heating coated paper clips, which can produce a
malodorous plume and burns from the molten coating. Avoid
copper paper clips, which can melt.
P.225
If the nai l i s torn or i f there i s a l acerati on through the l ateral nai l
fol d, the nai l pl ate can be removed and the nai l bed expl ored
(Fi gure 3A). Often, the nai l matri x remai ns attached, whereas the
di stal nai l may be separated from the nai l bed. The di stal nai l can
be cut free, and the l acerati on i n the nai l bed repai red wi th a fi ne
(6-0) absorbabl e (pol ygl ycan, Vi cryl ) suture.
Page 371
(3) If the nai l i s torn or i f there i s a l acerati on through the l ateral
nai l fol d, the nai l pl ate can be removed and the nai l bed expl ored.
P.226
CODING INFORMATION
When evacuati on of a hematoma i s performed, onl y code 11740
usual l y i s reported.

CPT Code Description
2002 Average 50th
Percentile Fee

11740 Evacuati on of subungual
hematoma
$87
11730 Avul si on of nai l pl ate, parti al
or compl ete, si mpl e, si ngl e
$120
11760 Repai r of nai l bed $375

Fi ne-ti pped battery cautery uni ts are avai l abl e from Aaron Medi cal
(hi gh-temperature cautery AA01, order at
http://www.hospi tal network.com) or from Advanced Medi tech
Internati onal (phone: 800-635-2452; thermal cautery CH-HI, about
$35 each, order at http://www.amedi tech.com). A suggested
Appendi x G.
BIBLIOGRAPHY
Aronson S. Evacuati on of a subungual hematoma. Hosp Med
1995;31:4748.
Baran R, Haneke E. Surgery of the nai l . In: Epstei n E, Epstei n E Jr,
eds. Ski n surgery, 6th ed. Phi l adel phi a: WB Saunders,
1987:534547.
Page 372
& Hal l , 1997:327328.
Buttaravol i P, Stai r T. Mi nor emergenci es: spl i nters to fractures. St.
Loui s: Mosby, 2000;413415.
1998;16:145164.
Dri scol l CE. Drai nage of a subungual hematoma. Pati ent Care
1991;25:113114.
Fi eg EL. Management of nai l bed l acerati ons [Letter]. Am Fam
Physi ci an 2002;65:1997B-1998.
Hel ms A, Brodel l RT. Surgi cal pearl s: prompt treatment of
subungual hematoma by decompressi on. J Am Acad Dermatol
2000;42:508509.
Roser SE, Gel l man H. Compari son of nai l bed repai r versus nai l
trephi nati on for subungual hematomas i n chi l dren. J Hand Surg Am
1999;24:11661170.
1998:7681.
Page 373
> Table of Cont ent s > Nail Procedures > 32 - Nail Bed Biopsy32
Nail Bed Biopsy
A nai l or nai l bed bi opsy i s a di rect means to di agnosi s when
routi ne cl i ni cal and l aboratory methods fai l to di sti ngui sh nai l
condi ti ons. Nai l bed bi opsy can prevent mi sdi agnosi s or del ay i n
the di agnosi s of potenti al l y seri ous or di sfi guri ng condi ti ons such
as subungual tumors. Occasi onal l y, a bi opsy can be therapeuti c.
Nai l bi opsy can provi de rapi d i nformati on that can gui de therapy for
i nfl ammatory and i nfecti ous nai l di sorders, and i t may prevent the
unnecessary use of potenti al l y hazardous, empi ri cal l y appl i ed
medi cati ons.
Nai l bed bi opsy i s easi l y performed i n an offi ce setti ng. The
techni que uses ski l l s si mi l ar to those i ncorporated i n ski n bi opsy of
other si tes. Despi te good safety for the procedure, the potenti al for
pati ent di scomfort and permanent nai l dystrophy di scourages many
provi ders from performi ng the techni que. Proper pati ent sel ecti on
and educati on i s i mportant to a successful outcome. Pati ents
shoul d be i nformed about the sl ow heal i ng after a nai l bed bi opsy.
Mean fi ngernai l growth i s 3 mm per month, and mean toenai l
growth i s 1 mm per month.
A correct understandi ng of nai l anatomy and physi ol ogy i s
i mportant to a successful outcome. Some gui di ng pri nci pl es for the
performance of nai l bed bi opsy are l i sted i n Tabl e 32-1. The nai l
bed provi des adherence of the nai l pl ate, and bi opsi es of the nai l
bed usual l y heal wi thout si gni fi cant scarri ng. A 2- or 3-mm punch
bi opsy through the nai l pl ate can provi de accurate i nformati on
about the nai l bed. The nai l matri x i s the nai l -formi ng ti ssue, and
bi opsi es of the nai l matri x can produce permanent dystrophy.
Certai n condi ti ons are best di agnosed from a nai l matri x bi opsy,
i ncl udi ng unexpl ai ned l ongi tudi nal mel anonychi a, nai l dystrophy
i nvol vi ng the enti re nai l pl ate, and tumors of the nai l matri x.
Page 374
TABLE 32-1. PRINCIPLES GUIDING NAIL BED BIOPSY

When the i nformati on can be obtai ned from another si te, avoi d bi opsy of the nai l
matri x.
Avoi d transecti ng the nai l matri x to prevent a spl i t nai l deformi ty.
Suture defects i n the matri x when possi bl e.
When possi bl e, perform a di stal rather than proxi mal matri x bi opsy.
Retai n the di stal curvature of the nai l matri x.

Adapted from Ri ch P. J Dermatol Surg Oncol 1992;18:673682.
P.228
When bi opsyi ng nai l matri x, avoi d transecti ng the matri x to prevent
formati on of a spl i t nai l deformi ty. The curvature of the l unul a
shoul d be mai ntai ned, because thi s curvature i s i mportant to the
proper contour of the nai l . The superi or surface of the nai l pl ate i s
formed i n the proxi mal matri x, and the undersi de of the nai l i s
formed i n the di stal matri x. Bi opsy shoul d be performed i n the
di stal matri x whenever possi bl e. The thi ckness of the nai l i s
determi ned by the l ength of the matri x. Ti ssue l oss i n the matri x
can produce permanent, focal thi nni ng of the nai l pl ate.
INDICATIONS
Di agnosi s and removal of subungual tumors: warts,
gl omus tumors, enchondromas, fi bromas, and squamous
cel l carci nomas (consi der a radi ograph to assess bony
i nvol vement by the mass)
Di agnosi s or excl usi on of acral l enti gi nous mel anoma i n
a pati ent wi th l ongi tudi nal mel anonychi a
Identi fi cati on of an i nfl ammatory nai l condi ti on (e.g.,
l i chen pl anus, psori asi s)
Al l evi ati on of a pai nful nai l condi ti on (e.g., gl omus
Page 375
tumor pai n)
Hi stol ogi c i denti fi cati on of an undi agnosed nai l condi ti on
Presence of di abetes, peri pheral vascul ar di sease, or
acti ve connecti ve ti ssue di sease
P.229
PROCEDURE
Anatomy of the nai l i s depi cted.
(1) Anatomy of the nai l .
After a di gi tal bl ock, a 3-mm punch bi opsy of the nai l bed can be
obtai ned. The techni que of nai l bed bi opsy can be performed wi th
or wi thout nai l pl ate avul si on. The punch i nstrument i s passed
verti cal l y down to the peri osteum, and the speci men i s cut free
wi th i ri s sci ssors. Monsel 's sol uti on can be used for hemostasi s,
and the si te heal s by secondary i ntenti on.
Page 376
(2) After a di gi tal bl ock, a 3-mm punch bi opsy speci men i s obtai ned
from the nai l bed.
P.230
The doubl e-punch techni que for nai l bed bi opsy. A 5- or 6-mm
punch i s used to remove nai l pl ate (Fi gure 3A). A 3-mm punch i s
then used i n the center of the previ ousl y created wi ndow i n the nai l
pl ate to obtai n a speci men of the nai l bed (Fi gure 3B).
(3) The doubl e-punch techni que for nai l bed bi opsy.
PITFALL: Do not damage the nail bed when using the larger
punch to remove nail plate. Proceed slowly and carefully until
the instrument just passes through the nail plate.
P.231
Page 377
After a di gi tal bl ock, the proxi mal nai l fol d i s separated from the
nai l pl ate usi ng a Freer septum el evator (Fi gure 4A). Lateral
i nci si ons i n the proxi mal nai l fol d (5 mm toward the di stal
i nterphal angeal joi nt) al l ow for the fol d to be refl ected (Fi gure 4B).
The nai l pl ate i s gentl y separated from underl yi ng ti ssues, and the
pl ate i s pl aced on the surgery tray (Fi gure 4C). A smal l , el l i pti cal
i nci si on i s created i n the di stal matri x, fol l owi ng the curvature of
the l unul a (Fi gure 4D). The defect i s cl osed wi th i nterrupted 6-0
absorbabl e (pol ygl ycan or Vi cryl ) suture. The nai l pl ate must be
reposi ti oned beneath the proxi mal nai l fol d to prevent permanent
dystrophy from scarri ng of the proxi mal nai l fol d onto the
underl yi ng matri x. A 5-0 nyl on suture can be used to cl ose the
i nci si ons i n the proxi mal nai l fol d (Fi gure 4E). Some practi ti oners
prefer to anchor the nai l pl ate by suturi ng i t to l ateral ti ssues.
(4) Nai l matri x bi opsy.
PITFALL: The nail plate may be unintentionally discarded during
Page 378
the procedure. Other materials, such as petroleum-impregnated
gauze or nonadherent or plastic dressings, can be used to
separate the proximal nail fold from the nail matrix for 1 to 2
weeks after the procedure.
P.232
CODING INFORMATION

2002 Average 50th
Percentile Fee

11755 Bi opsy of nai l uni t (nai l
pl ate, bed, or fol ds)
$296

Di sposabl e punch bi opsy i nstruments and suture materi al can be
obtai ned from surgi cal suppl y houses or from dermatol ogy suppl i ers
such as Del asco (http://www.del asco.com). The Freer septum
el evator i s avai l abl e from sel l ers of surgi cal i nstruments.
Appendi x A descri bes the i nstruments on a standard offi ce surgery
tray that can be used for nai l bi opsy. A suggested anesthesi a tray
that can be used for thi s procedure i s l i sted i n Appendi x G. Ski n
BIBLIOGRAPHY
Baran R, Haneke E. Surgery of the nai l . In: Epstei n E, Epstei n E Jr,
eds. Ski n surgery, 6th ed. Phi l adel phi a: WB Saunders,
1987:534547.
1998;16:145164.
Page 379
Cl ark RE, Tope WE. Nai l surgery. In: Wheel and RG, ed. Cutaneous
surgery. Phi l adel phi a: WB Saunders, 1994:375-402.
De Berker DA, Dahl MG, Comai sh JS, et al . Nai l surgery: an
assessment of i ndi cati ons and outcome. Acta Verereol (Stockh)
1996;76:484487.
Grammer-West NY, Corvette DM, Gi andoni MB. Cl i ni cal pearl : nai l
pl ate bi opsy for the di agnosi s of psori ati c nai l s. J Am Acad
Dermatol 1998;38:260262.
Haneke E, Baran R. Nai l s: surgi cal aspects. In: Pari sh LC, Lask GP,
eds. Aestheti c dermatol ogy. New York: McGraw-Hi l l ,
1991:236247.
Ri ch P. Nai l bi opsy i ndi cati ons and methods. J Dermatol Surg Oncol
1992;18:673682.
Ri ch P. Nai l bi opsy: i ndi cati ons and methods. Dermatol Surg
2001;27:229234.
Si egl e RJ, Swanson NA. Nai l surgery: a revi ew. J Dermatol Surg
Oncol 1982;8:659666.
Tosti A, Pi racci ni BM. Treatment of common nai l di sorders. Dermatol
Cl i n 2000;18:339348.
Van Laborde S, Scher RK. Devel opments i n the treatment of nai l
psori asi s, mel anonychi a stri ata, and onychomycosi s. Dermatol Cl i n
2000;18:3746.
1998:7075.
Page 380
> Table of Cont ent s > Nail Procedures > 33 - Paronychia Surgery33
Paronychia Surgery
A paronychi a i s a superfi ci al i nfecti on or abscess of the ti ssues
borderi ng the nai l s (i .e., nai l fol ds). The i nfecti ons devel op when a
di srupti on occurs between the seal of the proxi mal nai l fol d and the
nai l pl ate. Excessi ve contact wi th moi sture or chroni c i rri tants may
predi spose an i ndi vi dual to the devel opment of a paronychi a.
Trauma such as nai l bi ti ng, mani cure, or hangnai l removal may al so
predi spose to a paronychi a.
Acute paronychi a mani fests wi th rapi d devel opment of erythema
and swel l i ng i n the proxi mal or l ateral nai l fol d. Infecti on wi th
Staphyl ococcus aureus, streptococci , or Pseudomonas speci es i s
most common. Acute paronychi a may fol l ow a mani cure or
pl acement of scul ptured nai l s, and i t often produces tenderness and
throbbi ng pai n. Mi l d cases can be soaked i n warm water or treated
wi th topi cal or oral anti bi oti cs (i .e., amoxi ci l l i n and cl avul ani c aci d
or cl i ndamyci n to cover oral anaerobes).
Chroni c paronychi a must have been present for at l east 6 weeks.
These l esi ons often devel op sl owl y and i nsi di ousl y, and they may
be associ ated wi th l ow-grade i nfecti ons wi th Candi da al bi cans.
Chroni c paronychi a are common i n bakers, bartenders, di shwashers,
or thumbsuckers who expose thei r hands to repeated or prol onged
moi sture and i rri tati on. Women i n the mi ddl e reproducti ve years are
most commonl y affected, wi th some seri es reporti ng
femal e-to-mal e rati os of 10:1. Secondary nai l pl ate changes may be
found, i ncl udi ng onychol ysi s (i .e., separati on), l ateral greeni sh
brown di scol orati on, and transverse ri dgi ng.
El i mi nati on of the offendi ng acti vi ti es or agents and treatment wi th
anti fungal agents and topi cal or oral corti costeroi ds are advocated.
Al though medi cal therapy i s the mai nstay of treatment for
paronychi a, surgi cal therapy provi des benefi t for nonresponders.
Page 381
Advanced cases of acute paronychi a shoul d be i nci sed and drai ned.
Advanced cases of chroni c paronychi a resul t i n di sappearance of the
cuti cl e wi th retracti on of the proxi mal nai l fol d from the underl yi ng
nai l pl ate. Chroni c paronychi a can be treated wi th an eponychi al
exci si on techni que or by nai l removal . Al most al l of the surgi cal
procedures have medi cati ons i ncl uded i n the therapeuti c approach.
P.234
INDICATIONS
Abscess formati on or severe pai n i n acute paronychi a
Lack of response to medi cal therapy and avoi dance of
moi sture and i rri tati on
Deformi ty (i .e., l oss of the proxi mal nai l fol d) i n chroni c
paronychi a
Unfami l i ari ty of the practi ti oner wi th the techni ques
Bl eedi ng di athesi s or coagul opathy
Chroni c paronychi a surgery i n an unrel i abl e pati ent or
person unabl e to provi de wound care
P.235
PROCEDURE
A di gi tal bl ock i s commonl y performed (see Chapter 29) before
surgery, al though some practi ti oners prefer no anesthesi a or a
paronychi a bl ock when treati ng acute paronychi a. The paronychi a
bl ock uses a smal l (27- to 30-gauge) needl e i nserted from the
l ateral si de near the di stal i nterphal angeal joi nt, proxi mal to the
paronychi a. Admi ni ster between 1 and 3 mL of 1% l i docai ne at thi s
si te.
Page 382
(1) Paronychi a bl ock. Between 1 and 3 mL of 1% l i docai ne i s
i njected through a smal l -gauge needl e i nto the l ateral si de near
the di stal i nterphal angeal joi nt, proxi mal to the paronychi a.
P.236
Swel l i ng of the proxi mal and l ateral nai l fol d i s associ ated wi th thi s
abscess of an acute paronychi a (Fi gure 2A). A no. 15 scal pel bl ade
i s l ai d fl at on top of the nai l pl ate, wi th the ti p of the bl ade
di rected to the center of the abscess or fl uctuance (Fi gure 2B).
Al ternatel y, a no. 11 bl ade can be used, especi al l y i f addi ti onal
depth of i nserti on i s needed. The bl ade i s gui ded gentl y al ong the
nai l surface under the nai l fol d, and then the ti p i s el evated,
pul l i ng the nai l fol d upward (Fi gure 2C). The nai l pl ate acts as a
ful crum; pushi ng down on the back of the bl ade (or bl ade handl e)
causes the ti p to el evate. A l arge amount of pus may drai n on top
of the nai l pl ate (Fi gure 2D). Pus can be squeezed from beneath
the nai l and through the smal l openi ng. Thi s techni que has the
advantage of the absence of a ski n i nci si on.
Page 383
(2) El evati on of the nai l fol d al l ows drai nage of an abscess
associ ated wi th an acute paronychi a.
PITFALL: Failure to elevate the tissue sufficiently may permit
pus to remain in the site. Because the opening over the nail
plate is small and does not involve an incision, the site can reseal
and the abscess redevelop. Several sites along the nail fold may
require elevation to ensure adequate drainage, and the patient
should be reexamined in 2 days to check for reformation of the
paronychia.
An al ternate techni que produces an i nci si on through the nai l fol d,
wi th drai nage through the ski n.
(3) An al ternati ve techni que i s i nci si on through the nai l fol d,
al l owi ng drai nage through the ski n.
P.237
Page 384
Chroni c paronychi a can be treated wi th exci si on of the proxi mal nai l
fol d. After a di gi tal bl ock, a Freer septum el evator i s used to
separate the proxi mal nai l fol d from the nai l pl ate (Fi gure 4A). The
fl at el evator i s then posi ti oned beneath the proxi mal nai l fol d to
protect underl yi ng ti ssues duri ng the exci si on. A crescent-shaped,
ful l -thi ckness i nci si on i s made i n the proxi mal nai l fol d (Fi gure 4B).
The i nci si on extends from one l ateral nai l fol d to the other. The
i sl and of ski n to be removed i s 5 mm wi de (Fi gure 4C), i ncorporates
the enti re swol l en porti on of the proxi mal nai l fol d, and extends to
just proxi mal to the proxi mal nai l pl ate (Fi gure 4D). The si de heal s
by secondary i ntenti on after 2 months, wi th the resul ti ng nai l
reveal i ng a more vi si bl e l unul a.
(4) Treatment of chroni c paronychi a wi th exci si on of the proxi mal
nai l fol d.
PITFALL: Meticulous wound care is required after this
procedure, and the surgery is appropriate only for patients who
are able and willing to provide this care. Some physicians apply a
combination antifungal and steroid ointment at night and
antibiotic ointment during the day until the wound heals.
An al ternate techni que i s to remove the enti re nai l , pl aci ng
anti fungal and steroi d oi ntment on the si te dai l y.
Page 385
(5) Removal of the enti re nai l , fol l owed by dai l y appl i cati on of
anti fungal and steroi d oi ntment to the si te.
P.238
CODING INFORMATION
Codes for i nci si on and drai nage (I&D) are provi ded i n the fol l owi ng
chart.

2002 Average 50th
Percentile Fee

10060* I&D of abscess, paronychi a,
si mpl e or si ngl e
$120
10061 I&D of abscess, paronychi a,
compl i cated or mul ti pl e
$275

Instruments used for paronychi a surgery, such as no. 15 or no. 11
scal pel bl ades, can be obtai ned from l ocal surgi cal suppl y houses.
Freer septum el evators can be purchased from surgi cal i nstrument
deal ers or through surgi cal suppl y houses. A suggested anesthesi a
Page 386
BIBLIOGRAPHY
1998;16:145164.
Goodheart HP. Infecti ons: paronychi a and onychomycosi s. Womens
Heal th Pri m Care 1998;1:232237.
1991:236247.
Lee S, Hendri ckson MF. Paronychi a. Emedi ci ne June 20, 2002.
Avai l abl e at http://www.emedi ci ne.com/derm/topi c798.htm
Mayeaux EJ. Nai l di sorders. Pri m Care 2000;27:333351.
Parungao AJ. A swol l en, drai ni ng thumb. Am Fam Physi ci an
2002;65:105106.
Ri ch P. Nai l di sorders: di agnosi s and treatment of i nfecti ous,
i nfl ammatory, and neopl asti c nai l condi ti ons. Med Cl i n North Am
1998;82:11711183.
Roberge RJ, Wei nstei n D, Thi mons MM. Peri onychi al i nfecti ons
associ ated wi th scul ptured nai l s. Am J Emerg Med
1999;17:581582.
Rockwel l PG. Acute and chroni c paronychi a. Am Fam Physi ci an
2001;63:11131116.
Tosti A, Pi racci ni BM. Treatment of common nai l di sorders. Dermatol
Cl i n 2000;18:339348.
Page 387
> Table of Cont ent s > Nail Procedures > 34 - Digit al Mucous Cyst Removal34
Digital Mucous Cyst Removal
Di gi tal mucous cysts are cl ear or fl esh-col ored nodul es that appear
on fi ngers between the di stal i nterphal angeal (DIP) joi nt and the
proxi mal nai l fol d. Al so known as di gi tal myxoi d cysts, the l esi ons
are usual l y 3 to 12 mm i n di ameter, sol i tary, and more common on
the domi nant hand. The cysts typi cal l y appear just l ateral to the
mi dl i ne. The l esi ons are more common i n mi ddl e-aged to ol der
adul ts and rarel y are encountered on the toes. Women are affected
twi ce as often as men. The l esi ons woul d be better descri bed as
pseudocysts because they l ack a true epi thel i al l i ni ng.
Two di fferent types of cyst have been i denti fi ed. One type i s
associ ated wi th degenerati ve arthri ti s of the DIP joi nt and can
appear si mi l ar to gangl i ons or synovi al cysts. These l esi ons often
have an i denti fi abl e stal k that can be traced back to the joi nt. The
second type i s i ndependent of the joi nt and ari ses from metabol i c
derangement of the soft ti ssue fi brobl asts. These l esi ons are
associ ated wi th the l ocal i zed producti on of hyal uroni c aci d.
Pati ents may be asymptomati c or report pai n, tenderness, or nai l
deformi ty associ ated wi th the l esi on. Nai l ri dgi ng i s observed i n up
to one thi rd of pati ents. A pri or hi story of trauma may be reported
by i ndi vi dual s younger than 40 years of age wi th the cysts. One
l ongi tudi nal study found that the cysts occasi onal l y regress
spontaneousl y.
Asymptomati c l esi ons can be observed and may remai n stabl e for
years. Many di fferent treatment regi mens have been suggested for
symptomati c di gi tal mucous cysts. Aggressi ve surgery wi th removal
of the cyst and underl yi ng osteophytes may produce the fewest
recurrences. Osteophyte removal al one (wi thout cyst removal ) al so
appears effecti ve. Osteophyte removal has been associ ated wi th
hi gher cost and compl i cati ons of joi nt sti ffness, l oss of moti on, and
Page 388
nai l deformi ty.
Si mpl er treatment i nterventi ons have al so been advocated.
Repeated needl i ng of the cyst can provi de cure rates up to 70%. At
l east two to fi ve punctures appear to be necessary for cyst
resol uti on, and pati ents can be provi ded wi th steri l e needl es for
home treatment. Aspi rati on and i njecti on of steroi d has been
hi stori cal l y advocated, but the hi gh rate of recurrence l i mi ts thi s
techni que. Cryosurgi cal , chemi cal , or el ectrosurgi cal abl ati on of the
cyst base i s effecti ve i n eradi cati ng the cyst. If freezi ng i s
empl oyed, repeated freeze-thaw-freeze techni que appears superi or
to a si ngl e freeze. Even wi th proper cryosurgi cal techni que, there i s
a 10% to
P.240
15% recurrence rate after cryosurgery. A si mpl e offi ce exci si on
techni que al so i s descri bed i n thi s chapter.
Anti bi oti c oi ntment and a l i ght gauze dressi ng are pl aced after cyst
treatments. Some physi ci ans bel i eve i mmobi l i zati on i s unnecessary
after removal , but an al umi num spl i nt appl i ed 2 to 10 days after
the procedures can reduce di scomfort and may promote heal i ng.
INDICATIONS
Symptomati c nodul es on the dorsum of the fi nger
between the DIP joi nt and proxi mal nai l fol d
P.241
PROCEDURE
Cl ean the ski n surface wi th an al cohol wi pe, and enter the cyst wi th
a 25-gauge needl e. Cl ear, jel l y-l i ke contents wi l l protrude and can
be squeezed from the cyst. Mul ti pl e needl esti cks separated by days
may be superi or to mul ti pl e sti cks duri ng one sessi on.
Page 389
(1) Needl i ng the cyst.
Abl ati on of the cyst base. After the appl i cati on of l ocal or di gi tal
bl ock anesthesi a, shave off the ski n and cyst roof usi ng a
hori zontal l y hel d no. 15 scal pel bl ade (Fi gure 2A). Appl y the
cryosurgery probe to the cyst base, and create an i ce bal l that
extends outward onto 2 to 3 mm of the normal -appeari ng
surroundi ng ski n (Fi gure 2B). Use the freeze-thaw-freeze techni que.
(2) Abl ati on of the cyst base.
PITFALL: Avoid prolonged freezing of the tissues, because
notching of the proximal nail fold may develop. The length of the
freeze is based on the observed size of the ice ball.
Page 390
P.242
After di gi tal anesthesi a, the ski n over the cyst i s exci sed, and the
cyst i s di ssected and exci sed from the surroundi ng ti ssues (Fi gure
3A). Inci se a V-shaped base to thi s ci rcul ar defect, creati ng a
defect shaped l i ke an i ce cream cone. A smal l , i nverted U-shaped
rotati on fl ap i s i nci sed and undermi ned from nearby ski n on the
dorsum of the fi nger (Fi gure 3B). The fl ap i s moved over the defect
and preferabl y l eft to scar to the wound bed (Fi gure 3C). Not
suturi ng the fl ap may be preferabl e, because the l arger wound
produces scarri ng that may hel p to reduce cyst recurrence. Often,
the fl ap does not center over the wound, or excessi ve bl eedi ng may
occur. A si ngl e sti tch on one or both si des of the fl ap can hel p
al l evi ate these probl ems (Fi gure 3D). Anti bi oti c oi ntment and
spl i nti ng are provi ded after the procedure.
(3) The si mpl e exci si on techni que.
P.243
CODING INFORMATION
2002 Average 50th
Percentile Fee
20612 Aspi rati on or i njecti on of
Page 391
gangl i on cyst, any si te
26160 Exci si on of l esi on of tendon
sheath or joi nt capsul e
(mucous cyst)
$700

No reference fee avai l abl e because thi s i s a new code i n 2003.
A standard offi ce surgery tray, as descri bed i n Appendi x A, shoul d
be avai l abl e for the exci si on procedure. A suggested anesthesi a
BIBLIOGRAPHY
Mosby, 1988:754756.
Dodge LD, Brown RL, Ni ebauer JJ, et al . The treatment of mucous
cysts: l ong-term fol l ow-up i n si xty-two cases. J Hand Surg Am
1984;9:901904.
Epstei n E. A si mpl e techni que for managi ng di gi tal mucous cysts.
Arch Dermatol 1979;115:13151316.
Fri tz GR, Stern PJ, Di ckey M. Compl i cati ons fol l owi ng mucous cyst
exci si on. J Hand Surg Br 1997;22:225225.
1991:236241.
Hernandez-Lugo AM, Domi nguez-Cheri t J, Vega-Memi je AE. Di gi tal
mucoi d cyst: the gangl i on type. I nt J Dermatol 1999;38:531538.
Sal asche SJ. Myxoi d cysts of the proxi mal nai l fol d: a surgi cal
approach. J Dermatol Surg Oncol 1984;10:3539.
Si ngh D, Osterman AL. Mucous cyst. Emedi ci ne February 21, 2002.
Avai l abl e at http://www.emedi ci ne.com/orthoped/topi c520.htm
Page 392
Sonnex TS. Di gi tal myxoi d cysts: a revi ew. Cuti s 1986;37:8994.
Zuber TJ. Offi ce management of di gi tal mucous cysts. Am Fam
Physi ci an 2001;64:19871990.
Physi ci ans, 1998.
Page 393
> Table of Cont ent s > Gynecology and Urology > 35 - Endomet rial Biopsy35
Endometrial Biopsy
Endometri al bi opsy (EMB) i s a safe and effecti ve method for
di agnosi ng vari ous endometri al abnormal i ti es. It provi des a
mi ni mal l y i nvasi ve assessment of the endometri um that may be
used as an al ternati ve to di l atati on and curettage or hysteroscopy.
Modern sucti on catheters have made thi s outpati ent techni que easy
to l earn and perform.
EMB i s most commonl y empl oyed i n the workup of abnormal uteri ne
bl eedi ng, but i t can al so be used for cancer screeni ng, endometri al
dati ng, and i nferti l i ty eval uati on. Thi s techni que provi des part of a
cost-effecti ve di agnosti c workup for abnormal uteri ne bl eedi ng
wi thout reduci ng cl i ni cal accuracy.
Catheter-type EMBs are safe. Uteri ne perforati ons are rare unl ess
the devi ce i s forced. Postoperati ve i nfecti on i s rare but may be
prevented wi th the use of prophyl acti c anti bi oti c therapy such as
doxycycl i ne (100 mg) admi ni stered twi ce dai l y for 4 days after the
procedure. The pati ent may al so be premedi cated wi th i buprofen
(600 to 800 mg) at l east 1 hour before the procedure to decrease
the crampi ng associ ated wi th the sampl i ng. Bacteri al endocardi ti s
prophyl axi s can be consi dered (see Appendi x I). Intraoperati ve and
postoperati ve crampi ng i s a frequent si de effects of the procedure.
Some physi ci ans prefer to appl y a tenacul um and gi ve sl i ght
countertracti on toward the operator. Al though a tenacul um hel ps
stabi l i ze the cervi x, i t al so causes addi ti onal pai n and bl eedi ng. It
may al so be used to strai ghten a markedl y anteverted or
retroverted uterus and may make the procedure safer i n thi s
setti ng. If used, i t shoul d be appl i ed to the anteri or l i p of the
cervi x wi th the teeth i n a hori zontal pl ane.
Because of the stenosi s of the cervi cal os that devel ops i n
l ow-estrogen states, i t can be di ffi cul t to perform an EMB i n
Page 394
postmenopausal women. El derl y women can have a l ami nari a (i .e.,
thi n pi ece of dri ed, steri l e seaweed) pl aced i n the cervi x i n the
morni ng and then return i n the afternoon to have the swol l en (now
moi stened) l ami nari a removed i mmedi atel y before the procedure. A
cervi cal di l ator may al so be used when the EMB catheter can not be
passed through the i nternal os i n postmenopausal women.
Topi cal benzocai ne sol uti on (i .e., Hurri cai ne sol uti on) may be
appl i ed to the cervi x to decrease the pai n from entry of the curette
i nto the uterus. A cervi cal or peri cervi cal bl ock al so may be used.
For a cervi cal bl ock, i nject 1% to 2% l i docai ne wi th epi nephri ne
submucosal l y i n the center of each cervi cal quadrant.
P.248
Anesthesi a may be appl i ed at any ti me duri ng the procedure. Some
data suggest i nsti l l i ng 5 mL of 2% l i docai ne i nto the uteri ne cavi ty
before endometri al bi opsi es si gni fi cantl y decreases the pai n of the
EMB.
INDICATIONS
Exami nati on for dysfuncti onal uteri ne bl eedi ng (to rul e
out endometri al hyperpl asi a or cancer)
Workup for gl andul ar atypi a or endometri al cel l s seen on
the Papani col aou (Pap) smear
Moni tor unopposed estrogen therapy for the
devel opment of hyperpl asi a
Endometri al dati ng
Inferti l i ty eval uati on
CONTRAINDICATIONS
Pregnancy or suspected pregnancy
Acute pel vi c i nfl ammatory di sease
Acute cervi cal or vagi nal i nfecti ons
Uncooperati ve pati ent (rel ati ve contrai ndi cati on)
Severe cervi cal stenosi s (rel ati ve contrai ndi cati on)
P.249
Page 395
PROCEDURE
Expl ai n the procedure, and obtai n i nformed consent. Perform a
pel vi c exami nati on. Determi ne the si ze and posi ti on of the uterus.
Appl y povi done-i odi ne (Betadi ne) to the ectocervi x and external os
wi th a swab or cotton bal l . Sound the uterus (normal depth i s 6 to
9 cm).
(1) Appl y povi done-i odi ne (Betadi ne) to the ectocervi x and external
os wi th a swab or cotton bal l .
PITFALL: Check for masses or structural abnormalities, cervical
stenosis, or signs of infection that may make the procedure
more difficult or impossible.
PITFALL: When inserting the sound, apply firm, steady forward
pressure to pass through the tightly closed internal os of the
upper cervix. Be prepared to immediately pull back after the
internal os is penetrated, or the tip of the sound can be thrust
forward against the upper uterus and perforate the opposing
wall. Perforations also can occur through the thin lower uterine
Page 396
segment. Placement of a tenaculum and straightening of the
uterocervical angle can help reduce perforation after the sound
passes through the internal os.
P.250
Wi th the central pi ston ful l y i nserted i nto the sheath (do not pul l
out), the endometri al sampl er i s i nserted i nto the os unti l i t
reaches the fundus. Note the depth of i nserti on. Do not touch the
end of the devi ce that i s to be i nserted or al l ow i t to touch the
pati ent except at the os.
(2) Wi th the central pi ston ful l y i nserted i nto the sheath, the
endometri al sampl er i s i nserted i nto the os unti l i t reaches the
fundus.
PITFALL: If strong resistance is encountered, consider repeat
sounding the uterus. If still unable to enter the endometrial
cavity with the EMB catheter, abort the procedure. Forcing the
catheter may result in uterine perforation.
PITFALL: If the catheter bends excessively, apply a small
amount of torque to the catheter. This causes it to flex less.
Hol di ng the sheath steady, pul l back on the pi ston unti l i t stops.
Thi s creates negati ve pressure i nsi de the curette. Leave the pi ston
Page 397
ful l y retracted.
(3) Hol di ng the sheath steady, pul l back on the pi ston unti l i t
stops.
P.251
Rol l or twi rl the sheath l ateral l y between the thumb and fi ngers
whi l e si mul taneousl y movi ng the sheath ti p back and forth between
the fundus and i nternal os. Ti ssue shoul d move i nto the sheath as
the operati on progresses. Compl ete the maneuver three or four
ti mes to obtai n the sampl e.
(4) Rol l or twi st the sheath l ateral l y between the thumb and
fi ngers whi l e si mul taneousl y movi ng the sheath ti p back and forth
Page 398
between the fundus and i nternal os.
PITFALL: Do not allow the hole in the tip to emerge from the
cervix, or all of the suction will be lost.
P.252
Remove the sampl i ng devi ce, and cut off the di stal ti p (Fi gure 5A).
Sl owl y push the pi ston compl etel y i nto the sheath to expel the
sampl e i nto the fi xati ve (Fi gure 5B). Remove the specul um, and
al l ow the pati ent to si t up and rest before dressi ng.
Page 399
(5) Remove the sampl i ng devi ce, cut off the di stal ti p, and sl owl y
push the pi ston compl etel y i nto the sheath to expel the sampl e
i nto the fi xati ve.
PITFALL: Do not force the tissue out of the sampling hole
without cutting the tip off because this may distort the histologic
sample.
P.253
CODING INFORMATION

2002 Average 50th
Percentile Fee

58100* Endometri al sampl i ng
(bi opsy), wi th or wi thout
endocervi cal sampl i ng,
wi thout cervi cal di l atati on,
any method
$170
57800* Di l ati on of cervi cal canal ,
i nstrumental
$133
59200 Inserti on of cervi cal di l ator,
l ami nari a
$174

Catheter-type devi ces i ncl ude the Uni mar PIPELLE (Pi pel l e de
Corni er), whi ch can be ordered from CooperSurgi cal , Inc., Shel ton,
CT (phone: 1-800-243-2974 http://www.coopersurgi cal .com/), or the
Wal l ach Endocel l Endometri al Cel l Sampl er (20 pi ece box), whi ch
can be ordered from Wal l ach Surgi cal Devi ces, Inc., 235 Edi son
Road, Orange, CT 06477 (phone: 203-799-2000; fax:
203-799-2002; emai l :wal l ach@wal l achsurgi cal .com;
http://www.wal l achsurgi cal .com/).
BIBLIOGRAPHY
Page 400
Archer DF, Lobo RA, Land HF, et al . A comparati ve study of
transvagi nal uteri ne ul trasound and endometri al bi opsy for
eval uati ng the endometri um of postmenopausal women taki ng
hormone repl acement therapy. Menopause 1999;6:201208.
Bakour SH, Khan KS, Gupta JK. Control l ed anal ysi s of factors
associ ated wi th i nsuffi ci ent sampl e on outpati ent endometri al
bi opsy. Br J Obstet Gynecol 2000;107:13121314.
Bayer SR, DeCherney AH. Cl i ni cal mani festati ons and treatment of
dysfuncti onal uteri ne bl eedi ng. JAMA 1993;269:18231828.
Ci ci nel l i E, Di donna T, Schonauer LM, et al . Paracervi cal anesthesi a
for hysteroscopy and endometri al bi opsy i n postmenopausal women:
a randomi zed, doubl e-bl i nd, pl acebo-control l ed study. J Reprod Med
1998;43:10141018.
Di jkhui zen FP, Mol BW, Brol mann HA, et al . The accuracy of
endometri al sampl i ng i n the di agnosi s of pati ents wi th endometri al
carci noma and hyperpl asi a: a meta-anal ysi s. Cancer
2000;89:17651772.
Mi shel l DR Jr, Kauni tz AM. Devi ces for endometri al sampl i ng: a
compari son. J Reprod Med 1998;43:180-00184.
Ori el KA, Schranger S. Abnormal uteri ne bl eedi ng. Am Fam Physi ci an
1999;60:13711380.
Tahi r MM, Bi gri gg MA, Browni ng JJ, et al . A randomi zed control l ed
tri al compari ng transvagi nal ul trasound, outpati ent hysteroscopy
and endometri al bi opsy wi th i npati ent hysteroscopy and curettage.
Br J Obstet Gynaecol 1999;106:12591264.
Trol i ce MP, Fi shburne C Jr, McGrady S. Anestheti c effi cacy of
i ntrauteri ne l i docai ne for endometri al bi opsy: a randomi zed
doubl e-masked tri al . Obstet Gynecol 2000;95:345347.
Zuber TJ. Endometri al bi opsy. Am Fam Physi ci an
2001;63:11311135, 11371141.
Page 401
> Table of Cont ent s > Gynecology and Urology > 36 - Cervical Polyp Removal36
Cervical Polyp Removal
Cervi cal pol yps are peduncul ated tumors that commonl y ari se from
the mucosa of the endocervi cal canal . They are usual l y bri ght red
and have a soft, spongy structure. Cervi cal pol yps are common and
are most often seen i n peri menopausal and mul ti gravi d women i n
the thi rd through fi fth decades of l i fe. The cause of most pol yps i s
unknown, but they are associ ated wi th i ncreasi ng age,
i nfl ammati on, trauma, and pregnancy.
The hi stol ogy of cervi cal pol yps i s si mi l ar to that of the
endocervi cal canal , wi th a si ngl e tal l col umnar cel l l ayer and
occasi onal cervi cal gl ands. Vascul ar congesti on, edema, and
i nfl ammati on are frequentl y present. Many endocervi cal pol yps
demonstrate squamous metapl asi a, whi ch may cytol ogi cal l y and
col poscopi cal l y mi mi c dyspl asi a. Squamous dyspl asi a and cancer
may ori gi nate on cervi cal pol yps, but mal i gnant degenerati on i s
rare. However, i f a pol yp i s di scovered after an atypi cal
Papani col aou (Pap) smear, the pol yp shoul d be sent for pathol ogi c
study, especi al l y i f i t contai ns any acetowhi te epi thel i um.
Pol yps are often asymptomati c and are typi cal l y found at the ti me
of the routi ne gynecol ogi c exami nati on. They may be si ngl e or
mul ti pl e and may vary i n si ze from a few mi l l i meters to several
centi meters. Rarel y, the pedi cl e can become so el ongated that the
pol yp protrudes from the vagi nal i ntroi tus. There may be vagi nal
di scharge associ ated wi th cervi cal pol yps, especi al l y i f the pol yp
becomes i nfected. Ul cerati on of the ti p and vascul ar congesti on
often resul t i n postcoi tal or dysfuncti onal uteri ne bl eedi ng. Larger
pol yps may bl eed peri odi cal l y, produci ng i ntermenstrual spotti ng
and postcoi tal bl eedi ng. Val sal va strai ni ng al so may sti mul ate
bl eedi ng. Symptoms may be exactl y the same as i n the earl y stages
of cervi cal cancer.
Page 402
There i s an associ ati on between cervi cal and endometri al pol yps.
Postmenopausal women wi th cervi cal pol yps have a hi gher i nci dence
of coexi sti ng endometri al pol yps that i s unrel ated to hormone
repl acement therapy. Pati ents on tamoxi fen therapy have a very
hi gh associ ati on of cervi cal pol yps wi th endometri al pol yps and
probabl y shoul d be eval uated wi th di l atati on and curettage.
However, most physi ci ans perform si mpl e pol ypectomy i n the offi ce
i f the pati ent i s otherwi se asymptomati c. The di fferenti al di agnosi s
for cervi cal pol yps i s shown i n Tabl e 36-1.
TABLE 36-1. DIFFERENTIAL DIAGNOSIS

Endometri al pol yp
Prol apsed myoma
Incompl ete spontaneous aborti on
Lei omyosarcoma
Squamous papi l l oma
Sarcoma
Cervi cal mal i gnancy

Because most pol yps are beni gn, they may be removed or observed
on routi ne exami nati ons. They are often twi sted off duri ng routi ne
exami nati ons to reduce
P.255
the i nci dence of i nfl ammati on and i nci dental bl eedi ng. Pol yps may
al so be removed duri ng di l atati on and curettage, by hysteroscopi c
wi re or snare, by el ectrocautery, duri ng a l oop el ectrosurgi cal
exci si onal procedure, or by surgi cal exci si on.
After removal of a pol yp, the pati ent shoul d avoi d sexual
i ntercourse, douchi ng, and tampon usage for several days. A
fol l ow-up exami nati on shoul d be done i n 1 to 2 weeks to check for
probl ems, i f desi red. If acti ve bl eedi ng occurs, the pati ent shoul d
be seen i mmedi atel y. Exami nati on to check for regrowth shoul d be
Page 403
performed at routi ne gynecol ogi c vi si ts. Unfortunatel y, recurrence i s
common.
INDICATIONS
Removal of pol yps i s usual l y i ndi cated to prevent
i rri tati on, vagi nal di scharge, and bl eedi ng.
CONTRAINDICATIONS
Because the cervi x i s hi ghl y vascul ari zed duri ng
pregnancy, pol yps shoul d be observed i f they are stabl e
and appear beni gn. They shoul d be removed onl y i f they
are causi ng bl eedi ng.
P.256
PROCEDURE
Perform a standard gynecol ogi c exami nati on. Gentl y grasp the pol yp
wi th ri ng forceps, appl y sl i ght tracti on, and twi st repeatedl y unti l i t
fal l s off. If a si gni fi cant amount of the base of the pol yp remai ns,
i t may be scraped off wi th a curette.
(1) Gentl y grasp the pol yp wi th ri ng forceps, appl y tracti on, and
twi st unti l i t fal l s off.
PITFALL: Be sure to identify the location of the base of the polyp
to exclude the possibility of an endometrial polyp, which may
Page 404
produce extensive bleeding. If the pedicle extends too deeply to
be easily visualized, a Kogan endocervical speculum and
colposcopic magnification are often helpful.
Al ternati vel y, a smal l pol yp may be scraped off i n i ts enti rety wi th
a sharp curette or bi opsi ed off wi th a Ti schl er bi opsy forceps.
Bl eedi ng i s usual l y sel f-l i mi ted but can be control l ed wi th pressure,
Monsel 's sol uti on, or cautery.
(2) Al ternati vel y, a smal l pol yp may be bi opsi ed off wi th a Ti schl er
bi opsy forceps.
PITFALL: If multiple polyps, irregular bleeding, or ongoing
tamoxifen therapy is noted, it may be prudent to remove the
polyps while performing dilatation and curettage.
P.257
CODING INFORMATION
There i s no separate CPT code for cervi cal pol yp removal . Some
practi ti oners report pol ypectomy wi th 57500* (cervi x uteri bi opsy)
or 57505 (endocervi cal curettage). If the col poscope i s used to
i denti fy the pol yp base, 57452* can be used to report servi ces.
Ri ng forceps, curettes, Kogan's endocervi cal specul ums, and
cervi cal bi opsy forceps may be ordered from compani es l i sted i n
Chapter 37. A suggested anesthesi a tray that can be used for thi s
Page 405
BIBLIOGRAPHY
Abramovi ci H, Bornstei n J, Pascal B. Ambul atory removal of cervi cal
pol yps under col poscopy. I nt J Gynaecol Obstet 1984;22:4750.
Coeman D, Van Bel l e Y, Vanderi ck G, et al . Hysteroscopi c fi ndi ngs
i n pati ents wi th a cervi cal pol yp. Am J Obstet Gynecol
1993;169:15631565.
Davi d A, Mettl er L, Semm K. The cervi cal pol yp: a new di agnosti c
and therapeuti c approach wi th CO2 hysteroscopy. Am J Obstet
Gynecol 1978;130:662664.
Di Naro E, Bratta FG, Romano F, et al . The di agnosi s of beni gn
uteri ne pathol ogy usi ng transvagi nal endohysterosonography. Cl i n
Exp Obstet Gynecol 1996;23:103107.
Gol an A, Ber A, Wol man I, et al . Cervi cal pol yp: eval uati on of
current treatment. Gynecol Obstet I nvest 1994;37:5658.
Goudas VT, Sessi on DR. Hysteroscopi c cervi cal pol ypectomy wi th a
pol yp snare. J Am Assoc Gynecol Laparoscopi sts 1999;6:195197.
Hi l l ard GD. Case for di agnosi s: cervi cal pol yp. Mi l Med
1978;143:618, 631.
Khal i l AM, Azar GB, Kaspar HG, et al . Gi ant cervi cal pol yp: a case
report. J Reprod Med 1996;41:619621.
Lee WH, Tan KH, Lee YW. The aeti ol ogy of postmenopausal
bl eedi nga study of 163 consecuti ve cases i n Si ngapore.
Si ngapore Med J 1995;36:164168.
Neri A, Kapl an B, Rabi nerson D, et al . Cervi cal pol yp i n the
menopause and the need for fracti onal di l atati on and curettage. Eur
J Obstet Gynecol Reprod Bi ol 1995;62:5355.
Vi l odre LC, Bertat R, Petters R, et al . Cervi cal pol yp as ri sk factor
for hysteroscopi cal l y di agnosed endometri al pol yps. Gynecol Obstet
I nvest 1997;44:191195.
Page 406
> Table of Cont ent s > Gynecology and Urology > 37 - Colposcopy and Direct ed
Cervical Biopsy37
Colposcopy and Directed Cervical
Biopsy
The Papani col aou (Pap) smear i s a commonl y empl oyed screeni ng
test for dyspl asi a and cancer of the uteri ne cervi x. Col poscopy i s
the di agnosti c test to eval uate pati ents wi th an abnormal cervi cal
cytol ogi c smear or an abnormal -appeari ng cervi x. The mai n goal of
col poscopy i s to hi ghl i ght the areas of greatest abnormal i ty i n
hi gh-grade cervi cal i ntraepi thel i al neopl asi a (CIN) or vagi nal
i ntraepi thel i al neopl asi a (VAIN) for bi opsy. It entai l s the use of a
fi el d mi croscope to exami ne the cervi x after appl i cati on of aceti c
aci d (and possi bl y Lugol 's i odi ne) to temporari l y stai n the cervi x.
The cervi x and vagi na are exami ned under magni fi cati on, and al l
abnormal areas are i denti fi ed. The transformati on zone (TZ) i s the
area of the cervi x extendi ng from the ori gi nal (prepubertal )
squamocol umnar juncti on (SCJ) to the current SCJ. Thi s and other
beni gn col poscopi c fi ndi ngs are l i sted i n Tabl e 37-1. An atypi cal TZ
i s defi ned as one wi th fi ndi ngs suggesti ng cervi cal dyspl asi a or
neopl asi a.
TABLE 37-1. BENIGN COLPOSCOPIC FINDINGS
Page 407

Site or Condition Findings

Ori gi nal squamous epi thel i um The ori gi nal squamous epi thel i um i s a
featurel ess, smooth, pi nk epi thel i um that
has no features suggesti ng col umnar
epi thel i um such as gl and openi ngs or
Nabothi an cysts. Thi s epi thel i um i s
consi dered al ways squamous and
was not transformed from col umnar to
squamous.
Col umnar epi thel i um The col umnar epi thel i um i s a si ngl e-cel l
l ayer and mucus-produci ng ti ssue that
extends between the endometri um and the
squamous epi thel i um. Col umnar epi thel i um
appears red and i rregul ar wi th stromal
papi l l ae and cl efts. Wi th aceti c aci d
appl i cati on and magni fi cati on, col umnar
epi thel i um has a grapel i ke or sea anemone
appearance. It i s mostl y found i n the
endocervi x.
Squamocol umnar juncti on (SCJ) General l y, a cl i ni cal l y vi si bl e l i ne i s seen on
the ectocervi x or wi thi n the di stal
endocervi cal canal that demarcates
endocervi cal ti ssue from squamous or
squamous metapl asti c ti ssue.
Squamous metapl asi a It i s the normal physi ol ogi c process
whereby col umnar epi thel i um matures i nto
squamous epi thel i um. At the
squamocol umnar juncti on, i t appears as a
ghost whi te or whi te-bl ue fi l m wi th
appl i cati on of aceti c aci d. It i s usual l y
sharpl y demarcated toward the cervi cal os
and has very di ffuse borders peri pheral l y.
Transformati on zone (TZ) The geographi c area between the ori gi nal
squamous epi thel i um (before puberty) and
Page 408
the current squamocol umnar juncti on may
contai n gl and openi ngs, Nabothi an cysts,
and i sl ands of col umnar epi thel i um
surrounded by metapl asti c squamous
epi thel i um.
Vagi nocervi ci ti s Cervi ci ti s may cause abnormal Papani col aou
(Pap) smear resul ts and make col poscopi c
assessment more di ffi cul t. Many authori ti es
recommend treatment before bi opsy when a
sexual l y transmi tted di sease i s strongl y
suspected.
Traumati c erosi on Traumati c erosi ons are most commonl y
caused by specul um i nserti on and too
vi gorous Pap smears, but they can al so
resul t from i rri tants such as tampons,
di aphragms, and i ntercourse.
Atrophi c epi thel i um Atrophi c vagi nal or cervi cal epi thel i um may
cause abnormal Pap smears. Col poscopi sts
often prescri be estrogen for 2 to 4 weeks
before a col poscopy to normal i ze
the epi thel i um before the exami nati on. Thi s
i s thought to be safe even i f dyspl asi a or
cancer i s present because the durati on of
therapy i s short and these l esi ons do not
express any more estrogen receptors than a
normal cervi x.
Nabothi an cysts Nabothi an cysts are areas of
mucus-produci ng epi thel i um that are
roofed over wi th squamous
epi thel i um. They do not requi re any
treatment. They provi de markers for the
transformati on zone because they are i n
squamous areas but are remnants of
col umnar epi thel i um.
Page 409
ABNORMAL FINDINGS
Leukopl aki a i s typi cal l y an el evated, whi te pl aque on the cervi cal or
vagi nal mucosa seen before the appl i cati on of aceti c aci d. It resul ts
from a thi ck kerati n l ayer that obscures the underl yi ng epi thel i um.
It may represent exophyti c human papi l l oma vi rus (HPV) di sease or
may si gnal severe dyspl asi a or cancer. Al though i t may be
associ ated wi th beni gn fi ndi ngs, i t general l y warrants a bi opsy.
Acetowhi te l esi ons descri be transi ent, whi te-appeari ng areas of
epi thel i um after the appl i cati on of aceti c aci d. Acetowhi te changes
correl ate wi th areas of hi gher nucl ear densi ty i n the ti ssue.
Because both beni gn and dyspl asti c l esi ons may turn acetowhi te,
several features must be exami ned to esti mate the severi ty.
Assess the l esi on's margi ns, i ncl udi ng the sharpness of the margi n
and the angul ari ty of the contour of the margi n. The margi ns of
hi gh-grade CIN are strai ghter and sharper compared wi th the vague,
feathery, geographi c borders of CIN 1 or HPV di sease. When
hi gh-grade CIN coexi sts i n the same l esi on wi th a l ower-grade
l esi on, the hi gher-grade l esi on often mani fests wi th a sharpl y
defi ned i nternal margi n or border (i .e., border-wi thi n-a-border
pattern).
P.259
Wi th i ncreasi ng l evel s of CIN, desmosomes (i .e., i ntracel l ul ar
bri dges) that attach the epi thel i um to the basement membrane are
often l ost, produci ng an edge that easi l y peel s. Thi s l oss of ti ssue
i ntegri ty shoul d rai se the suspi ci on of hi gh-grade dyspl asi a. The
extreme expressi on of thi s effect i s the ul cerati on that someti mes
forms wi th i nvasi ve di sease. Hi gh-grade CIN l esi ons are usual l y
adjacent to the SCJ. Hi gher-grade l esi ons often appear dul l and
l ess whi te than most l ow-grade l esi ons, whi ch are usual l y snowy
whi te wi th a shi ny surface. Invasi ve l esi ons may l ose the
acetowhi te effect al together. Nodul ar el evati ons and ul cerati on may
i ndi cate hi gh-grade di sease or i nvasi ve cancer.
Increases i n l ocal factors such as tumor angi ogenesi s factor or
Page 410
vascul ar endothel i al growth factor cause growth of abnormal surface
vascul ature, produci ng punctati on, mosai c, and frankl y abnormal
vessel s. However, most hi gh-grade l esi ons do not devel op any
abnormal vessel s. Punctati on i s a sti ppl ed appearance of smal l
capi l l ari es seen end-on, often found wi thi n the acetowhi te area,
appeari ng as fi ne to coarse, red dots. Coarse punctati on represents
i ncreased cal i ber vessel s that are spaced at i rregul ar i nterval s and
i s more hi ghl y associ ated wi th i ncreasi ng l evel s of dyspl asi a.
P.260
Fi gure. No capti on avai l abl e.
The mosai c pattern i s an abnormal pattern of smal l bl ood vessel s
suggesti ng a confl uence of ti l es or a chi cken-wi re
pattern wi th reddi sh borders. It represents capi l l ari es that grow
on or near the surface of the l esi on that form parti ti ons between
bl ocks of prol i ferati ng epi thel i um. It devel ops i n a manner very
si mi l ar to punctati on and i s often found i n the same l esi ons. A
coarse mosai c pattern i s more hi ghl y associ ated wi th i ncreasi ng
l evel s of dyspl asi a.
Page 411
Abnormal bl ood vessel s are atypi cal , i rregul ar surface vessel s that
have l ost thei r normal arbori zati on or branchi ng pattern. They
represent an exaggerati on of the abnormal i ti es of punctati on and
mosai c, and i ncreasi ng severi ty of the l esi on. They are i ndi cati ve of
CIN3 or i nvasi ve cancer. These vessel s are usual l y nonbranchi ng,
appear wi th abrupt courses and patterns, and often appear as
commas, corkscrews, coarse paral l el vessel s, or spaghetti .
Lugol 's i odi ne stai ni ng (i .e., Schi l l er's test) may be used when
further cl ari fi cati on of potenti al bi opsy si tes i s necessary. It need
not be used i n al l cases, but the sharp outl i ni ng afforded by Lugol 's
i odi ne can be dramati c and very hel pful . It darkl y stai ns epi thel i um
contai ni ng gl ycogen, such as normal mature squamous epi thel i um.
Lugol 's sol uti on i s often very hel pful on the vagi na and proxi mal
vul va (i .e., nonkerati ni zed ski n). It can be used to exami ne the
enti re vagi na and cervi x for gl ycogen-defi ci ent areas, whi ch
correl ate wi th HPV or dyspl asi a i n nongl andul ar mucosa. Hi gh-grade
l esi ons uni forml y reject i odi ne due to the absence of gl ycogen and
produce a bei ge to mustard yel l ow effect.
The goal of col poscopy i s to i denti fy and bi opsy the most abnormal
appeari ng areas i n abnormal l esi ons. Thi s requi res that the borders
of al l l esi ons be seen i n enti rety. Col poscopy i s consi dered
sati sfactory i f the enti re TZ (i ncl udi ng the enti re SCJ) i s exami ned
and the extent of al l l esi ons i s seen. Di rected bi opsi es of the most
severe l esi ons are performed and l ead to a ti ssue di agnosi s of the
di sease present. If the enti re SCJ or the l i mi ts of al l l esi ons cannot
be compl etel y vi sual i zed (unsati sfactory exami nati on), a di agnosti c
coni zati on wi th a col d kni fe cone, l aser cone, or l oop el ectrosurgi cal
exci si onal procedure (LEEP) cone i s necessary. The uncooperati ve
pati ent or pati ent wi th a severel y fl exed uterus wi th i nadequate
vi sual i zati on
P.261
are common potenti al causes of unsati sfactory col poscopy. Lesi ons
that are more l i kel y to be mi ssed or underread by col poscopi c
Page 412
exami nati on i ncl ude endocervi cal l esi ons, extensi ve l esi ons that are
di ffi cul t to sampl e, and necroti c l esi ons.
GRADING LESIONS
Careful l y note the shape, posi ti on, and characteri sti cs of al l l esi ons
to draw a pi cture of the l esi ons and bi opsy si tes after the
procedure i s compl eted. Do not l et the fi ndi ng of vessel s di vert you
from careful l y observi ng acetowhi te and border changes, because
the areas wi th vessel abnormal i ti es may not be the most abnormal
areas on the cervi x. Cl assi cal l y, the parameters i n Tabl e 37-2 are
used to grade severi ty, and the more advanced fi ndi ngs
i ndi cate more severe dyspl asi a.
TABLE 37-2. PARAMETERS USED TO GRADE SEVERITY OF CERVICAL DYSPLASIA

Less Severe (More Normal) More Severe (More Dysplastic)

Mi l d acetowhi te epi thel i um Intensel y acetowhi te
No bl ood vessel pattern Punctati on
No bl ood vessel pattern or punctati on Mosai c
Diffuse vague borders Sharpl y demarcated borders
Normal surface contour of the cervi x Abnormal contour or humped up
Normal i odi ne reacti on (dark) Iodi ne-negati ve epi thel i um (yel l ow)

Leukopl aki a i s usual l y a very good si gn (i .e., condyl omata) or a
very bad si gn (i .e., hi gh-grade CIN or squamous cel l carci noma).
Abnormal vessel s are al ways suspi ci ous because they may i ndi cate
cancer. When mul ti pl e areas of dyspl asi a are present, the areas of
hi ghest-grade dyspl asi a are usual l y most proxi mal to the SCJ. Wi th
al l other thi ngs bei ng equal , the presence of vessel atypi a i n any
l esi on i mpl i es more severe dyspl asi a.
Large, hi gh-grade l esi ons that cover three or four quadrants of the
cervi x shoul d be careful l y eval uated for the possi bi l i ty of
unsuspected i nvasi ve cancer. Al though many l esi ons have vascul ar
abnormal i ti es, some i nvasi ve l esi ons are densel y acetowhi te and
Page 413
avascul ar. They may al so mani fest as ul cerati ve l esi ons. Lesi ons
that extend more than 5 mm i nto the cervi cal os have an i ncreased
ri sk of hi gher-grade di sease beyond the l i mi ts of the exami nati on.
Thi s i s why coni zati on i s recommended i n cases of an
unsati sfactory exami nati on wi th hi gh-grade di sease.
THE PROCEDURE
Assure your pati ent that you wi l l attempt to mi ni mi ze pai n,
because thi s i s often a consumi ng worry for pati ents. Al though
studi es show that the sharpness of the i nstruments i s the most
i mportant factor i n the pai n of a bi opsy, many physi ci ans appl y
topi cal 20% benzocai ne (i .e., Hurri cane sol uti on) to decrease pai n
(perform preprocedure testi ng i f necessary). Thi s topi cal anestheti c
i s effecti ve i n 30 to 45 seconds. Know the pregnancy status of your
pati ent. Ibuprofen (800 mg) may be admi ni stered 30 mi nutes to
several hours before the procedure.
Pl ace the pati ent i n the dorsal l i thotomy posi ti on. Insert a
specul um, and posi ti on the col poscopy to observe the cervi x. Gross
focus i s achi eved by movi ng
P.262
the scope toward or away from the cervi x. Fi ne focus i s achi eved by
knobs, handl es, or motori zed foot pedal s that fi nel y move the head
of the scope forward or backward.
When performi ng the procedure, appl y sol uti ons wi th a cotton bal l
hel d i n a ri ng forceps or wi th a rectal swab. Gentl y appl y copi ous
amounts of vi negar qui ckl y and wi thout trauma. Bi opsy posteri or
areas fi rst to avoi d bl ood dri ppi ng over future bi opsy si tes. The
cervi x can be mani pul ated wi th a cotton-ti pped appl i cator or hook i f
necessary to provi de an adequate angl e for bi opsy. It i s not
necessary to i ncl ude normal margi ns wi th bi opsy sampl es. If
bl eedi ng i s profuse from a parti cul ar si te and more bi opsi es are
needed, appl y a cotton-ti pped appl i cator (wi thout Monsel 's
sol uti on) to the area, and proceed wi th the next bi opsy. Begi nni ng
col poscopi sts often pl ace sampl es from di fferent bi opsy si tes i n
di fferent bottl es, subsequentl y correl ati ng them wi th col poscopi c
Page 414
i mpressi ons. Separate speci mens can i ncrease costs and general l y
are not necessary because the enti re TZ i s treated based on the
worse bi opsy resul t found.
It i s debatabl e whether endocervi cal curettage (ECC) adds any
useful i nformati on to a cl earl y adequate col poscopy, because of the
hi gh fal se-posi ti ve and fal se-negati ve rates. Pati ents i n whom
there i s not a cl ear vi ew of the canal or who have had previ ous
treatment shoul d have an ECC. The ECC can be performed before or
after taki ng bi opsi es, wi th the deci si on based on whether bl eedi ng
wi l l obscure subsequent bi opsy si tes. Fol l owi ng curettage, the ECC
sampl e appears as a coagul um of mucus, bl ood, and smal l ti ssue
fragments. Use ri ng forceps or a cytobrush to gentl y retri eve the
sampl e. In addi ti on to retrei vi ng the ECC, a cytobrush can be used
to eval uae the endocervi cal canal . A short dri nki ng straw pl aced
over a cytobrush can act as a sheath to protect the brush from
contami nati on from ectocervi cal di sease.
After a col poscopy, advi se pati ents to avoi d douchi ng, i ntercourse,
or tampons for 1 to 2 weeks (or unti l the return vi si t). Instruct
pati ents to return i f they experi ence a foul vagi nal odor or
di scharge, pel vi c pai n, or fever. Tyl enol , i buprofen, or naproxen
sodi um may be used for cramps. The fol l ow-up vi si t i s usual l y i n 1
to 3 weeks to di scuss pathol ogy resul ts and pl an treatment, i f
necessary. Wi th the hi gh regressi on rate of CIN 1, pati ents can be
fol l owed wi th seri al Pap smears or col poscopy i f adequate fol l ow-up
can be ensured. CIN 2 and 3 l esi ons are usual l y treated wi th
cervi cal cryotherapy, LEEP, or l aser vapori zati on. Be concerned i f a
si gni fi cant di screpancy i s found between the col poscopi c
i mpressi on, Pap smear cytol ogy, and bi opsy hi stol ogy, especi al l y i f
the bi opsy reports are si gni fi cantl y l ess severe than the Pap
cytol ogy. A di screpancy of two grades shoul d be consi dered
si gni fi cant and a contrai ndi cati on to abl ati ve therapy. If the
di screpancy cannot be expl ai ned or corrected on a repeat
col poscopy, coni zati on i s i ndi cated.
Cervi cal coni zati on (i .e., col d cone, l aser, or LEEP cone) i s i ndi cated
i f the ECC sampl e reveal s dyspl asi a, dyspl asi a vi sual l y extends i nto
Page 415
the cervi cal canal more than 3 or 4 mm, or the col poscopi c resul ts
are unsati sfactory. There i s a hi gher ri sk of poor outcomes i f
abl ati ve therapi es are used when di sease i s present i n the
endocervi cal canal . Posi ti ve ECC fi ndi ngs are someti mes a resul t of
contami nati on wi th dyspl asti c l esi ons at the verge of the os, but
thi s shoul d not be assumed.
P.263
INDICATIONS
Pap smear consi stent wi th HPV i nfecti on, dyspl asi a, or
cancer
Pap smear read as atypi cal squamous cel l s wi th posi ti ve
MVP testi ng for hi gh-ri sk types
Pap smear wi th repeated unexpl ai ned i nfl ammati on
Abnormal -appeari ng cervi x or abnormal -feel i ng cervi x (by
pal pati on)
Pati ents wi th a hi story of i ntrauteri ne di ethyl sti l bestrol
(DES) exposure
Pap smear wi th atypi cal gl andul ar cel l s (especi al l y i f
favor dyspl asi a)
Repeated smears wi th atypi cal squamous cel l s
CONTRAINDICATIONS
Acti ve cervi cal or vagi nal i nfecti on because i t can l ower
test sensi ti vi ty and i ncrease bl eedi ng (rel ati ve
P.264
PROCEDURE
Prepare your pati ent, obtai n i nformed consent (see Appendi x J),
and answer her questi ons. If a bi manual exami nati on was not done
wi th the Pap smear, perform i t now. Exami ne the vul va for obvi ous
condyl omata or other l esi ons. Warm the specul um wi th water, and
Page 416
gentl y i nsert i t. Consi der usi ng a vagi nal si de wal l retractor, a
Penrose drai n, or l atex gl ove thumb wi th obese, pregnant, or
mul ti parous women wi th vagi nal redundancy.
(1) Vagi nal si de wal l retractor i n a Graves specul um.
PITFALL: Repeating the Pap smear is usually unnecessary, and
even a correctly performed Pap smear may irritate the cervix
and cause bleeding.
P.265
Exami ne the cervi x for i nfl ammati on or i nfecti on. Gentl y bl ot or
wi pe away any excess mucus usi ng normal sal i ne. Look for
l eukopl aki a and abnormal vessel s. Appl y 5% aceti c aci d. Repeat the
appl i cati on every 25 mi nutes, as necessary. Exami ne the cervi x
starti ng wi th l ow power and usi ng whi te l i ght. Use hi gher
magni fi cati on and the red-free (green) fi l ter to careful l y document
any abnormal vascul ar patterns. Use a vi negar-soaked Q-ti p to hel p
mani pul ate the cervi x and SCJ i nto vi ew, as necessary.
Page 417
(2) Use a vi negar-soaked Q-ti p to hel p mani pul ate the cervi x and
SCJ i nto vi ew, as necessary.
PITFALL: Calling the solution acetic acid may increase the
patient' s perception of burning; describing the solution as
vinegar is preferable.
PITFALL: A tenaculum is almost never necessary to move the
cervix and may cause cervix-obscuring bleeding.
Determi ne i f the col poscopy i s sati sfactory. A Kogan endocervi cal
specul um can greatl y ai d the exami nati on of the di stal endocervi cal
canal . Mental l y map and characteri ze abnormal areas, and note al l
margi n features and vascul ar changes. Grade the severi ty of
l esi ons. Then, i f desi red, the cl i ni ci an may use Lugol 's sol uti on
(i .e., Schi l l er's test) and appl y benzocai ne (i .e., Hurri cai ne
sol uti on) to the enti re face of the cervi x usi ng a cotton bal l .
(3) A Kogan endocervi cal specul um.
PITFALL: Unsatisfactory colposcopy with cytologic evidence of
dysplasia usually requires cervical cone biopsy for further
Page 418
evaluation.
PITFALL: Make sure the patient is not allergic to iodine
(shellfish) or benzocaine before using these solutions.
P.266
Perform an endocervi cal curettage i f i ndi cated. Use a Kevorki an
curette (preferabl y wi thout a basket), and scrape al l wal l s of the
canal , rotati ng the curette twi ce through 360 degrees of rotati on.
Pl ace the curette i nto the canal unti l resi stance i s fel t (Fi gure 4A),
push i t agai nst the canal whi l e pul l i ng i t out (stop short of the
external os) (Fi gure 4B), and then push i t back i n wi th a sl i ght
(approxi matel y 30 degree) twi st to sampl e the next stri p of canal
wi th the next outward stroke (Fi gure 4C). After removi ng the
curette, use ri ng forceps or a cytobrush to gentl y retri eve the
sampl e.
Page 419
Page 420
(4) Perform an endocervi cal curettage i f i ndi cated.
PITFALL: Do not do an ECC on pregnant patients.
P.267
A cytobrush can be used to retri eve ECC sampl e or, al ternatel y, a
brush can be used to sampl e the endocervi cal canal . A short
dri nki ng straw may be pl aced over a cervi cal Pap smear brush (i .e.,
pi pe-cl eanertype brush) to act as a sheath to protect the brush
from contami nati on by the ectocervi x whi l e the devi ce i s bei ng
i ntroduced or wi thdrawn. Pl ace the brush i nsi de the straw, and
pl ace the straw agai nst the os (Fi gure 5A). Advance the brush i nto
the cervi cal canal , spi n i t around fi ve ti mes (Fi gure 5B), wi thdraw
the brush back i nto the straw (Fi gure 5C), and remove the straw
and brush from the vagi na (Fi gure 5D).
Page 421
(5) A short dri nki ng straw may be pl aced over a cervi cal Pap smear
brush to act as a sheath to protect the brush from contami nati on
Page 422
by the ectocervi x whi l e the devi ce i s bei ng i ntroduced or wi thdrawn.
P.268
Al i gn the forceps radi al l y from the os so that the fi xed jaw of the
forceps i s pl aced on the most posteri or part of the si te (Fi gure 6A).
Note that the fi xed posi ti on i s away from the os (above) and wi thi n
the os (bel ow). The jaws shoul d be centered over the area to be
bi opsi ed (Fi gure 6B). Bi opsi es shoul d be approxi matel y 3 mm deep
and shoul d i ncl ude al l areas wi th vessel atypi sm. Appl y pressure
and Monsel 's sol uti on, i f needed, to bl eedi ng si tes.
(6) Perform a cervi cal bi opsy.
PITFALL: Do not apply Monsel' s solution until all biopsies are
completed.
Page 423
PITFALL: Swab out the excess Monsel' s solution and blood
debris, which appears as a coffegrounds-like black substance
that eventually will pass and may cause alarm (and late-night
phone calls).
P.269
Gentl y remove the specul um, and vi ew the vagi nal wal l col l apse
around the recedi ng bl ades of the specul um. Inspect for any
abnormal areas on the vagi na or vul va. Careful l y draw and l abel a
pi cture of l esi ons and bi opsy si tes. Correl ate the pi ctures wi th the
submi tted sampl es, i f pl aced i n di fferent contai ners. Note whether
the col poscopy was sati sfactory.
(7) After the specul um has been removed, check for any abnormal
areas on the vagi na or vul va, and careful l y draw and l abel a pi cture
of l esi ons and bi opsy si tes.
PITFALL: Fainting and light-headedness are not uncommon.
Have the patient rest supine for at least several minutes and
then sit up slowly.
P.270
CODING INFORMATION
No 2002 fee is listed for new colposcopy codes introduced in 2003.
Page 424

2002 Average 50th
Percentile Fee

56820 Col poscopy of vul va
56821 Col poscopy of vul va wi th
bi opsy

57420 Col poscopy of enti re vagi na,
i ncl udi ng cervi x

57421 Col poscopy of enti re vagi na
wi th bi opsy

57452* Col poscopy of cervi x or upper
vagi na
$236
57454* Col poscopy of cervi x wi th
bi opsy, ECC
$310
57455 Col poscopy of cervi x wi th
bi opsy

ECC

LEEP bi opsy
$850
LEEP cone

57500* Cervi cal bi opsy,
si ngl e/mul ti pl e, or exci si on
$171
57505 ECC (not part of di l atati on
and curettage)
$185

A 20% sol uti on of benzocai ne (i .e., Hurri cane sol uti on) can be
obtai ned at Beutl i ch Pharmaceuti cal s LP, 1541 Shi el ds Dri ve,
Waukegan IL, 60085 (phone: 847-473-1100 or 800-238-8542;
http://www.beutl i ch.com/products.htm). Col poscopes and suppl i es
may be obtai ned from Ci rcon/Cryomedi cs, Raci ne WI (phone:
Page 425
888-524-7266 or 414-639-7205;
http://www.acmi corp.com/acmi /user/); CooperSurgi cal , Shel ton, CT
(phone: 800-645-3760 or 203-929-6321;
http://www.coopersurgi cal .com); DFV, 1990 NE 163rd Street, Sui te
107, North Mi ami Beach, FL 33162 (phone: 800-933-0009;
http://www.dfv.com.br); Gyne-tech Instruments, Burbank, CA
(phone: 800-496-3832 or 818-842-0933); Lei segang Medi cal , Inc.,
Boca Raton, FL (phone: 800-448-4450 or 561-994-0202;
http://www.l ei segang.com) Ol ympus Ameri ca, Inc., Mel vi l l e, NY
(phone: 800-548-555 or 631-844-5000;
http://www.ol ympusameri ca.com); Techman Internati onal Corp.,
Charl ton, MA (phone: 508-248-3211; http://www.techmani nc.com);
Wal l ach Surgi cal Devi ces, Inc., Orange, CT (phone: 203-799-2000 or
800-243-2463; http://www.wal l achsurgi cal .com); and Wel ch Al l en,
Skaneatel es Fal l s, NY (phone: 800-535-6663 or 315-685-4100;
http://www.wel chal l yn.com).
P.271
Aceti c aci d (3% to 5%) and normal sal i ne can be obtai ned from a
supermarket (i .e., whi te vi negar) or from a medi cal suppl y source.
Monsel 's sol uti on (i .e., ferri c subsul fate) performs best when i t has
a thi ck, toothpaste-l i ke consi stency. It can be bought thi s way or
produced by al l owi ng the stock sol uti on to si t exposed to the ai r i n
a smal l open contai ner. Thi s al l ows evaporati on and thi ckeni ng of
the agent, a process that can be enhanced by pl aci ng the open
contai ner i n a warm pl ace, such as on top of a refri gerator. The
resul ti ng paste texture can be mai ntai ned by keepi ng the paste i n a
cl osed contai ner and by addi ng smal l amounts of Monsel 's sol uti on
whenever the paste becomes excessi vel y thi ck. Appendi x B l i sts
standard gynecol ogi c i nstruments.
BIBLIOGRAPHY
Brotzman GL, Apgar BS. Cervi cal i ntraepi thel i al neopl asi a: current
management opti ons. J Fam Pract 1994;39:271278.
Ferri s DG, Harper DM, Cal l ahan B, et al . The effi cacy of topi cal
Page 426
benzocai ne gel i n provi di ng anesthesi a before cervi cal bi opsy and
endocervi cal curettage. J Low Geni tal Tract Di sease
1997;1:221227.
Ferri s DG, Wi l l ner WA, Ho JJ. Col poscopes: a cri ti cal revi ew. J Fam
Pract 1991;33:506515.
Grei mel ER, Gappmayer-Locker E, Gi rardi FL, et al . Increasi ng
women's knowl edge and sati sfacti on wi th cervi cal cancer screeni ng.
J Psychosom Obstet Gynecol 1997;18:273279.
Hoffman MS, Sterghos S Jr, Gordy LW, et al . Eval uati on of the
cervi cal canal wi th the endocervi cal brush. Obstet Gynecol
1993;82:573577.
McCord ML, Stoval l TG, Summi tt RL, et al . Di screpancy of cervi cal
cytol ogy and col poscopi c bi opsy: Is cervi cal coni zati on necessary?
Obstet Gynecol 1991;77:715719.
Newki rk GR, Granath BD. Teachi ng col poscopy and androscopy i n
fami l y practi ce resi denci es. J Fam Pract 1990;31:171178.
Rei d R, Campi on MJ. HPV-associ ated l esi ons of the cervi x: bi ol ogy
and col poscopi c features. Cl i n Obstet Gynecol 1989;32:157179.
Rei d R, Scal zi P. Geni tal warts and cervi cal cancer. VII. An i mproved
col poscopi c i ndex for di fferenti ati ng beni gn papi l l omavi ral
i nfecti ons from hi gh-grade cervi cal i ntraepi thel i al neopl asi a. Am J
Sadan O, Frohl i ch RP, Dri scol l JA, et al . Is i t safe to prescri be
hormonal contracepti on and repl acement therapy to pati ents wi th
premal i gnant and mal i gnant uteri ne cervi ces? Gynecol Oncol
1986;34:159163.
Schi ffman MH, Bauer HM, Hoover RN, et al . Epi demi ol ogi cal
evi dence showi ng that human papi l l omavi rus i nfecti on causes most
cervi cal i ntraepi thel i al neopl asi a. J Natl Cancer I nst
1994;85:958964.
Stafl A, Wi l banks GD. An i nternati onal termi nol ogy of col poscopy:
report of the nomencl ature commi ttee of the Internati onal
Federati on of Cervi cal Pathol ogy and Col poscopy. Obstet Gynecol
1991;77:31334.
Wri ght Jr TC, Cox JT, Massad LS, et al , for the 2001
Page 427
ASCCP-sponsored Consensus Conference. Consensus gui del i nes for
the management of women wi th cervi cal cytol ogi cal abnormal i ti es
and cervi cal cancer precursors. Part I. Cytol ogi cal abnormal i ti es.
JAMA 2002;287:21202129.
Page 428
> Table of Cont ent s > Gynecology and Urology > 38 - Cryot herapy for t he Ut erine
Cervix38
Cryotherapy for the Uterine Cervix
Cryotherapy i s a ti me-proven, abl ati ve method of treati ng l ower
grades of cervi cal dyspl asi a. The procedure i s easy to l earn,
perform, and appl y i n outpati ent setti ngs. It works by freezi ng and
ki l l i ng abnormal ti ssue, whi ch then sl oughs off, and new ti ssue
grows i n i ts pl ace. The ti p of the cryoprobe i s cool ed by a
refri gerant gas that i s fed i nto the hol l ow cryoprobe under pressure.
The gas then rapi dl y expands and absorbs heat i n the process. The
temperature of a ni trous oxi de probe ti p fal l s to -65C to -85C.
A water-sol ubl e l ubri cant i s appl i ed to the probe to act as a
thermocoupl e wi th the i rregul ar surface of the cervi x. Thi s produces
a more uni form freeze. A rapi d freeze fol l owed by a sl ow thaw
maxi mi zes cryonecrosi s, and a freeze-thaw-refreeze cycl e i s more
effecti ve than a si ngl e freeze.
After the cryoprobe i s pl aced i n contact wi th the cervi x and
acti vated, a ri ng of frozen ti ssue, or i ce bal l , extends outward. The
depth of freeze approxi mates the l ateral spread of the freeze. Cel l
death occurs when the temperature fal l s bel ow -10F. However,
there i s a ri ng of ti ssue (i .e., thermal i njury or recovery zone) that
freezes but does not reach the -10F necessary for cel l death.
Thi s i s why i t i s necessary to freeze wel l beyond the margi ns of any
l esi ons. Studi es have demonstrated that endocervi cal crypt (gl and)
i nvol vement of cervi cal i ntraepi thel i al neopl asi a (CIN) may
penetrate up to 3.8 mm i nto the cervi x. A freeze that causes cel l
death to 4 mm shoul d effecti vel y eradi cate 99.7% of l esi ons wi th
gl and i nvol vement. Current recommendati ons are to produce an i ce
bal l wi th a 5-mm l ateral spread to accompl i sh thi s goal .
The cryotherapy appoi ntment shoul d be schedul ed when the pati ent
i s not experi enci ng heavy menstrual fl ow. Sel ect the l argest
Page 429
specul um that the pati ent can comfortabl y tol erate, and open the
bl ades and the front end of the specul um as wi del y as possi bl e
wi thout di scomfort. If col l apsi ng si de wal l s are a probl em, pl ace a
condom wi th the ti p cut off, the thumb from a very l arge rubber
gl ove wi th the ti p cut off, or one hal f of a Penrose drai n over the
specul um. Al ternati vel y, tongue bl ades or si de-wal l retractors may
be pl aced to i mprove exposure.
The choi ce of treatment modal i ty for cervi cal dyspl asi a i s at the
di screti on of the heal th care provi der. The recent Nati onal Cancer
Insti tute/Ameri can Soci ety for Col poscopy and Cervi cal Pathol ogy
(NCI/ASCCP) consensus gui del i nes note that l i mi ted evi dence
supports any treatment modal i ty for al l grades of dyspl asi a. It i s
common practi ce i n the Uni ted States to treat CIN 3 wi th exci si onal
therapy
P.273
(e.g., l oop el ectrosurgi cal exci si onal procedure [LEEP]) to di scover
occul t mi croi nvasi ve cancer. Advantages and di sadvantages of
cryotherapy appear i n Tabl e 38-1.
TABLE 38-1. ADVANTAGES AND DISADVANTAGES OF CRYOTHERAPY FOR CERVICAL
INTRAEPITHELIAL NEOPLASIA

Advantages Disadvantages

Easi l y performed i n the outpati ent setti ng
wi th rel ati vel y si mpl e and i nexpensi ve
equi pment
Women experi ence a heavy di scharge for
several weeks fol l owi ng cryotherapy.
Qui ck and easy to l earn and to perform Uteri ne crampi ng often occurs duri ng
therapy but rapi dl y subsi des.
Seri ous i njuri es and compl i cati ons are rare Bl eedi ng and i nfecti on are rare probl ems
duri ng the reparati ve peri od.
Mi ni mal chance of heavy bl eedi ng duri ng or
after the procedure
Cervi cal stenosi s may occur.
Can be performed i n a short ti me and does
not i nterfere wi th other
Unl i ke exci si onal therapi es, there can be no
hi stol ogi c exami nati on of the enti re l esi on.
Page 430
acti vi ti es such as work or school l ater i n
the day
However, the cost of hi stol ogi c exami nati on
i s avoi ded.
No anestheti c i s requi red. The procedure i s
rel ati vel y pai nl ess, al though crampi ng may
occur
Future Pap smears and col poscopy may be
more di ffi cul t. The squamocol umnar juncti on
has a tendency to mi grate deeper i nto the
cervi cal os, maki ng i t di ffi cul t to sampl e the
endocervi x.
Least expensi ve and most wi del y avai l abl e
form of treatment for CIN
Possi bl e hi gher fai l ure rates than other
cervi cal procedures for hi gh-grade di sease.

No anestheti c i s requi red before cryotherapy because the procedure
i s rel ati vel y pai nl ess, al though some crampi ng may occur. Some
physi ci ans recommend the use of nonsteroi dal anti i nfl ammatory
drugs to decrease crampi ng. Submucosal i njecti on of 1% l i docai ne
wi th 1:100,000 epi nephri ne can be admi ni stered to decrease l ocal
pai n.
Al though the data are not extensi ve, cryotherapy apparentl y has
l i ttl e effect on ferti l i ty, l abor, or pregnancy outcome. The most
common mi nor compl i cati on occurs i f the probe touches the vagi nal
si de wal l and adheres to i t. Thi s causes pai n, and sl i ght bl eedi ng
may occur from the i njured vagi nal mucosa. Occasi onal l y, a pati ent
may experi ence an undue amount of pai n and crampi ng, whi ch i s
usual l y associ ated wi th a hi gh l evel of anxi ety. If thi s can be
anti ci pated, a paracervi cal bl ock before cryotherapy, oral or
i ntramuscul ar admi ni strati on of benzodi azepi nes (e.g., 1 mg of
Ati van gi ven i ntramuscul arl y), or i ntravenous sedati on may be
chosen for rel i ef. These measures are sel dom requi red.
Rarel y, a pati ent may experi ence a vasovagal reacti on. Al l owi ng the
pati ent to rest on the exami nati on tabl e after the procedure and to
get up sl owl y i s usual l y suffi ci ent to overcome thi s probl em. There
has been a reported case of anaphyl axi s due to col d urti cari a. Some
concern has been rai sed about occupati onal exposure to vented NO2
gas fol l owi ng cryotherapy, but the sci enti fi c evi dence for harm i s
very weak.
The pati ent shoul d refrai n from sexual i ntercourse and tampon use
Page 431
for 3 weeks after cryotherapy to al l ow the cervi x to reepi thel i al i ze.
Excessi ve exerci se al so shoul d l i kewi se be di scouraged to l essen
the chance of bl eedi ng after treatment.
P.274
Most pati ents experi ence a heavy and often odorous di scharge for
the fi rst month after cryotherapy. About one hal f of women rate the
postprocedure di scharge and i ts odor worse than a normal peri od.
Thi s di scharge resul ts from the sl oughi ng of dead ti ssue and
exudate from the treatment si te. Routi ne cervi cal eschar
dbri dement does not shorten the durati on or amount of
di scharge and offers no si gni fi cant advantage. Ami no-Cerv cream
may be prescri bed i f a heavy di scharge i s present after the
procedure, al though there i s no sci enti fi c evi dence of effi cacy.
Approxi matel y one thi rd of pati ents restri ct thei r acti vi ti es because
of si de effects of the procedure.
The fi rst fol l ow-up Papani col aou (Pap) smear shoul d not be
performed for 4 to 6 months. Cytol ogy can be very confusi ng i f
sampl ed duri ng the sl oughi ng or regenerati ve phases, whi ch take at
l east 3 months to compl ete. If the fi rst two fol l ow-up smears are
normal , Pap smears can be repeated every 6 months for 2 years
after treatment. Most recurrences take pl ace wi thi n 2 years of
treatment. Annual smears may be recommended after 2 years. An
al ternati ve fol l ow-up schedul e i nvol ves repl aci ng the i ni ti al and
each yearl y Pap smear wi th a col poscopi c exami nati on.
Unfortunatel y, pati ent compl i ance wi th seri al cytol ogy fol l ow-up i s
subopti mal .
If any of the fol l ow-up tests are posi ti ve, restart the workup as i f
there was a newl y di agnosed, fi rst-ti me dyspl asi a. Col poscopy wi th
di rected bi opsy i s usual l y i ndi cated. Unfortunatel y, col poscopy after
cryotherapy may be more di ffi cul t because of mi grati on of the
squamocol umnar juncti on deeper i nto the cervi cal os. Other
treatment methods (usual l y LEEP) are preferred i f persi stent
di sease i s di scovered.
Page 432
INDICATIONS
Bi opsy-proven cervi cal i ntraepi thel i al neopl asi a
Persi stent cervi cal di scharge unresponsi ve to other
therapi es wi th negati ve Pap smears or after a negati ve
col poscopi c resul t
An unsati sfactory col poscopi c exami nati on
A l esi on that extends more than 3 or 4 mm i nto the
cervi cal os because the area of destructi on may not
rel i abl y penetrate beyond thi s l evel
A posi ti ve endocervi cal curettage
A l esi on that covers more than two quadrants of the
cervi x
A l esi on that cannot be compl etel y covered by the
cryoprobe
CIN 3 l esi ons (rel ati ve contrai ndi cati on). There may be a
hi gher recurrence rate compared wi th LEEP for CIN 3
l evel l esi ons, possi bl y because of the greater depth of
gl andul ar i nvol vement wi th CIN 3.
A mi smatch of cytol ogi c, hi stol ogi c, and col poscopi c
fi ndi ngs greater than two hi stol ogi c grades
Pregnancy
Acti ve cervi ci ti s
Some physi ci ans recommend usi ng an exci si onal therapy
(e.g., LEEP) for recurrent dyspl asi a after abl ati ve
therapy.
Adenocarci noma-i n-si tu (must have col d kni fe
coni zati on)
P.275
PROCEDURE
Informed consent i s obtai ned. Perform a pregnancy test i f there i s
any doubt about the pati ent's pregnancy status. Make sure that
Page 433
there i s adequate pressure i n the tank; usual l y, the needl e i s i n
the green zone on the pressure gage.
(1) Ensure that there i s adequate pressure i n the tank. The needl e
usual l y i s i n the green zone on the pressure gauge.
Pl ace the pati ent i n the dorsal l i thotomy posi ti on, and pl ace a
vagi nal specul um. Sel ect a probe that adequatel y covers the enti re
l esi on and the enti re transformati on zone. Use onl y fl at-ended or
short ni ppl e-ti pped probes, not probes wi th l ong endocervi cal
extensi ons, because they cause more cervi cal stenosi s. Appl y a
water-sol ubl e l ubri cant to the probe to act as a thermocoupl e wi th
the i rregul ar surface of the cervi x.
(2) Use onl y fl at-ended or short ni ppl e-ti pped probes, not probes
wi th l ong endocervi cal extensi ons because they cause more cervi cal
stenosi s.
P.276
Page 434
Appl y the probe fi rml y to the cervi x, and make sure that i t i s not
touchi ng the si de wal l s of the vagi na. Start the freeze by pul l i ng
the cryogun tri gger or pressi ng the freeze button. Wi thi n a few
seconds, the probe wi l l be frozen to the cervi x. Usi ng very l i ght
backward pressure on the cryogun, gentl y draw the cervi x forward a
few mi l l i meters i nto the vagi na, where probe contact wi th the si de
wal l s i s l ess l i kel y.
(3) Usi ng very l i ght backward pressure on the cryogun, gentl y draw
the cervi x forward a few mi l l i meters i nto the vagi na, where probe
contact wi th the si de wal l s i s l ess l i kel y.
PITFALL: Be careful not to allow the cryoprobe to touch the
vaginal side wall, because it may stick to and freeze the vagina.
The operator may quickly push the vaginal mucosa off the probe
with a tongue blade or with a slight twist of the probe. If this is
not done quickly, it will become more difficult as the freeze
deepens, and more vaginal mucosa will be destroyed. The
operator should defrost the probe just enough to release the
sidewall and then continue the freeze.
A ri m of i ce shoul d form and grow to a wi dth of at l east 5 mm i n al l
quadrants. Di sconti nue the freeze. Rel ease the cryogun tri gger or
press the defrost button. Wai t unti l the probe vi si bl y defrosts
before attempti ng to di sengage i t from the cervi x. The cervi x
shoul d be al l owed to regai n i ts pi nk col or (usual l y over about 5
mi nutes). Repeat the freeze sequence as descri bed. The second
freeze i s usual l y faster. After the freeze i s compl eted, di sengage
Page 435
the probe and remove the specul um. The pati ent may get up, get
dressed, and l eave as soon as she i s ready.
(4) A ri m of i ce shoul d form and grow to a wi dth of at l east 5 mm
i n al l quadrants.
PITFALL: Fainting and light-headedness are not uncommon.
Have the patient rest supine for at least several minutes and
then sit up slowly.
P.277
CODING INFORMATION

2002 Average 50th
Percentile Fee

57511* Cryotherapy of uteri ne cervi x $232

The devi ce consi sts of a gas tank contai ni ng nonexpl osi ve, nontoxi c
gases (usual l y ni trous oxi de but may be carbon di oxi de). A 20-l b
Page 436
gas cyl i nder i s preferabl e to the 6-l b E-type tank, because the
former has a more effi ci ent pressure rel ease curve. Li qui d ni trogen
has been used i n the past but i s di ffi cul t to control and i s not
recommended. Tanks are usual l y obtai ned from l ocal suppl i ers.
Cryotherapy uni ts may be obtai ned from Ci rcon/Cryomedi cs, Raci ne
WI (phone: 888-524-7266 or 414-639-7205;
http://www.acmi corp.com/acmi /user); CooperSurgi cal , Shel ton, CT
(phone: 800-645-3760 or 203-929-6321;
http://www.coopersurgi cal .com); Gyne-tech Instruments, Burbank,
CA (phone: 800-496-3832 or 818-842-0933); Lei segang Medi cal ,
Inc., Boca Raton, FL (phone: 800-448-4450 or 561-994-0202;
http://www.l ei segang.com) Ol ympus Ameri ca, Inc., Mel vi l l e, NY
(phone: 800-548-555 or 631-844-5000;
http://www.ol ympusameri ca.com); Wal l ach Surgi cal Devi ces, Inc.,
Orange, CT (phone: 203-799-2000 or 800-243-2463;
http://www.wal l achsurgi cal .com); and Wel ch Al l en, Skaneatel es
Fal l s, NY (phone: 800-535-6663 or 315-685-4100;
http://www.wel chal l yn.com). Appendi x B l i sts standard gynecol ogi c
i nstruments.
BIBLIOGRAPHY
Anderson ES, Husth M. Cryosurgery for cervi cal i ntraepi thel i al
neopl asi a: 10-year fol l ow-up. Gynecol Oncol 1992:45:240242.
Anderson MC, Hartl ey RB. Cervi cal crypt i nvol vement by
i ntraepi thel i al neopl asi a. Obstet Gynecol 1990;55:546550.
Benedet JL, Mi l l er DM, Ni ckerson KG, et al . The resul ts of
cryosurgi cal treatment of cervi cal i ntraepi thel i al neopl asi a at one,
fi ve, and ten years. Am J Obstet Gynecol 1987;157:268273.
Charl es EH, Savage EW. Cryosurgi cal treatment of cervi cal
i ntraepi thel i al neopl asi a: anal ysi s of fai l ures. Gynecol Oncol
1980;9:361369.
Ferri s DG, Ho JJ. Cryosurgi cal equi pment: a cri ti cal revi ew. J Fam
Pract 1992;35:185193.
Harper DM, Mayeaux EJ Jr, Daal eman TP, et al . Heal i ng experi ences
after cervi cal cryosurgery. J Fam Pract 2000;49:701706.
Harper DM, Mayeaux EJ Jr, Daal eman TP, et al . The natural hi story
Page 437
of cervi cal cryosurgi cal heal i ng. J Fam Pract 2000;49:694699.
Hel l berg D, Ni l sson S. 20-Year experi ence of fol l ow-up of the
abnormal smear wi th col poscopy and hi stol ogy and treatment by
coni zati on or cryosurgery. Gynecol Oncol 1990;38:166169.
Hemmi ngsson E, Stendahl U, Stenson S. Cryosurgi cal treatment of
cervi cal i ntraepi thel i al neopl asi a wi th fol l ow-up of fi ve to ei ght
years. Am J Obstet Gynecol 1981;139:144147.
Hemmi ngsson E. Outcome of thi rd tri mester pregnanci es after
cryotherapy of the uteri ne cervi x. Br J Obstet Gynecol
1982;89:275277.
P.278
Mi tchel MF, Tortol ero-Luna G, Cook E, et al . A randomi zed cl i ni cal
tri al of cryotherapy, l aser vapori zati on, l oop el ectrosurgi cal exci si on
for treatment of squamous i ntraepi thel i al l esi ons of the cervi x.
Ri chart M, Townsend DE, Cri sp W, et al . An anal ysi s of
l ong-term fol l ow-up resul ts i n pati ents wi th cervi cal
i ntraepi thel i al neopl asi a treated by cryosurgery. Am J Obstet
Gynecol 1980;137:823826.
Sammarco MJ, Hartenbach EM, Hunter VJ. Local anesthesi a for
cryosurgery of the cervi x. J Reprod Med 1993;38:170172.
Schantz A, Thormann L. Cryosurgery for dyspl asi a of the uteri ne
ectocervi x. A randomi zed study of the effi cacy of the si nge- and
doubl e-freeze techni ques. Acta Obstet Gynecol Scand
1984;63:417420.
Spi tzer M. Ferti l i ty and pregnancy outcome after treatment for
cervi cal i ntraepi thel i al neopl asi a. J Low Geni tal Tract Di s
1998;2:225230.
Sti enstra KA, Brewer BE, Frankl i n LA. A compari son of fl at and
coni cal ti ps for cervi cal cryotherapy. J Am Board Fam Pract
1999;12:360366.
Weed JC, Curry SL, Duncan ID, et al . Ferti l i ty after cryosurgery of
the cervi x. Obstet Gynecol 1978;52:245246.
Page 438
Wri ght TC, Cox JT, Massad LS, et al . 2001 Consensus gui del i nes for
the management of women wi th cervi cal cytol ogi cal abnormal i ti es.
JAMA 2002;287:21202129.
Zacari an SA. Is l ateral spread of freeze a val i d gui de to depth of
freeze? J Dermatol Surg Oncol 1978;4:561563.
Page 439
> Table of Cont ent s > Gynecology and Urology > 39 - Loop Elect rosurgical
Excisional Procedure39
Loop Electrosurgical Excisional
Procedure
Premal i gnant cervi cal l esi ons usual l y occur i n women of chi l dbeari ng
years. Unti l recentl y, the hi stori cal choi ces for treatment of these
i ncl uded cryosurgery, el ectrocoagul ati on, l aser vapori zati on or
coni zati on, kni fe coni zati on, and hysterectomy. The fi rst three
opti ons are outpati ent procedures and al l ow for the possi bi l i ty of
future pregnanci es. However, because they are abl ati ve therapi es,
no ti ssue i s sent for pathol ogi c i nspecti on, rai si ng the possi bi l i ty of
mi ssi ng mi croi nvasi ve or i nvasi ve cancer. Coni zati on and
hysterectomy produce ti ssue speci mens wi th wi de margi ns but
usual l y requi re outpati ent surgery or hospi tal i zati on wi th general
anesthesi a, and hysterectomy precl udes future pregnanci es. The
l oop el ectrosurgi cal exci si onal procedure (LEEP) al l ows outpati ent
treatment of cervi cal l esi ons, produces good pathol ogy speci mens,
and has a l ow ri sk of i nterferi ng wi th chi l dbeari ng.
LEEP makes use of l ow-vol tage and rel ati vel y hi gh-frequency
el ectri c current. In pure cutti ng mode, hi gh-frequency current i s
produced i n a smooth, uni nterrupted si ne wave. The cutti ng effect
i s not produced by heati ng the wi re. As the l oop i s i ntroduced to
the ti ssue, an arc occurs near the poi nt of contact, causi ng the
cel l s to be rapi dl y heated and expl oded i nto steam. The steam
envel ope al l ows conti nued arci ng, extendi ng the cut. Thi s produces
a cl ean cut wi th l i ttl e coagul ati on
P.280
arti fact. The transformati on zone can be removed, wi th a
good-qual i ty speci men sent to the pathol ogy department for
exami nati on.
Page 440
In the coagul ati on mode, ful gurati on of ti ssue i s produced wi th
short bursts of hi gh-peak-vol tage current. Thi s mode i s often used
wi th a bal l el ectrode to achi eve hemostasi s. Most modern uni ts can
combi ne the amount of cutti ng and the coagul ati on currents i n
bl end modes. Wi th al l three operati onal modes, the current i s
qui ckl y di spersed to the groundi ng el ectrode. The l arge surface area
of the return el ectrode prevents hi gh charge densi ty and prevents
burns. An i mproperl y appl i ed return el ectrode can resul t i n burns.
Effi cacy and pati ent acceptance of LEEP compare favorabl y wi th
other treatment methods for cervi cal i ntraepi thel i al neopl asi a
(CIN). Few studi es di rectl y compare treatment modal i ti es wi th
suffi ci ent stati sti cal power to draw concl usi ons. A prospecti ve,
randomi zed study by Mi tchel et al . di d not fi nd any si gni fi cant
di fferences for cryotherapy, l aser abl ati on, and LEEP. Thi s study
coul d onl y detect l arge di fferences, and i t di d show a trend toward
better outcomes for CIN 3 wi th LEEP. General studi es i ndi cate LEEP
i s 91% to 98% effecti ve i n treati ng CIN. LEEP i s al so a
wel l -tol erated procedure, wi th 85% of pati ents reporti ng no
di scomfort. Most pati ents who do report di scomfort i ndi cate that
the degree of pai n i s mi l d.
MATERIALS
El ectrosurgi cal generators used for LEEP are i denti cal to ones used
Page 441
i n dermatol ogi c, l aparoscopi c, and urol ogi c surgery. The al ternati ng
current output ranges between 100 and 5,000 kHz. At frequenci es
greater than 100 kHz, cel l ul ar membrane depol ari zati on does not
occur, and there i s no associ ated shock or muscul ar contracti on.
The amount of current used depends on the generator and the l oop
si ze. The rel ati ve cutti ng power needed i s proporti onal to the
amount of wi re that comes i nto contact wi th the cervi x. As the
surface area of the cut i ncreases, the amount of power needed to
make the cut al so i ncreases. Larger or deeper cuts and l arger l oops
requi re hi gher current setti ngs. Dri er or more kerati ni zed ski n al so
requi res hi gher current setti ngs. Setti ng the current too hi gh
resul ts i n i ncreased thermal damage and i ncreased ri sk of
uni ntenti onal burns.
Modern el ectri cal generator features usual l y i ncl ude i sol ated
ci rcui try (i .e., uni t automati cal l y deacti vates i f any acti ve el ectrode
current i s not returned through the pati ent el ectrode) and return
el ectrode moni tori ng (i .e., warns i f the return ci rcui t i s
i nterrupted). Most generators al l ow swi tchi ng between cutti ng and
coagul ati on modes and can bl end a cutti ng effect wi th a
coagul ati on effect. These bl end modes permi t concomi tant
coagul ati on hemostasi s and surgi cal exci si on of ti ssues. Bl end
modes represent a greater proporti on of coagul ati on effect that
further mi ni mi zes bl eedi ng but often i ncreases thermal damage to
the exci sed ti ssue. If a thermal arti fact i s present, eval uati on of
the speci men margi n to excl ude margi n i nvol vement by tumor
becomes di ffi cul t.
Most l oops have an i nsul ated shaft and crossbar to prevent
acci dental thermal i njury. Common l oop si zes range from 1 1 cm
to 2.0 1.5 cm. The stai nl ess steel or tungsten wi re of the l oop
i s approxi matel y 0.2 mm thi ck. Bal l el ectrodes rangi ng from 3 to 5
mm are used for ful gurati on. The probe i s a monopol ar output and
requi res the use of a groundi ng el ectrode. Return (pati ent)
el ectrodes may be adhesi ve gel pads or a sol i d antenna
and may be di sposabl e or reusabl e.
P.281
Page 442
A smoke evacuator i s essenti al to remove the pl ume produced
duri ng the procedure. It fi l ters ai rborne parti cl es and coexi sti ng
mi croorgani sms present i n the pl ume. Several manufacturers have
combi ned an el ectrosurgi cal uni t wi th a smoke evacuator so that,
when the generator i s acti vated, the smoke evacuator al so i s
automati cal l y acti vated. Negati ve pressures from the smoke
evacuator cause ai r to fl ow i nto the vagi na, up the fi xed tubi ng i n
the specul um, and through the evacuator tubi ng toward the
equi pment. Thi s mi ni mi zes pl ume spi l l age i nto the treatment room.
A seri es of mi crofi l ters hel ps remove the carbon, odor, and vi ral
parti cl es generated. Because human papi l l omavi rus (HPV) has been
i sol ated from si mi l ar l aser pl umes, cl i ni ci ans usual l y wear
mi cro-pore or submi cron surgi cal masks.
Most el ectrosurgi cal generator manufacturers recommend usi ng
i nsul ated vagi nal specul ums to prevent secondary pati ent burns
from conducti on through the specul um to nonanestheti zed vagi nal
and vul var areas. Treat i nsul ated specul ums as i f they were not
i nsul ated; do not touch them wi th an acti vated el ectrode!
Nonconducti ve l ateral wal l retractors may assi st wi th vi sual i zati on
Page 443
to counteract l ateral vagi nal wal l redundancy and protect the
vagi nal wal l s.
PATIENT PREPARATION
Pati ent preparati on starts when the pati ent i s i nformed she has
dyspl asti c cervi cal cel l s on col poscopi cal l y di rected bi opsy. Basi c
educati on shoul d be provi ded about cervi cal di sease, treatment
opti ons, and the LEEP procedure. The pati ent may be gi ven
i nstructi ons to premedi cate wi th a nonsteroi dal anti i nfl ammatory
drug the ni ght before and the morni ng of the procedure i f there are
no contrai ndi cati ons. The opti mal ti mi ng of the procedure i s wi thi n
7 days of compl eti on of the menstrual peri od to mi ni mi ze the
l i kel i hood that the pati ent i s pregnant. After cervi cal LEEP, there
may be swel l i ng suffi ci ent to occl ude the endocervi cal canal , and
thi s can l ead to hematocol pos, wi th the need to drai n the uterus.
Pati ent consent i s mandatory, because every management strategy
carri es wi th i t some el ement of ri sk. Among states and geographi c
regi ons, there i s consi derabl e vari ati on about i ssues such as who
consti tutes a mi nor and when parental
P.282
consent must be recei ved by the physi ci an before treati ng a mi nor.
Many states do not requi re parental i nformed consent before
provi di ng treatment to a mi nor wi th a sexual l y transmi tted di sease.
Condi ti ons rel ated to HPV i nfecti ons, such as cervi cal dyspl asi a, fal l
wi thi n the l atter gui del i ne. The physi ci an shoul d record on the
mi nor pati ent's chart any and al l efforts to secure and recei ve
i nformed consent.
COMPLICATIONS
Burns i n the vagi nal vaul t are usual l y caused by poor vi sual i zati on
or operator i nexperi ence. There i s al so a ri sk of burns through
al ternate groundi ng si tes or under the pad due to poor return
el ectrode contact. Most of the l atter two sources of burns have
been el i mi nated wi th modern return el ectrode moni tori ng. When
testi ng the l oop before the procedure, avoi d i nadvertent contact
Page 444
wi th the pati ent.
When exci si ng the transformati on zone wi th the LEEP procedure,
peri operati ve bl eedi ng i s rare, especi al l y wi th the use of ful gurati on
and Monsel 's sol uti on. Si gni fi cant l ate bl eedi ng has been reported
i n 0% to 14% of pati ents who had LEEP therapy. Most di d not
requi re hospi tal i zati on and were treated wi th vagi nal packi ng or
suturi ng. Thi s compares wel l wi th bl eedi ng rates for l aser therapy
and for cryotherapy. Infecti on has been reported i n 0% to 8% of
pati ents.
A l ess common compl i cati on found i n l arger studi es was cervi cal
stenosi s (0.5% to 4% of cases). Rarel y, cervi cal os obl i terati on was
reported. These compl i cati ons occurred mai nl y wi th mul ti pl e
procedures and deep removal of extensi ve l esi ons. Two grams of
i ntravagi nal estrogen pl aced after LEEP coni zati on i n
postmenopausal women protects agai nst os stenosi s and
obl i terati on. The ri sk of i ncompetent cervi x and steri l i ty are
i ncl uded i n i nformed consent by some practi ti oners for theoreti cal
reasons, but there are no publ i shed cl i ni cal data to support thi s.
LEEP coni zati on has been found to have a hi gher compl i cati on rate
than LEEP exci si on of the transformati on zone.
PREGNANCY
Pregnancy rates after LEEP are comparabl e to those after l aser
therapy and better than rates after coni zati on. There al so appears
to be no si gni fi cant di fference i n compl i cati ons duri ng pregnancy
between pati ents who have undergone LEEP and those who have
had other destructi ve cervi cal therapi es. Al though the data are not
extensi ve, no di fference has been found between women who had
LEEP and matched control s i n regard to thei r abi l i ty to concei ve and
carry the pregnancy to term.
ADVANTAGES
LEEP i s approxi matel y 95% effecti ve for treatment of
i mmunocompetent women. Most recurrences happen wi thi n 1 year of
treatment. The procedure provi des an adequate speci men for
pathol ogi c study. Confi rmi ng compl ete removal of the l esi on by
Page 445
observi ng speci men margi ns essenti al l y el i mi nates the ri sk of
mi ssi ng mi croi nvasi ve cancers. Despi te removal of ti ssue, the
transformati on zone heal s wi th a normal appearance i n most
pati ents, al l owi ng for normal , l ong-term cytol ogi c and col poscopi c
fol l ow-up.
P.283
LEEP al so offers the advantage of bei ng a cl i ni c procedure
performed under l ocal anesthesi a. Treatment of even advanced
l esi ons can be accompl i shed wi th the compl ete removal of the
transformati on zone or coni zati on, wi th resul ts comparabl e to kni fe
coni zati on. The cost of a LEEP uni t i s much l ess than l aser
equi pment. In some cases, LEEP saves the hospi tal and anesthesi a
costs of coni zati on. By i mprovi ng di agnosti c accuracy, LEEP may
prevent the human and fi nanci al cost of mi ssi ng mi croi nvasi ve
cancer.
FOLLOW-UP
Pati ent i nstructi ons shoul d i ncl ude prohi bi ti on of sexual
i ntercourse, douchi ng, and tampon use for 2 to 4 weeks. A
di scharge i s expected for 2 to 3 weeks, but i t may l ast up to 6
weeks. The pati ent shoul d report any si gni fi cant bl eedi ng or
mal odorous vagi nal di scharge. A fol l ow-up Papani col aou (Pap)
smear wi th or wi thout col poscopy shoul d be schedul ed for 4 to 6
months l ater.
Pati ents are i nstructed to return i n 1 month for resul ts of the
pathol ogi c exami nati on. A report i ndi cati ng no dyspl asi a shoul d be
i nterpreted as showi ng that the sampl e had a cl ear margi n, not
that no dyspl asi a was present. Smal l i nternal l esi ons may be
mi ssed by pathol ogy. Pati ents wi th no dyspl asi a i n the resecti on
margi ns may be fol l owed for 2 years wi th Pap smears or col poscopy,
or both, every 6 months. If al l test resul ts remai n normal , routi ne
yearl y screeni ng may be resumed, al though the pati ent i s
permanentl y at hi gh ri sk for devel opi ng cervi cal dyspl asi a. Any si gn
of recurrence requi res repeat col poscopi c exami nati on.
Page 446
Because the recurrence rate wi th posi ti ve margi ns i s about 25%,
i mmedi ate retreatment i s usual l y not necessary. A posi ti ve
endocervi cal curettage (ECC) resul t after a LEEP cone or LEEP
procedure shoul d have cl ose fol l ow-up, usual l y wi th col poscopy wi th
di rected bi opsy and ECC, or referral for coni zati on. It i s i mportant
to check for recurrences deep i n the os (i .e., ski p l esi ons) and
al ong the edge of the ori gi nal LEEP cut. Pati ents wi th
bi opsy-proven recurrent l esi ons shoul d be offered retreatment or
hysterectomy. Women i nfected wi th human i mmunodefi ci ency vi rus
(HIV) have hi gh rates of recurrent and persi stent CIN despi te
standard therapy, and l ow l evel s of CD4-posi ti ve T cel l s and margi n
i nvol vement are ri sk factors for recurrence. The use of hi ghl y acti ve
anti retrovi ral therapy (HAART) i s associ ated wi th a l ower ri sk of
recurrence, persi stence, and progressi on of CIN.
SEE-AND-TREAT LOOP ELECTROSURGICAL
EXCISIONAL PROCEDURE
See-and-treat LEEP refers to the practi ce of di agnosi ng and treati ng
some pati ents i n a si ngl e vi si t. Thi s method i s not wi del y
performed i n the Uni ted States and seems to be l osi ng favor
worl dwi de. It has been proposed for pati ents wi th evi dence of
hi gh-grade dyspl asi a (not l ow-grade squamous i ntraepi thel i al
l esi ons or HPV l esi ons) on Pap smear cytol ogy wi th vi si bl e l esi ons
and an adequate col poscopi c exami nati on or for hi ghl y unrel i abl e
pati ents not l i kel y to fol l ow-up. It shoul d not be used when
col poscopi c fi ndi ngs are equi vocal or suggest i nvasi ve cancer. The
major concern wi th thi s approach i s that an exci si on procedure may
be performed unnecessari l y. Tradi ti onal col poscopy fol l owed by
treatment was been found to be more cost-effecti ve than
see-and-treat LEEP.
P.284
INDICATIONS
Treatment of bi opsy-proven CIN l esi on wi th an adequate
Page 447
col poscopy
Hi gh-grade di sease because of the ri sk of deep crypt
i nvol vement.
Dyspl asi a deemed i nappropri ate for cryotherapy, such as
l arge l esi ons not fi tti ng beneath a cryotherapy probe
Lesi ons extendi ng more than 5 mm i nto the cervi cal
canal , when the col poscopy i s i nadequate, or when the
ECC i s posi ti ve (LEEP coni zati on).
Cryotherapy fai l ures, especi al l y i f the subsequent
col poscopy i s unsati sfactory
An unresol vabl e bi opsy-Pap smear or bi opsy-i mpressi on
mi smatch (LEEP or LEEP coni zati on).
CONTRAINDICATIONS
HPV i nfecti on wi thout evi dence of dyspl asi a.
Vagi nal l esi ons due to ri sk of perforati on (rel ati ve
contrai ndi cati on).
Cl i ni cal l y apparent i nvasi ve carci noma
Bl eedi ng di sorders
Pregnancy
Acute cervi ci ti s (due to ri sk of spreadi ng i nfecti on and
i ncreased bl eedi ng)
Bei ng l ess than 3 months postpartum due to i ncreased
bl eedi ng (rel ati ve contrai ndi cati on)
Hi story of cervi cal coni zati on wi th recurrence (rel ati ve
Markedl y atrophi c cervi x (rel ati ve contrai ndi cati on)
Lesi ons that extend far l ateral l y
Suspected mi croi nvasi ve or i nvasi ve cancer
Adenocarci noma i n si tu (treated wi th a col d kni fe cone).
P.285
PROCEDURE
Page 448
Before performi ng a LEEP, col poscopi cal l y eval uate the cervi x. Appl y
Lugol 's sol uti on to ai d i n di sti ngui shi ng normal epi thel i um from
l esi ons. A return el ectrode i s attached to the pati ent, usual l y on
the upper l eg or under the buttocks. Anesthesi a i s performed usi ng
a 25- to 30-gauge needl e and 1% or 2% l i docai ne hydrochl ori de
wi th 1:100,000 epi nephri ne. Infi l trate the l i docai ne sol uti on very
superfi ci al l y at the 12-, 3-, 6-, and 9-o'cl ock posi ti ons or i nto the
center of each quadrant. About 5 mL total i s usual l y adequate.
Consi der appl yi ng 20% benzocai ne sol uti on before i njecti on and
addi ng between 1:1 and 1:4 of a 8.3% sodi um bi carbonate sol uti on
to the l i docai ne to decrease the amount of pai n wi th the i njecti on.
(1) Infi l trate the l i docai ne sol uti on very superfi ci al l y at the 12-, 3-,
6-, and 9-o'cl ock posi ti ons or i nto the center of each quadrant.
PITFALL: If using a side wall retractor, avoid pinching the vagina
between the retractor and the speculum. Slowly open the
retractor, making sure the side wall does not become
entrapped.
P.286
Page 449
Choose a l oop that al l ows exci si on of the enti re transformati on
zone (usual l y 12 to 20 mm wi de and 7 to 10 mm deep) i n one or
two passes wi thout major ri sk of contact wi th the vagi nal si de wal l .
Ri ng forceps hel d agai nst the cervi x may be a useful si ze referent.
Set the current (usual l y 40 to 60 watts or 4 to 6 on
hi gher-frequency uni ts), and set the uni t to a bl ended or pure
cutti ng mode. The l oop i s attached to a penci l -l i ke base that i s
control l ed wi th a fi nger swi tch or foot swi tch.
(2) Choose a l oop that al l ows exci si on of the enti re transformati on
zone (usual l y 12 to 20 mm wi de and 7 to 10 mm deep) i n one or
two passes wi thout major ri sk of contact wi th the vagi nal si de wal l .
P.287
To exci se ti ssue, the l oop i s hel d just above the surface of the
cervi x and 2 to 5 mm l ateral to the l esi on or edge of the
transformati on zone. Current i s appl i ed before the l oop contacts
the cervi x. The l oop i s pushed i nto the ti ssue to a depth of about
78 mm, because maxi mal crypt i nvol vement by CIN i s
approxi matel y 4 mm, and you must account for the vol ume of
i njected anestheti c.
Page 450
(3) To exci se ti ssue, the l oop i s hel d just above the surface of the
cervi x and 2 to 5 mm l ateral to the l esi on, and current i s appl i ed
before the l oop contacts the cervi x.
PITFALL: If current is applied after contact is made, significant
thermal injury will occur, and the quality of the cut will be poor.
Page 451
PITFALL: Activate the loop only when looking at it. This avoids
inadvertant alternate-site burns.
P.288
Draw the l oop sl owl y through the ti ssue unti l the l oop i s 2 to 5 mm
past the edge of the transformati on zone on the opposi te si de.
Remove the l oop perpendi cul arl y. The average cutti ng ti me i s
approxi matel y 5 to 10 seconds. Remove the speci men wi th the l oop
or ri ng forceps, and i mmedi atel y pl ace the speci men i n formal i n.
ECC i s recommended by many experts at thi s poi nt, especi al l y i f
one was not performed duri ng the precedi ng col poscopy.
Page 452
(4) Draw the l oop sl owl y through the ti ssue unti l the l oop i s 2 to 5
mm past the edge of the transformati on zone on the opposi te si de.
PITFALL: The excision should be done in a single, smooth motion
with continuous current. Stopping the cutting current before the
excision is completed causes extensive thermal injury and may
damage the loop.
Page 453
P.289
Superfi ci al ful gurati on i s usual l y appl i ed to the enti re crater (bei ng
careful to not ful gurate the cervi cal os) and to any spots of poi nt
hemorrhage. The normal edge of the defect (l ateral margi n) i s
al ways ful gurated. Appl y Monsel 's sol uti on to the defect's base.
(5) Superfi ci al ful gurati on i s usual l y appl i ed to the enti re crater
and to any spots of poi nt hemorrhage.
LEEP coni zati on, al so known as the cowboy hat procedure,
can be performed when an exci si on i nto the canal i s requi red. The
techni que i s often used when a l esi on extends i nto the endocervi cal
canal . The cervi x i s anestheti zed as descri bed earl i er, except that
an addi ti onal 0.5 to 2 mL of l i docai ne i s i nfi l trated at the 6- and
12-o'cl ock posi ti ons around the os to a depth of approxi matel y 1
cm.
Page 454
(6) In LEEP coni zati on, the cervi x i s anestheti zed as previ ousl y
descri bed, except that an addi ti onal 0.5 to 2 mL of l i docai ne i s
i nfi l trated at the 6- and 12-o'cl ock posi ti ons around the os to a
depth of approxi matel y 1 cm.
P.290
The transformati on zone i s exci sed i n the manner descri bed
previ ousl y. Then, the di stal endocervi cal canal can be exci sed an
addi ti onal 9 to 10 mm, usual l y wi th a 10 10 mm l oop or square
el ectrode.
(7) The transformati on zone i s exci sed i n the manner descri bed
previ ousl y, and the di stal endocervi cal canal can be exci sed an
addi ti onal 9 to 10 mm.
PITFALL: Orientation of the specimen is necessary for the
pathologist to be able to determine if the deep margin is
Page 455
involved with dysplasia.
PITFALL: Avoid extending the excision into or past the internal
cervical os. The depth or the remaining canal may be assessed
after ectocervical excision by placing an instrument or sound
into the canal.
P.291
CODING INFORMATION

2002 Average 50th
Percentile Fee

LEEP bi opsy
$850
LEEP coni zati on

57522 Coni zati on of the cervi x wi th
LEEP $833

LEEP uni ts and associ ated materi al s may be obtai ned from
Ci rcon/Cryomedi cs, Raci ne, WI (phone: 888-524-7266 or 414-
639-7205; http://www.acmi corp.com/acmi /user); Cooper Surgi cal ,
Shel ton, CT (phone: 800-645-3760 or 203-929-6321;
http://www.coopersurgi cal .com); El l man Internati onal , Inc.,
Hewl ett, NY (phone: 1-800-835 5355 or 516-569-1482;
http://www.el l man.com); Lei segang Medi cal , Inc., Boca Raton, FL
(phone: 800-448-4450 or 561-994-0202; http://www.l ei segang.com
); Ol ympus Ameri ca, Inc., Mel vi l l e, NY (phone: 800-548-555 or
631-844-5000; http://www.ol ympusameri ca.com); Utah Medi cal
Products, Inc., Mi dval e, UT (phone: 800-533-4984 or
801-566-1200; http://www.utahmed.com); Wal l ach Surgi cal
Page 456
Devi ces, Inc., Orange, CT (phone: 203-799-2000 or 800-243-2463;
http://www.wal l achsurgi cal .com); and Wel ch Al l en, Skaneatel es
Fal l s, NY (phone: 800-535-6663 or 315-685-4100;
http://www.wel chal l yn.com).
BIBLIOGRAPHY
Al thui si us SM, Schornagel IJ, Dekker GA, et al . Loop el ectrosurgi cal
exci si on procedure of the cervi x and ti me of del i very i n subsequent
pregnancy. I nt J Gynaecol Obstet 2001;72:3134.
Bi gri gg A, Haffenden DK, Sheeham AL, et al . Effi cacy and safety of
l arge l oop exci si on of the transformati on zone. Lancet
1994;343:3234.
Buxton EJ, Luesl ey DM, Shafi MI, et al . Col poscopy di rected punch
bi opsy: a potenti al l y mi sl eadi ng i nvesti gati on. Br J Obstet Gynaecol
1991;98:12731276.
Duggan BD, Fel i x JC, Muderspach LI, et al . Col d-kni fe coni zati on
versus coni zati on by the l oop el ectrosurgi cal exci si on procedure: a
randomi zed, prospecti ve study. Am J Obstet Gynecol
1999;180:276282.
Fel i x JC, Muderspach LI, Duggan BD, et al . The si gni fi cance of
posi ti ve margi ns i n l oop el ectrosurgi cal cone bi opsi es. Obstet
Gynecol 1994;84:9961000.
Ferri s DG, Hai ner BL, Pfenni nger JL, et al . El ectrosurgi cal l oop
exci si on of the cervi cal transformati on zone: the experi ence of
fami l y physi ci ans. J Fam Pract 1995;41:337344.
Gonzal ez DI Jr, Zahn CM, Retzl off MG, et al . Recurrence of
dyspl asi a after l oop el ectrosurgi cal exci si on procedures wi th
l ong-term fol l ow-up. Am J Obstet Gynecol 2001;184:315321.
Hol schnei der CH, Ghosh K, Montz FJ. See-and-treat i n the
management of hi gh-grade squamous i ntraepi thel i al l esi ons of the
cervi x: a resource uti l i zati on anal ysi s. Obstet Gynecol
1999;94:377385.
P.292
Kobak WH, Roman LD, Fel i x JC, et al . The rol e of endocervi cal
Page 457
curettage at cervi cal coni zati on for hi gh-grade dyspl asi a. Obstet
Gynecol 1995;85:197201.
Mathevet P, Dargent D, Roy M, et al . A randomi zed prospecti ve
study compari ng three techni ques of coni zati on: col d kni fe, LASER,
and LEEP. Gynecol Oncol 1994;54:175179.
Mayeaux EJ Jr, Harper MB. Loop el ectrosurgi cal exci si onal
procedure. J Fam Pract 1993:36:214219.
Mi tchel MF, Tortol ero-Luna G, Cook E, et al . A randomi zed cl i ni cal
tri al of cryotherapy, l aser vapori zati on, l oop el ectrosurgi cal exci si on
for treatment of squamous i ntraepi thel i al l esi ons of the cervi x.
Murdoch JB, Morgan PR, Lopes A, et al . Hi stol ogi cal i ncompl ete
exci si on of CIN after l arge l oop exci si on of the transformati on zone
(LLETZ) meri ts careful fol l ow up, not retreatment. Br J Obstet
Gynaecol 1992;99:990993.
Naumann RW, Bel l MC, Al varez RD, et al . LLETZ i s an acceptabl e
al ternati ve to di agnosti c col d-kni fe coni zati on. Gynecol Oncol
1994;55:224228.
Paraskevai di s E, Lol i s ED, Kol i opoul os G, et al . Cervi cal
i ntraepi thel i al neopl asi a outcomes after l arge l oop exci si on wi th
cl ear margi ns. Obstet Gynecol 2000;95:828831.
Prenti ce ME, Di nh TA, Smi th ER, et al . The predi cti ve val ue of
endocervi cal curettage and l oop coni zati on margi ns for persi stent
2000;4:155.
Sawchuck WS, Webber PJ, Lowy DR, et al . Infecti ous papi l l omavi rus
i n the vapor of warts treated wi th carbon di oxi de l aser or
el ectrocoagul ati on: detecti on and protecti on. J Am Acad Dermatol
1989;21:4149.
Spi tzer M. Ferti l i ty and pregnancy outcome after treatment for
1998;2:225230.
Spi tzer M. Vagi nal estrogen admi ni strati on to prevent cervi cal os
obl i terati on fol l owi ng cervi cal coni zati on i n women wi th
amenorrhea. J Low Geni tal Tract Di s 1997;1:5356.
Page 458
Wi l l i ams FS, Roure RM, Ti l l M, et al . Treatment of cervi cal
carci noma i n si tu i n HIV posi ti ve women. I nt J Gynaecol Obstet
2000;71:135139.
Page 459
> Table of Cont ent s > Gynecology and Urology > 40 - Treat ment of Bart holin's
Gland Cyst s and Abscesses40
Treatment of Bartholin's Gland
Cysts and Abscesses
Barthol i n's gl and cysts or abscesses devel op i n approxi matel y 2%
of al l women. These l esi ons can cause extreme pai n and l i mi tati on
of acti vi ty due to expansi on or i nfecti on. The gl ands' secreti ons
provi de some moi sture for the vul va but are not needed for sexual
l ubri cati on. Removal of a Barthol i n's gl and does not compromi se
the vesti bul ar epi thel i um or sexual functi oni ng.
The Barthol i n's gl ands are l ocated at 5 o'cl ock and 7 o'cl ock at the
vagi nal i ntroi tus and normal l y cannot be pal pated. Barthol i n's gl and
cysts devel op from di l ati on of the duct after bl ockage of the duct
ori fi ce. These l esi ons usual l y are 1 to 3 cm i n di ameter and
asymptomati c. When symptoms occur, the pati ent may report vul var
pai n, dyspareuni a, i nabi l i ty to engage i n sports, and pai n duri ng
wal ki ng or si tti ng.
When the Barthol i n's cysts become abscesses, pati ents may
experi ence severe dyspareuni a, di ffi cul ty i n wal ki ng or si tti ng, and
vul var pai n. Pati ents can devel op a l arge, tender mass i n the
vesti bul ar area wi th associ ated vul var erythema and edema. The
abscess usual l y devel ops over 2 to 4 days and can become l arger
than 8 cm i n di ameter. The condi ti on can be so pai nful that the
pati ent i s i ncapaci tated. The abscess tends to rupture and drai n
after 4 to 5 days. The i nfecti on may be gonococcal , chl amydi al , or
pol ymi crobi al and requi res broad-spectrum anti bi oti c coverage wi th
treatment.
The best method for treati ng a cyst or abscess i s one that
preserves physi ol ogi c functi on wi th a mi ni mum of scarri ng. Si mpl e
i nci si on and drai nage has a hi gh recurrence rate of about 70% to
80%. When treati ng an abscess, obtai n cul tures for Chl amydi a and
Page 460
gonorrhea, and prescri be oral broad-spectrum anti bi oti cs. Di abeti c
pati ents are more suscepti bl e to necroti zi ng i nfecti ons and need
careful observati on. Consi der i npati ent management of women wi th
severe i nfecti ons.
Si mpl e i nci si on and drai nage provi des prompt symptomati c rel i ef,
but recurrence i s common. Treatment i s not contrai ndi cated i n
pregnant women, al though the i ncrease i n bl ood fl ow to the pel vi c
area duri ng pregnancy may l ead to excessi ve bl eedi ng from the
procedure. If treatment i s necessary because of an abscess, l ocal
anesthesi a and most broad-spectrum anti bi oti cs are safe.
In 1964, Dr. B.A. Word i ntroduced a si mpl e fi stul i zati on techni que
usi ng a smal l , i nfl atabl e, sel f-seal i ng, bul b-ti pped catheter. Earl y
abscesses can be treated wi th si tz baths unti l the abscess poi nts,
maki ng i nci si on and defi ni ti ve treatment
P.294
easi er. Instruct the pati ent to return i n 4 weeks for a fol l ow-up
exami nati on or sooner i f she experi ences di scomfort, swel l i ng, or
other symptoms of i nfecti on. Pati ents may use i buprofen (400 to
800 mg taken every 6 hours) for di scomfort i n the i mmedi ate
postoperati ve peri od, and they shoul d refrai n from i ntercourse
duri ng the heal i ng ti me to prevent di spl acement of the catheter.
The catheter i s removed by defl ati ng the bal l oon, and over ti me,
the resul ti ng ori fi ce wi l l decrease i n si ze and become unnoti ceabl e.
Other opti ons for treatment of a Barthol i n's gl and abscess i ncl ude
the marsupi al i zati on or wi ndow procedure, carbon di oxi de l aser
exci si on, and surgi cal exci si on. The marsupi al i zati on procedure i s a
rel ati vel y strai ghtforward procedure that can be performed i n the
offi ce, emergency department, or outpati ent surgi cal sui te i n about
15 mi nutes usi ng l ocal anesthesi a. It can be used as pri mary
treatment or can be used i f a cyst or abscess recurs after treatment
wi th a Word catheter. The recurrence rate after marsupi al i zati on i s
10% to 15%.
A cyst that has recurred several ti mes despi te offi ce-based
treatment may requi re exci si on. Exci si on of a Barthol i n's gl and cyst
Page 461
i s an outpati ent surgi cal procedure that probabl y shoul d be
performed i n an operati ng sui te by an experi enced physi ci an
because of the possi bi l i ty of copi ous bl eedi ng from the underl yi ng
venous pl exus. Exci si on i s usual l y performed under general
anesthesi a or wi th a pudendal bl ock. It can resul t i n i ntraoperati ve
hemorrhage, hematoma formati on, secondary i nfecti on, and
dyspareuni a due to scar ti ssue formati on.
INDICATIONS
Enl arged or pai nful Barthol i n's cyst or abscess
CONTRAINDICATIONS
Surgery on an acutel y, severel y i nfl amed abscess
Asymptomati c cysts (rel ati ve contrai ndi cati on)
Latex al l ergy (e.g., to Word catheter)
P.295
PROCEDURE
Expl ai n the procedure of fi stul i zati on wi th a Word catheter and
obtai n i nformed consent. After l ocal anesthesi a and preparati on,
use a stab i nci si on wi th a no. 11 scal pel bl ade to make a 1.0- to
1.5-cm-deep openi ng i nto the cyst, preferabl y just i nsi de or, i f
necessary, just outsi de the hymenal ri ng. Consi der testi ng abscess
contents for Chl amydi a and gonorrhea.
Page 462
(1) After l ocal anesthesi a and preparati on, use a stab i nci si on to
create a 1.0- to 1.5-cm-deep openi ng i n the cyst.
PITFALL: Inject under and around the abscess, not into it.
Lidocaine injected into the cavity is trapped and cannot provide
anesthesia. Injection into the abscess can cause increased
internal pressure and outward rupture of the abscess.
PITFALL: Do not make the incision on the outer labium minus or
labium majus. The resulting scar may cause pain, a poor
cosmetic result, or a permanent fistula.
P.296
Break up l ocul ati ons wi th a hemostat or si mi l ar i nstrument, and
then i nsert the Word catheter (Fi gure 2A). After the ti p i s i nserted,
the bul b i s i nfl ated wi th water or l ubri cati ng gel (Fi gure 2B), and
the free end of the catheter i s tucked up i nto the vagi na (Fi gure
2C).
Page 463
(2) Insert the ti p of a Word catheter, and i nfl ate the bul b wi th
water or l ubri cati ng gel .
PITFALL: Use water or gel rather than air to prevent premature
deflation of the balloon.
P.297
Leave the catheter i n pl ace for up to 4 weeks to permi t compl ete
epi thel i al i zati on of the new tract. The pati ent may take dai l y baths
or showers and gentl y cl eanse the area wi th soap and water.
Contact the pati ent i f tests for sexual l y transmi tted di seases are
Page 464
posi ti ve.
(3) Keep the catheter i n pl ace for up to 4 weeks.
PITFALL: The catheter frequently falls out. Placement of a
vaginal suture into vulvar skin and tied to the catheter can help
hold those that recurrently fall out.
For marsupi al i zati on, wash the area wi th povi done-i odi ne sol uti on,
and make a fusi form i nci si on adjacent to the hymenal ri ng.
Page 465
(4) Make a fusi form i nci si on adjacent to the hymenal ri ng.
PITFALL: Do not make the incision on the outer labium minus or
labium majus. The resulting scar may cause pain, a poor
cosmetic result, or a permanent fistula.
P.298
The i nci si on shoul d measure about 2 cm l ong and shoul d be deep
enough to enter the cyst. Remove an oval wedge of vul var ski n and
the underl yi ng cyst wal l . The cyst or abscess wi l l drai n once i t has
been unroofed. Break up l ocul ati ons i nsi de the cyst, i f present.
Page 466
(5) Remove an oval wedge of vul var ski n and the underl yi ng cyst
wal l .
Suture the cyst wal l to the adjacent vesti bul ar ski n usi ng
i nterrupted 3-0 or 4-0 absorbabl e (Vi cryl ) sutures. The new tract
wi l l sl owl y shri nk over ti me and epi thel i al i ze, formi ng a new, l arger
duct ori fi ce.
Page 467
(6) Suture the cyst wal l to the adjacent vesti bul ar ski n.
PITFALL: If bleeding occurs, use suture placement or direct
pressure for hemostasis of the skin edge.
P.299
CODING INFORMATION

2002 Average 50th
Percentile Fee
56420* Inci si on and drai nage of
Barthol i n's gl and abscess
(i ncl udes Word catheter)
$190
56440 Marsupi al i zati on of
Barthol i n's gl and cyst
$649
56740 Exci si on of Barthol i n's gl and
or cyst
$788
Page 468
A standard offi ce surgi cal tray used for si mpl e surgi cal procedures
i s descri bed i n Appendi x A, and a suggested anesthesi a tray that
can be used for thi s procedure i s l i sted i n Appendi x G. Word
catheters may be ordered from Mi l ex Products, Inc., Chi cago, IL
(phone: 800-621-1278; http://www.mi l exproducts.com) or from your
l ocal Mi l ex deal er. Contact i nformati on for your l ocal di stri butor can
be obtai ned from the Mi l ex web si te.
BIBLIOGRAPHY
Andersen PG, Chri stensen S, Detl efsen GU, et al . Treatment of
Barthol i n's abscess: marsupi al i zati on versus i nci si on, curettage and
suture under anti bi oti c cover. A randomi zed study wi th 6 months'
fol l ow-up. Acta Obstet Gynecol Scand 1992;71:5962.
Bl eker OP, Smal braak DJ, Schutte MF. Barthol i n's abscess: the rol e
of Chl amydi a trachomati s. Geni touri n Med 1990;66:2425.
Brook I. Aerobi c and anaerobi c mi crobi ol ogy of Barthol i n's abscess.
Surg Gynecol Obstet 1989;169:3234.
Curti s JM. Marsupi al i sati on techni que for Barthol i n's cyst. Aust Fam
Physi ci an 1993;22:369.
Davi es JA, Rees E, Hobson D, et al . Isol ati on of Chl amydi a
trachomati s from Barthol i n's Ducts. Br J Vener Di s 1978;54:409
413.
Downs MC, Randal l HW. The ambul atory surgi cal management of
Barthol i n duct cysts. J Emerg Med 1989;7:623626.
Hi l l DA, Lense JJ. Offi ce management of Barthol i n gl and cysts and
abscesses. Am Fam Physi ci an 1998;57:16111616.
Lee YH, Ranki n JS, Al pert S, et al . Mi crobi ol ogi cal i nvesti gati on of
Barthol i n's gl and abscesses and cysts. Am J Obstet Gynecol
1977;129:150153.
Monaghan JC. Fi stul i zati on for Barthol i n's gl and cysts. Pati ent Care
1991;5:119122.
Wren MW. Bacteri ol ogi cal fi ndi ngs i n cul tures of cl i ni cal materi al
from Barthol i n's abscess. J Cl i n Pathol 1977;30:10251027.
Yavetz H, Lessi ng JB, Jaffa AJ, et al . Fi stul i zati on: An effecti ve
Page 469
treatment for Barthol i n's abscesses and cysts. Acta Obstet Gynecol
Scand 1987;66:6364.
Page 470
> Table of Cont ent s > Gynecology and Urology > 41 - Treat ment of Noncervical
Human Papillomavirus Genit al Infect ions41
Treatment of Noncervical Human
Papillomavirus Genital Infections
There are more than 1 mi l l i on new cases of noncervi cal human
papi l l omavi rus (HPV) geni tal i nfecti ons per year i n the Uni ted
States, and the i nci dence i s i ncreasi ng. Mani festati ons range from
mul ti pl e, exophyti c external geni tal warts to subcl i ni cal i nfecti ons
detectabl e onl y wi th col poscopi c exami nati on wi th aceti c aci d or
DNA probes. Al though al l age groups are affected, sexual l y acti ve
young adul ts account for most vi si ts to physi ci ans' offi ces. HPV
serotypes 6 and 11 are the most commonl y found i n external
geni tal warts.
HPV i nfects the acti ve basal l ayers of the ski n through
mi croabrasi ons that frequentl y occur duri ng i ntercourse.
Heterosexual and homosexual acti vi ty can spread HPV. A l atency
peri od of many years may occur before the di sease becomes
apparent, maki ng epi demi ol ogy and control of spread of the vi rus
di ffi cul t. Condyl omata acumi nata are most frequentl y found on the
prepuce i n men and on the vul va i n women.
HPV l esi ons can usual l y be di agnosed by thei r gross appearance.
Detecti on of fl at HPV l esi ons can be enhanced wi th the use of a
col poscope and 5% aceti c aci d, whi ch produces characteri sti c
acetowhi te changes. Any l esi on that has an atypi cal appearance, i s
pi gmented, or i s resi stant to therapy shoul d be bi opsi ed to rul e out
mal i gnancy. Laboratory tests for the detecti on of HPV DNA are not
useful for external geni tal warts. There i s no wi del y accepted
screeni ng test for the di agnosi s of external HPV l esi ons except
physi cal exami nati on (Tabl e 41-1).
TABLE 41-1. DIFFERENTIAL DIAGNOSIS FOR CONDYLOMATA ACUMINATA
Page 471

Condition Diagnostic Characteristics

Condyl oma l atum (syphi l i s) Broad-based smooth papul es; test wi th
RPR, VDRL, MHA-TP, or FTA-ABS
Common ski n l esi ons Seborrhei c keratoses, nevi , angi omas, ski n
tags, and pearl y peni l e papul es
Neopl asms VIN or VAIN, bowenoi d papul osi s, and
mal i gnant mel anoma
Buschke-Lowenstei n tumor (i .e., gi ant
condyl oma)
A l ow-grade, l ocal l y i nvasi ve mal i gnancy;
appears as a fungati ng condyl oma
Mol l uscum contagi osum Waxy, umbi l i cated papul es

FTA-ABS, fl uorescent treponemal anti body absorpti on test; MHA-TP,
mi crohemaggl uti nati on assay-Treponema pal l i dum; VAIN, vagi nal i ntraepi thel i al
neopl asm; VDRL, Venereal Di sease Research Laboratory test; VIN, vagi nal
i ntraepi thel i al neopl asi a.
External geni tal warts typi cal l y worsen duri ng pregnancy. Cesarean
secti on i s i ndi cated onl y i f the condyl omata physi cal l y obstruct the
pel vi c outl et, not to prevent HPV i nfecti on of the newborn. Al though
i nfant exposure to maternal HPV i s common, studi es i ndi cate that
HPV rarel y col oni zes the baby. Condyl omata acumi nata duri ng
pregnancy may be treated to reduce the ri sk of postpartum
hemorrhage and poor heal i ng i n condyl omatous ti ssue after
del i very, but there are no publ i shed prospecti ve studi es of the
effi cacy of treati ng l esi ons to control these probl ems. The use of
5-fl uorouraci l and podophyl l i n i s contrai ndi cated i n pregnancy.
Cryotherapy has been shown to be safe and effecti ve, and i t
remai ns the treatment of choi ce duri ng pregnancy.
P.301
HPV 6 and 11 can cause l aryngeal papi l l omatosi s, but the route of
transmi ssi on i s not understood. Peri natal transmi ssi on rates are
bel i eved to be l ow, consi deri ng the hi gh preval ence of maternal
HPV i nfecti ons and the l ow rates of peri natal i nfecti on. One study
suggested a transmi ssi on rate as hi gh as 30% for babi es born to
Page 472
mothers wi th l atent HPV i nfecti on but al so observed that al l of the
babi es cl eared the HPV DNA by 5 weeks of age.
The presence of geni tal HPV i nfecti on i n chi l dren shoul d arouse the
suspi ci on of chi l d abuse. HPV l esi ons may be seen i n gi rl s and
boys, and sexual and nonsexual routes of transmi ssi on have been
i denti fi ed. Types of nonsexual transmi ssi on that have been
documented i ncl ude gestati onal , duri ng bi rth, and from fami l i al
nonsexual contacts. When HPV l esi ons are found, a thorough
hi story shoul d be obtai ned, and testi ng for other sexual l y
transmi tted di seases shoul d be consi dered. The chi l d shoul d be
checked careful l y for si gns of abuse. Al l U.S. states requi re that
any suspected chi l d abuse be reported to the appropri ate
authori ti es.
External geni tal warts are more preval ent and di ffi cul t to treat i n
pati ents wi th concomi tant human i mmunodefi ci ency vi rus (HIV)
i nfecti on, and the severi ty of HPV l esi ons worsens as HIV i nfecti on
progresses. HPV i nfecti on occurs i n 40% to 52% of homosexual men
and up to 95% of heterosexual women wi th HIV. Most treatments
for HPV are effecti ve, but they may requi re more treatment
epi sodes over a l onger durati on to overcome the hi gher recurrence
rates. An i ncreased ri sk of cervi cal and anal carci noma has been
found i n women wi th HIV i nfecti on, and cervi cal dyspl asi a i s part of
the Centers for Di sease Control and Preventi on (CDC) cri teri a for
acqui red i mmunodefi ci ency syndrome (AIDS). There i s a need for
careful , repeti ti ve exami nati on of the cervi x and peri neum of
HIV-i nfected women.
The goal of treati ng noncervi cal HPV i nfecti ons i s the el i mi nati on of
obvi ous, symptomati c, or troubl esome l esi onsnot eradi cati on of
the vi rus. Because many warts regress over ti me, treatments that
do not have a si gni fi cant ri sk of scarri ng shoul d be consi dered
pri mari l y. Modern approaches have a much better safety profi l e
than ol der methods, but they are sti l l pl agued wi th hi gh recurrence
rates and vari abl e success rates. Treati ng mal e sexual partners
wi th HPV i nfecti on has not appeared to change the posttreatment
fai l ure rate i n women wi th cervi cal
Page 473
P.302
dyspl asi a. These fi ndi ngs shoul d not deter the cl i ni ci an from
appropri atel y counsel i ng, exami ni ng, and treati ng HPV-i nfected
men.
The epi demi ol ogy and transmi ssi bi l i ty of HPV shoul d be expl ai ned
to the pati ent so that steps can be taken to decrease further
spread. Inform pati ents that they are contagi ous to sexual
partners. Sexual absti nence, monogamous rel ati onshi ps, and
condoms may hel p decrease the spread of the vi rus. However,
condoms do not cover al l of the areas where the vi rus i nfects, and
they represent i mperfect barri ers.
THERAPY
5-Fl uorouraci l was once commonl y used for many types of l esi ons.
Cases of cl ear cel l carci noma ari si ng i n vagi nal adenosi s after
5-fl uorouraci l treatment for condyl omas has been reported. These
probl ems and the possi bi l i ty of severe si de effects have el i mi nated
thi s drug as a preferred treatment modal i ty.
In 1998, the Morbi di ty and Mortal i ty Weekl y Report publ i shed a l i st
of recommended therapi es, wi th several new therapi es si nce that
report. Treatment shoul d be gui ded by pati ent preference.
Practi ti oners shoul d be fami l i ar wi th at l east one pati ent-appl i ed
treatment (i .e., i mi qui mod and podofi l ox) and one provi der-appl i ed
therapy. Large exophyti c l esi ons general l y shoul d be pared down
before therapy.
Patient-Applied Treatments
Imiquimod Cream
Imi qui mod cream (Al dara) i s a i mmune-modi fyi ng agent that
i nduces mul ti pl e subtypes of i nterferon-al pha, several cytoki nes,
tumor necrosi s factor, and i nterl euki ns. These factors acti vate
natural ki l l er cel l s, T cel l s, pol ymorphonucl ear neutrophi l s, and
macrophages that attack the tumor. The drug has al most no
systemi c si de effects and i s a pregnancy cl ass B drug. It may hel p
i nduce i mmune memory and prevent future recurrence. Si de
Page 474
effects can i ncl ude erythema, erosi on, i tchi ng, ski n fl aki ng, and
edema. Therapy can be temporari l y hal ted i f symptoms become
probl emati c. Imi qui mod demonstrates cl earance rates of 72% for
women and 33% for men, wi th more than 50% wart reducti on rates
of 85% for women and 70% for men. The drug appears to work best
on moi st ti ssues, whi ch may account for i ts hi gher success rates i n
women.
Podofilox
Podofi l ox (Condyl ox) i s a puri fi ed, acti ve component of podophyl l i n.
Thi s puri fi ed form i s better standardi zed, safer, and i ndi cated for
pati ent appl i cati on. Podophyl l i n systemi c reacti ons may occur wi th
extensi ve appl i cati on, after appl i cati on to mucous membranes, or i f
l eft on the ski n for l ong peri ods. Reported reacti ons i ncl ude
nausea, vomi ti ng, fever, confusi on, coma, renal fai l ure, i l eus, and
l eukopeni a. Pai n and ul cerati on may al so occur. Because repeated
appl i cati on to the mouse cervi x produced dyspl asti c changes, i ts
use on the human uteri ne cervi x i s not recommended. It works by
i nhi bi ti on of nucl ear di vi si on at metaphase. Success rates vary from
44% to 88%.
P.303
Provider-Applied Treatments
Loop Electrosurgical Excisional Procedure
The l oop el ectrosurgi cal exci si onal procedure (LEEP) can be used to
treat peri neal condyl omata i n mal e and femal e pati ents. It may
al so produce ti ssue for the pathol ogi c study of l esi ons that are
questi onabl e or fai l to respond to treatment as expected. HPV can
be aerosol i zed, and HPV DNA has been found i n l aser and
el ectrocoagul ati on smoke. Operators shoul d wear a vi rus-fi l teri ng
mask. LEEP has not been extensi vel y studi ed i n pregnancy.
Loops used for the removal of external l esi ons are typi cal l y smal l er
and shorter than standard cervi cal l oops and are sel ected to al l ow
easy removal of the l esi on. The power setti ng must be hi gh enough
Page 475
to al l ow easy passage wi th l ow ti ssue drag through the l esi on and
epi dermi s. The smoke evacuator shoul d be acti vated before
performi ng LEEP. Anesthesi a can be obtai ned wi th 1% to 2%
l i docai ne wi th epi nephri ne (except on the peni s, where epi nephri ne
general l y i s avoi ded).
Fol l ow-up protocol s vary; typi cal l y, pati ents return i n 2 weeks to 1
months for fol l ow-up, unl ess unexpected pai n or i nfecti on becomes
a probl em. Late bl eedi ng has been reported i n 4% of pati ents
treated for vagi nal l esi ons, and i t can usual l y be control l ed wi th
Monsel 's sol uti on or ful gurati on. Infecti on i s an uncommon
compl i cati on that i s usual l y control l ed wi th topi cal (and rarel y,
systemi c) anti bi oti cs. Hypopi gmentati on and hypertrophi c scars are
rarel y reported. Success rates for treati ng noncervi cal l esi ons wi th
LEEP are i n the range of 90% to 96%.
Cryotherapy
Cryotherapy works by freezi ng and ki l l i ng abnormal ti ssue, whi ch
then sl oughs off, and new ti ssue grows i n i ts pl ace. Local i njecti on
or topi cal anesthesti c cream may be used but general l y i s
unnecessary. Recal ci trant l esi ons can be treated wi th a
freeze-thaw-refreeze techni que to i ncrease effi cacy. Fol l ow-up for
retreatment i s usual l y every 2 weeks unti l the l esi on i s resol ved.
The procedure does i nvol ve some pai n duri ng freezi ng and heal i ng.
Local i nfecti on and ul cerati on has been anecdotal l y reported. The
success rate for cryotherapy i s 71% to 79%.
Trichloroacetic Acid and Bichloracetic Acid
Tri chl oroaceti c aci d (TCA) and bi chl oraceti c aci d (BCA) work by
physi cal l y destroyi ng ti ssue. Because they are qui ckl y i nacti vated
after contact wi th ti ssue, toxi ci ty i s not a probl em. TCA can be
prepared i n di fferent strengths and must be compounded at a
pharmacy. BCA can be obtai ned i n a standard preparati on. The
fol l ow-up schedul e i s every 1 to 3 weeks unti l the l esi ons resol ve.
The depth of penetrati on of the aci d can be di ffi cul t to control , and
penetrati on through the dermi s can resul t i n sl ow-heal i ng
ul cerati ons and scar formati on. Pai n al so can be a probl em wi th thi s
Page 476
therapy. The response rates are between 50% and 81%, and there
i s a hi gh rate of recurrence.
Mechanical Excision
Shave bi opsy removal of external geni tal warts by sci ssors or
scal pel exci si on can be a si mpl e, effecti ve treatment. It may al so
produce ti ssue for the pathol ogi c
P.304
study. Sci ssors are especi al l y effecti ve for i sol ated peduncul ated
l esi ons. Cosmeti c resul ts are usual l y good, and the wound requi res
no sutures. Mechani cal exci si ons shoul d be performed at the mi ddl e
l evel of the dermi s. The goal i s to not penetrate too deepl y to
avoi d scarri ng. If penetrati on occurs to the l evel of fatty ti ssue,
convert the area to a fusi form exci si on, and cl ose wi th sutures.
INDICATIONS
El i mi nati on of obvi ous, symptomati c, or troubl esome
external geni tal warts
Debul ki ng HPV l esi ons before vagi nal del i very to prevent
bl eedi ng and teari ng of vagi nal or peri neal ti ssues
CONTRAINDICATIONS AND PRECAUTIONS
Imi qui mod i s not i ndi cated for use on occl uded mucous
membranes, the uteri ne cervi x, or i n chi l dren.
Imi qui mod may damage condoms or di aphragms.
Podofi l ox i s not recommended for use i n the vagi na,
urethra, peri anal area, or cervi x. It has not been studi ed
for pregnancy, but i ts parent compound i s
contrai ndi cated i n pregnancy.
LEEP i s not recommended for peni l e, vagi nal , and anal
verge l esi ons.
TCA and BCA are not recommended for use i n the
vagi na, cervi x, or uri nary meatus.
P.305
Page 477
PROCEDURE
Appl y the i mi qui mod cream to external geni tal warts three ti mes
each week every other day for up to 16 weeks. It shoul d be rubbed
i nto the l esi on to i ncrease absorpti on. The cream may be appl i ed to
the affected area, not excl usi vel y to the l esi on.
(1) Appl i cati on of i mi qui mod cream.
Appl y the podofi l ox sol uti on wi th an appl i cator or toothpi ck twi ce
dai l y for 3 consecuti ve days, wi th 4 consecuti ve days of no therapy
each week, for a maxi mum 4 weeks.
(2) Appl i cati on of podofi l ox.
P.306
To remove a l esi on wi th LEEP, fi rst i nject anestheti c under the si te.
Wi th the operator's hand resti ng agai nst the pati ent for stabi l i ty, a
medi um-si zed l oop or square l oop i s i ntroduced just above
Page 478
the base of the l esi on and pul l ed compl etel y through to debul k i t.
(3) Introduce a medi um-si zed l oop just above the base of the
l esi on, and pul l i t compl etel y through to debul k i t.
The remai ni ng l esi on shoul d be careful l y shaved down to the dermi s
usi ng the si de of the l oop and fi ne pai nt-brush or
featheri ng strokes. Ful gurati on can be used for hemostasi s, but i t
i s usual l y unnecessary. The bul k speci men may then be sent for
hi stol ogi c study i f desi red.
(4) The remai ni ng l esi on shoul d be careful l y shaved down to the
dermi s.
PITFALL: Care should be taken to not penetrate the dermis
Page 479
during the shave excision. A proper shave site has gently sloping
sides, dermis at the base, and no subcutaneous fat showing
through.
P.307
In cryotherapy, the l arge, cotton-ti pped appl i cators for l i qui d
ni trogen are easy to use and requi re l i ttl e ski l l . If usi ng a standard
l ong-handl ed, cotton-ti pped appl i cator, i ncrease the si ze of the
cotton head by pul l i ng wi sps of cotton off of a cotton bal l and
l oosel y rol l i ng them onto the appl i cator. Di p the appl i cator i nto
l i qui d ni trogen for 5 to 10 seconds, and then pl ace i t on the l esi on
unti l a 2-mm i ce bal l forms beyond the edges of the l esi on. Repeat
the appl i cati on once the i cebal l thaws. Therapy i s repeated at
2-week i nterval s unti l the l esi on resol ves. Cryouni ts usi ng NO2 may
al so be used (see Chapters 19 and 38).
(5) Di p the appl i cator i nto l i qui d ni trogen for 5 to 10 seconds, and
then pl ace i t on the l esi on unti l a 2-mm i ce bal l forms beyond the
edges of the l esi on.
A thi n l ayer of TCA or BCA sol uti on i s appl i ed onl y to the wart
i tsel f. If desi red, the normal surroundi ng ski n may be protected
wi th petrol eum jel l y, but i t i s unnecessary i f care i s used i n
appl i cati on of the aci d. Bi carbonate, tal c, or soap and water may be
used to neutral i ze any excess aci d. A 50% TCA sol uti on i s appl i ed
wi th a cotton-ti pped appl i cator or toothpi ck to the affected area
three ti mes each week for a maxi mum of 4 weeks (most commonl y
Page 480
used regi men), or an 80% sol uti on can be appl i ed twi ce dai l y for 3
consecuti ve days each week for a maxi mum of 4 weeks.
(6) Protect the normal ski n surroundi ng the l esi on wi th petrol eum
jel l y, and appl y a thi n l ayer of TCA or BCA to the wart.
Before mechani cal exci si on, wi pe the area to be shaved wi th
al cohol , and al l ow i t to dry. Inject anestheti c just beneath the
l esi on to rai se a wheal .
(7) Inject anestheti c just beneath the l esi on to rai se a wheal .
P.308
Stabi l i ze the area between the thumb and i ndex fi nger. Usi ng a no.
15 bl ade, shave the l esi on fl ush wi th the l evel of the normal
ti ssue. The bl ade shoul d be hel d nearl y paral l el to the surroundi ng
ski n. Pl ace the ti ssue i n formal i n, and send i t for pathol ogi c
Page 481
anal ysi s. Appl y Monsel 's sol uti on (i .e., ferri c subsul fate), pressure,
or cautery to stop bl eedi ng.
(8) Hol di ng a no. 15 bl ade nearl y paral l el to the surroundi ng ski n,
shave the l esi on fl ush wi th the l evel of the normal ti ssue.
PITFALL: Care should be taken to not penetrate the dermis
during the shave excision, because this can induce scarring.
Al ternati vel y, sci ssors may be used to remove the l esi ons. Wi th the
jaws of the sci ssors parti al l y cl osed, bri ng the smal l est poi nt of the
openi ng up agai nst the base of the l esi on. As soon as the sci ssors
start cutti ng the ski n, gentl y l i ft the l esi on upward wi th the bl ades
of the sci ssors as you are cutti ng. Thi s keeps the cut i n a shal l ow
pl ane that prevents formati on of a deep crater.
(9) Sci ssors may be used i nstead of a scal pel to exci se the l esi on.
P.309
Page 482
CODING INFORMATION
In addi ti on to the codes i n the fol l owi ng chart, you may al so
consi der usi ng beni gn exci si on from the geni tal i a codes
(1142011426) or mal i gnant exci si on from the geni tal i a codes
(1162011626), dependi ng on the pathol ogy fi ndi ngs.

2002 Average 50th
Percentile Fee

56501 Destructi on of l esi ons of the
vul va, si mpl e
$197
vul va, extensi ve
$700
56605* Bi opsy of vul va or peri neum,
1 l esi on
$184
56606* Bi opsy of vul va or peri neum,
each addl l esi on
$98
vagi na, si mpl e
$267
vagi na, extensi ve
$745
57100 Bi opsy of vagi nal mucosa,
si mpl e
$208
57105 Bi opsy of vagi na, extensi ve
and requi ri ng suture cl osure
$446
57135 Exci si on of vagi nal cyst or
tumor
$528
Suppl i ers for LEEP i ncl ude Ci rcon/Cryomedi cs, 2021 Cabot Boul evard
West, Langhorne, PA 19047 (http://www.acmi corp.com/acmi /user);
El l man Internati onal , 1135 Rai l road Avenue, Hewl ett, NY 11557 (
http://www.el l man.com); Utah Medi cal Products, 7043 South 300
Page 483
West, Mi dval e, UT 84074 (http://www.utahmed.com); and Wal l ach
Surgi cal Devi ces, 291 Pepe's Farm Road, Mi l ford, CT 06460 (
http://www.wal l achsurgi cal .com). A suggested anesthesi a tray that
can be used for thi s procedure i s l i sted i n Appendi x G.
Cryotherapy (NO2) uni ts can be obtai ned from Ci rcon/Cryomedi cs,
2021 Cabot Boul evard West, Langhorne, PA 19047
(http://www.acmi corp.com/acmi /user) and from Wal l ach Surgi cal
Devi ces, 291 Pepe's Farm Road, Mi l ford, CT 06460 (
http://www.wal l achsurgi cal ). Li qui d ni trogen Cryoguns can be
obtai ned from nati onal medi cal suppl y houses such as the Henry
Schei n Medi cal Catal og. Li qui d Ni trogen can usual l y be obtai ned
from l ocal suppl i ers.
TCA must be compounded at a pharmacy. It can be obtai ned from
pharmaci es that are members of the Professi onal Compoundi ng
Pharmaci es of Ameri ca (Houston, TX). To l ocate a member pharmacy
or obtai n compoundi ng i nformati on, cal l thei r tol l -free number
(800-331-2498).
P.310
Imi qui mod cream i s avai l abl e by prescri pti on from pharmaci es. The
Aseptex submi cron surgi cal mask (#1812) i s avai l abl e from 3M
Surgi cal Di vi si on, St. Paul , MN 55144.
BIBLIOGRAPHY
Annekathryn G, Zukerberg LR, Ni krui N, et al . Vagi nal adenosi s and
cl ear cel l carci noma after 5-fl uorouraci l treatment for condyl omas.
Cancer 1991;68:16281632.
Bergman A, Bhati a NN, Broen EM. Cryotherapy for the treatment of
geni tal condyl omata duri ng pregnancy. J Reprod Med
1984;29:432435.
Beutner KR, Von Krogh G. Current status of podophyl l otoxi n for the
treatment of geni tal warts. Semi n Dermatol 1990;9:148151.
Byrne MA, Robi nson DT, Munday PE, et al . The common occurrence
of human papi l l omavi rus i nfecti on and i ntraepi thel i al neopl asm i n
women i nfected wi th HIV. AI DS 1989;3:379382.
Page 484
Centers for Di sease Control and Preventi on. 1998 Sexual l y
transmi tted di seases treatment gui del i nes. MMWR Morb Mortal Wkl y
Rep 1998;47(Suppl ):8895.
Edwards L, Ferecenzy A, Eron L, et al . Sel f-admi ni stered topi cal 5%
i mi qui mod cream for external anogeni tal warts. Arch Dermatol
1998;134:2530.
Ferenczy A. Treatment of external geni tal warts. J Low Geni tal
Tract Di s 2000;4:128134.
Fl etcher JL. Peri natal transmi ssi on of human papi l l omavi rus. Am
Fam Physi ci an 1991;43:143148.
Gi l son RJ, Shupack JL, Fri edman-Ki en AE, et al . A randomi zed,
control l ed, safety study usi ng i mi qui mod for the topi cal treatment
of anogeni tal warts i n HIV-i nfected pati ents. Imi qui mod Study
Group. AI DS 1999;13:23972404.
Greene I. Therapy for geni tal warts. Dermatol Cl i n
1992;10:253267.
Hatch KD. Vul vovagi nal human papi l l omavi rus i nfecti ons: cl i ni cal
i mpl i cati ons and management. Am J Obstet Gynecol
1991;165:11831188.
Kl i ng AR. Geni tal wartstherapy. Semi n Dermatol
1992;11:247255.
Krebs HB, Hel mkamp BF. Treatment fai l ure of geni tal condyl omata
i n women: rol e of the mal e sexual partner. Obstet Gynecol
1991;165:337340.
Megyeri K, Au WC, Rosztoczy I, et al . Sti mul ati on of i nterferon and
cytoki ne gene expressi on by i mi qui mod and sti mul ati on of Sendai
vi rus uti l i ze si mi l ar si gnal i nducti on pathways. Mol Cel l Bi ol
1988;10:209224.
Nori ns AL, Caputo RV, Luckey AW, et al . Geni tal warts and sexual
abuse i n chi l dren. J Am Acad Dermatol 1984;11:529530.
Ri chart R. Ways of usi ng LEEP for external l esi ons. Contemp Obstet
Gynecol 1992;5:138152.
Sawchuk WS, Weber PJ, Lowy DR, et al . Infecti ous papi l l omavi rus i n
the vapor of warts treated wi th carbon di oxi de l aser or
el ectrocoagul ati on: detecti on and protecti on. J Am Acad Dermatol
Page 485
1989;21:4149.
Si egel JF, Mel l i nger BC. Human papi l l omavi rus i n the mal e pati ent.
Urol Cl i n North Am 1992;19:8391.
Watts DH, Koutsky LA, Hol mes KK, et al . Low ri sk of peri natal
transmi ssi on of human papi l l omavi rus: resul ts from a prospecti ve
cohort study. Am J Obstet Gynecol 1998;178:365373.
Page 486
> Table of Cont ent s > Gynecology and Urology > 42 - Fine- Needle Aspirat ion of
t he Breast 42
Fine-Needle Aspiration of the Breast
Fi ne-needl e aspi rati on (FNA) cytol ogy i s a rapi d, safe, i nexpensi ve,
and atraumati c method of sampl i ng cysti c and sol i d breast masses.
It i s commonl y performed i n the offi ce setti ng by a pri mary care
cl i ni ci an, surgeon, or occasi onal l y, a cytopathol ogi st. FNA can
rel i abl y di agnose beni gn and mal i gnant condi ti ons (Tabl e 42-1) and
has a fal se-negati ve rate for experi enced practi ti oners of 3% to
5%. The accuracy of the procedure somewhat depends on the ski l l
of the cl i ni ci an i n performi ng the bi opsy and of the pathol ogi st i n
readi ng the smear. FNA may al so be used to assess recurrent
masses after l umpectomy.
TABLE 42-1. APPROXIMATE FREQUENCY OF COMMON FINDINGS IN WOMEN WITH
BREAST LUMPS

Finding Frequency

Fi brocysti c changes 40%
No di sease 30%
Mi scel l aneous beni gn changes 13%
Cancer 10%
Fi broadenoma 7%
One of the major benefi ts of usi ng FNA on a breast mass i s the
abi l i ty to determi ne whether a l esi on i s cysti c or sol i d. Typi cal l y,
mammography cannot di sti ngui sh between a cysti c or sol i d l esi on.
However, when the needl e i s i nserted i nto the l esi on and
negati ve-pressure appl i ed, fl ui d i s readi l y obtai ned from a cyst.
Page 487
After the cyst i s drai ned, the si te shoul d be exami ned to excl ude a
persi sti ng mass, whi ch woul d requi re a bi opsy to rul e out the
presence of cysti c carci noma. If the cyst compl etel y di sappears, the
pati ent shoul d be reexami ned i n 1 month. If the cyst recurs, i t can
be drai ned one addi ti onal ti me and reexami ned i n another month. If
i t recurs a second ti me, the pati ent shoul d be referred for exci si on
of the l esi on to excl ude cysti c carci noma.
FNA, l i ke al l breast di agnosti c techni ques, i s i mperfect. However,
the tri pl e di agnosti c techni que of cl i ni cal breast exami nati on, FNA,
and mammography can provi de very useful i nformati on for the
woman, especi al l y when al l three techni ques suggest the l esi on i s
beni gn. Thi s al l ows many cl i ni ci ans to reassure the pati ent wi th
si mpl e outpati ent testi ng. Lesi ons that appear suspi ci ous on any of
the tri pl e di agnosti c tests shoul d be referred for bi opsy (Tabl e
42-2).
TABLE 42-2. COMMON MORPHOLOGIC FEATURES OF INVASIVE CANCER

Focal l esi ons extendi ng progressi vel y i n al l di recti ons
Lesi ons adherent (fi xed) to the deep chest wal l fasci a
Lesi ons extendi ng to the ski n and produci ng retracti on and di mpl i ng
Lymphati c bl ockage produci ng ski n thi ckeni ng, l ymphedema, and peau d'orange
(orange peel ) changes
Mai n ductal i nvol vement produci ng ni ppl e retracti on
Wi despread i nfi l trati on of the breast produci ng acute redness, swel l i ng, and
tenderness (i .e., i nfl ammatory carci noma)
Adapted from Cotran RS, Kumar V, Robbi ns SL, et al . Robbi ns pathol ogi c basi s of
di sease. Phi l adel phi a: WB Saunders, 1994:10891111.
When a mass i s di scovered, the breast can be reexami ned at the
opti mal ti me of the menstrual cycl e (i .e., days 4 to 10 of the
cycl e). Mammography i s usual l y performed before that offi ce vi si t i f
the woman i s of an appropri ate age. If FNA i s performed before
Page 488
mammography, al l ow at l east 2 weeks to el apse before attempti ng
mammography, so that any hematoma at the si te i s not erroneousl y
descri bed as a mal i gnancy. Mammographi cal l y i denti fi ed,
nonpal pabl e l esi ons shoul d not be approached wi th FNA i n the
offi ce setti ng.
The basi c pri nci pl e of FNA i nvol ves movi ng a 22- to 25-gauge
needl e back and forth wi thi n a l esi on, under sucti on from a 10- to
20-mL syri nge, to shave
P.312
and aspi rate cel l s and smal l ti ssue sampl es from the l esi on.
Several devi ces are avai l abl e to make i t easi er for the cl i ni ci an to
mai ntai n sucti on duri ng the sampl i ng process. A si mpl e 20-mL
syri nge and needl e al so may be used, but thi s i s consi dered i nferi or
because effort and attenti on must be di verted from the movement
of the needl e to mai ntai ni ng sucti on. The FNA-21 (Cooper Surgi cal )
i s an el egant devi ce wi th a spri ng wi thi n the syri nge. The spri ng
provi des negati ve pressure, al l owi ng the cl i ni ci an to focus on
pl acement of the needl e ti p. Ski n anesthesi a often i s unnecessary
for FNA, but l ocal 1% l i docai ne or l ocal col d therapy may be used i f
desi red. Steri l e drapes are usual l y unnecessary.
Recommended fol l ow-up protocol s for FNA resul ts are shown i n
Tabl e 42-3. When i nadequate smears are obtai ned, the procedure
can easi l y be repeated, often resul ti ng i n a sati sfactory speci men.
However, i f an adequate sampl e cannot be obtai ned, the cl i ni ci an
shoul d vi gorousl y pursue other bi opsy opti ons because cancers may
be mi ssed, especi al l y l obul ar cancer and ductal carci noma i n si tu.
TABLE 42-3. BREAST NEEDLE ASPIRATION CYTOLOGY OF SOLID LESIONS AND
RECOMMENDED FOLLOW-UP
Page 489

Result Suggested Follow-up

Scant or i nsuffi ci ent cel l s for di agnosi s Repeat needl e aspi rati on or bi opsy i f
cl i ni cal suspi ci on i s hi gh
Beni gnfi broadenoma Reassurance or symptomati c treatment i f
cel l ul ar changes are not compl ex or
associ ated wi th atypi cal hyperpl asi a
Beni gnfi brocysti c Symptomati c treatment i f not associ ated
wi th atypi cal hyperpl asi a
Beni gnother (i ncl udes fat necrosi s,
l i poma, i nfl ammati on, papi l l oma, and other
beni gn ductal epi thel i um)
Reassurance and cl i ni cal fol l ow-up
Atypi cal cel l s Cl i ni cal fol l ow-up can be consi dered reacti ve
or degenerati ve atypi a (seen i n fi brocysti c
change); mammogram and bi opsy for most
atypi a (especi al l y i f severe atypi a)
Suspi ci ous for mal i gnancy Surgi cal referral and bi opsy
Mal i gnant cel l s Surgi cal referral and bi opsy

The major ri sk of the FNA procedure i s fai l ure to pl ace the needl e
ti p i nto the l esi on. Si gni fi cant compl i cati ons of FNA, such as
pneumothorax, are rare. Some pati ents experi ence mi l d soreness,
hematoma formati on, and ski n di scol orati on. The pati ent wi th
control l ed anti coagul ati on may safel y undergo FNA i f parameters
are i n the therapeuti c range and adequate si te compressi on i s used
after the procedure to avoi d hematoma. Al l pati ents undergoi ng
FNA of breast l esi ons shoul d wear a supporti ve brassi ere after the
procedure.
In the past, there was concern about the possi bi l i ty of spreadi ng
mal i gnant cel l s by the needl e. However, occurrence of thi s probl em
has not been documented. Infecti on i s rare, and prophyl axi s for
bacteri al endocardi ti s i s not requi red.
P.313
Page 490
INDICATIONS
Presence of a pal pabl e suspi ci ous mass i n the breast
CONTRAINDICATIONS
Local i nfecti on
Absence of a qual i fi ed cytopathol ogi st capabl e of
i nterpretati on of the FNA sl i des
Lack of cl i ni ci an trai ni ng wi th the procedure
Severel y i mmunocompromi sed pati ents (rel ati ve
P.314
PROCEDURE
The FNA21 devi ce has the advantage of total focus of the
physi ci an's muscl es and attenti on on the needl e ti p, i nstead of on
creati ng sucti on and on movement. In contrast, the mechani cal
movement for the Cameco pi stol syri nge (Fi gure 1B) i s produced by
moti on of the arm and el bow. A 21-gauge butterfl y wi th extensi on
tubi ng can be attached to any devi ce or syri nge, wi th a nurse
appl yi ng the back pressure and the cl i ni ci an focusi ng ful l attenti on
on the needl e ti p (Fi gure 1C). We recommend the FNA21 or the
butterfl y techni que because of the greater tacti l e sense and control
of the needl e.
Page 491
(1) Vari ous FNA-assi st devi ces.
P.315
Page 492
Pal pate the l esi on, and mark the ski n to i ndi cate the poi nt of
needl e entry. Prep the ski n wi th 70% i sopropyl al cohol or
povi done-i odi ne. Attach the needl e, and draw approxi matel y 1 mL
of ai r i nto the syri nge.
(2) Attach the needl e, and draw approxi matel y 1 mL of ai r i nto the
syri nge.
PITFALL: Avoid injecting air because this may cause a vascular
air embolus.
Use the nondomi nant hand to surround and stabi l i ze the l esi on.
Surroundi ng the l esi on al l ows the sensory porti on of the fourth and
fi fth fi ngers to feel the needl e ti p enter the l esi on as the l esi on
moves agai nst these fi ngers. Rarel y, the gl ove may need to be
removed from the nondomi nant hand i f i t i nterferes wi th pal pati on
of the l esi on. Make sure the pati ent understands why the gl ove i s
bei ng removed.
PITFALL: Use care to avoid putting the needle tip through the
breast and into the examiner' s hand.
Page 493
(3) Use the nondomi nant hand to surround and stabi l i ze the l esi on.
PITFALL: Isolating the lesion by using the nondominant hand to
press the lesion down against the chest wall increases the risk
of a pneumothorax.
P.316
Insert the needl e i nto the l esi on, and ful l y wi thdraw the pl unger to
create a vacuum. If the FNA-21 needl e i s used, rel ease the spri ng
to create back pressure once the needl e ti p enters the l esi on. Make
10 to 20 up-and-down passes, keepi ng the needl e i n the l esi on.
The sampl e wi l l fi l l the needl e and possi bl y part of the hub. Wi th
the needl e sti l l i n the l esi on, return the pl unger to the resti ng
posi ti on to rel ease the sucti on. Then wi thdraw the needl e from the
ski n.
PITFALL: Do not let the needle come out of the skin while a
vacuum is present in the syringe. This causes the sample to be
drawn up into the syringe, where it may be difficult to remove.
Page 494
(4) Insert the needl e i nto the l esi on and ful l y wi thdraw the pl unger
to create a vacuum.
PITFALL: It is not necessary to change the angle of the needle
during the FNA, because it is the passage of the needle into the
center of a lesion and the subsequent back-and-forth motion of
the needle tip around the initial needle pass that allow shaved
fragments of cells to enter the syringe. Moving the needle tip off
this initial path in the center of the lesion often results in the
needle moving out of the lesion and causes undo errors.
P.317
Wi th the needl e poi nted downward, use the ai r i n the syri nge to
deposi t the sampl e onto the sl i de (Fi gure 5A). Pl ace another gl ass
sl i de upsi de down on top of the ori gi nal sl i de, and then gentl y pul l
the sl i des i n opposi te di recti ons to smear the cel l ul ar contents over
both sl i des (Fi gure 5B). Appl y spray fi xati ve as when obtai ni ng a
Papani col aou smear. Thi s techni que usual l y yi el ds two to four
sl i des. If a sol i d-core speci men i s expressed from the needl e (rare),
wash i t from the sl i de i nto a vi al of preservati ve, and submi t i t for
hi stol ogi c exami nati on (Fi gure 5C). Remove the syri nge from the
needl e, repl ace i t wi th a fresh one, and repeat the procedure i f
Page 495
desi red.
Page 496
Page 497
(5) Wi th the needl e poi nted downward, use the ai r i n the syri nge to
deposi t the sampl e onto the sl i de.
P.318
If a l esi on i s cysti c and fl ui d i s obtai ned, draw as much as possi bl e
i nto the syri nge. If the cyst compl etel y di sappears and the fl ui d i s
not bl oody, the fl ui d does not have to be sent for anal ysi s.
Otherwi se, submi t the fl ui d on sl i des or i n a steri l e (wi thout
anti coagul ant) bl ood col l ecti on tube.
(6) If a l esi on i s cysti c, draw as much fl ui d as possi bl e i nto the
syri nge.
P.319
Appl y compressi on to the aspi rati on si te wi th a gauze pad for 5 to
10 mi nutes to hel p mi ni mi ze brui si ng. Pl ace several fol ded gauze
pads under a snug brassi ere to form a compressi on dressi ng.
Page 498
Instruct the pati ent to l eave i t i n pl ace for several hours to prevent
hematoma formati on. A smal l i ce pack can be appl i ed to the FNA
si te for 15 to 60 mi nutes after the procedure.
(7) To hel p mi ni mi ze brui si ng, compress the i nserti on si te wi th a
gauze pad for 5 to 10 mi nutes.
P.320
CODING INFORMATION
2002 Average 50th
Percentile Fee
19000* Aspi rati on drai nage of a
breast cyst; one cyst
$138
19001 Aspi rati on drai nage of a
breast cyst; each addi ti onal
$72
Page 499
cyst
10021 FNA wi thout i magi ng
gui dance
$102

The Cameco syri nge pi stol ($286) i s avai l abl e from Preci si on
Dynami cs Corporati on, 13880 Del Sur Street, San Fernando, CA
91340-3490 (phone: 1-800-772-1122; http://www.pdcorp.com,
al though thi s i tem i s not on thei r web si te) and from Morton
Medi cal Ltd., 262a Ful ham Road, London SW10 9EL (phone, UK onl y:
0207 352 1297; phone outsi de of the UK: +44 207 352 1297;
http://www.mortonheal thcare.co.uk/products_i ndex.htm).
The FNA-21 Fi ne Needl e Aspi rati on Devi ce ($13 each) i s a steri l e,
si ngl e-use, spri ng-l oaded syri nge and 21-gauge needl e. It i s
avai l abl e i n 1 sampl e pack and i n 3, 12, and 24 packs. It i s
avai l abl e from CooperSurgi cal (phone: 1-800-243-2974; fax:
1-800-262-0105).
BIBLIOGRAPHY
Al -Kai si N. The spectrum of the gray zone i n breast
cytol ogy. Acta Cytol 1994;38:898908.
Conry C. Eval uati on of a breast compl ai nt: i s i t cancer? Am Fam
Physi ci an 1994;49:445450, 453454.
Eri ckson R, Shank JC, Gratton C. Fi ne-needl e breast aspi rati on
bi opsy. J Fam Pract 1989;28:306309.
Frabl e W. Thi n-needl e aspi rati on bi opsy. Am J Cl i n Pathol
1976;6:168182.
Hamburger JI. Needl e aspi rati on for thyroi d nodul es: ski p
ul trasounddo i ni ti al assessment i n the offi ce. Postgrad Med
Page 500
1988;84:6166.
Hammond S, Keyhani -Rofagha S, O'Tool e RV. Stati sti cal anal ysi s of
fi ne-needl e aspi rati on cytol ogy of the breast. A revi ew of 678 cases
pl us 4,265 cases from the l i terature. Acta Cytol 1987;3:276280.
Ku NNK, Mel a NJ, Fi ori ca JV, et al . Rol e of fi ne needl e aspi rati on
cytol ogy after l umpectomy. Acta Cytol 1994;38:927932.
Layfi el d LJ, Chri schi l l es EA, Cohen MB, et al . The pal pabl e breast
nodul e. Cancer 1993;72:16421651.
Lee KR, Foster RS, Papi l l o JL. Fi ne-needl e aspi rati on of the breast:
i mportance of the aspi rator. Acta Cytol 1987;3:281284.
Lever JV, Trott PA, Webb AJ. Fi ne-needl e aspi rati on cytol ogy. J Cl i n
Pathol 1985;3:111.
Stanl ey MW. Fi ne-needl e aspi rati on bi opsy: di agnosi s of cancerous
masses i n the offi ce. Postgrad Med 1989;85:163172.
Vural G, Hagmar B, Li l l eng R. A one-year audi t of fi ne needl e
aspi rati on cytol ogy of breast l esi ons. Acta Cytol
1995;39:12331236.
Page 501
> Table of Cont ent s > Gynecology and Urology > 43 - Fit t ing Cont racept ive
Diaphragms43
Fitting Contraceptive Diaphragms
Contracepti ve di aphragms provi de effecti ve, reversi bl e, epi sodi c
contracepti on wi thout hormonal i nfl uence. The devi ce consi sts of a
shal l ow, cup-shaped, l atex or si l i cone sheet anchored to a ci rcul ar
outer spri ng that i s contai ned i n the ri m. A di aphragm acts as a
physi cal barri er that prevents sperm from enteri ng the cervi x and
hol ds spermi ci de i n pl ace as an addi ti onal barri er. Di aphragms are
al ways used i n combi nati on wi th spermi ci des, whi ch usual l y contai n
nonoxynol -9 as thei r acti ve i ngredi ent, but preparati ons wi th
octoxynol -9 al so are avai l abl e.
Di aphragms are avai l abl e by prescri pti on from most pharmaci es.
They range i n si ze from 50 to 105 mm i n di ameter, wi th the 65- to
80-mm si zes most commonl y prescri bed. The di aphragm must be
fi tted by the practi ti oner i n the offi ce. Si zi ng must be rechecked 6
weeks after the bi rth of a chi l d, after si gni fi cant wei ght gai n or
l oss, and yearl y. Avoi d devi ces that are too l arge (i .e.,
uncomfortabl e or press on the urethra excessi vel y) or too smal l
(i .e., easi l y di spl aced or expel l ed). When the di aphragm i s pi nched,
the devi ce fol ds i nto an arc. Thi s al l ows the posteri or edge to
easi l y sl i p behi nd the cervi x and faci l i tates i nserti on. Di aphragms
requi re a hi gh l evel of pati ent moti vati on and compl i ance to be
effecti ve, and they may be used i n combi nati on wi th condoms to
hel p prevent transmi ssi on of human i mmunodefi ci ency vi rus (HIV).
They remai n popul ar because they do not use hormones, and most
pati ents and thei r partners cannot feel them when they are properl y
fi tted.
Di aphragms are l atex-based appl i ances and therefore shoul d be
avoi ded i n l atex-al l ergi c i ndi vi dual s. Pati ents shoul d be educated
that oi l -based l ubri cants may di ssol ve the l atex and cause
Page 502
contracepti ve fai l ure. The di aphragm shoul d be cl eaned after every
use wi th mi l d soap and water, gentl y dri ed, and stored i n a
protecti ve contai ner. The user shoul d never appl y powders on the
devi ce and shoul d al ways i nspect for hol es or damage before use.
Uri nary tract i nfecti ons may be more common i n di aphragm users,
but voi di ng after i ntercourse may hel p avoi d thi s compl i cati on.
The contracepti ve di aphragm has a fai l ure rate between 13% and
23%. Younger users (<25 years) and pati ents who have i ntercourse
more than four ti mes each week may have a hi gher fai l ure rate.
Di aphragms may be i nserted up to 6 hours before i ntercourse, and
they must be removed 6 to 24 hours after i ntercourse. Addi ti onal
spermi ci de must be appl i ed i ntravagi nal l y wi th an appl i cator
P.322
before any addi ti onal epi sodes of i ntercourse. When usi ng these
contracepti ve methods, the possi bi l i ty of system fai l ure or pati ent
noncompl i ance must be anti ci pated. Many pati ents can benefi t from
di scussi on about emergency contracepti on when a barri er method i s
deci ded on and peri odi cal l y thereafter.
INDICATIONS
Nonhormonal , reversi bl e contracepti on
CONTRAINDICATIONS
Vagi nal stenosi s
Uteri ne prol apse
Hi story of toxi c shock syndrome
Congeni tal vagi nal abnormal i ti es (septum)
Pati ent l ess than 6 weeks postpartum
Vagi nal cysts
Petrol eum-based products that may damage l atex
di aphragms
Latex and drug al l ergi es to the spermi ci des
P.323
Page 503
PROCEDURE
Expl ai n the di aphragm-fi tti ng procedure, and obtai n i nformed
consent. Wi th the pati ent i n the dorsal l i thotomy posi ti on, perform
a pel vi c exami nati on to rul e out di sease and i denti fy atypi cal
anatomy. Duri ng the bi manual exami nati on, pl ace the mi ddl e fi nger
i nto the posteri or cul -de-sac. Use the thumb to mark the poi nt
where the symphysi s pubi s abuts the i ndex fi nger (Fi gure 1A). The
di stance from the ti p of the mi ddl e fi nger to the poi nt marked on
the i ndex fi nger i s the approxi mate di ameter of the di aphragm. The
fi tti ng ri ng or di aphragm i s sel ected by measuri ng the marked
l ength or by pl aci ng the ri ng agai nst the measurement fi ngers
(Fi gure 1B).
(1) The di stance between the ti p of the mi ddl e fi nger to the poi nt
Page 504
marked on the i ndex fi nger i s the approxi mate di ameter of the
di aphragm.
P.324
Besi des the si ze measured, try i nserti ng di aphragms that are one
si ze l arger and one si ze smal l er, and prescri be the one that fi ts
best. When properl y fi tted, there shoul d be about a fi ngerti p's
wi dth between the di aphragm and the symphysi s pubi s, a good seal
wi th the l ateral vagi nal wal l s, and no sensati on of ti ghtness or
pressure. The di aphragm i s removed by hooki ng the i ndex fi nger
under the ri ng behi nd the symphysi s and pul l i ng.
(2) The di aphragm i s removed by hooki ng the i ndex fi nger under
the ri ng behi nd the symphysi s and pul l i ng.
PITFALL: Have the patient perform a Valsalva maneuver (i.e.,
cough). If the diaphragm is displaced or comes out, select the
next larger size, and try again.
PITFALL: Caution the patient not to puncture the diaphragm
with a long or ragged fingernail.
P.325
The woman shoul d then practi ce i nserti ng (wi th water-sol ubl e
l ubri cant), checki ng for pl acement, and removi ng the di aphragm i n
Page 505
the offi ce. A di aphragm that i s di ffi cul t for the woman to remove
may be too smal l . Have her wal k around and make sure the
di aphragm stays i n pl ace.
(3) The pati ent shoul d practi ce i nserti ng, checki ng for pl acement,
and removi ng the di aphragm i n the offi ce before headi ng home.
P.326
CODING INFORMATION
2002 Average 50th
Percentile Fee
57170 Di aphragm or cervi cal cap
fi tti ng wi th i nstructi ons
$82
Page 506
Di aphragms (e.g., Ortho-fl ex) are di spensed by prescri pti on from
pharmaci es. Fi tti ng ri ngs may be obtai ned from Ortho-McNei l
Pharmaceuti cal s (http://www.ortho-mcnei l .com/) or from your l ocal
Ortho-McNei l pharmaceuti cal representati ve.
BIBLIOGRAPHY
Bul ut A, Ortayl i N, Ri nghei m K, et al . Assessi ng the acceptabi l i ty,
servi ce del i very requi rements, and use-effecti veness of the
di aphragm i n Col ombi a, Phi l i ppi nes, and Turkey. Contracepti on
2001;63:267275.
Crai g S, Hepburn S. The effecti veness of barri er methods of
contracepti on wi th and wi thout spermi ci de. Contracepti on
1982;26:347359.
Fi hn SD, Latham RH, Roberts P, et al . Associ ati on between
di aphragm use and uri nary tract i nfecti ons. JAMA
1986;25:240245.
Grady MR, Haywood MD, Yagi J. Contracepti ve fai l ure i n the Uni ted
States. Esti mates from the 1982 Nati onal Survey of Fami l y Growth.
Fam Pl an Perspect 1986;18:200.
Graves WK. Contracepti on. In: Gl ass RH, Curti s MG, Hopki ns MP,
eds. Gl ass's offi ce gynecol ogy, 5th ed. Phi l adel phi a: Li ppi ncott
Wi l l i ams & Wi l ki ns, 1999:6194.
Hatcher RA, Stewart F, Trussel J, et al . Contracepti ve technol ogy,
15th ed. New York: Iverti ng, 1992.
Hooton TM, Hi l l i er S, Johnson C, et al . Escheri chi a col i bacteri uri a
and contracepti ve method. JAMA 1991;265:6469.
Hooton TM, Schol es D, Stapl eton AE, et al . A prospecti ve study of
asymptomati c bacteri uri a i n sexual l y acti ve young women. N Engl J
Med 2000;343:992997.
Mauck C, Cal l ahan M, Wei ner DH, et al . A comparati ve study of the
safety and effi cacy of FemCap, a new vagi nal barri er contracepti ve,
and the Ortho Al l -Fl ex di aphragm. Contracepti on 1999;60:7180.
Speroff L, Darney P. A cl i ni cal gui de for contracepti on, 2nd ed.
Bal ti more: Wi l l i ams & Wi l ki ns, 1996.
Page 507
> Table of Cont ent s > Gynecology and Urology > 44 - Int raut erine Device
Insert ion and Removal44
Intrauterine Device Insertion and
Removal
The i ntrauteri ne devi ce (IUD) i s the most commonl y used method of
reversi bl e contracepti on worl dwi de. However, i t i s used by onl y 1%
of women i n the Uni ted States who desi re reversi bl e contracepti on.
The i nfrequent use i n thi s country resul ts from publ i c fear of heal th
ri sks, compl i cated and promoted by medi col egal factors.
The IUD was devel oped i n the Uni ted States and was popul ar i n
thi s country unti l the mi d-1970s, when the Dal kon Shi el d came i nto
use and was associ ated wi th ascendi ng uteri ne i nfecti ons. Thi s
compl i cati on was not i ntri nsi c to al l IUDs, but was caused by use of
a brai ded IUD stri ng that provi ded a path for bacteri a to enter the
uterus. Thi s resul ted i n ascendi ng i nfecti ons, pel vi c i nfl ammatory
di sease, and i nferti l i ty. The devi ce was removed from the market i n
1975. Al though other IUDs, especi al l y those contai ni ng copper,
were safe and effecti ve, l i ti gati on and other economi c factors l ed to
most of them bei ng removed from the market i n the earl y 1980s.
The Copper T380A (ParaGard, Ortho-McNei l , Rari tan, NJ), i ntroduced
i n 1988, i s now commonl y used by pri mary care practi ti oners. It
contai ns copper on a pol yethyl ene T-shaped frame that i s 32 mm
wi de and 36 mm l ong. It may be used for 10 years before
repl acement and has a fai l ure rate of l ess than 1%. The Copper
T380A i s one of the most thoroughl y studi ed IUDs. Careful pati ent
sel ecti on, good pati ent educati on, and thorough i nformed consent
have greatl y reduced the medi col egal ri sk wi th thi s IUD. A 5-year
IUD (Mi rena, Berl ex Laboratori es, Montvi l l e, NJ) has emerged on the
U.S. market. The major advantage of thi s devi ce i s the reducti on of
bl eedi ng after 6 months of use. Approxi matel y 20% of women
experi ence amenorrhea after 1 year of use.
Page 508
The pri mary mechani sm of acti on of the Copper T380A IUD i s
probabl y through the spermi ci dal effects of the copper. Sperm are
damaged i n transi t, and few reach the ovum. Those that do ascend
are general l y i n poor shape. There al so may be al terati ons i n
cervi cal mucus produced by the IUD. IUDs al so cause a forei gn body
i nfl ammatory reacti on. The l evonorgestrel -rel easi ng system
provi des pregnancy preventi on by thi nni ng the l i ni ng of the uterus,
i nhi bi ti on of sperm movement, and thi ckeni ng of cervi cal mucus.
There i s mi ni mal sci enti fi c evi dence (despi te more than 30 years of
study) that the IUD i s an aborti faci ent. However, i f a pati ent i s not
abl e to accept thi s as a possi bl e mi ni mal mechani sm of acti on,
P.328
she may wi sh to consi der an al ternati ve form of bi rth control . IUDs
have a l ower actual fai l ure rate i n cl i ni cal use than oral
contracepti ves and most other reversi bl e contracepti ve methods.
Ferti l i ty usual l y returns promptl y after removal of an IUD.
The Copper T380A may be i nserted any ti me after del i very, after
aborti on, or duri ng the menstrual cycl e. The advantages of i nserti on
duri ng a menstrual peri od i ncl ude a possi bl y more open cervi cal
canal , the maski ng of i nserti on-rel ated bl eedi ng, and the
knowl edge that the pati ent i s not pregnant. Inserti ons can be more
di ffi cul t when the cervi x i s cl osed between peri ods.
Inserti on can be performed between 4 and 8 weeks postpartum
wi thout an i ncrease i n pregnancy rates, expul si on, uteri ne
perforati on, or removal for bl eedi ng or pai n. Inserti on can even
occur i mmedi atel y after a vagi nal del i very wi thout an i ncreased ri sk
of i nfecti on, uteri ne perforati on, postpartum bl eedi ng, or uteri ne
subi nvol uti on i f no i nfecti on i s present. Expect a sl i ghtl y hi gher
expul si on rate compared wi th i nserti on 4 to 8 weeks postpartum.
The IUD al so can be i nserted at the ti me of cesarean secti on, wi th
the expul si on rate sl i ghtl y l ower than i mmedi atel y after vagi nal
del i very. Inserti on of an IUD i n breast-feedi ng women i s associ ated
wi th a l ower removal rate for bl eedi ng or pai n. An IUD can be
i nserted i mmedi atel y after a fi rst-tri mester aborti on, but the
Page 509
pati ent shoul d wai t after a second-tri mester aborti on unti l uteri ne
i nvol uti on occurs.
Pati ent sati sfacti on studi es have reveal ed hi gher rati ngs for IUDs
than for most other contracepti ve methods. Increased menstrual
bl eedi ng and crampi ng i s a typi cal si de effect of IUD use. Bl eedi ng
causes removal of the T380A duri ng the fi rst year i n 5% to 15 % of
pati ents. Nonsteroi dal anti i nfl ammatory drugs often hel p reduce
these probl ems.
Infecti ons caused by IUDs usual l y occur wi thi n the fi rst 20 days
after i nserti on. The overal l rate of i nfecti on i s onl y 0.3%.
Doxycycl i ne (200 mg) or azi thromyci n (500 mg) may be gi ven oral l y
1 hour before i nserti on to reduce the rate of i nserti on-rel ated
i nfecti ons. Defi ni ti ve studi es that demonstrate benefi ts of
prophyl acti c anti bi oti cs wi th IUD i nserti on are yet to be performed
and the need for them i n women at l ow ri sk for sexual l y
transmi tted di seases (STDs) i s questi onabl e. Cases of tuboovari an
acti nomycosi s associ ated wi th IUD use have been reported. If thi s
organi sm i s reported on a Papani col aou (Pap) smear i n an
asymptomati c pati ent, the IUD shoul d be removed and may be
repl aced when a repeat Pap smear i s negati ve.
The ectopi c pregnancy rate wi th use of the T380A i s l ower than wi th
no contracepti on (90% reducti on i n ri sk). However, i f a pati ent
becomes pregnant wi th an IUD i n pl ace, i t i s more l i kel y that the
pregnancy i s ectopi c. There i s no i ncrease i n ectopi c pregnancy wi th
a hi story of pri or IUD use. Intrauteri ne pregnancy wi th an IUD i n
pl ace causes a 20-fol d i ncreased ri sk of devel opi ng l i fe-threateni ng,
second-tri mester septi c aborti on. The IUD therefore shoul d be
removed as earl y as possi bl e i f i ntrauteri ne pregnancy occurs.
Spontaneous expul si on occurs i n 5% of women duri ng the fi rst year,
most often duri ng the fi rst menses after i nserti on. Parti al expul si on
or di spl acement i s marked by l engtheni ng of the IUD stri ng. The
IUD may be i mmedi atel y rei nserted i f no i nfecti on i s present
(prophyl acti c anti bi oti cs are recommended).
Di spl acement of the IUD may occur, and absence of the stri ng on
the pati ent's sel f exami nati on i s cause for further eval uati on. Pl ai n
Page 510
fi l ms of the abdomen can determi ne the presence of the IUD, and
ul trasonography or hysteroscopy can be used to determi ne i ts
l ocati on or to extract the devi ce. If the
P.329
devi ce i s i n the abdomi nal cavi ty, l aparoscopy i s usual l y successful
at removal . Uteri ne perforati on may occur duri ng i nserti on but i s
uncommon.
Pati ents wi th newl y i nserted IUDs shoul d attempt to feel the
stri ngs before they l eave the exami ni ng room. Gi ve the pati ent the
cut ends of the stri ngs as a sampl e of what to feel . The pati ent
shoul d make a fol l ow-up vi si t i n 1 month to confi rm presence of the
IUD and to tri m the stri ng i f i t i s too l ong. Pal pati on of the stri ngs
shoul d be performed monthl y by the pati ent to veri fy conti nui ng
presence of the IUD after each menstrual fl ow.
INDICATIONS
Reversi bl e contracepti on for pati ents i n a monogamous
rel ati onshi p at l ow ri sk for STDs and wi th no hi story of
previ ous pel vi c i nfl ammatory di sease
CONTRAINDICATIONS
Undi agnosed geni tal bl eedi ng
Wi l son's di sease and al l ergy to copper
Nonparous or a hi story of severe dysmenorrhea or
menorrhagi a (rel ati ve contrai ndi cati on)
An abnormal l y shaped uterus (the uteri ne cavi ty shoul d
sound to 6 to 10 cm)
Si gn of cervi ci ti s or vagi ni ti s on the day of i nserti on
Pati ents at hi gh ri sk for endocardi ti s (e.g., prostheti c
val ves, major val ve abnormal i ti es, shunt l esi ons)
Use wi th great cauti on wi th anti coagul ati on.
P.330
PROCEDURE
Page 511
Expl ai n the IUD i nserti on procedure, and obtai n i nformed consent.
Wi th the pati ent i n the l i thotomy posi ti on, perform a bi manual
exami nati on to determi ne the uteri ne si ze and posi ti on and to rul e
out structural abnormal i ti es. Pl ace a steri l e specul um i n the vagi na,
and swab the cervi x wi th an anti septi c sol uti on such as an i odi ne or
benzal koni um preparati on. Make sure the IUD package i s i ntact and
that al l of the parts are present.
(1) Exami ne the IUD package to make sure i t i s i ntact and contai ns
al l the pi eces.
P.331
Usi ng steri l e techni que, grasp the anteri or l i p of the cervi x wi th a
tenacul um and sound the uterus (shoul d be between 6 and 10 cm).
A paracervi cal bl ock can be used to decrease the pai n of the
procedure. Inject 2% l i docai ne just off the cervi x at the 3- and
9-o'cl ock posi ti ons (or 4- and 10-o'cl ock posi ti ons i f preferred).
Page 512
(2) Grasp the anteri or l i p of the cervi x wi th a tenacul um, and sound
the uterus.
PITFALL: A paracervical block takes a few minutes for full
effect. Wait 2 to 3 minutes following the injections before
initiating the procedure.
P.332
Wi th steri l e gl oves or through the steri l e wrapper, fol d down the
arms of the IUD i nto the i nserti on tube just enough to hol d them i n
pl ace duri ng i nserti on. The phl ange on the i nserti on tube i s set to
the di stance of the soundi ng. Thi s permi ts vi sual confi rmati on of
when the top of the IUD reaches the fundus.
Page 513
(3) Usi ng steri l e gl oves, fol d down the arms of the IUD i nto the
i nserti on tube just enough to hol d them i n pl ace duri ng i nserti on.
PITFALL: Fold the arms right before or during the procedure.
Prolonged bending of the arms causes them to release slowly
and increases the likelihood of device expulsion.
P.333
Insert the devi ce i nto the uteri ne cavi ty unti l i t meets resi stance at
the fundus; and then sl i ghtl y wi thdraw (i .e., a few mi l l i meters).
Whi l e hol di ng the i nserti on rod i n pl ace, wi thdraw the i nserti on
tube 1 to 2 cm to rel ease the arms of the IUD i n the hori zontal
pl ane of the uterus.
Page 514
(4) Insert the IUD i nto the uteri ne cavi ty unti l i t meets the fundus,
and then sl i ghtl y wi thdraw the devi ce.
PITFALL: Do not push the insertion rod upward to elevate the
IUD. This practice is painful for the patient and increases the
risk of perforation.
Wi thdraw the i nserti on rod and tube, l eavi ng the stri ng protrudi ng
from the cervi cal os. You can ensure that the Copper T380A i s i n a
hi gh fundal posi ti on i f, after removi ng the sol i d rod, you push the
i nserti on tube up agai nst the cross arm of the T before wi thdrawi ng
i t.
Page 515
(5) Wi thdraw the i nserti on rod and tube, l eavi ng the stri ng
protrudi ng from the cervi cal os.
P.334
Cut the stri ng to a l ength that al l ows the pati ent to easi l y pal pate
i t on sel f-exami nati on (i .e., 2.5 to 4 cm).
Page 516
(6) Cut the stri ng to a l ength that al l ows the pati ent to easi l y
pal pate i t on sel f-exami nati on.
PITFALL: Do not cut the strings too short; err on the side of too
long because the strings can always be cut again. If the strings
are cut too short, they tend to impale the end of the glans penis
and cause pain during intercourse.
PITFALL: Despite proper placement, early expulsion is possible.
Inform the patient of this possibility, and instruct her to return
the IUD to your office. The manufacturer will provide a sterile
replacement for reinsertion at no cost.
Removal of an IUD usual l y can be accompl i shed by graspi ng the
stri ng wi th a ri ng forceps and exerti ng fi rm, steady tracti on (usual l y
duri ng the menstrual peri od).
(7) Grasp the stri ng wi th ri ng forceps, and exert fi rm steady
tracti on.
P.335
Page 517
If stri ngs cannot be seen, they can often be extracted from the
cervi cal canal by rotati ng two cotton-ti pped appl i cators or a Pap
smear cytobrush i n the endocervi cal canal .
(8) Stri ngs can be extracted from the cervi cal canal by rotati ng two
cotton-ti pped appl i cators i n the endocervi cal canal .
If IUD stri ngs cannot be i denti fi ed or extracted from the
endocervi cal canal , a l i ght pl asti c uteri ne sound shoul d be passed
i nto the endometri al cavi ty after admi ni strati on of a paracervi cal
bl ock. The IUD can frequentl y be fel t wi th the sound and l ocal i zed
agai nst the anteri or or posteri or wal l of the uterus. The devi ce can
then be removed usi ng pol yp- or al l i gator-type forceps di rected to
where the devi ce was fel t.
Page 518
(9) If the IUD stri ngs cannot be extracted from the endocervi cal
canal , a l i ght pl asti c uteri ne sound shoul d be passed i nto the
endometri al cavi ty.
PITFALL: Because there is a risk of perforation with this
procedure, patients are often referred for hysteroscopic
removal at this stage.
P.336
CODING INFORMATION

2002 Average 50th
Percentile Fee

58300* Inserti on of IUD $159
58301 Removal of IUD $98
Page 519
ParaGard IUDs can be obtai ned from Ortho-McNei l Pharmaceuti cal s
(phone: 1-800-322-4966). A physi ci an can establ i sh an account free
of charge and pl ace orders for the product. They may be ordered
si ngl y or i n a box of fi ve at a l ower cost per uni t.
Mi rena may be ordered from Berl ex Laboratori es, Inc. (phone:
1-866-647-3646). Before any i nserti on, i t i s i mportant to obtai n
trai ni ng on the proper techni que speci fi c to Mi rena. Trai ni ng can be
found at http://www.mi rena-us.com or by wri ti ng Berl ex
Laboratori es, Inc., 6 West Bel t Road, Wayne, NJ 07470-6806.
Instruments and materi al s i n a standard gynecol ogi cal tray are
l i sted i n Appendi x B.
BIBLIOGRAPHY
Croxatto HB, Orti z ME, Val dez E. IUD mechani sms of acti on. In:
Bardi n CW, Mi shel l DR Jr, eds. Proceedi ngs of the Fourth
I nternati onal Conference on I UDs. Boston; Butterworth-Hei nemann,
1994.
Del banco SF, Maul don J, Smi th MD. Li ttl e knowl edge and l i mi ted
practi ce: emergency contracepti ve pi l l s, the publ i c, and the
obstetri ci an-gynecol ogi st. Obstet Gynecol 1997;89:10061011.
Hi l l DA, Wei ss NS, Voi gt LF, et al . Endometri al cancer i n rel ati on to
i ntra-uteri ne devi ce use. I nt J Cancer 1997;70:278281.
Mendel son MA. Contracepti on i n women wi th congeni tal heart
di sease. Heart Di s Stroke 1994;3:266269.
Mi shel l DR Jr. Intrauteri ne devi ces: mechani sms of acti on, safety,
and effi cacy. Contracepti on 1998;58(Suppl ):45S53S.
Nel son AL. The i ntrauteri ne contracepti ve devi ce. Obstet Gynecol
Cl i n North Am 2000;27:723740.
Rami rez Hi dal go A, Pujol Ri bera E. Use of the i ntrauteri ne devi ce:
effi cacy and safety. Eur J Contracept Reprod Heal th Care
2000;5:198207.
Shel ton JD. Ri sk of cl i ni cal pel vi c i nfl ammatory di sease attri butabl e
to an i ntrauteri ne devi ce. Lancet 2001;357:443.
Speroff L, Darney P. A cl i ni cal gui de for contracepti on, 2nd ed.
Bal ti more: Wi l l i ams & Wi l ki ns, 1996.
Thonneau P, Goul ard H, Goyaux N. Ri sk factors for i ntrauteri ne
Page 520
devi ce fai l ure: a revi ew. Contracepti on 2001;64:3337.
Trussel l J, Koeni g J, El l ertson C, et al . Preventi ng uni ntended
pregnancy: the cost-effecti veness of three methods of emergency
contracepti on. Am J Publ i c Heal th 1997;87:932937.
Zi mmer DF. Avoi di ng l i ti gati on i n a new age of IUDs. Obstet
Gynecol Surv 1996;51:S56S60.
Page 521
> Table of Cont ent s > Gynecology and Urology > 45 - Gomco Clamp Circumcision
45
Gomco Clamp Circumcision
Ci rcumci si on i s the most common procedure performed on mal e
chi l dren younger than 5 years of age. The Gomco cl amp i s the
i nstrument most commonl y used i n performi ng nonri tual
ci rcumci si on i n the Uni ted States. It i s desi gned to
ci rcumferenti al l y crush a 1-mm band of foreski n, al l owi ng
hemostati c removal of the foreski n whi l e protecti ng the gl ans from
i njury. The cl amp i s popul ar because of i ts ease of use and l ong
safety record.
The Jewi sh fai th ri tual ci rcumci si on (Beri t Mi l a) dates back 5,000
years to Abraham. Thi s ceremony usual l y occurs on the ei ghth day
of an i nfant boy's l i fe and i s usual l y performed by a ri tual
ci rcumci ser known as a mohel . Premature i nfants or i nfants who are
i l l may have the ceremony deferred unti l they are abl e to safel y
undergo ci rcumci si on. Checki ng wi th a l ocal rabbi i s a good way to
fi nd out about tradi ti ons and opti ons for Jewi sh fami l i es.
Infant feedi ngs are suspended for 1 to 3 hours before the procedure
to reduce the ri sk of aspi rati on. The i nfant i s usual l y restrai ned i n
a mol ded pl asti c restrai nt devi ce. Many i nfants uri nate soon after
bei ng pl aced i n the restrai nt, and the practi ti oner may have to
move qui ckl y to avoi d the stream. An i nfant warmer shoul d be
consi dered i f the room i s cool . The peni s, scrotum, and groi n area
are typi cal l y cl eaned wi th Betadi ne or a si mi l ar di si nfecti ng sol uti on
and steri l el y draped. Inspect the i nfant for gross anatomi c
abnormal i ti es.
Anesthesi a i s usual l y obtai ned usi ng a dorsal peni l e nerve bl ock.
Mul ti pl e studi es document a decrease i n pai n percei ved by neonates
duri ng routi ne ci rcumci si on when a dorsal peni l e nerve bl ock i s
used. A 1:10 mi xture of 1% sodi um bi carbonate and 1% l i docai ne
Page 522
may decrease the pai n caused by the aci di c pH of the anestheti c
sol uti on. Dorsal peni l e nerve bl ocks have been performed si nce
1978 wi thout
P.338
any major compl i cati ons reported i n the l i terature. The most
common probl em associ ated wi th i t i s occasi onal fai l ure to provi de
adequate anal gesi a. Thi s i s often the resul t of fai l ure to wai t the
necessary 5 mi nutes for the bl ock to take effect. Avoi d thi s probl em
by admi ni steri ng the bl ock before drapi ng the area, and then gentl y
massage the area whi l e wai ti ng the 5 mi nutes requi red for
maxi mum anestheti c effect. Mi nor compl i cati ons such as l ocal
brui si ng, hematoma, and excessi ve bl eedi ng at the i njecti on si te
are rarel y reported. The use of epi nephri ne i s contrai ndi cated i n any
procedure i nvol vi ng the peni l e shaft. Whi l e topi cal pri l ocai ne and
l i docai ne (i .e., EMLA cream) have been demonstrated to hel p, avoi d
the use of pri l ocai ne i n chi l dren under 1 month of age.
One of the most di ffi cul t parts of the procedure for novi ce
practi ti oners i s deci di ng how much foreski n to remove. Usual l y,
about two thi rds of the di stal foreski n i s removed. The amount of
shaft ski n that wi l l remai n after ci rcumci si on shoul d be careful l y
assessed after the cl amp i s pl aced but before the screw i s
ti ghtened. If i t i s necessary to adjust the amount of foreski n to be
removed after the cl amp i s i n pl ace, di sassembl e the devi ce, and
pul l the bel l away from the base pl ate. If the foreski n i s adjusted
Page 523
whi l e the cl amp and bel l are sti l l assembl ed, there i s a ri sk that
vessel s between the foreski n and the underl yi ng mucosa wi l l be
damaged and cause bl eedi ng.
The peni s shoul d be i nspected after the procedure for si gns of
bl eedi ng. Appl y a dressi ng of petrol eum jel l y or petrol eum gauze to
the cut l i ne, whi ch may be removed i n 12 to 24 hours. Most
nurseri es requi re that the i nfant uri nate before undergoi ng
ci rcumci si on, but barri ng compl i cati ons duri ng ci rcumci si on, thi s i s
probabl y not necessary. Warn parents that some swel l i ng may
occur, that a crust wi l l often form on the i nci si on l i ne, and that
smal l bl eedi ng spots may be found i n the di aper. Ask them to
report any bl oodstai n greater than a quarter or any si gns of
i nfecti on. If soi l ed, the area may be gentl y cl eaned wi th soap and
water.
Rarel y, the gl ans i s not be vi si bl e 30 mi nutes after the procedure.
Thi s i ndi cates the presence of conceal ed peni s, whi ch
resul ts from i nadequate removal of foreski n or underl yi ng mucosa.
The peni l e shaft and gl ans are pushed back i nto the scrotal fat, and
the peni s i s buri ed. There i s no need for further procedure at thi s
ti me as l ong as the baby i s abl e to uri nate wi thout probl ems.
However, a revi si on of the ci rcumci si on by a urol ogi st may be
necessary at a l ater ti me.
INDICATIONS
Medi cal i ndi cati ons, i ncl udi ng phi mosi s, paraphi mosi s,
recurrent bal ani ti s, extensi ve condyl oma acumi nata of
the prepuce, and squamous cel l carci noma of the
prepuce (al l rare i n neonates)
Parental request or rel i gi ous reasons
CONTRAINDICATIONS
Routi ne ci rcumci si on i s contrai ndi cated wi th the
presence of urethral abnormal i ti es such as hypospadi as,
epi spadi as, or megaurethra (i .e., foreski n may be
needed for future repai r or reconstructi on).
Less than 1 cm of peni l e shaft i s vi si bl e when pushi ng
Page 524
down at the base of the peni s (i .e., short peni l e shaft).
Ci rcumci si on i n i nfants who are i l l or premature shoul d
be del ayed unti l they are wel l or ready for di scharge
form the hospi tal .
Bl eedi ng di athesi s, myel omeni ngocel e, or i mperforate
anus
P.339
PROCEDURE
Perform a dorsal peni l e nerve bl ock by tenti ng the ski n at the base
of the peni s and i njecti ng 0.2 to 0.4 mL of 1% l i docai ne (wi thout
epi nephri ne) i nto the subcutaneous ti ssue on ei ther si de at the
dorsal base of the peni s. A paci fi er di pped i n 25% sucrose al so
appears to reduce i nfant di scomfort. Drape the baby's torso (but
not head) wi th a fenestrated drape.
(1) Start a dorsal peni l e nerve bl ock by tenti ng the ski n at the base
of the peni s and i njecti ng 0.2 to 0.4 mL of 1% l i docai ne (wi thout
epi nephri ne) i nto the subcutaneous ti ssue on ei ther si de at the
dorsal base of the peni s.
PITFALL: To avoid inadvertent intravascular injection, apply
negative pressure to the syringe immediately before injection to
check for a backflow of blood.
The si ze of the bel l of the Gomco cl amp used for the ci rcumci si on i s
sel ected based on the di ameter of the gl ans (not the l ength of the
peni l e shaft). The bel l shoul d be l arge enough to compl etel y cover
Page 525
the gl ans peni s wi thout overl y di stendi ng the foreski n. A bel l that
i s too smal l wi l l fai l to protect the gl ans and may cause too l i ttl e
foreski n to be removed.
(2) The si ze of the bel l of the Gomco cl amp used for the
ci rcumci si on i s sel ected based on the di ameter of the gl ans.
PITFALL: Check the base, rocker arm, and bell of the Gomco
clamp to make sure they all fit together. The bell and base from
a 1.45-cm clamp will close but will not seal the skin properly if
used with the rocker arm of a 1.3-cm set. Check to make sure
that there are no defects in any of the parts.
P.340
Careful l y i nsert a bl unt probe or cl osed hemostat i nto the preputi al
ri ng down to the l evel of the corona whi l e gentl y peel i ng back the
foreski n (Fi gure 3A). Sl i de the i nstrument down to the ri ght and l eft
si des to break up adhesi ons between the i nner mucosal l ayer and
the gl ans. Careful l y avoi d the ventral frenul um, because teari ng i t
often causes bl eedi ng (Fi gure 3B). Exami ne the peni s to make sure
hypospadi as or megameatus i s not present.
Page 526
(3) Careful l y i nsert a bl unt probe or cl osed hemostat i nto the
preputi al ri ng down to the l evel of the corona whi l e gentl y peel i ng
back the foreski n.
PITFALL: Failure to completely free mucosal adhesions from the
glans is the most common reason for a poor cosmetic result. If
the adhesions are not completely separated, not enough mucosa
will be removed, and phimosis may result.
PITFALL: If hypospadias or megameatus is present, terminate
the procedure because any repair of these congenital anomalies
may require the use of foreskin tissue.
P.341
Page 527
After the coronal sul cus i s freed of adhesi ons, ci rcumferenti al l y
grab the ski n near the base of the peni s, and pul l i t over the gl ans
unti l the foreski n returns to i ts anatomi c posi ti on.
(4) After the coronal sul cus i s freed of adhesi ons, ci rcumferenti al l y
grab the ski n near the base of the peni s, and pul l i t over the gl ans
unti l the foreski n returns to i ts anatomi c posi ti on.
Grasp the end of the foreski n on ei ther si de of the dorsal mi dl i ne at
the 10- and 2-o'cl ock posi ti ons wi th two hemostats. Make sure to
avoi d the gl ans and stay out of the urethral meatus.
(5) Grasp the foreski n on ei ther si de of the dorsal mi dl i ne at the
Page 528
10- and 2-o'cl ock posi ti ons wi th two hemostats.
P.342
Create a crush l i ne on the dorsal aspect of the foreski n usi ng a
strai ght hemostat. The crushed ski n i s cut wi th sci ssors, taki ng
care to avoi d the gl ans. The cut shoul d proceed down the center of
the crush l i ne to avoi d bl eedi ng that occurs i f the cut strays
l ateral l y.
(6) Create a crush l i ne on the dorsal aspect of the foreski n usi ng a
strai ght hemostat.
PITFALL: Make sure the crush line is far enough above the
coronal sulcus that it will be completely removed in the
circumcision. If the cut extends too far onto the penile shaft, the
proximal portion of the incision (apex) cannot be pulled into the
Gomco clamp.
P.343
Insert the bel l of the Gomco cl amp under the foreski n and over the
gl ans. Bri ng the two hemostats that are hol di ng the edges of the
foreski n together over the bel l (Fi gure 7A). Pl ace an addi ti onal
hemostat di rectl y through the hol e i n the base pl ate. Then use the
Page 529
hemostat to draw the edges of the dorsal sl i t together over the
fl are of the bel l , and remove the ori gi nal hemostats (Fi gure 7B).
Pul l the hemostat, foreski n, and stem of the bel l through the hol e
i n the base pl ate (Fi gure 7C).
Page 530
(7) Insert the bel l of the Gomco cl amp under the foreski n and over
the gl ans.
P.344
Page 531
Al ternati vel y, i nsert a smal l safety pi n through both edges of the
dorsal sl i t and bri ng the edges together over the fl are of the bel l .
The safety pi n may be passed through the hol e i n the base pl ate
al ong wi th the stem of the bel l .
(8) Al ternati vel y, i nsert a smal l safety pi n through both edges of
the dorsal sl i t, and bri ng the edges together over the fl are of the
bel l .
PITFALL: Be careful not to cause inadvertent injury to the
clinician or the infant with the sharp end of the safety pin.
Make sure that equal amounts of mucosa and foreski n are brought
through the base pl ate. Determi ne i f the amount of foreski n above
the basepl ate i s appropri ate for removal and that the remai ni ng
shaft ski n i s adequate. The amount and symmetry of the ski n may
sti l l be adjusted at thi s ti me. The rocker arm of the Gomco cl amp i s
then attached and brought around i nto the notch of the base pl ate.
The arms of the bel l are settl ed i nto the yoke, and the nut i s
ti ghtened, crushi ng the foreski n between the bel l and the base
pl ate. Leave the cl amp i n pl ace for 5 mi nutes.
Page 532
(9) The rocker arm of the Gomco cl amp i s then attached and
brought around i nto the notch of the base pl ate.
PITFALL: Make sure the apex of the dorsal slit is visible above
the plate before putting the arms in the yoke and excising the
foreskin.
PITFALL: Make sure the rocker arm is well settled into the notch
of the base plate. The clamp may be tightened outside of the
notch, but it will not seal the skin well and will risk causing a
degloving injury.
P.345
Pl ace a scal pel bl ade fl at agai nst the base pl ate, and cut the top of
the crush l i ne. Loosen the nut, and remove the top and base pl ate
from the bel l . The shaft ski n sti cks to the bel l but can be peel ed
off usi ng a gauze pad or bl unt probe. The peni s shoul d be i nspected
after the procedure for si gns of bl eedi ng. Appl y a dressi ng of
petrol eum jel l y or petrol eum gauze to the cut l i ne. Addi ti onal i nfant
soothi ng can be provi ded by pl aci ng hte undressed i nfant on the
mother's chest (ski n-to-ski n contact) i mmedi atel y fol l owi ng the
procedure.
Page 533
(10) Pl ace a scal pel bl ade fl at agai nst the base pl ate, and cut the
top of the crush l i ne.
PITFALL: Cutting the foreskin at an angle into the base plate
may disrupt the crush line and cause bleeding.
P.346
CODING INFORMATION

2002 Average 50th
Percentile Fee

54150 Newborn ci rcumci si on usi ng a
cl amp or other devi ce
$176
54152 Ci rcumci si on usi ng a cl amp or
other devi ce, other than
newborn
$330
Gomco Ci rcumci si on Cl amps may be obtai ned from Spectrum
Surgi cal Instruments, 4575 Hudson Dri ve, Stow, OH 44224 (phone:
800-444-5644 or 330-686-4550;
http://www.spectrumsurgi cal .com/catal og/i nstrument/ci rcumci si on.h
Page 534
tm) or from Premi er Medi cal Group Co. Ltd, P.O. Box 4132, Kent,
WA 98032 (phone: 800-955-2774;
http://www.premi eremedi cal .safeshopper.com/).
BIBLIOGRAPHY
Anderson GF. Ci rcumci si on. Pedi atr Ann 1989;18:205213.
Fontai ne P, Di ttberner D, Schel tema KE. The safety of dorsal peni l e
nerve bl ock for neonatal ci rcumci si on. J Fam Pract
1994;39:243244.
Hol man JR, Lewi s EL, Ri ngl er RL. Neonatal ci rcumci si on techni ques.
Am Fam Physi ci an 1995;52:511518.
Lander J, Brady-Fryer B, Metcal f JB, et al . Compari son of ri ng bl ock,
dorsal peni l e nerve bl ock, and topi cal anesthesi a for neonatal
ci rcumci si on. JAMA 1997;278:21572162.
Laumann EO, Masi CM, Zuckerman EW. Ci rcumci si on i n the Uni ted
States: preval ence, prophyl acti c effects, and sexual practi ce. JAMA
1997;277:10521957.
Lawl er FH, Basonni RS, Hol tgrave DR. Ci rcumci si on: a deci si on
anal ysi s of i ts medi cal val ue. Fam Med 1991;23:587593.
Mal l on E, Hawki ns D, Di nneen M, et al . Ci rcumci si on and geni tal
dermatoses. Arch Dermatol 2000;136:350354.
Ni ku SD, Stock JA, Kapl an GW. Neonatal ci rcumci si on. Common
Probl Pedi atr Urol 1995;22:5765.
Pel eg D, Stei ner A. The Gomco ci rcumci si on: common probl ems and
sol uti ons. Am Fam Physi ci an 1998;58:891898.
Ti emstra JD. Factors affecti ng the ci rcumci si on deci si on. J Am Board
Fam Pract 1999;12:1620.
Page 535
> Table of Cont ent s > Gynecology and Urology > 46 - No- Scalpel Vasect omy46
No-Scalpel Vasectomy
Vasectomy i s an easy-to-perform and effecti ve form of permanent
contracepti on. About 500,000 vasectomi es are performed annual l y
i n the Uni ted States. Unfortunatel y, many men have fears that
prevent greater acceptance of the techni que. The no-scal pel
techni que offers an al ternati ve to standard procedures, provi di ng
shorter operati ng ti me, l ess pai n and swel l i ng, and faster recovery.
Because there i s no i nci si on, thi s techni que may decrease the fear
of the procedure. About one thi rd of al l vasectomi es performed i n
the Uni ted States use the no-scal pel techni que.
The no-scal pel vasectomy techni que uses a 2- to 3-mm mi dl i ne
puncture i nto the scrotum usi ng a speci al sharp-ti pped vasectomy
di ssecti ng forceps. The i nstrument has the appearance of a curved
hemostat sharpened to a fi ne poi nt and i s used to el evate the vas
through the ski n. The three-fi nger i sol ati on techni que (i .e., thumb
and i ndex fi nger on top and mi ddl e fi nger beneath the scrotum) i s
used to mani pul ate the vas to just beneath the mi dl i ne ski n and
throughout the procedure. After the vas i s el evated from the ski n, a
second speci al i nstrument, the atraumati c vas cl amp or ri ng cl amp,
i s used to hol d the vas. Al l other ti ssues are separated from the
vas, and two parti al i nci si ons are made i nto the vas on both si des
of the cl amp. The ti p of a battery cautery uni t i s i nserted wi thi n
the cut vas, and the ends that wi l l remai n wi thi n the body (not hel d
i n the cl amp) are thermal l y seal ed. The short pi ece of vas ( to
i nch) hel d by the ri ng cl amp can be removed. The cut ends of
the vas are separated by pul l i ng fasci al ti ssue over one end and
pl aci ng a smal l metal cl i p on the fasci a (not the vas). The metal
cl i p al so l i mi ts or prevents bl eedi ng from the vas artery. The
ti ssues are then repl aced wi thi n the scrotum, the other vas i s
swung under the mi dl i ne puncture si te, and these techni ques
Page 536
repeated on the second si de.
One of the compl i cati ons of vasectomy i s the formati on of sperm
granul omas. These granul omas are usual l y 0.5 to 2 cm, fi rm,
someti mes exqui si tel y tender nodul es that devel op at the end of
the cut vas. Al though the granul omas often resol ve over ti me, they
can produce si gni fi cant postoperati ve di stress. The method of
handl i ng the cut ends of the vas i nfl uences the rate of formati on of
sperm granul omas. Metal cl i ps pl aced di rectl y on the vas or tyi ng
the vas wi th suture i ncreases the rate of granul oma formati on.
Heat cautery (not el ectrosurgery) appears to produce the l owest
rates of granul omas.
P.348
Removal of a smal l pi ece of vas duri ng the procedure al l ows for
hi stol ogi c confi rmati on that the vas was severed. Such reassurance
i s expensi ve, costi ng $150 to $200 i n some setti ngs. One
al ternati ve i s to send the speci mens home wi th the pati ent (i .e.,
avoi di ng speci men storage by the physi ci an). The speci mens, whi ch
are pl aced i n formal i n, are kept i n a secure l ocati on unti l the
postoperati ve semen checks are cl ear. If the semen anal ysi s does
not cl ear, the speci mens can then be eval uated hi stol ogi cal l y. Some
practi ti oners do not remove any vas but i nstead i nterpose fasci al
ti ssue between cut ends of the vas. However, there may be
psychol ogi cal benefi t for pati ents to vi ew removed segments of
tube i n a cl ear pl asti c contai ner i mmedi atel y after the procedure.
Adequate l ocal anesthesi a can produce pai n-free procedures for
most pati ents. After admi ni strati on of anestheti c i nto the mi dl i ne
ski n, the three-fi nger techni que i s used to sl i de the ri ght vas bel ow
thi s si te. External spermati c sheath i njecti on i s performed,
i nfi l trati ng anestheti c around the vas and vasal nerves. The
anesthesi a needl e i s di rected adjacent to vas toward the external
i ngui nal ri ng (abdomi nal end) and 1 to 2 mL of 1% l i docai ne
i nfi l trated proxi mal to the surgi cal si te. The l eft si de i s
anestheti zed si mi l ar to the ri ght si de. Thi s techni que provi des
Page 537
superi or resul ts and i s more popul ar wi th pati ents than ol der
anestheti c techni ques.
Preoperati ve counsel i ng i s essenti al to determi ne the
appropri ateness of a candi date (or coupl e) for a permanent
procedure (Tabl e 46-1). Studi es have determi ned that up to 10% of
coupl es may express regret after permanent steri l i zati on and that
1% to 2% request reversal . Vasectomy reversal procedures are
expensi ve and have rel ati vel y l ow success rates (20% to 60%) i n
faci l i tati ng pregnancy. Those who request reversal of the procedure
tend to request vasectomy at a young age, are si ngl e or not i n a
stabl e, l ong-term rel ati onshi p, or have few or no chi l dren at the
ti me of the procedure. Pati ents shoul d never be pressured i nto
havi ng a procedure. It i s i mportant to have both partners present
for the counsel i ng sessi on; i f ei ther partner i s not i n agreement for
a permanent procedure, thi s choi ce of contracepti on shoul d be
deferred.
TABLE 46-1. GOALS FOR THE PREOPERATIVE COUNSELING SESSION

Determi ne the appropri ateness of pati ent (coupl e) for permanent and i rreversi bl e
steri l i zati on.
Di mi ni sh fears (e.g., procedure i s not castrati on, pati ent wi l l sti l l enjoy sex).
Obtai n i nformed consent (e.g., ri sks, benefi ts compl i cati ons of the procedure).
Inform of the ri sk of earl y or l ate fai l ure (<1% for the procedure descri bed i n thi s
chapter).
Di scuss al ternate contracepti on and the need for contracepti on after procedure
unti l the ejacul ate i s cl ear.
Inform the pati ent about the procedure techni que and i mportance of fol l owi ng
postoperati ve i nstructi ons.
Exami ne the pati ent to i denti fy the vas bi l ateral l y and excl ude scrotal pathol ogy.
Remi nd the pati ent to avoi d aspi ri n preoperati vel y, bri ng an athl eti c supporter to
Page 538
the procedure, and cl i p (not shavi ng) hai r on the anteri or or l ateral si de of the
scrotum the ni ght before the procedure.
Provi de sedati on (e.g., di azepam prescri pti on) for the procedure, i f desi red.
Informed consent shoul d be obtai ned before sedati ves are admi ni stered.

Pati ents shoul d cl i p the hai r on the anteri or and l ateral si des of the
scrotum the ni ght before the procedure. Instructi on shoul d be gi ven
to avoi d aspi ri n and aspi ri n-contai ni ng medi cati ons for 10 days
before the vasectomy. The pati ent shoul d bri ng an athl eti c
supporter to the procedure. After the procedure, gauze i s l ai d over
both si des of the scrotum, and the supporter i s pl aced to secure
the gauze
P.349
and to provi de el evati on and comfort to the scrotal ti ssues.
Pati ents are i nstructed to l i mi t strenuous acti vi ti es for a week after
the procedure. Sex may be attempted for the fi st ti me 1 week after
the procedure. After 25 ejacul ati ons (usual l y 3 to 4 months after
the procedure), the pati ent i s i nstructed to bri ng a speci men to the
offi ce to ensure the absence of sperm. Repeat exami nati ons of
speci mens usual l y i s unnecessary, but they can be performed at the
pati ent's request or i f the fi rst speci men i s not compl etel y cl ear of
sperm.
INDICATIONS
Permanent steri l i zati on
Poorl y or noncounsel ed pati ent regardi ng procedure
techni que and permanent consequences
Page 539
Young pati ent (<23 years ol d), si ngl e pati ent, chi l dl ess
pati ent, pati ent not i n a wel l -establ i shed monogamous
rel ati onshi p
Presence of scrotal tumors or masses
Unabl e to pal pate ei ther vas deferens at the
preprocedure vi si t
P.350
PROCEDURE
Instruct the pati ent about the proper l ocati on of the hai r to be
cl i pped (not shaved) the ni ght before the procedure. Have the
pati ent shower after the hai r cl i ppi ng.
(1) Instruct pati ent to cl i p hai r on the anteri or and l ateral si des of
the scrotum the ni ght before the procedure.
PITFALL: Patients may incorrectly clip the entire hair over the
symphysis pubis onto the abdomen. Give proper instruction to
avoid unnecessary clipping.
PITFALL: Shaving traumatizes skin and increases surgical
Page 540
infection rates. Instruct patients to clip, not shave the hairs.
The i nstruments for the procedure are the atraumati c ri ng cl amp
(Fi gure 2A) and the vas di ssecti ng forceps (Fi gure 2B).
(2) The ri ng cl amp and vas di ssecti ng forceps.
P.351
The ri ght vas i s pal pated; i t feel s l i ke a fi rm, thi n cord runni ng from
the testi cl e i nto the i ngui nal area. Al though other structures can
feel l i ke vas, they usual l y fl atten as the ti ssue i s rol l ed between
the fi ngers. The i ndex fi nger and thumb grasp the vas above the
scrotum, and the mi ddl e fi nger i s pl aced beneath. Grab the vas at
the juncti on of the mi ddl e and upper thi rds of the scrotum.
Page 541
(3) The three-fi nger techni que.
PITFALL: Handle the vas gently. Rough manipulation, especially
if traction is applied on the vas, will produce significant
discomfort and unnecessary anxiety for the patient.
P.352
Cross secti on of the spermati c cord structures i s shown (Fi gure 4A).
Nonsteri l e gl oves can be used for thi s part of the procedure (Tabl e
46-2). Rai se a ski n wheel i n the mi dl i ne ski n above the vas (Fi gure
4B). Now sl i de the needl e al ongsi de the vas, di recti ng the needl e
to about 1 i nch above the pl anned surgi cal si te (Fi gure 4C). The
needl e i s di rected toward the external i ngui nal ri ng (toward the
abdomen). Admi ni ster 1 to 2 mL of anestheti c i nsi de the external
spermati c fasci a, i mmedi atel y adjacent to the vas. The needl e i s
wi thdrawn, the l eft vas i s swung to the mi dl i ne, and the procedure
repeated on the opposi te si de. A ri ght-handed operator often fi nds
i t easi er to face the pati ent's feet and to perform the i sol ati on of
the l eft vas wi th the l eft hand (Fi gure 4D).
Page 542
(4) Anesthesi a.
P.353
PITFALL: Failure to achieve adequate anesthesia often results
from failure to administer the anesthetic within the external
spermatic fascia. Use the posterior middle finger to feel the
needle as it slides immediately adjacent to the vas.
Page 543
PITFALL: It is possible to direct the needle through the posterior
scrotum and into the practitioner' s middle finger. Slow and
careful advancement of the needle should avoid this problem.
TABLE 46-2. NONSTERILE TRAY FOR ANESTHESIA AND POSTOPERATIVE CARE

Nonsteri l e gl oves
Povi done-i odi ne sol uti on soaked i nto 4 4 gauze (i n a steri l e basi n)
10-mL syri nge fi l l ed wi th 1% l i docai ne
25- or 27-gauge 1 i nch needl e
i nch of anti bi oti c oi ntment on gauze
2 i nches of nonsteri l e 4 4 gauze
Pati ent-suppl i ed athl eti c supporter
1 postoperati ve semen col l ecti on contai ner (wi th pati ent's name) i n a brown paper bag
Formal i n contai ner for exci sed porti ons of the vas deferens
Basi n wi th steri l e water poured onto 1 i nch of 4 4 gauze (for cl eani ng scrotum after
procedure)

P.354
Prep the ski n wi th povi done-i odi ne, pl ace a steri l e drape, and use
steri l e gl oves (Tabl e 46-3). Bri ng the ri ght vas to i mmedi atel y
bel ow the mi dl i ne wi th the three-fi nger techni que. Hol d the cl amp
i n the ri ght hand (pal m up), sl i ghtl y open the ti ps of the cl amp,
and grasp the vas and ski n i nsi de the cl amp (Fi gure 5A). Lower the
handl es of the ri ng cl amp (Fi gure 5B). Pl ace the mi ddl e fi nger of
the l eft hand under the cl amp, and the i ndex fi nger i s pl aced above
the cl amp to stretch the ski n over the vas (Fi gure 5C).
Page 544
(5) Hol d the cl amp i n the ri ght hand (pal m up), sl i ghtl y open the ti ps of the cl amp, and
grasp the vas and ski n i nsi de the cl amp.
TABLE 46-3. STERILE PROCEDURE TRAY
Page 545

Steri l e gl oves
Steri l e fenestrated drape
Vas di ssecti ng hemostat (forceps)
Atraumati c ri ng cl amp
Di sposabl e battery cautery uni t pl aced i nsi de a steri l e gl ove
2 i nches of 4 4 gauze
2 pai rs of strai ght hemostats
1 curved hemostat
Surgi cal cl i p (Hemocl i p) appl i cator
1 contai ner (cl i p) of medi um metal surgi cal cl i ps (Hemocl i ps)
Iri s sci ssors

Adapted from: Zuber TJ. Offi ce procedures forms: The AAFP col l ecti onqui ck reference
gui des for fami l y physi ci ans. Bal ti more: Wi l l i ams & Wi l ki ns, 1999:110.
P.355
The vas di ssecti ng forceps are grasped i n the ri ght hand wi th the
ti ps poi nted down toward the scrotum. A puncture i s made i nto the
vas usi ng one bl ade of the forceps (Fi gure 6A). Both ti ps are used
to spread the ski n i mmedi atel y over the vas (Fi gure 6B). The l ateral
bl ade of the forceps pi erces the wal l of the vas (Fi gure 6C), and the
pal m i s rotated to l i ft the vas outsi de the scrotum (Fi gure 6D).
Page 546
(6) The vas di ssecti ng forceps are grasped i n the ri ght hand wi th
the ti ps poi nted down to the scrotum.
P.356
Some physi ci ans have troubl e el evati ng the vas from the scrotum
usi ng a si ngl e bl ade of the forceps. After puncturi ng and stretchi ng
the ski n, the forceps can be used to l ateral l y swi ng under the vas
(Fi gure 7A) and l i ft the vas from the scrotal ski n (Fi gure 7B).
Page 547
(7) The forceps can be used to l ateral l y swi ng under the vas and
l i ft the vas from the scrotal ski n.
Remove the ri ng cl amp whi l e the vas i s hel d above the scrotum
wi th the di ssecti ng forceps. Grab the center of the vas wi th the ri ng
cl amp (Fi gure 8A), and use the vas di ssecti ng forceps to separate
the vasal fasci a and artery (Fi gure 8B) from the vas (Fi gure 8C).
The vas shoul d be compl etel y i sol ated (Fi gure 8D).
Page 548
(8) Remove the ri ng cl amp whi l e the vas i s hel d above the scrotum
wi th the di ssecti ng forceps, and grab the center of the vas wi th the
ri ng cl amp.
PITFALL: When dissecting the vas free, the vasal artery may
bleed. A small hemostat can be placed on the bleeding artery, if
needed.
P.357
Make two parti al i nci si ons (i .e., hemi transecti on) i nto the vas usi ng
the strai ght i ri s sci ssors. The cut i s made l ow (near the fasci a) on
the testi cul ar si de and hi gh up (near the cl amp) on the abdomi nal
si de (Fi gure 9A). The ti p of the battery cautery uni t i s pl aced i n
both ends beneath the hemi transecti ons (the porti ons that wi l l
Page 549
remai n wi thi n the body) (Fi gure 9B). Acti vate the cautery for just a
few seconds; wi thdraw the ti p after i t begi ns to heat the ti ssue.
Proper cautery resul ts i n mi ni mal whi te formati on i n the end of the
ti ssue, and the ti p of the cautery uni t tends to sti ck to the
vas as i t i s wi thdrawn.
(9) Make two parti al i nci si ons i nto the vas usi ng the strai ght i ri s
sci ssors.
PITFALL: Do not cut more than halfway across the vas. If a full
wall incision is made, the cut vas will retract back into the
scrotum before it can be cauterized.
PITFALL: If both cuts are made high near the clamp, it will be
difficult to interpose fascia over one end.
PITFALL: Do not create a full-thickness burn in the wall of the
vas. A full-thickness burn will result in necrosis, the end of the
vas will be resorbed, and the result will be an untreated free
end of vas.
P.358
Compl ete the parti al cut on the vas on the testi cul ar end onl y
Page 550
(Fi gure 10A). The testi cul ar vas often retracts back i nto the
scrotum. Li ft up the fasci a, and pul l i t over the testi cul ar end of
vas. A smal l metal cl i p i s used to seal the fasci a over the testi cul ar
end (Fi gure 10B). The cl i p must extend across to the abdomi nal end
of the vas but shoul d not cl amp onto the vas. Bl eedi ng
compl i cati ons can be reduced i f the vasal artery i s occl uded i n the
fasci a cl i p i mmedi atel y adjacent to the vas (Fi gure 10C). After the
metal cl i p i s pl aced, i nspect to ensure a bl oodl ess fi el d. Compl ete
the cut on the abdomi nal vas, and remove the speci men i n the
cl amp (Fi gure 10D). The ri ght si de i s returned to the scrotum, and
the l eft si de sl i d medi al l y wi th the same techni que performed on
the l eft. After the l eft si de i s compl eted, wash the povi done-i odi ne
off the ski n, pl ace anti bi oti c oi ntment and gauze over the si te, and
appl y the athl eti c supporter.
Page 551
(10) Compl ete the parti al cut on the vas on the testi cul ar end onl y.
P.359
CODING INFORMATION
2002 Average 50th
Percentile Fee
55250 Vasectomy, i ncl udi ng
postoperati ve semen
exami nati on
$550
Page 552
A pati ent counsel i ng vi deo (i ntroducti on can be personal i zed for a
parti cul ar practi ce) can be ordered from Pl ai nl y Creati ve Works,
Inc., 809 El m Street, Essexvi l l e, MI 48732 (phone: 989-892-7614).
A trai ni ng package (i ncl udi ng more than 60 sl i des about techni que,
$100), i l l ustrated gui de to the techni que, WHO vi deo, and scrotal
model for practi ci ng the techni que can be ordered from
EngenderHeal th (http://www.engenderheal th.org). An i l l ustrated,
step-by-step gui de ($35), trai ni ng vi deo ($35), pati ent educati on
gui de ($90), pati ent educati on brochures, marketi ng brochures,
scrotal trai ni ng model , and anatomy di agrams can be ordered from
Advanced Medi tech Internati onal (http://www.amedi tech.com).
Surgi cal cl i ps can be ordered from Weck Cl osure Systems, 2917
Weck Dri ve, P.O. Box 12600, Research Tri angl e Park, NC 27709
(phone: 800-234-9325; http://www.weckcl osure.com;
http://www.pi l l i ngweck.com). Ri nged forceps, surgi cal hemostat
(di ssecti ng cl amp or forceps), fi ne-ti pped thermal cautery, and
surgi cal cl i ps can be ordered from Advanced Medi tech Internati onal
(http://www.amedi tech.com). A ri ng cl amp and vasectomy hemostat
($150 to $170 per set) can be ordered from Mi l tex (
http://www.steel es.com).
BIBLIOGRAPHY
Al derman PM. Compl i cati ons i n a seri es of 1224 vasectomi es. J Fam
Pract 1991;33:579584.
Page 553
Badrakumar C, Gogoi NK, Sundaram SK. Semen anal ysi s after
vasectomy: when and how many? BJU I nt 2000;86:479481.
Cl enney TL, Hi ggi ns JC. Vasectomy techni ques. Am Fam Physi ci an
1999;60:137152.
Cox B, Sneyd MJ, Paul C, et al . Vasectomy and ri sk of prostate
cancer. JAMA 2002;287:31103115.
Davi s LE, Stockton MD. Offi ce procedures. No-scal pel vasectomy.
Pri m Care 1997;24:433461.
Esho J, Cass AS. Recanal i zati on rate fol l owi ng method of vasectomy
usi ng i nterposi ti on of fasci al sheath of vas deferens. J Urol
1978;120:178179.
Gol dstei n M. No-scal pel vasectomy: a ki nder, gentl er approach.
Pati ent Care 1994;28:5573.
Gonzal es B, Marston-Ai nl ey S, Vansi ntejan G, et al . No-scal pel
vasectomy: an i l l ustrated gui de for surgeons. New York:
Associ ati on for Vol untary Surgi cal Contracepti on, 1992.
Lesko SM, Loui k C, Vezi na R, et al . Vasectomy and prostate cancer.
J Urol 1999;161:18481852.
Li PS, Li SQ, Schl egel PN, et al . External spermati c sheath i njecti on
for vasal nerve bl ock. Urol ogy 1992;39:173176.
Li SQ, Gol dstei n M, Zhu J, et al . No-scal pel vasectomy. J Urol
1991;145:341344.
P.360
Manson JE, Ri dker PM, Spel sberg A, et al . Vasectomy and
subsequent cardi ovascul ar di sease i n U.S. physi ci ans.
Contracepti on 1999;59:181186.
Mason RG, Dodds L, Swami SK. Steri l e water i rri gati on of the di stal
vas deferens at vasectomy: does i t accel erate cl earance of sperm?
A prospecti ve randomi zed tri al . Urol ogy 2002;59:424427.
Mi l l er WB, Shai n RN, Pasta DJ. The pre- and post-steri l i zati on
regret i n husbands and wi ves. J Nerv Ment Di s 1991;179:602608.
Nangi a AK, Myl es JL, Thomas AJ. Vasectomy reversal for the
post-vasectomy pai n syndrome: a cl i ni cal and hi stol ogi cal
Page 554
eval uati on. J Urol 2000;164:19391942.
Potts JM. Pati ent characteri sti cs associ ated wi th vasectomy
reversal . J Urol 1999;161:18351839.
Schmi dt SS, Mi nckl er TM. The vas after vasectomy: compari son of
cauteri zati on methods. Urol ogy 1992;40:468470.
Si vardeen KA. Post vasectomy anal ysi s: cal l for a uni form
evi dence-based protocol . Ann R Col l Surg Engl 2001;83:177179.
Stockton MD, Davi s LE, Bol ton KM. No-scal pel vasectomy: a
techni que for fami l y physi ci ans. Am Fam Physi ci an
1992;46:11531164.
Zuber TJ. Offi ce procedures. The AAFP col l ecti on-qui ck reference
gui des for fami l y physi ci ans. Bal ti more: Wi l l i ams & Wi l ki ns,
1999:139148.
Page 555
> Table of Cont ent s > Gast roent erology > 47 - Anoscopy wit h Biopsy47
Anoscopy with Biopsy
Anorectal di sorders resul t from a vari ety of causes, i ncl udi ng
i nfecti on, structural abnormal i ti es, or systemi c di sorders. Anoscopy,
a common procedure used to di agnose these condi ti ons, i s
performed i n ambul atory and emergency department setti ngs. It i s
used to eval uate pati ents wi th rectal bl eedi ng, those wi th peri anal
or anal compl ai nts, sexual assaul t vi cti ms, and human
i mmunodefi ci ency vi rus (HIV)-posi ti ve pati ents. It i s al so commonl y
performed i n associ ati on wi th col onoscopy or fl exi bl e
si gmoi doscopy.
The anorectum i s the anatomi c structure i n whi ch the endodermal
i ntesti ne uni tes wi th the ectodermal anal canal and ski n (see
Fi gure 1). The dentate l i ne (or pecti nate l i ne) marks the juncti on of
these structures. The mucosa of the anal canal consi sts of
strati fi ed squamous epi thel i um wi thout hai r fol l i cl es or sweat
gl ands. The most di stal part of the anal canal (at the external
openi ng) i s the anal verge, where the epi thel i um thi ckens and hai r
fol l i cl es and cutaneous appendages appear. Proxi mal to the dentate
l i ne, the mucosa has 8 to 14 convol uted, l ongi tudi nal fol ds cal l ed
the col umns of Morgagni , wi th thei r associ ated crypts. At the base
of some of these crypts i s a smal l anal gl and that secretes mucus
to l ubri cate the anal canal . Two sl eeves of ci rcul ar muscl es, the
i nternal and external sphi ncters, surround the di stal rectum and
anal canal . Infecti on of these crypts and gl ands may resul t i n
crypti ti s, fi ssures, abscesses, and fi stul as (i .e., anal sepsi s).
Page 556
(1) The anatomy of the anal canal .
No bowel preparati on i s needed for an anoscopi c exami nati on. A
di gi tal exami nati on shoul d al ways precede an anoscopi c
exami nati on to assess whether the pati ent wi l l tol erate passage of
an anoscope. The presence of an assi stant i s often hel pful . A
gl oved assi stant can separate the buttocks to al l ow better access
and vi si bi l i ty of the peri anal area. Inspecti on al one can reveal the
presence of some fi ssures, fi stul as, peri anal dermati ti s, masses,
thrombosed external hemorrhoi ds, condyl oma, and other growths.
Pati ents may percei ve anoscopy as extremel y embarrassi ng and
Page 557
uncomfortabl e. Objecti vel y and honestl y di scuss the procedure wi th
the pati ent whi l e obtai ni ng consent. Anoscopy general l y has few
compl i cati ons; possi bi l i ti es i ncl ude mi nor l acerati ons, abrasi ons, or
teari ng of hemorrhoi ds. Bl eedi ng occasi onal l y occurs after bi opsy,
and i nfecti on i s rare.
The Ives sl otted anoscope provi des the best unobstructed vi ew of
the wal l s of the anal canal . The sl otted i nstrument does not
compress the mucosa, so smal l
P.364
l esi ons and hemorrhoi ds are more easi l y seen and treated. Because
of i ts l arger openi ng, i t i s the preferred i nstrument for treati ng
hemorrhoi ds. The anoscope and obturator can be autocl aved.
Di sposabl e pl asti c anoscopes al l ow vi sual i zati on of the compressed
mucosa through the i nstrument, but they have a smal l er worki ng
openi ng, and thei r use can resul t i n fai l ure to vi sual i ze smal l
l esi ons.
INDICATIONS
Ini ti al eval uati on of rectal bl eedi ng
Anal or peri anal pai n
Pruri tus ani
Anal di scharge
Rectal prol apse
External or i nternal hemorrhoi ds
Anal fi ssures or fi stul as
Peri anal condyl oma
Pal pabl e masses or excessi ve pai n on di gi tal
exami nati on
HIV-posi ti ve pati ents wi th hi gh serum HIV l oad, a
hi story of anal dyspl asi a, or condyl omas
CONTRAINDICATIONS
Severe debi l i tati on
Acute myocardi al i nfarcti on
Page 558
Acute abdomen (rel ati ve contrai ndi cati on)
Marked anal canal stenosi s
P.365
PROCEDURE
The anatomy of the anal canal i s demonstrated.
Pl ace the pati ent i n the l eft l ateral decubi tus posi ti on wi th the l eft
si de down on the tabl e and the head toward the l eft as the
exami ner faces the pati ent. Sl i ghtl y fl ex the pati ent's hi ps and
knees, and draw the buttocks sl i ghtl y off the edge of the tabl e
toward the exami ner.
(2) Pl ace the pati ent i n the l eft l ateral decubi tus posi ti on wi th the
l eft si de down on the tabl e and the head toward the l eft as the
exami ner faces the pati ent.
PITFALL: Patients can be placed in a knee-chest position, but
this is more uncomfortable for the patient to maintain.
P.366
Vi sual l y i nspect the external anus. Look for i nfl ammati on or other
dermatol ogi c condi ti ons. Gentl y everti ng the buttocks usual l y
everts the anus enough to vi sual i ze anal ski n tags, peri anal
abscesses, thrombosed external hemorrhoi ds, and anal fi ssures.
Look for a senti nel ski n tag i n the posteri or or anteri or mi dl i ne that
that woul d i ndi cate the presence of a fi ssure.
Page 559
(3) Vi sual l y i nspect the external anus.
Start a di gi tal anorectal exami nati on by i nformi ng the pati ent that
you wi l l touch the anus. Wi th a gl oved fi nger wel l l ubri cated wi th a
water-sol ubl e l ubri cant or 2% l i docai ne jel l y, appl y gentl e pressure
to the anal verge so that the exami ni ng fi nger enters the anal
canal . Anal fi ssures mani fest as pal pabl e defects or i ndurati ons,
usual l y i n the posteri or mi dl i ne. Assess the prostate gl and i n mal e
pati ents. Assess anal sphi ncter functi on by aski ng the pati ent to
squeeze down as i f to try to stop a bowel movement and by
feel i ng for the ti ghteni ng of the external sphi ncter. Sweep the
exami ni ng fi nger around the enti re di stal rectum.
(4) Perform a di gi tal anorectal exami nati on.
P.367
An Ives sl otted anoscope i s used wi th the obturator i n pl ace for
i nserti on i nto the anal canal (Fi gure 5A) and wi thdrawn for vi ewi ng
Page 560
(Fi gure 5B).
(5) Ives sl otted anoscope.
P.368
Wi th the obturator i n pl ace, l ubri cate the anoscope wi th a
water-sol ubl e l ubri cant or 2% l i docai ne jel l y. Ask the pati ent to
gentl y take a few deep breaths. Insert the anoscope very gentl y
Page 561
i nto the anal aperture, gradual l y overcomi ng the resi stance of the
sphi ncters. Gentl y advance the i nstrument unti l the ful l l ength of
the anoscope i s i nserted.
(6) Wi th the obturator i n pl ace, l ubri cate the anoscope wi th a
water-sol ubl e l ubri cant, have the pati ent take a few deep breaths,
and i nsert the anoscope very gentl y i nto the anal aperture.
Remove the obturator to exami ne the mucosa. Observe the
appearance of the epi thel i um, the dentate l i ne, the mucosal
vascul ature, and for any abnormal fi ndi ngs such as bl ood, mucus,
pus, or hemorrhoi ds. Gradual l y wi thdraw the anoscope, observi ng
the anal canal as i t i s extracted. Then rotate the anoscope 120
degrees, and repeat the process. Repeat the procedure unti l the
enti re ci rcumference of the anal canal i s exami ned. A vari ety of
l ong-handl ed bi opsy i nstruments can be used to take a bi opsy
speci men. Keep the bi opsy superfi ci al ; onl y 3 or 4 mm of ti ssue are
needed. Control any bl eedi ng wi th pressure or Monsel 's sol uti on, or
both.
Page 562
(7) Remove the obturator to exami ne the mucosa.
PITFALL: If fecal matter is encountered, remove it with a large
cotton swab.
P.369
CODING INFORMATION

2002 Average 50th
Percentile Fee

46600 Anoscopy $65
46606 Anoscopy wi th bi opsy, si ngl e
or mul ti pl e
$128
46608 Anoscopy wi th forei gn body
removal
$219
The Ives sl otted anoscope ($160) i s avai l abl e from Redfi el d
Corporati on, 336 West Passai c Street, Rochel l e Park, NJ (phone:
800-678-4472; http://www.redfi el dcorp.com). A suggested
anesthesi a tray that can be used for thi s procedure i s descri bed i n
Page 563
Appendi x G.
BIBLIOGRAPHY
Dani el GL, Longo WE, Vernava AM 3rd. Pruri tus ani : causes and
concerns. Di s Col on Rectum 1994;37:670674.
de Rui ter A, Carter P, Katz DR, et al . A compari son between
cytol ogy and hi stol ogy to detect anal i ntraepi thel i al neopl asi a.
Geni touri n Med 1994;70:2225.
Ernst AA, Green E, Ferguson MT, et al . The uti l i ty of anoscopy and
col poscopy i n the eval uati on of mal e sexual assaul t vi cti ms. Ann
Emerg Med 2000;36:432437.
Indi nni meo M, Ci cchi ni C, Stazi A, et al . Anal ysi s of a fol l ow-up
program for anal canal carci noma. J Exp Cl i n Cancer Res
2001;20:199203.
Kel l y SM, Sanowski RA, Foutch PG, et al . A prospecti ve compari son
of anoscopy and fi ber endoscopy i n detecti ng anal l esi ons. J Cl i n
Gastroenterol 1986;8:658660.
Korki s AM, McDougal l CJ. Rectal bl eedi ng i n pati ents l ess than 50
years of age. Di g Di s Sci 1995;40:15201523.
Lewi s JD, Brown A, Local i o AR, et al . Ini ti al eval uati on of rectal
bl eedi ng i n young persons: a cost-effecti veness anal ysi s. Ann
I ntern Med 2002;136:99110.
Sobhani I, Vuagnat A, Wal ker F, et al . Preval ence of hi gh-grade
dyspl asi a and cancer i n the anal canal i n human
papi l l omavi rus-i nfected i ndi vi dual s. Gastroenterol ogy 2001;120:857
866.
Surawi cz CM, Ki rby P, Cri tchl ow C, et al . Anal dyspl asi a i n
homosexual men: rol e of anoscopy and bi opsy. Gastroenterol ogy
1993;105:658666.
Wi l l i am DC, Fel man YM, Ri ccardi NB. The uti l i ty of anoscopy i n the
rapi d di agnosi s of symptomati c anorectal gonorrhea i n men. Sex
Transm Di s 1981;8:1617.
Page 564
> Table of Cont ent s > Gast roent erology > 48 - Flexible Sigmoidoscopy48
Flexible Sigmoidoscopy
Fl exi bl e si gmoi doscopy i s a commonl y performed techni que for
exami nati on of the rectum and di stal col on. Si gmoi doscopy has
been advocated for i ndi vi dual s ol der than 50 years of age every 3
to 5 years as a screeni ng strategy to detect adenomas and col on
cancer. The techni que i s safe, easi l y performed i n an offi ce setti ng,
and produces a 30% to 40% reducti on i n col on cancer mortal i ty.
Trai ni ng i n endoscopi c maneuveri ng and i n anatomy and pathol ogy
recogni ti on i s requi red for performance of si gmoi doscopy.
Experi enced practi ti oners often perform the procedure i n l ess than
10 mi nutes. Most physi ci ans report comfort wi th performi ng the
procedure unsupervi sed after compl eti ng 10 to 25 preceptor-gui ded
sessi ons.
About 60% of al l col orectal cancers are wi thi n reach of the
si gmoi doscope. Rectal bl eedi ng i n i ndi vi dual s ol der than 50 years
shoul d be eval uated by ful l col onoscopy because of the ri sk for
i sol ated proxi mal neopl asms beyond the vi ew of the si gmoi doscope.
Mul ti pl e opti ons exi st when eval uati ng a younger i ndi vi dual wi th
rectal bl eedi ng. For persons between the ages of 30 and 39 years,
the i nci dence of col on cancer i s onl y 3 cases per 1000 peopl e, but
di fferenti ati ng the few wi th seri ous pathol ogy from those wi th anal
di sease can be di ffi cul t. Because proxi mal l esi ons al so peak i n
i ndi vi dual s before the age of 40 years, ful l col onoscopy and fl exi bl e
si gmoi doscopy wi th bari um enema are appropri ate strategi es for
i ndi vi dual s between the ages of 30 and 49 years. Most bl eedi ng i n
i ndi vi dual s younger than 30 years i s caused by beni gn anal di sease.
Fl exi bl e si gmoi doscopy i s a reasonabl e opti on i n that age group i f
anoscopi c fi ndi ngs are normal .
About 7% to 10% of fl exi bl e si gmoi doscopi es reveal the presence
of adenomas. Hi stori cal l y, the presence of an adenoma
Page 565
necessi tated referral for col onoscopy to l ook for proxi mal neopl asi a.
Some physi ci ans have recommended col onoscopy onl y for l arger (>1
cm) adenomas, because l arger l esi ons were more l i kel y to have
hi gher-ri sk vi l l ous features. However, the major benefi t of uni versal
bi opsy of pol yps di scovered at si gmoi doscopy may be to di sti ngui sh
tubul ar adenomas from vi l l ous adenomas. Persons wi th tubul ar
adenomas of any si ze appear to have the same rate of proxi mal
neopl asi a as i ndi vi dual s wi th no adenomas at si gmoi doscopy (about
5.5%). A di stal tubul ovi l l ous or vi l l ous adenoma has a hi gher rate
of proxi mal neopl asi a (about 12%), and thi s fi ndi ng shoul d i ncur
referral for col onoscopy.
P.371
Di mi nuti ve (<5 mm) pol yps found at si gmoi doscopy often are
hyperpl asti c. Al though hyperpl asti c pol yps general l y are not
thought to be associ ated wi th proxi mal adenomas, thi s opi ni on i s
not uni versal l y accepted i n the l i terature. Many practi ces offer
bari um enema, and others recommend no further screeni ng when
hyperpl asti c pol yps are found on si gmoi doscopi c bi opsy.
Many physi ci ans recommend ful l col onoscopy for col on cancer
screeni ng every 10 years for al l i ndi vi dual s ol der than 50 years.
Indi vi dual s at hi gher ri sk (i .e., those wi th a fami l y hi story of col on
cancer) may benefi t from thi s strategy. Si gni fi cant feasi bi l i ty i ssues
conti nue to prevent thi s approach from bei ng recommended for
popul ati on screeni ng. A more feasi bl e strategy i s to perform
screeni ng si gmoi doscopy at age 50 for average-ri sk i ndi vi dual s.
Onl y a smal l proporti on of screened i ndi vi dual s wi th an occul t
proxi mal neopl asm wi l l have the l esi on progress to symptomati c
col on cancer, and those that do progress take many years. Peri odi c
si gmoi doscopy fol l owed by a si ngl e screeni ng col onoscopy at age 65
may be a more appropri ate, cost-effecti ve popul ati on strategy.
The average procedure ti me for si gmoi doscopy wi thout bi opsy i s
about 17 mi nutes. Performance of a bi opsy adds about 10 mi nutes
to the procedure. Al though i t i s desi rabl e to i nsert the enti re scope
Page 566
l ength (60 to 70 cm), the average depth of i nserti on i s about 52
cm. Both procedure ti me and the depth of i nserti on appear to be
operator dependent. Women have a more acute angl e at the
rectosi gmoi d juncti on, maki ng endoscope passage more di ffi cul t.
Studi es i n women al so demonstrate that a hi story of pri or pel vi c or
abdomi nal surgery i ncreases the di scomfort and decreases the
depth of endoscope i nserti on. Si gmoi doscopy i n women averages
i nserti on depths of onl y 40 cm.
In a l arge seri es i n Engl and, about 80% of i ndi vi dual s rated the
di scomfort of si gmoi doscopy as no or mi l d pai n. The
remai nder rated thei r di scomfort as moderate to severe, wi th
women reporti ng si gni fi cantl y more di scomfort. About 16% stated
thei r di scomfort was greater than what they expected. Most
procedures can be performed wi thout sedati on or anal gesi a, but i f
pati ents i nsi st, premedi cati on opti ons i ncl ude oral di azepam (10
mg) or tri azol am (0.5 mg) taken 1 hour before the procedure,
i ntranasal butorphanol (two squi rts) i mmedi atel y before the
procedure, or i ntramuscul ar ketorol ac (60 mg) admi ni stered 30
mi nutes before the procedure. Appendi x F provi des the gui del i nes
for moni tori ng pati ents recei vi ng consci ous sedati on for endoscopy
procedures.
Adequate preparati on of the l eft col on i s essenti al for fl exi bl e
si gmoi doscopy. Eati ng after mi dni ght i s hi ghl y associ ated wi th
stool i n the si gmoi d, and pati ents must be i nstructed to consume
onl y cl ear l i qui ds the morni ng of the procedure. Most practi ces
recommend the admi ni strati on of one or two enemas before the
procedure. Home admi ni strati on of the enemas may reduce pati ent
embarrassment and ti me demands on offi ce nursi ng staffs.
However, many pati ents refuse to admi ni ster home enemas, feel i ng
unabl e to perform the task or feari ng a mess. Proper educati on of
enema admi ni strati on and offeri ng an al ternate, oral l y admi ni stered
bowel preparati on may reduce noncompl i ance wi th home bowel
cl eansi ng. Appendi x E provi des recommendati ons for endoscope
di si nfecti on.
Indi vi dual s often choose not to undergo si gmoi doscopy. Offeri ng
Page 567
fecal occul t bl ood testi ng si mul taneousl y wi th si gmoi doscopy can
cause some pati ents to avoi d the i nvasi ve procedure. Increased
acceptance of si gmoi doscopy can be achi eved by sendi ng a l etter
descri bi ng the si gni fi cance of col on cancer and i nvi ti ng i ndi vi dual s
to parti ci pate i n col on screeni ng. Other factors that may favorabl y
i ncrease the uptake of the procedure i ncl ude enthusi asm of the
pri mary care physi ci an and staff for the procedure, tel ephone
remi nders before the procedure,
P.372
hi gher l evel s of general educati on i n the target popul ati on, and
ski l l of the practi ti oner performi ng endoscopy (especi al l y for
repeated screeni ng).
About one hal f of pri mary care physi ci ans who are trai ned to
perform fl exi bl e si gmoi doscopy do not conti nue the procedure i n
practi ce. One study documented that the mai n deterrents to
conti nui ng to offer the servi ce i ncl uded the ti me requi red to
perform the procedure, the avai l abi l i ty of the procedure from other
physi ci ans i n thei r l ocal e, and the avai l abi l i ty of adequatel y trai ned
staff. Low rei mbursement for the ti me i nvol ved i n the procedure,
especi al l y from the Medi care program, i s often ci ted as a reason for
di sconti nui ng si gmoi doscopy screeni ng.
INDICATIONS
Col orectal cancer screeni ng
Eval uati on of bri ght red rectal bl eedi ng, especi al l y i n
younger pati ents
Eval uati on of an abnormal fi ndi ng on rectal exami nati on
(e.g., pal pabl e mass, pol yp)
Eval uati on of a woman wi th pri or gynecol ogi c mal i gnancy
Eval uati on of an abnormal i ty i denti fi ed radi ographi cal l y
Investi gati on of abdomi nal pai n
Suspected forei gn body
Eval uati on of symptoms that coul d be attri butabl e to the
col on (e.g., wei ght l oss, i ron defi ci ency anemi a,
persi stent di arrhea, change i n bowel habi ts, pai nful
Page 568
defecati on)
Survei l l ance of col on pathol ogy (e.g., i nfl ammatory
bowel di sease, pri or pol ypectomy)
Fol l ow-up after col ectomy
Acute peri toni ti s
Acute di verti cul i ti s (do not i nsert the scope past a newl y
di scovered i nfl amed di verti cul um)
Acute ful mi nant col i ti s
Suspected i schemi c bowel necrosi s
Inadequate bowel preparati on
Extensi ve pel vi c adhesi ons
Severe cardi ac or pul monary di sease
Pel vi c adhesi ons (especi al l y women wi th a pri or
hysterectomy), whi ch can i ncrease the procedure's
di scomfort
Toxi c megacol on
Anti coagul ant or aspi ri n use at ti me of the procedure
(di sconti nue aspi ri n at l east 10 days before and
coumadi n at l east 2 days before the procedure)
Paral yti c i l eus
Large (>5 cm) abdomi nal aneurysms
Suspected perforati on of the bowel
P.373
PROCEDURE
Thi s i s the vi ew from above the exami nati on tabl e of the proper
posi ti oni ng of the pati ent for the procedure. The pati ent i s i n the
Si ms or l eft l ateral decubi tus posi ti on, wi th the l eft si de of the
body down on the tabl e. The l eft hi p and knee are both fl exed, and
the ri ght l eg remai ns fai rl y strai ght.
Page 569
(1) Vi ew from above the exami nati on tabl e of the proper
posi ti oni ng of the pati ent for the procedure.
P.374
A rectal exami nati on i s performed wi th the l ubri cated, gl oved i ndex
fi nger. The nondomi nant hand l i fts the ri ght buttock. The anal canal
and di stal rectum are exami ned for pathol ogy and to excl ude any
obstructi on, forei gn body, or stool that may prevent endoscope
i nserti on. Use of 5% l i docai ne oi ntment may decrease di scomfort
from the subsequent endoscopi c procedure.
Page 570
(2) Perform a rectal exami nati on.
PITFALL: Overly aggressive performance of a digital
examination will make the patient uncomfortable and possibly
reduce patient tolerance of the ensuing endoscopy. Perform the
examination gently, and talk to the patient (i.e., verbal
anesthesia) from the very beginning.
Because the endoscope does not vi sual i ze the anal canal wel l ,
many authori ti es recommend performance of anoscopy before
si gmoi doscopy. The Ives anoscope i s a sl otted, metal scope that
affords extensi ve vi ewi ng i n the canal . The l ubri cated anoscope i s
i nserted three ti mes to vi ew al l three hemorrhoi dal pads (see
Chapter 52).
(3) Because the endoscope does not vi sual i ze the anal canal wel l ,
performi ng an anoscopy before si gmoi doscopy i s recommended.
P.375
Page 571
The endoscope i s hel d i n the l eft hand. The umbi l i cal cord to the
l i ght source si ts over the thumb web space and travel s across the
wri st. The endoscope head si ts i n the pal m of the hand. The l eft
thumb operates the i nner (up and down) and outer (ri ght and l eft)
control knobs. The i ndex fi nger and mi ddl e fi nger depress the ai r or
water and sucti on val ves. The l eft fourth and fi fth fi ngers grasp and
support the endoscope.
(4) The endoscope i s hel d i n the l eft hand.
PITFALL: Many individuals with small hands complain about the
difficulty of holding the endoscope. It may be difficult for the
thumb to reach the outer knob if the operator' s hand is small.
Individuals with small hands must learn to turn the scope right
and left by turning the scope using the right hand.
P.376
The ri ght hand i s used to grasp the scope and to twi st the scope
(Fi gure 5A). Thi s hel ps wi th the i nserti on techni ques descri bed
l ater. As the l eft thumb moves the scope ti p up and down (Fi gure
5B), the ri ght hand can torque the curl ed scope ti p to move i t ri ght
or l eft (Fi gure 5C). Al ternatel y, some practi ti oners prefer to have a
nurse assi stant perform the scope i nserti on and wi thdrawal and to
Page 572
use the ri ght hand to work the outer (ri ght or l eft) knob. Inserti on
by a second person l i mi ts the abi l i ty to feel tensi on on the col on
wal l and to perform torqui ng maneuvers.
(5) The ri ght hand i s used to grasp and twi st the scope.
P.377
The scope i s l ubri cated wi th water-sol ubl e jel l y, and i nserti on i s
performed by di rect i nserti on of the scope ti p i nto the anus or by
pushi ng the scope ti p i nsi de wi th the i ndex fi nger behi nd the scope.
Some practi ti oners press tangenti al l y on the anal verge to faci l i tate
i nserti on.
Page 573
(6) Lubri cate the scope wi th water-sol ubl e jel l y, and di rectl y i nsert
the scope ti p i nto the anus.
PITFALL: Do not apply lubricating jelly on the tip of the scope
because it will smear the lens and distort the image.
PITFALL: Care must be taken when inserting the scope in
women to avoid an embarrassing and potentially injurious
intravaginal insertion.
P.378
The scope i s i nserted i nto the rectum (7 to 17 cm), and ai r i s
i nsuffl ated to reveal the l umen. Some practi ti oners sucti on fl ui d
from the rectum. The l umen i s used as a gui de for i nserti on,
thereby reduci ng pati ent di scomfort and ri sk of perforati on. Ai r can
be conti nuousl y or i ntermi ttentl y i nserted to open the i nsi de of the
col on for passage and vi ewi ng.
Page 574
(7) The scope i s i nserted i nto the rectum (7 to 17 cm), and ai r i s
i nsuffl ated to reveal the l umen.
PITFALL: Avoid suctioning any solid stool, because this can
rapidly dry and clog the suction channel, necessitating costly
repairs to the endoscope. Even fluid in the rectum may have
stool, and suctioning should be performed only when needed.
Insert the scope as rapi dl y as possi bl e to l i mi t pati ent di scomfort
and spasm, whi ch can make i nserti on more di ffi cul t. Three
transverse fol ds of mucosa are seen i n the rectum (Fi gure 8A), and
these are passed to enter the rectosi gmoi d. Torqui ng the
endoscope wi th the ri ght hand al l ows passage through turns (Fi gure
8B). Di theri ng i s the rapi d back-and-forth moti on that someti mes
faci l i tates fi ndi ng the l umen and passi ng the scope.
Page 575
(8) Insert the scope as rapi dl y as possi bl e to l i mi t pati ent
di scomfort and spasm, whi ch makes i nserti on more di ffi cul t.
P.379
The hooki ng and strai ghteni ng techni que may be used for passage
through a tortuous si gmoi d. As the endoscope i s i nserted i n the
si gmoi d, the si gmoi d may bow upward, produci ng si gni fi cant pati ent
di scomfort (Fi gure 9A). The endoscope ti p i s maxi mal l y defl ected
(Fi gure 9B), and the si gmoi d i s hooked as the scope i s
wi thdrawn (Fi gure 9C). The scope ti p can paradoxi cal l y appear to
move forward through the l umen as the endoscope i s wi thdrawn.
The si gmoi d i s strai ghtened (Fi gure 9D), and the endoscope passes
through the si gmoi d.
Page 576
(9) The hooki ng and strai ghteni ng techni que may be used for
passage through a tortuous si gmoi d.
The endoscope i s maxi mal l y i nserted. Vi ewi ng takes pl ace as the
endoscope i s wi thdrawn. Depi cted are a di verti cul ar openi ng,
normal vascul ari ty of the col on wal l , a peduncul ated pol yp, and a
cancer occupyi ng one thi rd of the wal l of the col on. Use the
marki ngs on the endoscope to document depth of i nserti on of the
scope for al l pathol ogy encountered.
(10) The endoscope i s maxi mal l y i nserted.
PITFALL: Do not mistake the lumen for a large diverticular
orifice. The posterior walls of diverticular sacs can be quite thin,
and perforation is easily accomplished by inadvertent entry into
a diverticular sac.
P.380
Bi opsy i s performed by threadi ng the metal bi opsy i nstrument
Page 577
through the bi opsy channel . The open bi opsy forceps can serve as a
gui de to the si ze of l esi ons, measuri ng approxi matel y 5 mm when
opened (Fi gure 11A). A syri nge-l i ke pl unger on the end of the
bi opsy forceps i s used to open and cl ose the forceps (Fi gure 11B).
(11) Bi opsy i s performed by threadi ng the metal bi opsy i nstrument
through the bi opsy channel .
P.381
After the endoscope i s wi thdrawn to the rectum (i .e., 10 to 15 cm
i nserted), the scope ti p i s retroverted to exami ne the di stal rectal
vaul t. Thi s area i s not wel l vi sual i zed by the forward-di rected scope
as i t passes the area. Retroversi on i s achi eved by maxi mal l y
defl ecti ng the i nner (up and down) knob wi th the l eft thumb whi l e
si mul taneousl y i nserti ng the scope wi th the ri ght hand (Fi gure
12A). The bl ack scope can be seen enteri ng the rectum past some
i nternal hemorrhoi ds and a hi dden tumor (Fi gure 12B).
Page 578
(12) After the endoscope i s wi thdrawn to the rectum (10 to 15 cm
i nserted), the scope ti p i s retroverted to exami ne the di stal rectal
vaul t.
The scope i s strai ghtened, and the l umen vi ewed. Ai r i s wi thdrawn
from the rectum before the scope i s wi thdrawn. The scope i s
i mmedi atel y pl aced i n soapy water, and the sucti on channel i s
fl ushed to prevent cl oggi ng of the channel . The anus i s wi ped cl ean
wi th gauze, and the pati ent i s offered the opportuni ty to go to the
bathroom. The pati ent i s permi tted to get dressed after the
procedure and before the fi ndi ngs are di scussed.
(13) The rectum i s empti ed of ai r before the scope i s wi thdrawn.
The anus i s wi ped cl ean wi h gauze.
PITFALL: Vasovagal responses are possible during or after the
Page 579
procedure. Patients should be allowed to sit for a minute with
the legs dangling off the table before being allowed to get off
the examination table.
P.382
CODING INFORMATION
For codi ng purposes, si gmoi doscopy i nvol ves exami nati on of the
enti re rectum, si gmoi d col on, and may i ncl ude a porti on of the
descendi ng col on.

2002 Average 50th
Percentile Fee

45330 Fl exi bl e si gmoi doscopy wi th
or wi thout brushi ngs or
washi ngs
$230
si ngl e or mul ti pl e bi opsi es
$320
forei gn body removal
$387
tumor, pol yp, l esi on removal
(hot bi opsy forceps)
$458
control of bl eedi ng (cautery,
coagul ator)
$554
Informati on on endoscopy equi pment orderi ng, trai ni ng, and atl ases
i s provi ded i n Chapter 49. The i nformati on on orderi ng the Ives
anoscope i s i ncl uded i n Chapter 52. Recommendati ons for
endoscope cl eani ng appear i n Appendi x E.
BIBLIOGRAPHY
Page 580
Ameri can Academy of Fami l y Physi ci ans. Fl exi bl e si gmoi doscopy
preceptori al trai ni ng program: a syl l abus for the physi ci an starti ng
to perform fl exi bl e si gmoi doscopy i n the offi ce. Kansas Ci ty:
Ameri can Academy of Fami l y Physi ci ans, 1985.
Atki n WS, Hart A, Edwards R, et al . Uptake, yi el d of neopl asi a, and
adverse effects of fl exi bl e si gmoi doscopy screeni ng. Gut
1998;42:560565.
Cohen LB. A new i l l ustrated how to gui de to fl exi bl e
si gmoi doscopy. Pri m Care Cancer 1989;9:1320.
Davi s PW, Stanfi el d CB. Fl exi bl e si gmoi doscopy: i l l umi nati ng the
pearl s for passage. Postgrad Med 1999;105:5162.
Esber EJ, Yang P. Retrofl exi on of the si gmoi doscope for the
detecti on of rectal cancer. Am Fam Physi ci an 1995;51:17091711.
Herman M, Shaw M, Loewen B. Compari son of three forms of bowel
preparati ons for screeni ng fl exi bl e si gmoi doscopy. Gastroenterol
Nurs 2001;24:178181.
Hol man JR, Marshal l RC, Jordan B, et al . Techni cal competence i n
fl exi bl e si gmoi doscopy 2001;14:424429.
Levi n TR, Pal i tz A, Grossman S, et al . Predi cti ng advanced proxi mal
col oni c neopl asi a wi th screeni ng si gmoi doscopy. JAMA
1999;281:16111617.
Lewi s JD, Asch DA, Gi nsberg GG, et al . Pri mary care physi ci ans'
deci si ons to perform fl exi bl e si gmoi doscopy. J Gen I ntern Med
1999;14:297302.
P.383
Lewi s JD, Asch DA. Barri ers to offi ce-based screeni ng
si gmoi doscopy: does rei mbursement cover costs? Ann I ntern Med
1999;130:525530.
Lund JN, Buckl ey D, Bennett D, et al . A randomi zed tri al of hospi tal
versus home admi ni stered enemas for fl exi bl e si gmoi doscopy. Br
Med J 1998;317:1201.
Mayberry MK, Mayberry JF. Towards better i nformed consent i n
endoscopy: a study of i nformati on and consent processes i n
Page 581
gastroscopy and fl exi bl e si gmoi doscopy. Eur J Gastroenterol
Hepatol 2001;13:14671476.
McCal l i on K, Mi tchel l RM, Wi l son RH, et al . Fl exi bl e si gmoi doscopy
and the changi ng di stri buti on of col orectal cancer: i mpl i cati ons for
screeni ng. Gut 2001;48:522525.
Ransohoff DF, Lang CA. Si gmoi doscopi c screeni ng i n the 1990s.
JAMA 1993;269:12781281.
Rees MK. We shoul d al l be performi ng fl exi bl e si gmoi doscopy. Mod
Med 1987;55:3, 12.
Snowski RA. Fl exi bl e fi beropti c si gmoi doscopy. Research Tri angl e
Park, NC: Gl axo, 1992.
Verne JE, Aubrey R, Love SB, et al . Popul ati on based randomi zed
study of uptake and yi el d of screeni ng by fl exi bl e si gmoi doscopy
compared wi th screeni ng by faecal occul t bl ood testi ng. Br Med J
1998;317:182185.
Wal l ace MB, Kemp JA, Trnka YM, et al . Is col onoscopy i ndi cated for
smal l adenomas found by screeni ng fl exi bl e si gmoi doscopy? Ann
I ntern Med 1998;129:273178.
Wi l l i ams JJ. Why fami l y physi ci ans shoul d perform si gmoi doscopy
[Edi tori al ]. Am Fam Physi ci an 1990;4:1722, 1724.
Wi nawer SJ. Offi ce screeni ng for col orectal cancer. Pri m Care Cancer
1993;13:3746.
Zuber TJ. Fl exi bl e si gmoi doscopy. Am Fam Physi ci an
2001;63:13751380, 13831388.
Zuber TJ. Offi ce procedures. The Academy col l ecti on qui ck
Wi l ki ns, 1999:3542.
Page 582
> Table of Cont ent s > Gast roent erology > 49 - Esophagogast roduodenoscopy49
Esophagogastroduodenoscopy
Esophagogastroduodenoscopy (EGD) i s an endoscopi c di agnosti c
and therapeuti c procedure that provi des cl i ni ci ans wi th excel l ent
vi ews of the mucosal surfaces of the upper gastroi ntesti nal tract.
EGD i s advocated for the eval uati on of a vari ety of abdomi nal and
chest compl ai nts, and i t can be safel y performed i n an offi ce
setti ng. The techni que i s di agnosti cal l y superi or to di agnosti c
gastroi ntesti nal radi ographi c procedures and affords added benefi ts
of di agnosti c bi opsi es or testi ng for Hel i cobacter pyl ori i nfecti on.
Many benefi ts have been suggested for the performance of EGD i n
pri mary care practi ces. Performance of EGD i n an offi ce setti ng can
provi de rapi d assessment of pati ents' compl ai nts, avoi d l engthy
referral del ays, i mprove access to the procedure, i ncrease pati ents'
comfort by performance of the procedure i n a fami l i ar setti ng,
reduce costs compared wi th referral to speci al i zed setti ngs, and
i mprove the physi ci an's understandi ng of the i nvol ved pathol ogy.
Al l of these benefi ts may transl ate i nto i mproved heal th care
qual i ty for the pati ent.
Most procedures hi stori cal l y have been performed usi ng consci ous
sedati on. The i ntravenous benzodi azepi nes di azepam or mi dazol am
can be combi ned wi th the i ntravenous narcoti c meperi di ne to
provi de good pati ent rel axati on for the procedure. Mi dazol am
provi des a degree of amnesi a, a desi rabl e effect i f i ni ti al i ntubati on
i s di ffi cul t. Gui del i nes for moni tori ng the pati ent recei vi ng
consci ous sedati on for gastroi ntesti nal endoscopy are i ncl uded i n
Appendi x F. Topi cal anesthesi a of the oral cavi ty can be achi eved
wi th a vi scous 2% l i docai ne sol uti on and wi th 20% benzocai ne
(Hurri cai ne) spray. Use of thi n (7.9 or 9.0 mm outer di ameter)
pedi atri c endoscopes can i mprove safety, because the thi n
endoscopes reduce oxygen desaturati on duri ng the procedure.
Page 583
Ul trathi n scopes have been devel oped that can be i nserted
i ntranasal l y for eval uati on of the esophagus, but these scopes
appear to have l i mi tati ons for vi ewi ng the di stal stomach and
duodenum.
Noni ntravenous methods of sedati on have been used successful l y
for EGD. Practi ti oners may be more comfortabl e wi th admi ni steri ng
si mi l ar medi cati ons by noni ntravenous routes i n an offi ce setti ng.
Pati ents can take the benzodi azepi ne tri azol am (Hal ci on, 0.25 or
0.5 mg) oral l y 1 hour before the procedure. Butorphanol tartrate
nasal spray (Stadol ) can be admi ni stered (one or two sprays)
i mmedi atel y before the procedure i f addi ti onal anesthesi a i s
requi red. Good resul ts from thi s regi men were reported i n a pi l ot
study, but thi s regi men has not been compared wi th i ntravenous
regi mens. Pati ents undergoi ng noni ntravenous
P.385
sedati on are moni tored si mi l ar to those undergoi ng i ntravenous
sedati on. Cost savi ngs can be achi eved by avoi di ng the pl acement
of an i ntravenous l i ne for the procedure. Consent must be obtai ned
before any anesthesi a i s admi ni stered.
Because of the cost and i nvasi ve nature of EGD, many experts
recommend that the procedure be performed for the eval uati on of
aci d-pepti c di sorders onl y after a tri al of medi cati on therapy.
Pati ents wi th si gns of seri ous organi c di sease (e.g., wei ght l oss,
anorexi a) or wi th severe upper abdomi nal di stress shoul d be
eval uated promptl y. Gastroi ntesti nal bl eedi ng shoul d be eval uated
i n the control l ed envi ronment of a hospi tal gastroi ntesti nal
l aboratory. Some practi ti oners prefer to perform studi es on pati ents
wi th acqui red i mmunodefi ci ency syndrome (AIDS) or hepati ti s i n
hospi tal setti ngs to use automated cl eani ng systems for the
endoscopes. Recommendati ons for endoscope di si nfecti on are
i ncl uded i n Appendi x E. Good pati ent outcomes often fol l ow proper
pati ent sel ecti on, and speci al ty referral of medi cal l y unstabl e or
hi gh-ri sk pati ents appears prudent.
Testi ng for H. pyl ori , the bacteri a hi ghl y associ ated wi th antral
Page 584
gastri ti s and pepti c ul cer di sease, i s an i mportant component of the
EGD exami nati on. H. pyl ori produces urease, the enzyme i nvol ved i n
breakdown of urea to ammoni a. Ammoni a can be eval uated
col ori metri cal l y, and a red col or change i s seen i n the gel testi ng
medi um when urease acti vi ty i s present i n the bi opsy speci men. It
i s advocated that two bi opsi es be obtai ned for H. pyl ori , one from
the antral l esser curvature (at or near the i nci sura) and the other
from the antral greater curvature. These two bi opsi es yi el d nearl y
100% sensi ti vi ty for the i nfecti on.
Correct i denti fi cati on of pathol ogy i s a major chal l enge i n l earni ng
EGD. Experi ence hel ps, but even seasoned endoscopi sts consul t
books and atl ases to revi ew thei r vi sual observati ons. Photographi c
or vi deotape recordi ng of procedures can hel p wi th documentati on
and l earni ng. Al though referral may be requi red for unusual or
uncertai n pathol ogy, EGD i s appropri atel y performed i n pri mary care
practi ces because of the l arge percentage of normal study resul ts
for pati ents wi th appropri ate i ndi cati ons for the procedure.
INDICATIONS
Dyspepsi a unresponsi ve to medi cal therapy
Peri odi c survei l l ance of pati ents wi th bi opsy proven
Barrett's esophagus
Dysphagi a or odynophagi a
Persi stent vomi ti ng of unknown ori gi n
Documentati on of H. pyl ori
Persi stent regurgi tati on of undi gested food
Suspected mal absorpti on
Peri odi c moni tori ng of pati ents wi th gastri c pol yps, or
Gardner's syndrome
Documentati on of cl earance of gastri c ul cers
Iron defi ci ency anemi a
Atypi cal chest pai n wi th negati ve cardi ac workup
Esophageal refl ux symptoms unresponsi ve to medi cal
therapy
Eval uati on of upper gastroi ntesti nal bl eedi ng
Suspected bezoar
Page 585
Suspected Zenker's di verti cul um
Suspected upper i ntesti nal or gastri c obstructi on
Dyspepsi a associ ated wi th seri ous si gns such as wei ght
l oss
Eval uati on of abnormal radi ographi c fi ndi ngs
P.386
Screeni ng for gastri c cancer (especi al l y i n hi gh-ri sk
popul ati ons such as the Japanese)
Known or suspected perforated vi scus
Acute, severe, or unstabl e cardi opul monary di sease
Severe or acti ve upper gastroi ntesti nal bl eedi ng
Pati ents requi ri ng therapeuti c EGD that cannot be
performed by the practi ti oner i n that setti ng
Hemodynami cal l y unstabl e pati ent
P.387
PROCEDURE
Dentures are removed, and oral topi cal anesthesi a i s admi ni stered.
The pati ent can swi sh, gargl e, and swal l ow 5 to 10 mL of 2%
vi scous l i docai ne. Benzocai ne spray i s then appl i ed to the posteri or
pharyngeal wal l to bl unt the gag refl ex. The exami ner's gl oved l eft
i ndex fi nger depresses the tongue, exposi ng the pharynx for two 2-
to 5-second sprays. Avoi d touchi ng the pati ent's ti ssues
(contami nati ng) the extensi on spray tubi ng from the mul ti use spray
bottl e.
Page 586
(1) Benzocai ne spray i s appl i ed to the posteri or pharyngeal wal l to
bl unt the gag refl ex.
PITFALL: The benzocaine spray has a pungent taste, even with
flavoring added. Warn the patient about the taste, and allow
time for a brief respite before the second spray.
The pati ent i s posi ti oned i n the l eft l ateral posi ti on, wi th the
pati ent's l eft si de down on the tabl e. A pi l l ow i s pl aced beneath
the pati ent's head, and the head ti l ted forward. Di sposabl e
absorbant pads are pl aced beneath the pati ent's head and neck for
secreti ons that may drai n duri ng the procedure. The assi stant may
need to hol d the head duri ng i nserti on of the endoscope.
(2) The pati ent i s posi ti oned i n the l eft l ateral posi ti on, wi th the
pati ent's l eft si de down on the tabl e and wi th a pi l l ow beneath the
Page 587
pati ent's head, whi ch i s ti l ted forward.
P.388
If noni ntravenous anesthesi a i s admi ni stered, the pati ent can
recei ve one or two sprays of butorphanol . Use the nondomi nant
hand to open the nares, and admi ni ster the spray wi th the ti p of
the appl i cator bottl e kept outsi de of the nose. Do not touch
(contami nate) the mul ti use appl i cator ti p to the pati ent. If
i ntravenous anesthesi a i s used, the medi cati ons can be
admi ni stered (25 to 75 mg of meperi di ne and 2 to 8 mg of
mi dazol am) after obtai ni ng i ntravenous access.
(3) Open the pati ent's nares, and admi ni ster one or two sprays of
butorphanol wi thout touchi ng the ti p of the appl i cator bottl e to the
pati ent.
P.389
The endoscope i s shown (Fi gure 4A), and the components of the
endoscope head (Fi gure 4B) and the endoscope ti p (Fi gure 4C) are
depi cted.
Page 588
(4) The endoscope.
P.390
The mouthpi ece i s pl aced, and the pati ent i s asked to gentl y but
fi rml y pl ace the teeth around the mouthpi ece. The pati ent's neck i s
fl exed (chi n to the chest), and the l ubri cated di stal endoscope i s
i nserted through the mouthpi ece. The endoscope i s sl i d over the
posteri or tongue and angl ed downward to vi ew the l arynx. The
scope i s i nserted sl owl y and kept off the si de wal l s of the
Page 589
hypopharynx to l i mi t gaggi ng. The scope ti p i s i nserted to the
posteri or l arynx, away from the vocal cords, just proxi mal to the
cl osed cri copharyngeus muscl e (scope i nserted about 18 cm from
the i nci sors) (Fi gure 5A). Ask the pati ent to swal l ow, whi ch opens
the muscl e and al l ows access to the esophagus (Fi gure 5B). The
scope ti p i s i nserted as the pati ent swal l ows, and i f the esophagus
i s i ntubated, the characteri sti c appearance of the upper esophagus
can be seen (Fi gure 5C).
(5) After the scope ti p i s i nserted to the posteri or l arynx, the
pati ent i s asked to swal l ow, whi ch opens the muscl e and al l ows
access to the esophagus.
PITFALL: The patient often gags when the scope is inserted. As
soon as intubation is accomplished, stop and prevent movement
of the scope tip. This allows the patient to resume normal
respiratory pattern and become accustomed to the sensation
created by the tube. Verbal anesthesia assists the patient at this
time; talk the patient through this most difficult aspect of the
procedure.
PITFALL: Tracheal intubation can happen if the tube is forcibly
inserted with the scope tip positioned over the vocal cords. The
endoscope produces distress from the inability to breath and
possibly from laryngospasm. The scope should be completely
withdrawn if tracheal intubation occurs (i.e., tracheal rings are
visualized) or is suspected.
P.391
Page 590
The scope i s i nserted under di rect vi sual i zati on. Insuffl ate ai r, and
advance the endoscope onl y when l umen i s vi sual i zed. Exami ne the
di stal esophagus and gastroesophageal juncti on (about 40 cm from
the i nci sors).
(6) Exami ne the di stal esophagus and gastroesophageal juncti on.
Passage i nto the stomach reveal s the characteri sti c gastri c fol ds
(Fi gure 7A). Turn the scope ti p to encounter the gastri c l ake (i .e.,
gastri c secreti on pool ). Sucti on the pool i mmedi atel y to faci l i tate
compl ete exami nati on of the stomach and to make the exami nati on
safer (i .e., empty the stomach to prevent possi bl e aspi rati on i f
vomi ti ng devel ops) (Fi gure 7B).
(7) Sucti on the gastri c secreti on pool i mmedi atel y to compl etel y
exami ne the stomach and to prevent possi bl e aspi rati on i f vomi ti ng
Page 591
devel ops.
P.392
Pass the endoscope to the pyl orus. Angul ati on of the scope ti p may
be requi red, and the contracti ons of the stomach can be fol l owed to
reveal the pyl orus. Posi ti on the scope ti p just proxi mal to the
pyl orus, i nsuffl ate ai r, and i nsert the scope as the pyl orus opens
wi th a contracti on.
(8) Pass the endoscope to the pyl orus.
PITFALL: The longer the scope is in the stomach, the greater is
the degree of pylorospasm. Rapid intubation of the duodenum is
advocated to reduce difficulty in passing through the pylorus.
PITFALL: Often, the scope tip slips back into the stomach, and
the scope must be reinserted into the duodenum.
Exami ne the enti re duodenal bul b. Thi s requi res movi ng the scope
ti p up (anteri or wal l ), down (posteri or wal l ), l eft (i nferi or wal l ), and
ri ght (superi or wal l ).
Page 592
(9) Exami ne the enti re duodenal bul b.
P.393
Intubate the second porti on of the duodenum. In 30% of
i ndi vi dual s, thi s i s accompl i shed wi th strai ght i nserti on of the
scope. In 70% of i ndi vi dual s, there i s a sharp downward turn to the
ri ght. The i nstrument ti p i s posi ti oned just di stal to the proxi mal
duodenal fol d and then turned sharpl y to the ri ght as i t i s i nserted.
(10) Intubate the second porti on of the duodenum.
P.394
After thorough exami nati on of the duodenum, the scope i s brought
back i nto the stomach. Two bi opsi es are obtai ned i n the antrum for
H. pyl ori testi ng (CLOtest). Because of the ri sk of mal i gnancy,
mul ti pl e bi opsi es are performed on al l gastri c ul cers, i n contrast to
duodenal ul cers that do not requi re bi opsy. Bi opsy al so i s
performed on abnormal growths, pol yps, or other pathol ogi c
changes.
Page 593
(11) After thorough exami nati on of the duodenum, the scope i s
brought back i nto the stomach, where two bi opsi es are obtai ned i n
the antrum for H. pyl ori testi ng.
PITFALL: Do not biopsy pulsatile or vascular lesions, because the
resulting bleeding can be extensive and difficult to control.
PITFALL: Esophageal ulcerations or erosions may be better
assessed by brushing or washing. The esophagus is much
thinner than the stomach, and risk of perforation from biopsy is
greater at this location. Beware of biopsying the base of a deep
gastric ulcer, because perforation can occur in this situation.
The endoscope i s retrofl exed wi thi n the stomach to exami ne the
fundus and cardi a. Exami nati on of the gastroesophageal juncti on i s
i mportant to l ook for possi bl e gastri c mal i gnancy at thi s si te. To
vi ew the GE juncti on, maxi mal l y defl ect the ti p of the scope wi th
the i nner knob whi l e i nserti ng the endoscope.
(12) Exami ne the fundus and cardi a.
P.395
The ai r i n the stomach i s sucti oned out, and the scope wi thdrawn
i nto the esophagus. Exami nati on of the di stal esophagus i s
performed agai n. Hi atal herni as may be i denti fi ed by aski ng the
pati ent to sni ff, contracti ng the di aphragm, and noti ng the di stance
between the di aphragmati c i ndenti on and the gastroesophageal
juncti on (i .e., Z-l i ne).
Page 594
(13) Exami ne the di stal esophagus agai n, checki ng for hi atal
herni as.
Wi thdraw the scope, exami ni ng the esophagus and l arynx on
removal . Remove the mouthpi ece. Wi pe off any oral secreti ons that
have drai ned from the mouth. Observe the pati ent unti l the
sedati on wears off or the pati ent i s stabl e for di scharge wi th a
fami l y member or caregi ver.
(14) Exami ne the esophagus and l arynx on removal of scope, and
wi pe off any secreti ons that have drai ned from the mouth after
removal of the mouthpi ece.
P.396
Page 595
CODING INFORMATION
For comprehensi ve upper gastroi ntesti nal (GI) endoscopi c
procedures, 43239 i s the code most commonl y reported. In the
offi ce setti ng, a surgery tray charge may be bi l l ed i n addi ti on
(99070 or A4550) to cover some of the admi ni strati ve costs.

2002 Average 50th
Percentile Fee

43200 Esophagoscopy wi th or
wi thout brushi ngs
$505
43202 Esophagoscopy wi th bi opsi es $560
43234 Si mpl e pri mary upper GI
endoscopy
$528
43235 Upper GI endoscopy,
i ncl udi ng duodenum wi th
brushi ngs
$575
43239 Upper GI endoscopy,
i ncl udi ng duodenum wi th
bi opsi es
$676

Compl ete endoscopy equi pment such as endoscopes, l i ght sources,
vi deo endoscopy moni tors, cl eani ng and di si nfecti on ai ds, and
mouthpi eces are avai l abl e from Ol ympus Corporati on, Mel vi l l e, NY (
http://www.ol ympusameri ca.com) and from Pentax Preci si on
Instrument Corporati on, Orangeburg, NY (
http://www.pentaxmedi cal .com). A vi scous 2% l i docai ne topi cal
sol uti on i s avai l abl e from Al pharma USPD, Owi ngs Mi l l s, MD (
http://www.al pharma.com). Benzocai ne 20% spray (Hurri cai ne
topi cal anestheti c) i s avai l abl e i n several fl avors from Beutl i ch
Pharmaceuti cal s, Waukegan, IL (http://www.beutl i ch.com). CLOtest
Page 596
ki ts can be obtai ned from Tri -Med Speci al ti es, Lenexa, KS (
http://www.tri med.com). Butorphanol tartrate (Stadol ) nasal spray
i s avai l abl e from Bri stol -Myers Squi bb (http://www.bms.com).
Intravenous materi al s (e.g., Intracaths, normal sal i ne sol uti on,
i ntravenous tubi ng) can be obtai ned from l ocal hospi tal s or surgi cal
suppl y houses.
Redcommendati ons for endoscope cl eani ng appear i n Appendi x E.
Gui del i nes for moni tori ng pati ents recei vi ng consci ous sedati on
appear i n Appendi x F.
Trai ni ng i s avai l abl e i n resi dency or fel l owshi p programs or by
attendi ng one or more postgraduate conti nui ng educati on courses.
Sel f-study can al so enhance ski l l s, usi ng atl ases, vi deotapes, or
computer-assi sted programs. Preceptor-gui ded trai ni ng i s hi ghl y
recommended under the supervi si on of experi enced physi ci ans.
Di scri mi nati on between pathol ogi c condi ti ons and normal anatomy
i s an i mportant ski l l to acqui re. Compl ete i nformati on on trai ni ng
methodol ogy i s avai l abl e from the Ameri can Academy of Fami l y
Physi ci ans (http://www.aafp.org/practi cemgt.xml ).
Computer-based trai ni ng i s an emergi ng technol ogy. New uni ts such
as the GI Mentor II from Si mbi oni x (
http://www.si mbi oni x.com/GI_Mentor.html ) can provi de experi ence
i n repeti ti ve endoscope mani pul ati on, feedback on techni que, and
vari ous cl i ni cal scenari os and pathol ogy exposure for the trai nees.
Recommended atlases: Keeffe EB, Jeffrey RB, Lee RG. Atl as of
gastroi ntesti nal endoscopy. Phi l adel phi a: Appl eton & Lange, 1998.
P.397
Marti n DM, Lyons RC. The atl as of gastroi ntesti nal endoscopy.
Avai l abl e at http://www.mi ndspri ng.com/:dmmmd/atl as_1.html
Murra-Saca J. El Sal vador atl as of gastroi ntesti nal vi deoendoscopy.
Avai l abl e at http://www.gastroi ntesti nal atl as.com
Owen DA, Kel l y JK. Atl as of gastroi ntesti nal pathol ogy.
Phi l adel phi a: WB Saunders, 1994.
Schi l l er KF, Cockel R, Hunt RH, et al . A col our atl as of
Page 597
gastroi ntesti nal endoscopy. Phi l adel phi a: WB Saunders, 1986.
Si l verstei n FE, Tytgat Gui do NJ. Atl as of gastroi ntesti nal
endoscopy. St. Loui s: Mosby, 1996.
Tadataka Y. Atl as of gastroenterol ogy. Phi l adel phi a:
Li ppi ncott-Raven, 1999.
BIBLIOGRAPHY
Ackerman RJ. Performance of gastroi ntesti nal tract endoscopy by
pri mary care physi ci ans. Arch Fam Med 1997;6:5258.
Ameri can Academy of Fami l y Physi ci ans.
Esophagogastroduodenoscopy: a short course i n basi c ski l l s and
cogni ti ve knowl edge. Kansas Ci ty: Ameri can Academy of Fami l y
Physi ci ans, 1992.
Ameri can Soci ety for Gastroi ntesti nal Endoscopy. Appropri ate use of
gastroi ntesti nal endoscopy: a consensus statement from the
Ameri can Soci ety for Gastroi ntesti nal Endoscopy. Manchester, MA:
Ameri can Soci ety for Gastroi ntesti nal Endoscopy, 1989.
Axon AT. Worki ng party report to the Worl d Congresses.
Di si nfecti on and endoscopy: summary and recommendati ons. J
Gastroenterol Hepatol 1991;6:2324.
Bytzer P, Hansen JM, Schaffal i tzky DE, et al . Empi ri cal H2-bl ocker
therapy or prompt endoscopy i n management of dyspepsi a. Lancet
1994;343:811816.
Cass OW, Freeman ML, Pei ne CJ, et al . Objecti ve eval uati on of
endoscopy ski l l s duri ng trai ni ng. Ann I ntern Med 1993;118:4044.
Col eman WH. Gastroscopy: a pri mary di agnosti c procedure. Pri m
Care 1988;15:111.
Fl ei sher D. Moni tori ng the pati ent recei vi ng consci ous sedati on for
gastroi ntesti nal endoscopy: i ssues and gui del i nes. Gastroi ntest
Endosc 1989;35:262266.
Genta RM, Graham DY. Compari son of bi opsy si tes for the
hi stopathol ogi c di agnosi s of Hel i cobacter pyl ori : a topographi c
study of H. pyl ori densi ty and di stri buti on. Gastroi ntest Endosc
1994;40:342345.
Heal th and Publ i c Pol i cy Commi ttee, Ameri can Col l ege of
Physi ci ans. Endoscopy i n the eval uati on of dyspepsi a. Ann I ntern
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Med 1985;102:266269.
Heal th and Publ i c Pol i cy Commi ttee, Ameri can Col l ege of
Physi ci ans. Cl i ni cal competence i n di agnosti c
esophagogastroduodenoscopy. Ann I ntern Med 1987;107:937939.
Hocutt JE, Rodney WM, Zurad EG, et al .
Esophagogastroduodenoscopy for the fami l y physi ci an. Am Fam
Physi ci an 1994;49:109116, 121122.
LaLuna L, Al l en ML, Di Mari no AJ. The compari son of mi dazol am and
topi cal l i docai ne spray versus the combi nati on of mi dazol am,
meperi di ne, and topi cal l i docai ne spray to sedate pati ents for upper
endoscopy. Gastroi ntest Endosc 2001;53:289293.
Li eberman DA, Wuerker CK, Katon RM. Cardi opul monary ri sk of
esophagogastroduodenoscopy: rol e of endoscope di ameter and
systemi c sedati on. Gastroenterol ogy 1985;88:468472.
Nel son DB, Bl ock KP, Bosco JJ, et al . Technol ogy status eval uati on
report: ul trathi n endoscopes. Gastroi ntest Endosc
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Rodney WM, Weber JR, Swedberg JA, et al .
Esophagogastroduodenoscopy by fami l y physi ci ans phase II: a
nati onal mul ti si te study of 2500 procedures. Fam Pract Res J
1993;13:121131.
Sgammato J. Shoul d you be doi ng EGD? Fam Pract Manag
1994;1:6377.
Si l verstei n MD, Petterson T, Tal l ey NJ. Ini ti al endoscopy or
empi ri cal therapy wi th or wi thout testi ng for Hel i cobacter pyl ori for
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1996;110:7283.
P.398
Spach DH, Si l verstei n FE, Stamm WE. Transmi ssi on of i nfecti on by
gastroi ntesti nal endoscopy and bronchoscopy. Ann I ntern Med
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Swedberg JA. Sedati on for offi ce esophagogastroduodenoscopy
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Woodl i ff DM. The rol e of upper gastroi ntesti nal endoscopy i n
pri mary care. J Fam Pract 1979;8:715719.
Zuber TJ. A pi l ot project i n offi ce-based di agnosti c
esophagogastroduodenoscopy compari ng two noni ntravenous
methods of sedati on and anesthesi a. Arch Fam Med
1995;4:601607.
reference gui des for fami l y physi ci ans. Kansas Ci ty: Ameri can
Academy of Fami l y Physi ci ans, 1998:2333.
Page 600
> Table of Cont ent s > Gast roent erology > 50 - Colonoscopy50
Colonoscopy
Col onoscopy refers to the endoscopi c exami nati on of the enti re
col on and rectum and often i ncl udes the termi nal i l eum. Common
acti vi ti es performed duri ng col onoscopy i ncl ude i nspecti on, bi opsy,
photography, and vi deo recordi ng. The procedure i s techni cal l y
chal l engi ng and requi res consi derabl e trai ni ng and experi ence.
Hi gh-qual i ty exami nati ons requi re good cl i ni cal judgment, anatomy
and pathol ogy recogni ti on, techni cal ski l l i n mani pul ati ng the scope
and performi ng bi opsi es, appropri ate pati ent moni tori ng, and
wel l -mai ntai ned and cl eaned equi pment to ensure pati ent safety.
Vi deo col onoscopes enabl e compl ete exami nati ons of the enti re
col on i n more than 95% of exami nati ons.
Most col orectal cancers appear to devel op from beni gn neopl asti c
(adenomatous) l esi ons. Ameri cans of average ri sk have a 6%
l i feti me ri sk of devel opi ng col on cancer. Adenomas occur i n about
30% of i ndi vi dual s at age 50 and 55% at age 80. Several screeni ng
modal i ti es are advocated to detect earl y adenomas and cancer,
i ncl udi ng col onoscopy every 10 years after age 50. Col onoscopy has
sensi ti vi ti es of 75% to 85% for pol yps l ess than 1 cm i n di ameter
and 95% for l arger pol yps and cancers. The speci fi ci ty for the
exami nati on approaches 100%.
A si ngl e screeni ng col onoscopy i n asymptomati c i ndi vi dual s at age
65 has been advocated for reduci ng mortal i ty from col orectal
cancer. Several anal yses have suggested that a si ngl e screeni ng or
repeated screeni ngs every 10 years after age 50 may be
cost-effecti ve strategi es. Despi te i ncreased i nsurance coverage for
col onoscopy screeni ng, the feasi bi l i ty of screeni ng an enti re
popul ati on has yet to be establ i shed.
Col onoscopy i s the di agnosti c procedure of choi ce for pati ents wi th
a posi ti ve fecal occul t bl ood test (FOBT). Approxi matel y 50% of
Page 601
i ndi vi dual s wi th a posi ti ve FOBT have a neopl asti c l esi on
(adenomas, 38%; cancer, 12%) at endoscopy. Pati ents wi th
l ong-standi ng ul cerati ve col i ti s shoul d undergo col onoscopy wi th
bi opsy to exami ne for dyspl asi a begi nni ng 8 years after the
devel opment of pancol i ti s or 15 years after the devel opment of
di stal di sease.
Col onoscopy i s i ndi cated for vi l l ous adenomas of any si ze that are
di scovered duri ng fl exi bl e si gmoi doscopy. Di stal tubul ar adenomas
are not associ ated wi th an i ncrease i n proxi mal adenomas, and
some cl i ni ci ans do not bel i eve that col onoscopy i s requi red after
removal of a smal l , di stal tubul ar adenoma. Hi stori cal l y, adenomas
l arger than 1 cm i n di ameter have been referred for col onoscopy.
Larger col oni c l esi ons are more often vi l l ous or tubul ovi l l ous,
necessi tati ng
P.400
col onoscopi c removal of the l esi on and exami nati on for synchronous
l esi ons. Some studi es suggest that purel y tubul ar l esi ons that are
l arger than 1 cm i n di ameter can be fol l owed wi thout i mmedi ate
col onoscopy. Thi s strategy may be probl emati c, because a bi opsy
sampl e from wi thi n a l arge l esi on may fai l to recogni ze the most
si gni fi cant pathol ogy (i .e., mi ssed vi l l ous or cancerous el ements).
Despi te some contrary opi ni ons, col onoscopy i s general l y not
i ndi cated after the di agnosi s of a hypertrophi c di stal pol yp.
Average procedure ti mes for experi enced endoscopi sts are about 10
mi nutes to reach the cecum and 30 mi nutes to compl ete the enti re
procedure. Inadequate preparati on i s the most common reason for
prol onged or i ncompl ete exami nati ons. Most i ndi vi dual s i n the
Uni ted States recei ve 3 to 4 L of a pol yethyl ene gl ycol -based
el ectrol yte sol uti on the day before the exami nati on. Some studi es
have suggested l onger procedures and greater di scomfort occur i n
women undergoi ng the procedure, possi bl y because of thei r
anatomi cal l y l onger col ons and greater si gmoi d mobi l i ty. Ol der
i ndi vi dual s may present greater di ffi cul ty i n reachi ng the cecum.
Col onoscopy routi nel y i s performed after the admi ni strati on of
Page 602
consci ous sedati on. Intravenous mi dazol am and meperi di ne have
been the drugs most commonl y empl oyed. Unfortunatel y, 15% of
i ndi vi dual s recei vi ng these two medi cati ons are di ssati sfi ed wi th
thei r sedati on. Propofol i s an i ntravenous, short-acti ng sedati ve
used for the i nducti on of general anesthesi a. Propofol may provi de
superi or sedati on and more rapi d recovery, but i ts safety i n offi ce
si tuati ons has not been demonstrated. Studi es have demonstrated
that the procedure can be performed i n sel ected i ndi vi dual s wi thout
sedati on, wi th rel ati vel y hi gh (70% to 85%) rates of pati ents
wi l l i ng to undergo a si mi l ar procedure agai n wi thout sedati on. Many
physi ci ans feel more comfortabl e wi th routi ne admi ni strati on of
sedati on to i mprove procedure acceptance among pati ents.
Appendi x F contai ns gui del i nes for moni tori ng the pati ent recei vi ng
consci ous sedati on at endoscopy.
Debate exi sts about the number of procedures that trai nees need
to perform to become competent i n col onoscopy. The Ameri can
Soci ety of Gastroenterol ogy (ASG) has hi stori cal l y used 200
procedures as i ts standard. Al though pri mary care physi ci ans have
argued that thi s number i s unnecessari l y hi gh and precl udes
wel l -trai ned pri mary care physi ci ans from performance of
col onoscopy, there i s evi dence that at l east 100 to 150 procedures
are needed by many l earners to achi eve hi gh rates (>95%) of
i ntubati on of the cecum. Usi ng reach-the-cecum rates and other
markers of competence, l ess than 3% of gastroi ntesti nal surgery
fel l ows are graded as competent after 100 procedures.
Pol ypectomy i s the most commonl y performed therapeuti c procedure
performed at col onoscopy. Pati ents can experi ence consi derabl e
morbi di ty from bl eedi ng or col on perforati on at pol ypectomy. There
i s a strong rel ati onshi p between compl i cati on rates of di agnosti c
and therapeuti c col onoscopy and the experi ence of the endoscopi st.
The hi ghest rates of these compl i cati ons appear i n the fi rst 500
procedures.
Pri mary care physi ci ans desi ri ng to perform di agnosti c screeni ng
col onoscopi es may create added heal th care costs i f they do not
perform pol ypectomy. Because 20% to 50% of screeni ng
Page 603
col onoscopi es have pol yps or tumors di agnosed at screeni ng, i t i s
argued that fai l ure to perform pol ypectomy produces unnecessary
referral s. Less experi enced endoscopi sts may have two to three
ti mes the fai l ure rate i n di agnosi ng advanced-stage adenomatous
pol yps and cancers compared wi th experi enced endoscopi sts.
Fai l ure to recogni ze pathol ogy at col onoscopy coul d create harmful
ci rcumstances for pati ents and medi col egal i ssues for the cl i ni ci an.
P.401
The ASGE suggests that hospi tal credenti al i ng for col onoscopy
shoul d i ncl ude the abi l i ty to perform associ ated therapeuti c
procedures. Accordi ng to the ASGE, there are l i mi ted al ternate
paths for credenti al i ng outsi de of compl eti on of a ful l
gastroenterol ogy or gastroi ntesti nal surgery fel l owshi p program.
However, they recommend pri vi l eges onl y for physi ci ans abl e to
achi eve comparabl e trai ni ng to a fel l owshi p. Al though fami l y
physi ci ans may have troubl e achi evi ng adequate numbers of
procedures to recei ve appropri ate consi derati on for col onoscopy
pri vi l eges accordi ng to ASGE gui del i nes, more than 1400 fami l y
physi ci ans currentl y have hospi tal pri vi l eges to perform col onoscopy
i n a hospi tal setti ng. In rural areas, an average of 6% of fami l y
physi ci ans perform the procedure.
Many pri mary care physi ci ans attend short courses to recei ve i ni ti al
trai ni ng i n col onoscopy. Short courses can augment techni cal and
cl i ni cal ski l l s, but the ASGE feel s these courses cannot repl ace
pati ent procedures i n gai ni ng experi ence. Proctored or precepted
procedures shoul d be performed unti l physi ci ans can demonstrate
competence i n performi ng compl ete exami nati ons, supervi si on of
consci ous sedati on, and pol yp removal techni ques.
INDICATIONS
Eval uati on of a radi ographi c abnormal i ty
Screeni ng of asymptomati c i ndi vi dual s for col on
neopl asi a or cancer
Eval uati on of unexpl ai ned gastroi ntesti nal bl eedi ng
Page 604
Posi ti ve FOBT
Unexpl ai ned i ron defi ci ency anemi a
Exami nati on for a synchronous col on neopl asti c l esi on
when a l esi on i s found i n the rectosi gmoi d
Survei l l ance or fol l ow-up study after removal of a pri or
neopl asti c l esi on
Suspected i nfl ammatory bowel di sease or survei l l ance
for previ ousl y di agnosed i nfl ammatory bowel di sease
Eval uati on of symptoms suggesti ve of si gni fi cant col on
di sease (e.g., chroni c di arrhea, wei ght l oss, abdomi nal
or pel vi c pai n)
Therapeuti c procedures (e.g., pol yp removal , forei gn
body removal )
Ful mi nant col i ti s
Acute di verti cul i ti s
Hemodynami cal l y unstabl e pati ent
Recent (<3 months) myocardi al i nfarcti on
Recent (<1 week) bowel surgery
When the procedure resul ts wi l l not produce a change i n
management
P.402
PROCEDURE
The pati ent i s pl aced on the exami nati on tabl e i n the l eft l ateral
posi ti on. Intravenous access i s obtai ned, and sedati on i s
admi ni stered (25 to 75 mg of meperi di ne and 2 to 8 mg of
mi dazol am). Appropri ate pati ent moni tori ng i ncl udes frequent vi tal
si gns, oxi metry, and heart rhythm (el ectrocardi ographi c) eval uati on
throughout the procedure (see procedural i l l ustrati ons 110 i n
Chapter 48). These i l l ustrati ons al so appl y to the scope i nserti on
Page 605
and exami nati on techni ques i n the rectosi gmoi d at col onoscopy.
(1) Intravenous access i s obtai ned, and sedati on i s admi ni stered
(25 to 75 mg of meperi di ne and 2 to 8 mg of mi dazol am).
Traversi ng the rectosi gmoi d juncti on i s the one of the most di ffi cul t
aspects of the procedure. Pri or pel vi c surgery may produce
extensi ve adhesi ons i n thi s area (see techni ques to pass through
thi s area i n Chapter 48). Insert the scope onl y through vi si bl e
l umen.
(2) Insert the scope onl y through vi si bl e l umen.
PITFALL: Sliding the scope along the colon wall (i.e., slide-by
technique) is not advocated, because this technique may result
in perforation at the rectosigmoid junction.
P.403
The wal l of the descendi ng (ri ght) col on has a characteri sti c ci rcul ar
appearance wi th enci rcl i ng fol ds (Fi gure 3A). A sharp turn appears
Page 606
at the spl eni c fl exure. A bl ui sh col or of the vascul ar spl een may be
vi si bl e through the col on wal l . A sharp turn of the scope ti p (wi th
torqui ng) often i s requi red to pass through thi s fl exure (Fi gure 3B).
The wal l of the transverse col on has a characteri sti c tri angul ar
appearance (Fi gure 3C).
(3) The descendi ng col on wal l has a characteri sti c ci rcul ar
appearance wi th enci rcl i ng fol ds, and the transverse col on wal l has
a characteri sti c tri angul ar appearance.
The passage through the transverse col on i s rel ati vel y strai ght.
Another sharp angl e exi sts at the hepati c fl exure. The hepati c
fl exure can be i denti fi ed by the bl ui sh brown shadow of the l i ver
seen through the col on wal l . The exami ner al so may noti ce
transi l l umi nati on through the l eft upper abdomi nal wal l from the
endoscope l i ght. The assi stant can press down on the pati ent's
ri ght upper abdomen to faci l i tate the downward defl ecti on of the
scope ti p i nto the ascendi ng (l eft) col on. The ascendi ng col on has a
characteri sti c pattern of mucosal fol ds that do not enci rcl e the
l umen compl etel y.
Page 607
(4) To faci l i tate the downward defl ecti on of the scope ti p i nto the
ascendi ng col or, have an assi stant press down on the pati ent's
ri ght upper abdomen.
PITFALL: Avoid creation of loops within the colon, which can
increase discomfort and risk of complications. Keep the
instrument as straight (short) as possible. Repeated short
insertions and withdrawals and aspiration of air at the flexures
can pleat the colon wall onto the instrument. Abdominal
pressure by the assistant can eliminate loops in the transverse
or sigmoid colon and facilitate more rapid insertion.
P.404
Traversi ng the l eft col on can be chal l engi ng. The scope ti p i s
advanced by pul l i ng back on the endoscope, causi ng paradoxi cal
i nserti on (Fi gure 5A). The scope ti p i s centered i n the l umen, and
sucti on i s appl i ed (Fi gure 5B) to further advance the scope through
the col on. The appendi ceal and i l eocecal ori fi ces may be recogni zed
when the cecum i s reached. The appendi ceal ori fi ce often appears
on a crow's foot, and the three taeni ae form a confl uent
fol d l eadi ng to the ori fi ce (Fi gure 5C). In many exami nati ons, the
appendi ceal ori fi ce may not be seen. Reachi ng the cecum can be
confi rmed by feel i ng the scope ti p i n the pati ent's ri ght l ower
quadrant through the abdomi nal wal l or seei ng the l i ght
transi l l umi nati ng through abdomi nal wal l (Fi gure 5D).
Page 608
(5) Reachi ng the cecum can be confi rmed by feel i ng the scope ti p i n
the pati ent's ri ght l ower quadrant through the abdomi nal wal l or by
seei ng the l i ght transi l l umi nati ng through the abdomi nal wal l .
P.405
Attempt to i ntubate the i l eocecal ori fi ce, whi ch often appears as a
Page 609
sl i t on the medi al wal l 3 cm above the pol e (i .e., most proxi mal
porti on) of the ascendi ng col on (Fi gure 6A). Fi rst, aspi rate the fl ui d
from the cecal pol e. The i l eocecal ori fi ce often i s angl ed downward,
and several attempts may be requi red for i ntubati on. Angl e the
scope ti p toward the ori fi ce, and posi ti on the ti p just past the
ori fi ce (Fi gure 6B). Gentl y wi thdraw the scope (Fi gure 6C) unti l the
angl ed ti p fl attens the D-shaped mucosal fol d. After the i nstrument
vi sual i zes the i l eocecal ori fi ce and the val ve begi ns to open, the
i nstrument i s strai ghtened and advanced. Paradoxi cal advancement
by wi thdrawal of the scope can ai d i n enteri ng the termi nal i l eum.
(6) Attempt to i ntubate the i l eocecal ori fi ce.
Vi sual i zati on i s performed on wi thdrawal of the scope. Wi thdrawal
must be sl ow, wi th careful i nspecti on of the enti re ci rcumferenti al
wal l before the scope i s moved. Inspect behi nd every fol d to ensure
hi dden l esi ons are not mi ssed.
Page 610
(7) Vi sual i zati on i s performed duri ng sl ow wi thdrawal of the scope,
i nspecti ng behi nd every fol d to ensure hi dden l esi ons are not
mi ssed.
P.406
After a pol yp i s di scovered, the scope i s posi ti oned a few
centi meters away. The el ectrocautery snare i s i nserted through the
bi opsy channel . The snare sheath i s posi ti oned next to the pol yp,
the wi re l oop i s advanced over the pol yp, and the wi re l oop i s
sl owl y secured over the base of the pol yp or pedi cl e. The scope ti p
i s maneuvered so that the snare l oop i s not touchi ng col on wal l to
reduce the ri sk of perforati on. Appl y the el ectrocautery current.
(8) El ectrosurgi cal pol ypectomy.
PITFALL: Colonic explosion has occurred in individuals
undergoing electrosurgical polypectomy. Explosion of
intraluminal methane gas is unlikely if the colon has been
Page 611
adequately prepped.
Smal l pol yps can be retri eved through the scope usi ng the snare or
graspi ng forceps. Larger pol yps can be removed by sucti oni ng the
pol yp agai nst the scope and wi thdrawi ng the scope.
(9) Smal l pol yps can be retri eved through the scope usi ng the snare
or graspi ng forceps, and l arger pol yps can be removed by sucti oni ng
the pol yp agai nst the scope and wi thdrawi ng the scope.
PITFALL: Reinsertion of the scope may be needed if the scope
has to be withdrawn to remove a large polyp and the tip cannot
adequately visualize the colon wall.
PITFALL: Occasionally, polyps fall away or are mishandled, or a
large number must be removed. Unretrieved polyps can be
recovered after the procedure. Patients may strain to move
them out of the colon, or added bowel prep solution (i.e.,
polyethylene glycol solution or phosphate enema) can be
administered through the scope to induce evacuation. The fluid
is filtered so that the polyps can be recovered for histologic
examination.
PITFALL: Suspected perforation after polypectomy necessitates
hospital observation and evaluation.
P.407
CODING INFORMATION
Current Procedural Termi nol ogy (CPT) codes l i sted here i ncl ude
the termi nol ogy proxi mal to the spl eni c fl exure i n the code
Page 612
descri ptor. However, for reporti ng purposes, col onoscopy i s the
exami nati on of the enti re col on from the rectum to the cecum and
may i ncl ude exami nati on of the termi nal i l eum. For an i ncompl ete
col onoscopy, wi th ful l preparati on admi ni stered wi th the i ntent to
perform a ful l col onoscopy, use the col onoscopy codes above wi th a
-52 modi fi er to si gni fy reduced servi ces. In the offi ce setti ng, a
tray charge can be bi l l ed (99070 or A4550) to hel p cover procedure
costs.

2002 Average 50th
Percentile Fee

45378 Fl exi bl e col onoscopy wi th
brushi ng, washi ng
$807
removal of forei gn body
$985
45380 Fl exi bl e col onoscopy wi th one
or more bi opsi es
$913
bl eedi ng control by
coagul ator
$1,041
abl ati on of tumors or pol yps
$1,124
tumor or pol yp removal by
hot bi opsy forceps
$1,154
tumor or pol yp removal by
snare techni que
$1,205
Informati on on endoscopy equi pment orderi ng, trai ni ng, and atl ases
can be found i n Chapter 49. The i nformati on on orderi ng the Ives
anoscope i s i ncl uded i n Chapter 52.
Propofol (1% Di pri van) i njecti on i s avai l abl e from Astra-Zeneca,
Page 613
Wi l mi ngton, DE (http://www.astrazeneca-us.com). Meperi di ne
(Demerol ) i njecti on i s avai l abl e from Wyeth-Lederl e (
http://www.wyeth.com). Mi dazol am (Versed) i njecti on i s avai l abl e
from Roche, Nutl ey, NJ (http://www.roche.com). Recommendati ons
for endoscopi c cl eani ng appear i n Appendi x E. Gui del i nes for
moni tori ng pati ents recei vi ng consci ous sedati on appear i n
Appendi x F
BIBLIOGRAPHY
Akerkar GA, Yee J, Hung R, et al . Pati ent experi ence and
preferences toward col on cancer screeni ng: a compari son of vi rtual
col onoscopy and conventi onal col onoscopy. Gastroi ntest Endosc
2001;54:310315.
Ameri can Soci ety for Gastroi ntesti nal Endoscopy. Appropri ate use of
gastroi ntesti nal endoscopy. Consensus statement of the ASGE.
Gastroi ntest Endosc 2000;52:831837.
Ameri can Soci ety for Gastroi ntesti nal Endoscopy. Statement on rol e
of short courses i n endoscopi c trai ni ng. Gui del i nes for cl i ni cal
appl i cati on. Gastroi ntest Endosc 1999;50:913914.
P.408
Ameri can Soci ety for Gastroi ntesti nal Endoscopy. The rol e of
col onoscopy i n the management of pati ents wi th col oni c pol yps
neopl asi a. Gui del i nes for cl i ni cal appl i cati on. Gastroi ntest Endosc
1999;50:921924.
Anderson JC, Messi na CR, Cohn W, et al . Factors predi cti ve of
di ffi cul t col onoscopy. Gastroi ntest Endosc 2001;54:558562.
Arezzo A. Prospecti ve randomi zed tri al compari ng bowel cl eani ng
preparati ons for col onoscopy. Surg Laparosc Endosc Percutan Tech
2000;10:215217.
Bond JH, Frakes JT. Who shoul d perform col onoscopy? How much
trai ni ng i s needed? Gastroi ntest Endosc 1999;49:657659.
Charl es RJ, Chak A, Cooper GS, et al . Use of open access i n GI
endoscopy at an academi c medi cal center. Gastroi ntest Endosc
1999;50:480485.
Page 614
Hoffman MS, Butl er TW, Shaver T. Col onoscopy wi thout sedati on. J
Cl i n Gastroenterol 1998;26:279282.
Imperi al e TF, Wagner DR, Li n CY, et al . Ri sk of advanced proxi mal
neopl asms i n asymptomati c adul ts accordi ng to the di stal col orectal
fi ndi ngs. N Engl J Med 2000;343:169174.
Ki m WH, Cho YJ, Park JY, et al . Factors affecti ng i nserti on ti me and
pati ent di scomfort duri ng col onoscopy. Gastroi ntest Endosc
2000;52:600605.
Lee JG, Leung JW. Col onoscopi c di agnosi s of unsuspected
di verti cul osi s. Gastroi ntest Endosc 2002;55:746748.
Li eberman DA, Rex DA. Feasi bi l i ty of col onoscopy screeni ng:
di scussi on of i ssues and recommendati ons regardi ng
i mpl ementati on [Edi tori al ]. Gastroi ntest Endosc
2001;54:662667.
Marshal l JB, Perez RA, Madsen RW. Useful ness of a pedi atri c
col onoscope for routi ne col onoscopy i n women who have undergone
hysterectomy. Gastroi ntest Endosc 2002;55:838841.
Nel son DB, McQuai d KR, Bond JH, et al . Procedural success and
compl i cati ons of l arge-scal e screeni ng col onoscopy. Gastroi ntest
Endosc 2002;55:307314.
Nobl e J, Greene HL, Levi nson W, et al . Tumors of the l arge bowel .
In: Nobl e J, Greene HL, Levi nson W, et al , eds. Textbook of pri mary
care medi ci ne. St. Loui s: Mosby, 2001:953959.
Patel K, Hoffman NE. The anatomi cal di stri buti on of col orectal
pol yps at col onoscopy. J Cl i n Gastroenterol 2001;33:222225.
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adenoma mi ss rates. Gastroi ntest Endosc 2000;51:3336.
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Assoc J 2000;163:12771278.
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by nurses supervi sed by endoscopi sts. Gastroi ntest Endosc
2002;55:815825.
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i n screeni ng for col orectal cancer. Arch I ntern Med
Page 615
2002;162:163168.
Wexner SD, Li twi n D, Cohen J, et al . Pri nci pl es of pri vi l egi ng and
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Page 616
> Table of Cont ent s > Gast roent erology > 51 - Excision of Thrombosed Ext ernal
Hemorrhoids51
Excision of Thrombosed External
Hemorrhoids
Acute thrombosi s of external hemorrhoi ds can cause extreme
di scomfort and di sabi l i ty. The condi ti on often mani fests i n younger
i ndi vi dual s, and up to one thi rd of women experi ence the condi ti on
i mmedi atel y postpartum. Strai ni ng wi th defecati on i s bel i eved to be
causati ve, and i ndi vi dual s often report pai n after severe bouts of
di arrhea or consti pati on. Exami nati on often reveal s a tender,
enl arged, peri anal mass, wi th the bl ue cl ot seen through the ski n.
Drai nage or mi l d bl eedi ng can occur i f the cl ot ruptures through the
ski n.
External hemorrhoi ds are composed of the di l ated tri butari es of the
i nferi or rectal vei n, and they appear bel ow the dentate l i ne.
Because the speci al i zed anoderm i n the anal canal bel ow the
dentate l i ne i s heavi l y i nnervated, thrombosed external
hemorrhoi ds can produce excruci ati ng di scomfort. Acutel y
thrombosed hemorrhoi ds benefi t from surgi cal i nterventi on, and
many physi ci ans sti l l consi der thi s the treatment of choi ce.
Thrombosi s that has been present more than 72 hours general l y
shoul d be treated conservati vel y, because the pai n from the surgery
often exceeds the pai n experi enced from sl ow resol uti on of the
l esi on. Conservati ve management i ncl udes si tz baths, oral
anal gesi cs, stool softeners, nonsteroi dal anti i nfl ammatory drugs
(NSAIDs), and topi cal anestheti cs such as l i docai ne. Topi cal
ni fedi pi ne and topi cal ni trogl yceri n appear to be promi si ng
i nterventi ons for more rapi d symptom resol uti on i n pati ents not
surgi cal l y treated.
Pri mary care physi ci ans hi stori cal l y have performed i nci si on and
drai nage procedures on thrombosed hemorrhoi ds. Thi s procedure
Page 617
can remove l arge cl ots, but reports of hi gh recurrence rates wi thi n
24 hours have l ed many physi ci ans to advocate more extensi ve
surgi cal i nterventi on. A fusi form exci si on i s recommended, wi th
removal of the cl ot adherent to the overl yi ng ski n. Many physi ci ans
advocate removal of the enti re underl yi ng hemorrhoi dal compl ex.
Some have reported i ncreased di scomfort i n i ndi vi dual s whose
wounds are cl osed wi th sutures, but subcutaneous cl osure provi des
the benefi t of more rapi d heal i ng and l ess drai nage from the
surgi cal si te. Arteri ol es i n the hemorrhoi dal compl ex may
experi ence spasm when cut. Sutured wounds are l ess l i kel y to
experi ence bri sk bl eedi ng from the surgery si te several hours after
the procedure once the spasm i s rel i eved.
P.410
The natural hi story of thrombosed hemorrhoi ds i s sl ow resol uti on
over 1 to 2 weeks. The swol l en ti ssue di mi ni shes to form an
external ski n tag. Tags are al most al ways asymptomati c, and
surgi cal removal usual l y i s not i ndi cated. Novi ce physi ci ans may
confuse external tags wi th al ternate anal pathol ogy, but the
presence of tags si gni fi es remote di sease.
INDICATIONS
Severe symptoms (e.g., pai n, i tchi ng) requi ri ng surgi cal
i nterventi on
Ul cerated or ruptured external thrombosed hemorrhoi ds
Recurrent thrombosi s after i nci si on procedure
Presence of symptoms for more than 72 hours (may sti l l
consi der surgery, but pai n of surgery may exceed pai n of
conservati ve management)
Presence of compl i cati ng di sease (e.g., fi ssures,
fi stul as, cancer) that requi re more extensi ve surgery
Page 618
P.411
PROCEDURE
Appearance of a thrombosed external thrombosed hemorrhoi d.
(1) A thrombosed external hemorrhoi d.
The surroundi ng area i s i nfi l trated wi th 3 to 5 mL of 1% l i docai ne
wi th epi nephri ne. Some physi ci ans prefer a l onger-acti ng anestheti c
such as 0.5% bupi vacai ne wi th epi nephri ne. Make sure to i nfi l trate
beneath the hemorrhoi d.
Page 619
(2) Infi l trate the area wi th 3 to 5 mL of 1% l i docai ne wi th
epi nephri ne.
PITFALL: The perianal tissues are highly vascular. Avoid
intravascular injection of the anesthetic when injecting into
these tissues.
P.412
An el l i pti cal i nci si on i s made over the hemorrhoi d (Fi gure 3A). The
i nci si on shoul d remai n outsi de the anal verge. After the ski n
i nci si on, grasp the central fusi form i sl and of ski n wi th an Al l i s
cl amp (Fi gure 3B). Undermi ne thi s central i sl and of ski n wi th
sci ssors or a scal pel bl ade, cutti ng deepl y enough to mai ntai n
attachment of the thrombosed hemorrhoi d to the overl yi ng ski n
(Fi gure 3C). If addi ti onal hemorrhoi dal compl ex (vei n) i s seen
beneath the cl ot, these can be exci sed wi th ti ssue sci ssors (Fi gure
3D).
(3) Make an el l i pti cal i nci si on over the hemorrhoi d outsi de the anal
verge, and grasp the central fusi form i sl and of ski n wi th an Al l i s
cl amp.
PITFALL: Bleeding can occur during the procedure. Clamping a
hemostat on a bleeding vessel inside the wound often provides
Page 620
effective control. The instrument can be removed after a
minute, and closure of the wound can be performed.
Electrocautery is an alternate option for hemostasis, but it may
leave char in the wound base.
PITFALL: The ellipse can be oriented parallel to the anal canal,
rather than radially as pictured above. Parallel incisions expose
more hemorrhoidal sinusoids beneath the skin, but are more
difficult to close (suture doesn' t hold well on the side near the
canal).
P.413
Many surgeons prefer to l eave the area open, wi th heal i ng
accompl i shed by secondary i ntenti on (Fi gure 4A). A runni ng
subcuti cul ar 4-0 pol ygal acti n (Vi cryl ) suture can be pl aced. Ti e the
suture across the deep ti ssue on one end of the wound (Fi gure 4B).
Run the suture back and forth across the wound to the other end
(Fi gure 4C). Ti e the suture at the far end, buryi ng the knot i nto the
wound base. Anti bi oti c oi ntment i s appl i ed to the si te, and gauze
can be pl aced between the buttocks over the wound. Encourage
fl ui d i ntake, stool -bul ki ng agents and stool softeners, and good
hygi ene unti l the fol l ow-up vi si t i n 1 to 2 weeks.
(4) If the area i s l eft open, heal i ng occurs by secondary i ntenti on.
Al ternatel y, cl osure can be accompl i shed wi th a buri ed absorbabl e
suture.
PITFALL: Limit the use of narcotics postoperatively, because
Page 621
these medications can produce constipation that can interfere
with wound healing. Consider alternating doses of ibuprofen and
acetaminophen for discomfort.
P.414
CODING INFORMATION
Most physi ci ans report 46320 i f the exci si on i s performed for a
thrombosed hemorrhoi d. Because thi s i s a starred surgi cal
procedure (i .e., code wi th an asteri sk), onl y the surgi cal servi ce i s
i ncl uded i n the rei mbursement. Separate bi l l i ng may be permi tted
for eval uati on and management servi ces (i .e., offi ce vi si t).

2002 Average 50th
Percentile Fee

46083 Inci si on of thrombosed
external hemorrhoi d
$187
46250 External hemorrhoi dectomy,
compl ete
$763
46320* Enucleati on or exci si on of
external thromboti c
hemorrhoi d
$203

The i nstruments on the offi ce surgi cal tray (see Appendi x A) are
appropri ate for hemorrhoi dal surgery. The addi ti on of two strai ght
hemostats may be benefi ci al . Some physi ci ans prefer to grasp and
el evate the cl ot and hemorrhoi dal compl ex usi ng an Al l i s cl amp. Al l
i nstruments are avai l abl e from surgi cal suppl y houses or i nstrument
deal ers. A suggested anesthesi a tray that can be used for thi s
BIBLIOGRAPHY
Abramowi tz L, Sobhani I, Beni fl a JL, et al . Di s Col on Rectum
Page 622
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Bul s JG. Exci si on of thrombosed external hemorrhoi ds. Hosp Med
1994;30:3942.
Fri end WG. External hemorrhoi ds. Med Ti mes 1988;116:108109.
Grosz CR. A surgi cal treatment of thrombosed external
hemorrhoi ds. Di s Col on Rectum 1990;33:249250.
Hul me-Moi r M, Bartol o DC. Hemorrhoi ds. Gastroenterol Cl i n
2001;30:183197.
Hussai n JN. Offi ce management of common anorectal probl ems.
Pri m Care Cl i n Offi ce Pract 1999;26:3551.
Jani cke DM, Pundt MR. Anorectal di sorders. Emerg Med Cl i n North
Am 1996;14:757788.
Lei bach JR, Cerda JJ. Hemorrhoi ds: modern treatment methods.
Hosp Med 1991;27:5368.
Medi ch DS, Fazi o VW. Hemorrhoi ds, anal fi ssure, and carci noma of
the col on, rectum, and anus duri ng pregnancy. Surg Cl i n North Am
1995;75:7788.
Nagl e D, Rol andel l i RH. Pri mary care offi ce management of peri anal
and anal di sease. Gastroenterol ogy 1996;23:609620.
Orki n BA, Schwartz AM, Orki n M. Hemorrhoi ds: what the
dermatol ogi st shoul d know. J Am Acad Dermatol
1999;41:449456.
Perrotti P. Conservati ve treatment of acute thrombosed external
hemorrhoi ds wi th topi cal ni fedi pi ne. Di s Col on Rectum
2001;44:405409.
Schussman LC, Lutz LJ. Outpati ent management of hemorrhoi ds.
Pri m Care 1986;13:527541.
Zuber TJ. Di seases of the rectum and anus. In: Tayl or RB, Davi d
AK, Johnson TA, et al , eds. Fami l y medi ci ne pri nci pl es and practi ce,
5th ed. New York: Spri nger-Verl ag, 1998:788794.
Zuber TJ. Hemorrhoi dectomy for thrombosed external hemorrhoi ds.
Am Fam Physi ci an 2002;65:16291632, 16351636, 1639.
Page 623
> Table of Cont ent s > Gast roent erology > 52 - Treat ment of Int ernal Hemorrhoids
52
Treatment of Internal Hemorrhoids
It i s esti mated that nearl y 75% of al l adul ts i n the Uni ted States
suffer at some ti me from hemorrhoi ds. Hemorrhoi ds are di stended
vascul ar cushi ons that l i ne the anal canal . These cushi ons normal l y
reduce the effect of stool passi ng through the canal . Wi th chroni c
passage of hard stool or strai ni ng, the cushi ons can l ose thei r
fi brocol l agenous i nternal support. Wi thout thi s support, the
cushi ons di l ate and prol apse i nto the anal canal as hemorrhoi ds.
The sensory i nnervati on of the anal ti ssues general l y travel s i nward
to the dentate l i ne. Internal hemorrhoi ds devel op above the
dentate l i ne and usual l y mani fest wi th pai nl ess bl eedi ng. Pati ents
often noti ce bl eedi ng i nto the toi l et or on the toi l et ti ssue, but
they al so may compl ai n of a protrudi ng mass or i tchi ng. The four
degrees of i nternal hemorrhoi ds are descri bed i n Tabl e 52-1.
TABLE 52-1. FOUR DEGREES OF INTERNAL HEMORRHOIDS

Fi rst degree: They do not protrude through the anal ori fi ce but
are seen wi thi n the l umen of the canal .
Second degree: They protrude through the anal ori fi ce, usual l y wi th
defecati on, but then spontaneousl y reduce back i nto
the anorectum.
Thi rd degree: They protrude through the anus and must be
manual l y repl aced i nto the anorectum.
Fourth degree: They protrude permanentl y and cannot be reduced
(uncommon, usual l y requi re urgent surgi cal
i nterventi on).
Internal hemorrhoi ds and the anal cushi ons occur i n three
consi stent l ocati ons wi thi n the anal canal . These areas are
Page 624
descri bed as the ri ght posteri or posi ti on, ri ght anteri or posi ti on,
and l eft l ateral posi ti on. The l ubri cated, sl otted anoscope i s
i nserted three ti mes to adequatel y vi ew each of these l ocati ons.
Most often, pati ents are exami ned i n the l eft l ateral posi ti on (i .e.,
pati ent's l eft si de down on the tabl e). In thi s posi ti on, the
hemorrhoi d posi ti ons correspond to the 10-, 2-, and 6-o'cl ock
l ocati ons wi thi n the canal (see Fi gure 3).
Hemorrhoi ds can be managed conservati vel y wi th medi cati ons,
physi cal measures, or l i festyl e changes (Tabl e 52-2). Surgi cal
therapy i s effecti ve but usual l y must be performed i n expensi ve
setti ngs (i .e., operati ng rooms) and can produce si gni fi cant
postoperati ve di scomfort. Pri mary care physi ci ans often encounter
second- and thi rd-degree i nternal hemorrhoi ds that can be
el i mi nated wi th si mpl e
P.416
offi ce procedures. The two most commonl y used techni ques, rubber
band l i gati on and i nfrared coagul ati on, are di scussed i n thi s
chapter.
TABLE 52-2. CONSERVATIVE MANAGEMENT OPTIONS FOR INTERNAL
HEMORRHOIDS

Si tz baths (warm soaks) for 20 mi nutes i n the bathtub
Stool softeners (e.g., docusate sodi um) taken twi ce dai l y
At l east 5 or 6 gl asses of water or fl ui d dai l y
Dai l y stool bul ki ng agent (i .e., psyl l i um or methyl cel l ul ose powder i n a l arge gl ass of
orange jui ce)
Proper di et wi th i ncreased consumpti on of fresh frui ts and vegetabl es
Avoi d del ayed toi l eti ng after the urge appears, prol onged si tti ng or readi ng on the
toi l et, and strai ni ng at toi l eti ng
Rubber band l i gati on i s performed by pl aci ng two l atex ri ngs at the
base of the i nternal hemorrhoi d usi ng a speci al appl i cator. The
bandi ng produces necrosi s and sl oughi ng of the ti ssues i n the week
Page 625
after the procedure. The procedure i s popul ar because i t requi res
i nexpensi ve equi pment, i s easy to perform, and has a proven track
record over many decades. Rubber band l i gati on can produce
postoperati ve bl eedi ng and di scomfort and rarel y causes a
l i fe-threateni ng condi ti on known as pel vi s sepsi s.
Infrared coagul ati on i s an offi ce procedure that i s a safe and hi ghl y
effi caci ous. A 0.7-cm l i ght ti p appl i es the i nfrared energy to the
superi or aspect of the hemorrhoi d i n a 1.25- to 1.5-second ti med
pul se. The energy produces a burn wi th a maxi mum penetrati on of 3
mm and tethers the hemorrhoi d to the underl yi ng ti ssues. The
resul ti ng scar prevents the hemorrhoi d from di stendi ng wi th bl ood
and from bl eedi ng or prol apsi ng. Several appl i cati ons are appl i ed to
each hemorrhoi d, and the treatment general l y i s wel l tol erated
wi thout the need for anesthesi a. Pati ents may report some mi l d
burni ng duri ng the procedure, but thi s techni que has the advantage
of no postoperati ve sl oughi ng, l ess postoperati ve di scomfort, and
no reported cases of pel vi c sepsi s. Many studi es have demonstrated
equal effi cacy of i nfrared treatment wi th other common treatments
for i nternal hemorrhoi ds.
Narcoti cs shoul d be avoi ded after hemorrhoi d treatment, because
they can produce further consti pati on, strai ni ng, and bl eedi ng.
Nonprescri pti on i buprofen (three 200-mg tabl ets three ti mes dai l y
wi th food) and acetami nophen (two tabl ets every 6 hours) can be
used i f needed for di scomfort. Mi l d bl eedi ng shoul d be expected
after treatment of i nternal hemorrhoi ds, but excessi ve bl eedi ng
that requi res medi cal attenti on i s rare. The recommendati ons i n
Tabl e 52-2 are gi ven to i ndi vi dual s fol l owi ng treatment.
INDICATIONS
Persi stent bl eedi ng from i nternal hemorrhoi ds
Symptomati c second-, thi rd-, or fourth-degree i nternal
hemorrhoi ds
Fai l ure of symptomati c i nternal hemorrhoi ds to respond
to conservati ve or medi cal management
Page 626
Presence of seri ous anorectal di sorders such as
i nfecti ous procti ti s, untreated syphi l i s, drai ni ng fi stul as,
or anorectal abscesses
Cel l ul i ti s or bacteremi a
P.417
PROCEDURE
The anatomy of the anal canal i s shown, demonstrati ng the l ocati on
of i nternal and external hemorrhoi ds.
(1) Anatomy of the anal canal showi ng the l ocati on of i nternal and
external hemorrhoi ds.
Pati ents are most commonl y exami ned i n the l eft l ateral posi ti on.
The pati ent l i es wi th the l eft si de down on the tabl e, wi th the head
toward the l eft when the exami ner faces the pati ent. The pati ent's
hi ps and knees are sl i ghtl y fl exed. Al ternatel y, pati ents can be
pl aced i n a knee-chest posi ti on, but thi s i s more uncomfortabl e to
mai ntai n.
Page 627
(2) Pati ents are most commonl y exami ned i n the l eft l ateral
posi ti on.
Locati on of i nternal hemorrhoi ds wi thi n the canal .
(3) Locati on of i nternal hemorrhoi ds wi thi n the anal canal .
P.418
A sl otted, metal anoscope wi th the obturator i n pl ace i s i nserted
i nto the anal canal (Fi gure 4A), and the obturator i s wi thdrawn for
vi ewi ng (Fi gure 4B). The anoscope and obturator can be autocl aved.
The anoscope i s used to vi ew al l three anal cushi ons or
hemorrhoi ds, and the fi ndi ngs are documented.
Page 628
(4) A sl otted, metal anoscope wi th the obturator i n pl ace i s
i nserted i nto the anal canal , and the obturator i s wi thdrawn for
vi ewi ng hemorrhoi ds.
PITFALL: Slotted, metal anoscopes are preferred over the
disposable, plastic anoscopes because of the improved
visualization above and below the dentate line. The metal,
slotted anoscopes provide a larger and longer opening due to
the strength of the instrument.
P.419
The McGi vney hemorrhoi d l i gator has a 7-i nch worki ng l ength
(Fi gure 5A). The l oadi ng cone (Fi gure 5B) i s used to pl ace the
rubber bands on the end of the i nstrument. The hemorrhoi d i s
pul l ed i nsi de i nto the hol l ow appl i cator wi th graspi ng forceps
(Fi gure 5C).
Page 629
(5) Rubber band l i gati on i nstruments: the McGi vney hemorrhoi d
l i gator, the l oadi ng cone, and graspi ng forceps.
P.420
Two rubber bands are rol l ed onto the l i gator drum usi ng the l oadi ng
cone (Fi gure 6A). The l oadi ng cone i s removed, l eavi ng two rubber
bands on the drum (Fi gure 6B). The forceps i s pl aced i nsi de the
l i gator, and both are pl aced i nsi de the anoscope. The hemorrhoi d i s
grasped wi th the forceps and pul l ed i nto the l i gator drum (Fi gure
6C). The handl e of the l i gator i s squeezed, wi th the two rubber
bands rel eased to the base of the hemorrhoi d. Note the appearance
of the hemorrhoi d after removal of the i nstruments (Fi gure 6D). The
hemorrhoi d sl oughs i n the next week.
Page 630
(6) Use of the McGi vney l i gator.
PITFALL: Treatments for internal hemorrhoids cannot be applied
to external hemorrhoids or lesions originating below the dentate
line. Inadvertent banding of an external hemorrhoid usually
produces excruciating discomfort in the week after the
procedure.
P.421
Page 631
The i nfrared coagul ator (Fi gure 7A) and the handpi ece and ti p
(Fi gure 7B) are shown.
(7) The i nfrared coagul ator, the handpi ece, and ti p.
P.422
The i nfrared ti p i s fi rml y appl i ed to the hemorrhoi d (Fi gure 8A). The
i nstrument handl e i s squeezed, produci ng a bri ght l i ght as i nfrared
energy i s del i vered to the i nstrument ti p. Several appl i cati ons can
be appl i ed i n an arc over the superi or aspect of the hemorrhoi d
(Fi gure 8B) or i n a di amond pattern (Fi gure 8C). The hemorrhoi d
shri nks fol l owi ng thi s treatment.
Page 632
(8) The i nfrared ti p i s fi rml y appl i ed to the hemorrhoi d, and the
i nstrument handl e i s squeezed, produci ng a bri ght l i ght as i nfrared
energy i s del i vered to the i nstrument ti p.
PITFALL: Do not indent the tissue with excessive force when
applying the infrared tip to the tissue. Excessive pressure can
push the tip into the tissue and create a burn that is deeper than
needed or desired.
PITFALL: The diamond pattern tethers the distal portion of the
hemorrhoid but can cause greater patient discomfort because it
produces burns closer to the dentate line, which may be highly
innervated.
P.423
CODING INFORMATION

2002 Average 50th
Percentile Fee
46221 Hemorrhoi dectomy by rubber
band l i gati on
$268
46934 Destructi on of i nternal
hemorrhoi ds, any method
$450
Page 633
The i nfrared coagul ator ($3,700) and the metal , sl otted Ives
anoscope ($160) are avai l abl e from Redfi el d Corporati on, 336 West
Passai c Street, Rochel l e Park, NJ (phone: 800-678-4472;
http://www.redfi el dcorp.com). The McGi vney hemorrhoi dal l i gator
(i ncl udi ng l oadi ng cone), l atex O-ri ngs (i .e., rubber bands), and
McGi vney hemorrhoi d graspi ng forceps are avai l abl e from Mi l tex
Inc., 589 Davi es Dr., York, PA 17402 (phone: 800-645-8000;
http://www.ssrsurgi cal .com).
BIBLIOGRAPHY
Ambrose NS, Morri s D, Al exander-Wi l l i ams J, et al . A randomi zed
tri al of photocoagul ati on or i njecti on scl erotherapy for the
treatment of fi rst- and second-degree hemorrhoi ds. Di s Col on
Rectum 1985;28:238240.
Bat L, Mel zer E, Kol er M, et al . Compl i cati ons of rubber band
l i gati on of symptomati c i nternal hemorrhoi ds. Di s Col on Rectum
1993;36:287290.
Denni son A, Whi ston RJ, Rooney S, et al . A randomi zed compari son
of i nfrared photocoagul ati on wi th bi pol ar di athermy for the
outpati ent treatment of hemorrhoi ds. Di s Col on Rectum
1990;33:3234.
Ferguson EF. Al ternati ves i n the treatment of hemorrhoi dal
di sease. South Med J 1988;81:606610.
Jani cke DM, Pundt MR. Anorectal di sorders. Emerg Med Cl i n North
Am 1996;14:757788.
Johanson JF, Ri mm A. Opti mal nonsurgi cal treatment of
hemorrhoi ds: a comparati ve anal ysi s of i nfrared coagul ati on, rubber
band l i gati on, and i njecti on scl erotherapy. Am J Gastroenterol
1992;87:16011606.
Lei cester RJ, Ni chol l s RJ, Chi r M, et al . Infrared coagul ati on: a new
treatment for hemorrhoi ds. Di s Col on Rectum 1981;24:602605.
Li ebach JR, Cerda JJ. Hemorrhoi ds: modern treatment methods.
Hosp Med 1991;27:5368.
Li nares SE, Gomez PM, Ol i vares M, et al . Effecti veness of
Page 634
hemorrhoi dal treatment by rubber band l i gati on and i nfrared
photocoagul ati on. Rev Esp Enferm Di g 2001;93:238247.
Nagl e D, Rol andel l i RH. Pri mary care offi ce management of peri anal
and anal di sease. Gastroenterol ogy 1996;23:609620.
Russel TR, Donohue JH. Hemorrhoi dal bandi ng: a warni ng. Di s Col on
Rectum 1985;28:291293.
Schussman LC, Lutz LJ. Outpati ent management of hemorrhoi ds.
Pri m Care 1986;13:527541.
Stahl TJ. Offi ce management of common anorectal probl ems.
Postgrad Med 1992;92:141154.
Templ eton JL, Spence RA, Kennedy TL, et al . Br Med J
1983;286:13871389.
P.424
Wal ker AJ, Lei cester RJ, Ni chol l s RJ, et al . A prospecti ve study of
i nfrared coagul ati on, i njecti on and rubber band l i gati on i n the
treatment of haemorrhoi ds. I nt J Col orectal Di s 1990;5:113116.
Zuber TJ. Anorectal di sease and hemorrhoi ds. In: Tayl or RB, ed.
Manual of fami l y practi ce. Boston: Li ttl e, Brown, 1997:381384.
Zuber TJ. Offi ce procedures. The AAFP Academy col l ecti on qui ck
Wi l ki ns, 1998:115121.
Page 635
> Table of Cont ent s > Ear, Nose, and Throat Procedures > 53 - Conjunct ival and
Corneal Foreign Body Removal53
Conjunctival and Corneal Foreign
Body Removal
Conjuncti val and corneal forei gn objects are commonl y seen
probl ems i n the pri mary care offi ce and i n the emergency
department. Usual l y, removal of the forei gn object i s easi l y
accompl i shed and can be performed i n the outpati ent setti ng. When
a pati ent presents, document a thorough hi story, i ncl udi ng
mechani sm of i njury, job status, probabl e type of forei gn body
(especi al l y i f i t may be i ron based), whether fi rst ai d was rendered,
and the condi ti on of the eye before i njury. Al ways test and
document the pati ent's vi si on before and after treatment. Use a
Snel l en chart or an equi val ent vi sual acui ty chart i f possi bl e.
The corneal and conjuncti val epi thel i a are some of the
fastest-heal i ng areas of the body. If consi derabl e progress toward
heal i ng has not been made wi thi n 24 hours of forei gn body
extracti on, reexami ne for addi ti onal forei gn bodi es or si gns of
i nfecti on. Local anestheti c drops are often used duri ng mechani cal
removal of forei gn objects but shoul d not be prescri bed for
outpati ent use because they may retard corneal heal i ng and
because pai n may be an i mportant i ndi cator of devel opi ng corneal
ul cerati on or that addi ti onal forei gn bodi es are present. Topi cal
steroi ds al so shoul d be avoi ded.
There are some gui del i nes for when to refer pati ents to decrease
the ri sk of i mpai red vi si on or bl i ndness. The i ntraocul ar presence of
an object requi res prompt referral to an ophthal mol ogi st. Injury
from chemi cal s may be mi l d to severe. If pai n or functi onal
i mpai rment persi sts after i rri gati on, the pati ent shoul d be referred
to an ophthal mol ogi st. Possi bl e aci d or al kal i contami nati on of the
eye i s a true ophthal mol ogi c emergency.
Page 636
Cl i ni ci ans must use extreme cauti on when attempti ng to remove
forei gn objects by mechani cal means such as cotton-ti pped
appl i cators or needl es. Any downward pressure on the object may
resul t i n more damage to the epi thel i um or deeper l ayers. If
cl i ni ci ans are unsure of thei r abi l i ty to remove an object wi thout
exerti ng downward pressure on i t, the pati ent shoul d be referred to
an ophthal mol ogi st for removal . Object removal i s most successful
i n cases of recent, superfi ci al forei gn bodi es.
Tradi ti onal l y, eye patches were appl i ed i n accordance wi th the
theory that they decreased photophobi a, teari ng, forei gn body
sensati on, pai n, and heal i ng ti mes. However, l ater studi es i ndi cate
that patchi ng does not i mprove pai n scores,
P.428
heal i ng ti mes, or treatment outcomes and may sl ow heal i ng and
decrease compl i ance wi th treatment pl ans.
Because of the ri sk of compl i cati ons, obtai ni ng i nformed consent
makes practi cal sense. Possi bl e compl i cati ons of forei gn body
removal i ncl ude i nfecti on, perforati on of the cornea, and i ncompl ete
removal of a forei gn body. Speci al care must be taken wi th
i ron-based forei gn objects, because rust i s toxi c to the cornea and
may prevent i t from heal i ng. There i s a ri sk of scarri ng, and when
the i njury i s i n the cornea, there i s an addi ti onal ri sk of permanent
vi sual i mpai rment.
If the pati ent has si gni fi cant pai n, consi der usi ng a cycl opl egi c
agent to decrease spasm of the i ri s. Appl y anti bi oti c drops or
oi ntment for anti bi oti c prophyl axi s. Prescri be oral pai n medi cati on
as i ndi cated. Instruct the pati ent not to rub the eye, because i t
may di srupt the new epi thel i al l ayers on the cornea.
Reepi thel i al i zati on i s compl ete i n 3 to 4 days for more than 90% of
pati ents, but i t can take weeks. Reexami ne every 24 hours unti l the
eye i s heal ed. Perform and document a vi sual acui ty test on the
l ast vi si t. Conti nue anti bi oti c drops for an addi ti onal 3 days after
the eye i s symptom free. The pati ent may be unusual l y recepti ve at
thi s ti me to educati on about eye safety measures such as
Page 637
protecti ve eyewear. If at any ti me duri ng the fol l ow-up the pai n
i ncreases or si gns of conjuncti val or orbi tal i nfecti on are seen,
i mmedi atel y refer the pati ent to an ophthal mol ogi st.
INDICATIONS
Smal l , conjuncti val or corneal forei gn bodi es embedded
l ess than 24 hours
CONTRAINDICATIONS
Forei gn bodi es embedded i n the cornea for more than 24
hours (i .e., ri sk of i nfecti on)
Iron-based forei gn bodi es, whi ch may cause a rust ri ng
Deepl y or central l y embedded forei gn bodi es (i .e.,
ophthal mol ogi c referral )
Possi bl e aci d or al kal i contami nati on of the eye (i .e.,
ophthal mol ogi c emergency)
Ruptured gl obe (i .e., ophthal mol ogi c emergency)
Hyphema, l ens opaci fi cati on, abnormal anteri or chamber
exami nati on, or i rregul ari ty of the pupi l (i .e., possi bl e
ruptured gl obe, whi ch i s an ophthal mol ogi c emergency)
Si gns or symptoms of i nfecti on (i .e., ophthal mol ogi c
referral )
P.429
PROCEDURE
Check and record the pati ent's vi sual acui ty usi ng a Snel l en chart.
Then posi ti on the pati ent i n the supi ne posi ti on (Fi gure 1A). For
corneal forei gn bodi es, posi ti on the pati ent's head so that the
forei gn body and the eye are i n the most el evated posi ti on (Fi gure
1B). For conjuncti val forei gn bodi es, posi ti on the head to gi ve the
exami ner maxi mal access to the affected area.
Page 638
(1) Check the pati ent's vi sual acui ty usi ng a Snel l en chart, and
have the pati ent l i e down i n the supi ne posi ti on.
P.430
Hol d the pati ent's eyel i ds apart wi th your thumb and i ndex fi nger of
the nondomi nant hand. A wi re eye specul um may be used but
usual l y i s not avai l abl e i n pri mary care offi ces. Ask the pati ent to
fi x and mai ntai n hi s or her gaze on a di stant object and to hol d the
head as moti onl ess as possi bl e throughout the procedure.
Page 639
(2) Hol d the pati ent's eyel i ds apart wi th the thumb and i ndex
fi nger of your nondomi nant hand, and ask the pati ent to fi x and
mai ntai n hi s or her gaze on a di stant object.
P.431
If the object i s not readi l y vi si bl e, put 2 drops of topi cal anestheti c
i nto the retracted l ower eyel i d whi l e the pati ent gazes i n an upward
di recti on. Wet a fl uorescei n stri p wi th the same sol uti on, and appl y
i t to the undersi de of the l ower eyel i d. Inspect the cornea for dye
pool i ng near objects or abrasi ons that may hel p i denti fy the
l ocati on of a forei gn body.
Page 640
(3) Appl y 2 drops of topi cal anestheti c i nto the retracted l ower
eyel i d whi l e the pati ent gazes i n an upward di recti on.
PITFALL: Putting drops directly on a scratched cornea can be
very painful.
PITFALL: Vertical scratches on the cornea may indicate a foreign
body imbedded in the upper lid, necessitating eyelid eversion
and examination with a cotton-tipped applicator.
P.432
Attempt to wash out the object usi ng steri l e normal sal i ne or an
ophthal mi c i rri gant. Thi s may be done by pouri ng a smal l ,
conti nuous vol ume of fl ui d i nto the affected eye. An al ternati ve
method i s to pl ace an i ntravenous bag of normal sal i ne wi th tubi ng
on a pol e, cut off the end of the tubi ng, and use the gentl e stream
comi ng from the end of the tubi ng to i rri gate the eye.
Page 641
(4) Attempt to wash out the object usi ng steri l e sal i ne or an
ophthal mi c i rri gant.
If thi s i s unsuccessful , attempt to di sl odge the object usi ng a
cotton-ti pped appl i cator or corner of a soft cotton gauze. Moi sten
the cotton wi th l ocal anestheti c, and gentl y l i ft the object by
l i ghtl y touchi ng i t.
(5) If i rri gati on i s unsuccessful , attempt to di sl odge the object
usi ng a cotton-ti pped appl i cator moi stened wi th l ocal anestheti c.
Page 642
PITFALL: Never use force or rub the cornea because this can
produce pain, damage the epithelium, and cause deeper corneal
injuries.
P.433
If the object i s sti l l l odged, a steri l e needl e may be used to remove
the object. Pl ace a 26-gauge needl e on a tubercul i n syri nge and
hol d i t i n wi th a penci l gri p. Stabi l i ze your operati ng hand on the
pati ent's brow or zygomati c arch. Approach the object wi th the
needl e bevel upward from a tangenti al di recti on, and use the
needl e ti p to gentl y l i ft the object.
(6) If the object i s sti l l l odged, use the ti p of a steri l e, 26-gauge
needl e to gentl y l i ft the object.
PITFALL: If the object cannot be readily removed, refer the
patient for removal under slit lamp by an ophthalmologist.
PITFALL: If any residual corneal rust is found, immediately refer
the patient to an ophthalmologist because rust is toxic to
corneal epithelium.
P.434
Page 643
Turn the pati ent's head l ateral l y, and copi ousl y i rri gate the eye.
Retest and record the pati ent's vi sual acui ty.
(7) After the object i s removed, turn the pati ent's head l ateral l y,
and copi ousl y i rri gate the eye.
P.435
CODING INFORMATION
CPT Code Description 2002 Average 50th
Page 644
Percentile Fee

65205* Removal of forei gn body,
external eye; conjuncti val
superfi ci al
$77
external eye, conjuncti val l y
embedded
$98
external eye, corneal wi thout
sl i t l amp
$100
corneal wi th sl i t l amp
$126

A Snel l en chart or equi val ent vi sual acui ty chart can be obtai ned
from Premi er Medi cal , P.O. Box 4132, Kent, WA 98032 (phone:
800-955-2774; http://www.premi eremedi cal .safeshopper.com/).
Magni fi cati on devi ces, l oupes, and Wood's l i ghts may be ordered
from medi cal suppl y compani es. Topi cal ophthal mi c anestheti c,
cycl opl egi c drops, and fl uorescei n stri ps may be ordered from
pharmaci es.
BIBLIOGRAPHY
Appen RE, Hutson CF. Traumati c i njuri es: offi ce treatment of eye
i njury. 1. Injury due to forei gn materi al s. Postgrad Med
1976;60:223225, 237.
Hol t GR, Hol t JE. Management of orbi tal trauma and forei gn
bodi es. Otol aryngol Cl i n North Am 1988;21:3552.
Kai ser PK. A compari son of pressure patchi ng versus no patchi ng for
corneal abrasi ons due to trauma or forei gn body removal . Corneal
Abrasi on Patchi ng Study Group. Ophthal mol ogy
1995;102:19361942.
Le Sage N, Verreaul t R, Rochette L. Effi cacy of eye patchi ng for
traumati c corneal abrasi ons: a control l ed cl i ni cal tri al . Ann Emerg
Page 645
Med 2001;38:129134.
Nayeen N. Stansfi el d D. Management of corneal forei gn bodi es i n
A&E departments. Arch Emerg Med 1992;9:257.
Newel l SW. Management of corneal forei gn bodi es. Am Fam
Physi ci an 1985;31:149156.
Owens JK, Sci bi l i a J, Hezoucky N. Corneal forei gn bodi esfi rst
ai d, treatment, and outcomes. Ski l l s revi ew for an occupati onal
heal th setti ng. AAOHN J 2001;49:226230.
Rei ch JA. Removal of corneal forei gn bodi es. Aust Fam Physi ci an
1990;19:719721.
Page 646
> Table of Cont ent s > Ear, Nose, and Throat Procedures > 54 - Chalazia Removal
54
Chalazia Removal
Chal azi a appear as chroni c subcutaneous nodul es of the eyel i d.
Chal azi a devel op from the obstructi on of the mei bomi an gl and duct
at the eyel i d margi n. Leaki ng contents from an engorged,
obstructed gl and i nduce a l i pogranul omatous (forei gn body)
reacti on. The gel ati nous contents wi thi n chal azi a usual l y are
steri l e, al though l esi ons can become secondari l y i nfected.
Chal azi a are frequentl y confused wi th hordeol ums or styes.
Hordeol ums are acute, focal , i nfl ammatory processes that mani fest
as suddenl y appeari ng, erythematous, tender l umps i n the eyel i d.
Hordeol ums usual l y are sel f-l i mi ted, but i nternal hordeol ums
occasi onal l y devel op i nto chroni c chal azi a. Chal azi a often appear i n
i ndi vi dual s wi th ski n di sorders such as seborrhei c dermati ti s or
rosacea, and the coexi sti ng bl ephari ti s wi th these condi ti ons can
add to the di agnosti c confusi on wi th hordeol ums.
Because chal azi a may resol ve spontaneousl y i f the duct opens,
some physi ci ans advocate the appl i cati on of warm compresses four
ti mes dai l y. Al though one thi rd of l esi ons may resol ve over 3
months, a month of warm compress therapy i s suffi ci ent to i denti fy
those that wi l l respond to conservati ve management. Chal azi a
present for more than a month general l y requi re more aggressi ve
management. One to three steroi d i njecti ons have been shown to
resol ve many l esi ons wi thi n a few weeks ti me. A smal l i ntral esi onal
i njecti on of 0.05 to 0.2 mL of tri amci nol one (5 mg/dL) can be
admi ni stered from a tubercul i n syri nge. Depi gmentati on i s not
uncommon, especi al l y i n darkl y pi gmented i ndi vi dual s.
Long-standi ng chal azi a often are managed wi th a si mpl e offi ce
surgi cal procedure. Physi ci ans can shi el d the eye duri ng the
procedure to promote safety and greater comfort for the pati ent
Page 647
and operator. The i nci si on and curettage procedure i s si mi l ar to
other dermatol ogi c procedures. Al though success rates are hi gh,
there are recurrences, especi al l y i n i ndi vi dual s wi th predi sposi ng
ski n condi ti ons. Anti bi oti cs are not necessary for postprocedure
care, but the anti i nfl ammatory effect of tetracycl i ne and other
anti bi oti cs may prevent recurrence i n i ndi vi dual s wi th rosacea or
chroni c bl ephari ti s.
P.437
INDICATIONS
Chroni c nodul es on the i nternal (conjuncti val ) or
external (ski n) porti on of the eyel i d
Cosmeti c concerns or chroni c i rri tati on from a chroni c
chal azi on
Hordeol ums (sel f-l i mi ted)
Chal azi a that have not undergone more conservati ve
i nterventi ons (i .e., warm compresses)
Known eyel i d di sease (e.g., sarcoi d nodul es, mal i gnancy
such as basal cel l carci noma)
Injecti on i n darkl y pi gmented i ndi vi dual
P.438
PROCEDURE
Tri amci nol one (0.05 to 0.2 mL of a 5 mg/mL concentrati on) i s
admi ni stered usi ng a 30-gauge needl e on a tubercul i n syri nge.
When the chal azi on i s external , enter the l esi on l ateral l y wi th the
needl e di rected away from the gl obe (Fi gure 1A). If the chal azi on i s
i nternal , consi der pl acement of a corneal eye shi el d (di scussed
l ater). The eyel i d i s everted for i njecti on (Fi gure 1B).
Page 648
(1) Injecti on of chal azi a.
PITFALL: Patients may suddenly move during any injection,
endangering the eye. The supine patient' s head should be
stabilized against a firm surface, such as an examination table,
with one or more assistants helping to steady the patient' s
head.
Proparacai ne ophthal mi c sol uti on i s l i beral l y admi ni stered to the
pati ent's affected eye.
(2) Admi ni ster proparacai ne ophthal mi c sol uti on l i beral l y to the
pati ent's affected eye.
P.439
Page 649
A pl asti c corneal shi el d i s l ubri cated wi th tobramyci n ophthal mi c
oi ntment and then gentl y pl aced over the gl obe. A sucti on cup can
be attached to the convex surface of the shi el d for i nserti on and
removal (Fi gure 3A). Ask the pati ent to l ook down, and sl i de the
upper edge under the upper l i d (Fi gure 3B). As the pati ent l ooks up,
the l ower l i d i s grasped and el evated, and the l ower porti on of the
shi el d pl aced beneath the l ower l i d (Fi gure 3C). The sucti on cup i s
removed.
(3) Lubri cate a pl asti c corneal shi el d wi th tobramyci n ophthal mi c
oi ntment, and gentl y pl ace i t over the gl obe.
P.440
Admi ni ster a smal l amount (0.1 to 0.4 mL) of 1% l i docai ne wi thout
epi nephri ne i n the ski n surroundi ng the chal azi on. Al ways angl e the
needl e ti p away from the gl obe as di scussed earl i er. If used, the
chal azi on forceps (cl amp) can be appl i ed at thi s poi nt (Fi gure 4A).
The fl at porti on of the cl amp i s pl aced agai nst the ski n, and the
chal azi on protrudes through the open ri ng (Fi gure 4B). The
procedure can be performed wi thout the cl amp, usi ng pressure from
the fi ngers of the nondomi nant hand to stabi l i ze the l esi on and
control bl eedi ng.
Page 650
(4) Admi ni ster a smal l amount of 1% l i docai ne wi thout epi nephri ne
to the ski n surroundi ng the chal azi on, and appl y the chal azi on
forceps.
P.441
A 2- to 3-mm i nci si on i s made i nto the chal azi on wi th a no. 11
bl ade (Fi gure 5A). Pl ace a 2-mm chal azi on curette (i ce cream
scoop ) i nto the chal azi on cavi ty. Gel ati nous materi al i s
extruded (Fi gure 5B) and wi ped onto gauze. The wal l s of the
chal azi on are scraped vi gorousl y i n al l di recti ons, causi ng the
chal azi on to scar cl osed.
Page 651
(5) Make a 2- to 3-mm i nci si on i nto the chal azi on wi th a no. 11
bl ade, and pl ace a 2-mm chal azi on curette i nto the chal azi on cavi ty
to remove gel ati nous materi al .
The chal azi on curette and forceps (cl amp) are removed. Any
bl eedi ng can usual l y be control l ed wi th gentl e pressure appl i ed wi th
gauze. After 5 mi nutes of pressure, the sucti on cup i s appl i ed to
the corneal shi el d, and the shi el d gentl y removed. Sal i ne eyewash
can be appl i ed, and a drop of anti bi oti c (e.g., gentami ci n
ophthal mi c sol uti on) appl i ed. The pati ent i s observed for 5 to 10
mi nutes and then rel eased. No patchi ng i s necessary.
(6) Any bl eedi ng usual l y can be control l ed wi th gentl e pressure
appl i ed wi th gauze.
PITFALL: Sit the patient up slowly after the procedure. Observe
for lightheadedness or a vasovagal reaction after lying flat for
the procedure.
Page 652
P.442
CODING INFORMATION

2002 Average 50th
Percentile Fee

67800 Exci si on of chal azi on, si ngl e $187
67801 Exci si on of chal azi a,
mul ti pl e, same l i d
$240
67805 Exci si on of chal azi a,
mul ti pl e, di fferent l i ds
$306
67808 Exci si on under general
anesthesi a or requi ri ng
hospi tal i zati on
$513

Corneal eye shi el ds protect the gl obe when performi ng eyel i d
surgery can be ordered from El l man Internati onal , 1135 Rai l road
Avenue, Hewl ett, NY 11557 (phone: 800-835-5355;
http://www.el l man.com). Chal azi on forceps (e.g., Desmarres, Ayer,
Franci s, Wei s, Spencer; we prefer Heath 12 14 mm or Franci s 12
14 mm) and chal azi on curettes (e.g., Skeel e, Meyhoeffer,
Heath; we prefer a 5-i nch [2- or 2.5-mm] Meyhoeffer) can be
ordered from http://www.Surgi cal 911.com, 13 West Mai n St., Sui te
A, Cl i nton, CT 06413, CT (http://www.surgi cal 911.com).
Proparacai ne hydrochl ori de (0.5%), gentami ci n ophthal mi c sol uti on,
and tobramyci n ophthal mi c oi ntment can be obtai ned from Fal con
Pharmaceuti cal s, 6201 South Freeway, Ft. Worth, TX 76134 (
http://www.fal conpharma.com). Tri amci nol one suspensi on can be
ordered from Fuji sawa Heal thcare, 3 Parkway North, Deerfi el d, IL
60015 (http://www.fuji sawa.com). A suggested anesthesi a tray that
can be used for thi s procedure i s l i sted i n Appendi x G.
Page 653
BIBLIOGRAPHY
Bedrossi an EH. Treatment of hordeol ums: styes and chal azi a. Hosp
Med 1997;33:5964.
Bl ack RL, Terry JE. Treatment of chal azi a wi th i ntral esi onal
tri amci nol one i njecti on. J Am Optom Assoc 1990;61:904906.
Cottrel l DG, Bosanquet RC, Fawcett IM. Chal azi ons: the frequency
of spontaneous resol uti on [Letter]. Br Med J 1983;287:1595.
Di egel JT. Surgery for chal azi on. In: Benjami n RB, ed. Atl as of
outpati ent and offi ce surgery, 2nd ed. Phi l adel phi a: Lea & Febi ger,
1994:2225.
Epstei n GA, Putterman AM. Combi ned exci si on and drai nage wi th
i ntral esi onal corti costeroi d i njecti on i n the treatment of chroni c
chal azi a. Arch Opthal mol 1988;106:514516.
Jackson TL, Beun L. A prospecti ve study of cost, pati ent
sati sfacti on, and outcome of treatment of chal azi on by medi cal and
nursi ng staff. Br J Ophthal mol 2000;84:782785.
Lederman C, Mi l l er M. Hordeol a and chal azi a. Pedi atr Rev
1999;20:283284.
Mustafa TA. Three methods of treatment of chal azi a i n chi l dren.
Saudi Med J 2001;22:968972.
Procope JA, Ki dwel l EDR. Del ayed postoperati ve hemorrhage
compl i cati ng chal azi on surgery. J Natl Med Assoc
1994;86:865866.
Rei fl er DM, Leder DR. Eyel i d crease approach for chal azi on
exci si on. Ophthal mol Pl ast Reconstr Surg 1989;5:6367.
Vi daurri LJ, Pe'er J. Intral esi onal corti costeroi d treatment of
chal azi a. Ann Ophthal mol 1986;18:339340.
Zuber TJ. Offi ce procedures. The AAFP academy col l ecti on qui ck
Wi l ki ns, 1999:8995.
Page 654
> Table of Cont ent s > Ear, Nose, and Throat Procedures > 55 - Treat ment for
Ant erior Epist axis55
Treatment for Anterior Epistaxis
Epi staxi s (i .e., nosebl eed) i s a very common compl ai nt among
pri mary care pati ents. Because the bl ood suppl y to the nasal cavi ty
ori gi nates i n the caroti d arteri es, epi staxi s may produce profuse
bl eedi ng. More than 90% of nosebl eeds ori gi nate from the anteri or
part of the nose, usual l y from Ki essel bach's pl exus on the nasal
septum. Thi s chapter focuses on the more common anteri or bl eeds.
Ki essel bach's pl exus i s readi l y accessi bl e to objects i nserted i nto
the nose. The presence of nasal trauma, recent use of i ntranasal
agents, presence of a forei gn body, recent i nfecti on, exacerbated
al l ergy, and no sensati on of bl ood fl owi ng down the back of the
throat al l suggest an anteri or si te of bl eedi ng.
Local and systemi c di sorders may cause nosebl eeds (Tabl e 55-1).
In a pati ent ol der than 40 years of age, bl eedi ng i s often posteri or
and may be associ ated wi th systemi c di sease. The si te of bl eedi ng
shoul d be i denti fi ed i n al l pati ents, even those i n whom the
bl eedi ng has stopped, because the severi ty of the probl em and the
treatment opti ons vary by si te. If seri ous bl eedi ng exi sts, the
hi ghest pri ori ty i s to secure the pati ent's ai rway, breathi ng, and
ci rcul ati on. One thi rd of chi l dren presenti ng wi th recurrent epi staxi s
have a di agnosabl e coagul opathy.
TABLE 55-1. COMMON CAUSES OF EPISTAXIS
Page 655

Infecti ons such as rhi ni ti s, nasopharyngi ti s, and si nusi ti s
Trauma, i nfl i cted (e.g., faci al bone fractures) and sel f-i nduced (e.g., nose-pi cki ng)
Nasal forei gn body
Mucosal atrophy from chroni c steroi d nasal sprays
Nasal surgery
Local i rri tants such as nasal sprays and cocai ne abuse
Dry nasal mucosa
Al l ergi c and atrophi c rhi ni ti s
Hypertensi on and atheroscl eroti c cardi ovascul ar di sease
Tumors and pol yps, beni gn or mal i gnant
Nasal defects, congeni tal or acqui red
Bl eedi ng di sorders, i ncl udi ng hemophi l i a A, hemophi l i a B, von Wi l l ebrand di sease,
thrombocytopeni a, and hypoprothrombi nemi a
Li ver di sease
Renal fai l ure or uremi a
Di ssemi nated i ntravascul ar coagul ati on
Drug-i nduced, i ncl udi ng nonsteroi dal anti i nfl ammatory drugs (especi al l y sal i cyl ates),
hepari n, warfari n, thrombol yti cs, and heavy metal s
When a pati ent presents wi th epi staxi s, obtai n a bri ef hi story to
determi ne the durati on and severi ty of bl eedi ng and the presence
of any contri buti ng factors. If bl eedi ng i s severe, consi der getti ng a
compl ete bl ood cel l count (CBC), prothrombi n ti me and parti al
thrombopl asti n ti me (PT/PTT), bl ood type, and screen. Determi ne i f
the bl eedi ng ori gi nates i n the anteri or or posteri or part of the nasal
cavi ty. It may be di ffi cul t to determi ne the source of the bl eedi ng
because cl ots may be present, and bl ood can refl ux i nto the
unaffected si de. Have the pati ent bl ow hi s or her nose to di sl odge
cl ots. Sucti on wi th a Fraser ti p may be hel pful . Adequate l i ghti ng
and sucti on are essenti al to a good physi cal exami nati on. The
physi cal exami nati on shoul d i ncl ude vi tal si gns, eval uati on for
orthostasi s, and i nspecti on of the oral cavi ty and nasopharynx.
Anteri or epi staxi s usual l y can be stopped by di rect pressure, use of
vasoconstri ctors, si mpl e cautery, and packi ng. Di rect pressure i s
often the fi rst therapy appl i ed, typi cal l y usi ng the cl osed hand
Page 656
techni que. It provi des fi rm compressi on and makes i t easi er for the
pati ent to mai ntai n hi s or her gri p. Ti me the nasal compressi on (5
to 10 mi nutes), because pati ents usual l y underesti mate the
el apsed ti me.
P.444
If di rect pressure i s unsuccessful , appl y a combi ned
vasoconstri cti ve agent and anestheti c (Tabl e 55-2) usi ng a spray
bottl e, atomi zer, or pl edget. A moi stened pl edget provi des better
contact wi th the nasal mucosa whi l e al so provi di ng a l ocal
tamponade effect. Cocai ne provi des excel l ent vasoconstri cti on and
anesthesi a, but i t i s rarel y avai l abl e.
TABLE 55-2. VASOCONSTRICTIVE AND ANESTHETIC AGENTS FOR EPISTAXIS

0.51.0% phenyl ephri ne (Neo-Synephri ne) mi xed 2:1 wi th 4% l i docai ne up to a total
dosage of 4 mg/kg of l i docai ne
0.05% oxymetozal i ne (Afri n) mi xed wi th 4% l i docai ne up to a total dosage of 4 mg/kg of
l i docai ne
0.25 mL of 1% (1:1000 concentrati on) epi nephri ne mi xed wi th 20 mL of 4% l i docai ne up
to a total dosage of 4 mg/kg of l i docai ne
Cocai ne (40 mg/mL) up to a total dosage of 2 to 3 mg/kg i n adul ts (contrai ndi cated i n
chi l dren)

Chemi cal cautery wi th si l ver ni trate sti cks i s effecti ve treatment for
mi nor anteri or nasal bl eedi ng. Fi rst, control bl eedi ng usi ng
vasoconstri ctors or di rect pressure, or both, because i t i s di ffi cul t
to cauteri ze an acti vel y bl eedi ng area by chemi cal means al one.
El ectri cal and thermal cautery al so may be used, but these are no
better at hemorrhage control than chemi cal cautery.
Battery-powered, di sposabl e heat cautery devi ces are di ffi cul t to
control for the depth of cautery, and si gni fi cant i njury can occur.
Anteri or nasal packi ng shoul d be consi dered when the previ ous
methods fai l after three attempts. Prepare the nasal cavi ty wi th a
Page 657
combi ned vasoconstri ctor and anestheti c agent. (Tabl e 55-2). The
nasal cavi ty i s packed usi ng stri ps of petrol atum- or
i odoform-i mpregnated gauze or an appropri ate commerci al devi ce.
If nasal packi ng does not control i sol ated anteri or bl eedi ng, the
anteri or pack shoul d be rei nserted to ensure proper pl acement.
Leave anteri or packs i n pl ace for 48 hours. Ask the pati ent to report
any fever or recurrent bl eedi ng and to return i mmedi atel y i f
bl eedi ng recurs or i f there i s a sensati on of bl ood tri ckl i ng down the
back of the throat.
P.445
Commerci al products have been speci fi cal l y devel oped to make the
i nserti on of an anteri or nasal pack easi er and more comfortabl e for
the pati ent. The Merocel nasal sponge (Merocel Corp., Mysti c, CT)
i s a dehydrated, spongel i ke materi al that expands on contact wi th
moi sture. The Merocel sponge may be more comfortabl e than a
bal l oon or gauze packi ng. It has been reported that the effi cacy of
thi s devi ce i s comparabl e to other methods. Gel foam packs al so can
be used.
Compl i cati ons from di rect pressure, chemi cal cautery, and anteri or
nasal packi ng are rare. Conti nued bl eedi ng i s al ways a possi bi l i ty,
and i nfecti ons may occur. Septal perforati ons have been reported
wi th overzeal ous use of chemi cal cautery. Compl i cati ons from
anteri or nasal packi ng i ncl ude di sl odgement of the packi ng,
recurrent bl eedi ng, and si nusi ti s. Pati ents di scharged wi th nasal
packi ng shoul d be gi ven anti bi oti cs to prevent the rare compl i cati on
of toxi c shock syndrome. Anti bi oti c choi ces i ncl ude cephal exi n (250
to 500 mg four ti mes dai l y), amoxi ci l l i n-cl avul anate (250 to 500 mg
three ti mes dai l y), cl i ndamyci n (150 to 300 mg four ti mes dai l y), or
tri methopri m-sul famethoxazol e DS (twi ce dai l y). If the pati ent
compl ai ns of choki ng or a forei gn body sensati on i n the back of the
throat, l ook for l ayers of an anteri or nasal pack that have fal l en
backward i nto the nasopharynx. If there i s evi dence of conti nued
bl eedi ng after the i nserti on of an anteri or pack, consi der the
Page 658
possi bi l i ty of i nadequate packi ng or a posteri or bl eedi ng si te. If
attempts to control the bl eedi ng fai l , consul t an otol aryngol ogi st.
If the bl eedi ng i s control l ed, i nstruct the pati ent not to mani pul ate
the external nares or i nsert forei gn objects or fi ngers i nto the nasal
cavi ty. Petrol atum or tri pl e anti bi oti c oi ntment may be appl i ed to
dry nasal mucosa wi th a cotton-ti pped appl i cator once or twi ce each
day for several days. Have pati ents avoi d aspi ri n or nonsteroi dal
anti i nfl ammatory drugs (NSAIDs) for 3 or 4 days. If bl eedi ng recurs,
the pati ent shoul d use home measures such as over-the-counter
nasal sprays or di rect pressure for 5 to 10 mi nutes before returni ng
for medi cal care. If bl eedi ng conti nues after repeati ng compressi on
twi ce more, have the pati ent seek i mmedi ate medi cal hel p.
Posteri or packi ng may be requi red for uncontrol l ed posteri or
bl eedi ng. Posteri or paddi ng requi res ski l l and practi ce i n the face of
vi gorous bl eedi ng and i s best performed i n emergency departments
or hospi tal setti ngs by physi ci ans experi enced i n such i nserti on.
INDICATIONS
Epi staxi s that persi sts despi te adequate external
pressure and vasoconstri cti on
Cl otti ng abnormal i ti es because aggressi ve packi ng may
cause further bl eedi ng (normal i ze cl otti ng mechani sms
before removi ng nasal packs i f possi bl e)
Chroni c obstructi ve pul monary di sease (moni tor for a
drop i n oxygen parti al pressure)
Trauma (consi der referral )
Known or suspected cerebrospi nal fl ui d l eak
Drug abuse (e.g., cocai ne)
Al l ergy to anestheti cs or vasoconstri ctors
P.446
PROCEDURE
Ki essel bach's pl exus i s a compl ex anastomosi s of arteri ol es i n the
Page 659
superfi ci al regi on of the nasal mucosa on the nasal septum. It i s
fed by the septal branches of the anteri or ethmoi d (AE), posteri or
ethmoi d (PE), sphenopal ati ne (S), superi or l abi al (SL), and greater
pal ati ne (GP) arteri es.
(1) Arteri al anatomy of the nasal septum.
Appl y pressure usi ng the cl osed hand method. Vasoconstri ctors may
be used i n conjuncti on wi th or i ndependent of di rected pressure.
(2) Appl y pressure usi ng the cl osed hand method.
PITFALL: Using two fingers to pinch the nose (rather than the
closed hand method) makes it more difficult to maintain a grip
and keep adequate pressure on the nose.
Page 660
P.447
If anteri or epi staxi s cannot be control l ed wi th vasoconstri ctors or
di rect pressure, or both, chemi cal cautery may be attempted.
Prepare the nasal cavi ty wi th combi ned vasoconstri ctor and
anestheti c agent (Tabl e 55-2). After the bl eedi ng has stopped, dry
the mucosa, and cauteri ze i t by touchi ng the bl eedi ng source wi th
the ti p of a si l ver ni trate sti ck for 10 to 15 seconds. Wi pe away any
resi dual si l ver ni trate and appl y anti bi oti c oi ntment i f desi red.
(3) Chemi cal cautery can be used i f anteri or epi staxi s cannot be
control l ed wi th vasoconstri ctors or di rect pressure.
Gauze packi ng may be used for resi stant anteri or epi staxi s. Prepare
the nasal cavi ty wi th combi ned vasoconstri ctor and anestheti c
agent (Tabl e 55-2). Vi sual i ze the nasal cavi ty usi ng a nasal
specul um to ensure proper gauze pl acement.
Page 661
(4) Gauze packi ng can be used for resi stant anteri or epi staxi s.
PITFALL: Blind packing often results in loose placement of the
gauze and inadequate compression. Inadequate packing is
probably the most common cause of treatment failure.
P.448
Usi ng bayonet forceps, grasp one end of a l ong stri p of -i nch
petrol atum or i odoform gauze saturated wi th anti bi oti c oi ntment
approxi matel y 2 to 3 cm from i ts end (Fi gure 5A). Al l ow the end to
doubl e over, and i nsert i t through the nasal specul um to the
posteri or l i mi t of the fl oor of the nose (Fi gure 5B).
(5) Wi th bayonet forceps, grasp one end of a l ong stri p of -i nch
petrol atum gauze saturated wi th anti bi oti c oi ntment, al l ow the end
to doubl e over, and i nsert i t through the nasal specul um to the
posteri or l i mi t of the fl oor of the nose.
Wi thdraw the bayonet forceps and nasal specul um. Rei ntroduce the
nasal specul um on top of the fi rst l ayer of packi ng. Grasp another
l oop of gauze wi th the bayonet forceps. Insert i t on top of the
previ ous course usi ng an accordi on techni que so that part
of each l ayer l i es anteri or to the previ ous l ayer, preventi ng the
gauze from fal l i ng posteri orl y i nto the nasopharynx. Wi th each
l ayer, use the forceps to gentl y push the underl yi ng stri p
Page 662
downward.
(6) Wi thdraw the bayonet forceps and nasal specul um, and
rei ntroduce the nasal specul um on top of the fi rst l ayer of packi ng.
P.449
Conti nue to repeat unti l the enti re nasal cavi ty i s fi l l ed wi th l ayers
of packi ng materi al . Observe the pati ent for 30 mi nutes to make
sure that adequate hemostasi s has been achi eved.
(7) Conti nue to l ayer gauze usi ng an accordi on techni que
Page 663
unti l the enti re nasal cavi ty i s fi l l ed wi th l ayers of packi ng
materi al .
Al ternati vel y, the Merocel sponge may be used for anteri or packi ng.
The sponge absorbs the bl ood and secreti ons and qui ckl y expands
to provi de a good tamponade effect. Insert the sponge rapi dl y,
because i t wi l l start to expand al most i mmedi atel y on contact,
unl ess i t i s coated wi th a water-sol ubl e anti bi oti c cream.
(8) Al ternati vel y, you can use a Merocel sponge for anteri or
packi ng.
PITFALL: If there is inadequate expansion after insertion, inject
sterile saline using a syringe and intravenous catheter to
rehydrate the sponge.
P.450
CODING INFORMATION
2002 Average 50th
Percentile Fee
30901* Control nasal hemorrhage,
anteri or, si mpl e (l i mi ted
cautery and nasal packi ng),
any method
$154
Page 664
30903* Control nasal hemorrhage,
anteri or, compl ex (extensi ve
cautery and nasal packi ng),
any method
$224

Sucti on ti ps and nasal specul ums may be obtai ned from most
nati onal suppl y houses such as
http://www.Al l Heart.com-Professi onal Appearances, Inc., 431 Cal l e
San Pabl o, Camari l l o, CA 93012 (fax: 805-445-8816;
http://www.store.yahoo.com/al l heart/i ndex.html ) or from MD Depot,
7590 Commerce Court, Sarasota, FL 34243 (phone: 888-355-2606;
fax: 800-359-8807; http://www.mddepot.com). Merocel sponges
may be obtai ned from Invotec Internati onal , 6833 Phi l l i ps Industri al
Boul evard, Jacksonvi l l e, FL 32256 (phone: 800-998-8580;
http://www.i nvotec.net/pva_pl us.html ).
BIBLIOGRAPHY
Aeumjaturapat S, Supanakorn S, Cutchavaree A. Toxi c shock
syndrome after anteri or-posteri or nasal packi ng. J Med Assoc Thai
2001;84:453458.
Chopra R. Epi staxi s: a revi ew. J R Soc Heal th 2000;120:3133.
Frazee TA, Hauser MS. Nonsurgi cal management of epi staxi s. J Oral
Maxi l l ofac Surg 2000;58:419424.
Hol l and NJ, Sandhu GS, Ghufoor K, et al . The Fol ey catheter i n the
management of epi staxi s. I nt J Cl i n Pract 2001;55:1415.
Kotecha B, Fowl er S, Harkness P, et al . Management of epi staxi s: a
nati onal survey. Ann R Col l Surg Engl 1996;78:444446.
Murthy P, Lai ng MR. An unusual , severe adverse reacti on to si l ver
ni trate cautery for epi staxi s i n an i mmunocompromi sed pati ent.
Page 665
Rhi nol ogy 1996;34:186187.
O'Donnel l M, Robertson G, McGarry GW. A new bi pol ar di athermy
probe for the outpati ent management of adul t acute epi staxi s. Cl i n
Otol aryngol 1999;24:537541.
Pond F, Si zel and A. Epi staxi s: strategi es for management. Aust Fam
Physi ci an 2000;29:933938.
Pothul a V, Al derson D. Nothi ng new under the sun: the
management of epi staxi s. J Laryngol Otol 1998;112:331334.
Randal l DA, Freeman SB. Management of anteri or and posteri or
epi staxi s. Am Fam Physi ci an 1991;43:20072014.
Sandoval C, Dong S, Vi si ntai ner P, et al . Cl i ni cal and l aboratory
features of 178 chi l dren wi th recurrent epi staxi s. J Pedi atr Hematol
Oncol 2002;24:4749.
Sri ni vasan V, Sherman IW, O'Sul l i van G. Surgi cal management of
i ntractabl e epi staxi s: audi t of resul ts. J Laryngol Otol
2000;114:697700.
Tan LK, Cal houn KH. Epi staxi s. Med Cl i n North Am
1999;83:4356.
Page 666
> Table of Cont ent s > Ear, Nose, and Throat Procedures > 56 - Flexible
Nasolaryngoscopy56
Flexible Nasolaryngoscopy
Fl exi bl e fi beropti c nasol aryngoscopy i s an i nexpensi ve and
easy-to-l earn di agnosti c techni que performed by pri mary care
physi ci ans. The thi n, 3-mm-di ameter endoscope permi ts accurate
assessment of the nasal cavi ty, nasopharynx, and l arynx (Tabl e
56-1). The techni que provi des more compl ete exami nati ons than
hi stori cal l y used i ndi rect techni ques and provi des a wi ndow through
whi ch the physi ci an can i mprove di agnosti c accuracy and treatment
strategi es. In one l arge seri es of pati ents i n a fami l y practi ce
setti ng, 70% of pati ents had a change i n thei r management pl an as
a resul t of undergoi ng di agnosti c fl exi bl e nasol aryngoscopy.
TABLE 56-1. ANATOMIC AREAS EXAMINED DURING NASOLARYNGOSCOPY

Nose and nasopharynx: nares, septum, i nferi or meatus, i nferi or turbi nate, mi ddl e
meatus, mi ddl e turbi nate, maxi l l ary si nus osti a, i nfundi bul um (osteomeatal compl ex),
torus tubari us (ri ght and l eft), Eustachi an tube osti a (ri ght and l eft), Rosenmul l er's
fossa (ri ght and l eft), adenoi d pad or scars (postadenoi dectomy, ri ght and l eft),
sphenoi d si nus osti a, superi or turbi nate
Hypopharynx and l arynx: uvul a, posteri or tongue, posteri or pharyngeal wal l , l i ngual
tonsi l s, epi gl otti s, val l ecul a, aryepi gl otti c fol ds (ri ght and l eft), pi ri form si nus (ri ght
and l eft), true vocal cords (i ncl udi ng symmetri c movement), fal se vocal cords, arytenoi d
carti l age (corni cul ate and cunei form processes, ri ght and l eft), posteri or l arynx (upper
esophageal sphi ncter muscul ature)
Al l ergy and ear, nose, and throat (ENT) speci al i sts have wi del y
i ncorporated thi s exami nati on as part of thei r i ni ti al assessment of
pati ents. Speci al i sts often empl oy l arger scopes to i ncorporate
bi opsy channel s. Pri mary care physi ci ans general l y use thi nner
scope wi thout a bi opsy channel . The thi nner scopes are better
Page 667
tol erated by pati ents, and bi opsy procedures can i nduce si gni fi cant
upper aerodi gesti ve tract bl eedi ng that may be di ffi cul t to control
i n a nonsurgi cal offi ce setti ng. Because most pri mary care
procedures do not encounter pathol ogy that requi res bi opsy, the
thi nner scopes fi t wel l i nto the di agnosti c armamentari um of
general i st physi ci ans.
Scope mani pul ati on duri ng the procedure i s rel ati vel y si mpl e and
uses si mi l ar ski l l s requi red i n other pri mary care endoscopi c
procedures. The major chal l enge wi th thi s procedure i s l earni ng the
compl ex anatomy of the nose and throat. Physi ci ans performi ng
fl exi bl e nasol aryngoscopy must master the recogni ti on of normal
anatomy and then tackl e the i denti fi cati on of pathol ogy. Atl ases
and
P.452
teachi ng vi deotapes can greatl y ai d the l earner. Physi ci ans who
perform the procedure i nfrequentl y shoul d revi ew the anatomy pri or
to each procedure.
Several common di sease states produce much of the pathol ogy
encountered duri ng nasol aryngoscopy i n general i st practi ces (Tabl e
56-2). Al l ergi c rhi ni ti s frequentl y produces mucosal swel l i ng, cl ear
nasal and postnasal drai nage, pharyngeal and postl i ngual
cobbl estoni ng, and i t may predi spose to si nus osti a cl osure and
si nusi ti s. Purul ent drai nage can be i denti fi ed comi ng from speci fi c
si nus osti a duri ng the exami nati on. Eustachi an tube drai nage can
be observed, as can hypertrophy of l ymphoi d ti ssue on the tongue
after an upper respi ratory i nfecti on. Vocal cord swel l i ng may be
caused by l ocal i zed vi ral i nfecti on (i .e., l aryngi ti s), or aci d may
refl ux to the posteri or l arynx, produci ng posteri or erythema and
swel l i ng, and cause aci d l aryngi ti s. Sol i d growths, such as pol yps or
tumors, are i nfrequentl y encountered.
TABLE 56-2. COMMON PATHOLOGY OBSERVED DURING NASOLARYNGOSCOPY
Page 668

Nose and nasopharynx: mucosal swel l i ng, mucosal drai nage or rhi ni ti s, turbi nate
hypertrophy, septal hematoma, forei gn body, Eustachi an tube drai nage, enl arged
adenoi d, nasopharyngeal cancer, si nus osti a drai nage
Hypopharynx or l arynx: enl arged tonsi l , l ymphoi d hypertrophy of the tongue or posteri or
pharynx, Candi da i nfecti on, cl ear al l ergi c drai nage i nto hypopharynx, l aryngeal pol yp,
l aryngeal edema, l aryngeal papi l l oma, l aryngeal cancer, vocal cord nodul e, aci d
l aryngi ti s (or swel l i ng of the posteri or l arynx), vocal cord paral ysi s or dysfuncti on, vocal
cord ul cerati on, forei gn body

Fl exi bl e fi beropti c nasol aryngoscopy i s wel l tol erated by adul ts and
chi l dren. Experi enced exami ners know how to gentl y i nsert and
wi thdraw the scope wi thout sudden movements, and they can
prevent the scope ti p from touchi ng l ateral structures.
Compl i cati ons are extremel y uncommon for these physi ci ans. If the
scope ti p i s not wel l control l ed duri ng the exami nati on, the pati ent
may experi ence gaggi ng, coughi ng, sneezi ng, bl eedi ng,
l aryngospasm, or even vagal response or syncope.
INDICATIONS
Cancer screeni ng of hi gh-ri sk i ndi vi dual s (e.g., posi ti ve
fami l y hi story, smokers wi th chroni c symptoms)
Survey of the enti re upper aerodi gesti ve tract, especi al l y
when exami ni ng for mul ti focal or synchronous squamous
cel l carci noma
Eval uati on of persi stent hoarseness, suspected
si nusi ti s, suspected forei gn body, suspected neopl asi a,
chroni c cough, chroni c postnasal dri p, recurrent
epi staxi s, recurrent otal gi a, head or neck masses,
hemoptysi s, dysphagi a, forei gn body sensati on i n the
hypopharynx, nasal obstructi on, persi stent nasal or
pharyngeal pai n, chroni c hal i tosi s, hi story of previ ous
head and neck cancer, chroni c rhi norrhea, or recurrent
serous oti ti s medi a i n an adul t
CONTRAINDICATIONS
Page 669
Epi gl otti ti s because scope passage can i nduce ai rway
cl osure
Bl eedi ng di athesi s, acti ve bl eedi ng i n the upper
respi ratory tract, or uncontrol l ed epi staxi s
P.453
PROCEDURE
The pati ent i s pl aced i n the seated posi ti on, wi th the chi n hel d
sl i ghtl y forward i n a sni ffi ng posi ti on (Fi gure 1A). If the pati ent i s
seated on an el ectri c tabl e or adjustabl e chai r, the hei ght of the
pati ent's head can be adjusted to a l evel that i s just bel ow or at
the same hei ght as the exami ner's head (Fi gure 1B). Some
exami ners pl ace a drape over the pati ent's shoul ders and torso and
gi ve the pati ent some ti ssues and a pl asti c emesi s basi n to hol d i n
one hand.
(1) The pati ent i s pl aced i n the seated posi ti on wi th the chi n hel d
Page 670
sl i ghtl y forward i n a sni ffi ng posi ti on.
P.454
Topi cal decongestant spray (2 sprays of 0.05% oxymetazol i ne
hydrochl ori de i n each nostri l ) and topi cal anestheti c spray (2 to 10
sprays of 4% l i docai ne) are admi ni stered. The l i docai ne must be
transferred from the stock bottl e i nto a smal l pl asti c spray bottl e or
atomi zer. When admi ni steri ng the sprays from mul ti use contai ners,
make sure the ti p of the spray bottl e i s not contami nated by
pati ent contact. The nondomi nant hand can gentl y squeeze open
the nares, and the ti p of the bottl e i s hel d just outsi de the nose
(but not i n contact wi th the pati ent) to admi ni ster the sprays. The
sprays are then repeated unti l the pati ent achi eves adequate
anesthesi a (i .e., the pati ent reports numbness on the back of the
throat).
(2) Topi cal decongestant spray and topi cal anestheti c spray are
admi ni stered.
PITFALL: The lidocaine solution has a bitter taste. Warn the
patient about this unpleasant effect. The examiner should pause
for a few seconds after administering the first two sprays to
allow the anesthetic to take effect and to permit the patient to
Page 671
respond to the taste.
P.455
Hol d the fl exi bl e fi beropti c scope i n the l eft hand between the
thumb and i ndex fi nger. The eyepi ece i s hel d up, and the scope ti p
hangs down toward the fl oor. The thumb i s pl aced over the
up-and-down knob, and the scope body traverses the pal mar crease
of the l eft hand. Make sure the l i ght source i s turned on and that
adequate l i ght projects from the scope ti p. Adjust the focus as
necessary.
Page 672
(3) Hol d the fl exi bl e fi beropti c scope i n the l eft hand between the
thumb and i ndex fi nger, wi th the eyepi ece up and the scope ti p
hangi ng down toward the fl oor.
P.456
The di stal scope i s l ubri cated wi th 2% l i docai ne jel l y. The jel l y i s
Page 673
appl i ed wi th 4 4 gauze and admi ni stered to the di stal 4 to 5 cm
of the scope.
(4) Lubri cate the di stal scope wi th 2% l i docai ne jel l y.
PITFALL: Do not apply the jelly to the scope tip, because it will
obscure viewing through the scope. Always apply the jelly from
the end of the scope moving proximally, so that jelly is not
dragged onto the tip.
The thi rd, fourth, and fi fth fi ngers of the ri ght hand are appl i ed to
the pati ent's l eft cheek for i nserti on of the scope. By anchori ng the
i nserti on hand to the pati ent, the hand i s steadi ed and moves wi th
the pati ent's head i f sudden movement occurs. The fi rst and second
fi ngers pi nch the scope for i nserti on, graspi ng the scope 3 to 7 cm
from the ti p and perpendi cul ar to the axi s of the scope.
Page 674
(5) Appl y the thi rd, fourth, and fi fth fi ngers of the ri ght hand to the
pati ent's l eft cheek for i nserti on of the scope.
PITFALL: A patient' s glasses can interfere with anchoring the
hand to the patient' s face or be hit during the procedure.
Consider asking the patient to remove glasses before the
procedure.
P.457
Up-and-down moti ons of the scope ti p are control l ed by the acti on
of the l eft thumb on the knob on the scope head (Fi gure 6A).
Strong twi sti ng acti on of the ri ght fi rst and second fi ngers torque
the scope ti p from i ts verti cal moti on to the ri ght and l eft, and
conti nued up-and-down movement of the l eft thumb faci l i tates ri ght
and l eft turni ng (Fi gure 6B).
Page 675
(6) Up-and-down moti on of the scope ti p i s control l ed by the acti on
of the l eft thumb on the knob on the scope head.
The scope ti p i s gentl y i nserted i nto the nares. The fi rst two
fi ngers stabi l i ze the scope and thread the scope i nto the nose after
the scope ti p i s confi rmed i n a nonobstructed posi ti on.
(7) The scope ti p i s gentl y i nserted i nto the nares and i s threaded
i nto the nose wi th the fi rst two fi ngers.
PITFALL: Warn the patient that initial insertion of the scope tip
Page 676
can produce a tickling sensation or even sneezing.
P.458
The i nferi or turbi nate i s seen and the scope sl i d al ong the fl oor of
the nose or i nferi or meatus (meatus means open area; i n the nose,
i t means the area under a turbi nate). Pass the scope through the
l argest passage to reach the nasopharynx.
(8) The i nferi or turbi nate i s noted, and the physi ci an sl i des the
scope al ong the fl oor of the nose.
PITFALL: Enlargement of a turbinate (i.e., hypertrophy) or prior
nasal septal deviation can make passage along the floor of the
nose impossible. Insertion of the scope to the nasopharynx may
need to be accomplished above the nasal cavity floor (alongside
the turbinate).
The torus tubari us i s the l arge mound of ti ssue surroundi ng the
Eustachi an tube openi ng. Rosenmul l er's fossa i s the verti cal cl eft
i mmedi atel y posteri or to the torus tubari us and i s a common
l ocati on for the devel opment of nasopharyngeal cancer. The
adenoi d pad i s l ocated on the posteri or wal l and can contai n an
enl arged adenoi d or stel l ate scar i f the pati ent has undergone pri or
adenoi dectomy.
Page 677
(9) Exami ne the nasopharynx.
PITFALL: During insertion of the endoscope, mucus can adhere
and obscure the view through the scope. Gently tap the tip of
the scope against the wall of the nasopharynx to clean the view
on the scope. It is almost never necessary to completely
withdraw the scope to clear the lens.
P.459
Ask the pati ent to repeat KKK. Pronounci ng the
l etter produces movement i n the soft pal ate. Turn the scope ti p
down past the di stal soft pal ate, and on passi ng the uvul a, the
l aryngeal structures can be vi sual i zed i n the di stance.
Page 678
(10) Turn the scope ti p down past the di stal soft pal ate, and on
passi ng the uvul a, vi sual i ze the l aryngeal structures.
Sl owl y and careful l y move the scope ti p to just above the
epi gl otti s. Survey the structures of the l arynx. Ask the pati ent to
say EEEEE to observe movement i n the vocal cords, and
then ask the pati ent to sti ck out the tongue to observe the
val l ecul a. Observe al l l aryngeal structures for pathol ogy.
(11) Sl owl y and careful l y move the scope ti p to just above the
epi gl otti s, and survey the structures of the l arynx.
PITFALL: Touching the scope tip to the posterior pharyngeal
wall will induce coughing and possible discomfort. Keep a firm
grasp on the scope with the fingers of the right hand, and keep
the scope tip in the center of the pharyngeal cavity, away from
the tongue and posterior or lateral structures.
Page 679
PITFALL: Do not insert the scope tip between or beneath the
vocal cords. Touching the scope tip to laryngeal or
hypolaryngeal structures can induce laryngospasm. If
laryngospasm occurs, immediately withdraw the scope from the
patient. Laryngospasm is scary for the patient and physician but
is fortunately only rarely fatal.
P.460
Wi thdraw the scope ti p from above the l arynx to the posteri or
nasopharynx. The openi ng to the sphenoi d si nus and superi or
turbi nate can be observed by sharpl y turni ng the scope ti p upward
al ong the posteri or wal l of the nasopharynx. A rapi d movement i s
requi red for thi s techni que; the scope ti p i s i nserted whi l e
si mul taneousl y pushi ng the l eft thumb downward, movi ng the scope
ti p upward.
(12) Exami ne the openi ng to the sphenoi d si nus and superi or
turbi nate by sharpl y turni ng the scope ti p upward al ong the
posteri or wal l of the nasopharynx.
PITFALL: The posterior nasopharynx receives little of the
anesthetic spray, and flipping the scope tip upward along the
back wall of the nose can be somewhat painful. A rapid
assessment is recommended, and if the scope tip is not easily
passed into the upper posterior nasopharynx, this portion of the
Page 680
examination can be deferred.
The scope i s agai n strai ghtened and wi thdrawn to the mi ddl e
porti on of the nasal fl oor. An attempt i s made to exami ne the
mi ddl e meatus (i .e., under the smal l er mi ddl e turbi nate). The area
i s anatomi cal l y narrow, and exami nati on may be i mpossi bl e or
uncomfortabl e for your pati ent. Attempt to vi sual i ze the
i nfundi bul um area (i .e., osteomeatal compl ex) and the maxi l l ary
si nus osti a. The scope i s wi thdrawn, and the other nasal cavi ty
exami ned i f necessary. Gi ve the pati ent the opportuni ty to bl ow hi s
or her nose. The physi ci an revi ews the fi ndi ngs wi th the pati ent.
(13) Attempt to vi sual i ze the i nfundi bul um area and the maxi l l ary
si nus osti a.
P.461
CODING INFORMATION
Many addi ti onal codes can be reported i f si nus endoscopy, surgery,
or bi opsy i s performed wi th the procedure. Most pri mary care
physi ci ans report onl y code 31575 i f they do a compl ete eval uati on
of the nasopharynx and l arynx. Techni cal l y, mul ti pl e endoscopy
codes can be bi l l ed i f mul ti pl e areas are exami ned as part of the
di agnosti c eval uati on.
Page 681
2002 Average 50th
Percentile Fee

31231 Nasal endoscopy, di agnosti c
(uni l ateral or bi l ateral )
$226
31575 Laryngoscopy, fl exi bl e
fi beropti c, di agnosti c
$265
92511 Nasopharyngoscopy wi th
endoscope
$188

Nasol aryngoscopes may be ordered from Ol ympus USA, 2 Corporate
Center Dri ve, Mel vi l l e, NY 11747 (http://www.ol ympusameri ca.com);
Wel chAl l yn, 4341 State Street Road, Skaneatel es Fal l s, NY 13153
(phone: 800-535-6663; http://www.wel chal l yn.com/medi cal );
Endosheath Technol ogy, Vi si on Sci ences, 9 Strathmore Road,
Nati ck, MA 01760 (phone: 800-874-9975;
http://www.endosheath.com); and Pentax, 30 Ramtand Road,
Orangeburg, NY 10962 (phone: 800-431-5880;
http://www.pentax-endoscopy.com). Used equi pment may be
obtai ned from HMB Endoscopy Products or Endoscopy Support
Servi ces (http://www.medcatal og.com/endoscop.htm).
Li docai ne hydrochl ori de (4% sol uti on or 2% jel l y) can be obtai ned
from Astra Pharmaceuti cal s, Westborough, MA (phone:
508-366-1100) or through a l ocal pharmacy. Oxymetazol i ne
hydrochl ori de (0.05%) (Afri n spray) i s produced by Scheri ng-Pl ough,
Keni l worth, NJ (phone: 908-298-4000) and can be obtai ned through
a l ocal pharmacy.
Several onl i ne atl ases are avai l abl e to assi st physi ci ans:
Uni versi ty of Toronto Medi cal Student ENT atl as
Wake Forest Uni versi ty Gal l ery of Laryngeal Pathol ogy
(http://www.bgsm.edu/voi ce/gal l ery.html )
Uni versi ty of Muni ch ENT Gal l ery
BIBLIOGRAPHY
Page 682
Castel l anos J, Axel rod D. Fl exi bl e fi beropti c rhi noscopy i n the
di agnosi s of si nusi ti s. J Al l ergy Cl i n I mmunol 1989;83:9194.
Curry RW. Fl exi bl e fi beropti c nasol aryngoscopy. Fam Pract Recert
1990;12:2136.
DeWi tt DE. Fi beropti c rhi nol aryngoscopy i n pri mary care: a new
di recti on for expandi ng i n-offi ce di agnosti cs. Postgrad Med
1988;84:12544.
Hayes JT. Fl exi bl e nasol aryngoscopy: a l ow-ri sk, hi gh-yi el d
procedure. Postgrad Med 1999;106:107110, 114.
P.462
Hocutt JE, Corey GA, Rodney WM. Nasol aryngoscopy for fami l y
physi ci ans. Am Fam Physi ci an 1990;42:12571268.
Koufman JA, Ami n MR, Panetti M. Preval ence of refl ux i n 113
consecuti ve pati ents wi th l aryngeal and voi ce di sorders.
Otol aryngol Head Neck Surg 2000;123:385388.
Lancer JM, Jones AS. Fl exi bl e fi breopti c rhi nol aryngoscopy: resul ts
of 338 consecuti ve exami nati ons. J Laryngol Otol
1985;99:771773.
Lancer JM, Moi r AA. The fl exi bl e fi breopti c rhi nol aryngoscope. J
Laryngol Otol 1985;99:767770.
O'Hol l aren MT. When dyspnea comes from the l arynx. J Respi r Di s
1991;12:845860.
Patton D, DeWi tt D. Fl exi bl e nasol aryngoscopy: a procedure for
pri mary care. Pri m Care Cancer 1992;12:1321.
Reul bach TR, Bel afsky PC, Bl al ock PD, et al . Occul t l aryngeal
pathol ogy i n a communi ty-based cohort. Otol aryngol Head Neck
Surg 2001;124:448450.
Rosen CA, Murray T. Di agnosti c l aryngeal endoscopy. Otol aryngol
Cl i n North Am 2000;33:751758.
Shanmugham MS. The rol e of fi breopti c nasopharyngoscopy i n
nasopharyngeal carci noma (NPC). J Laryngol Otol
1985;99:779782.
Tenenbaum DJ. A buyer's gui de to nasopharyngoscopes. Fam Pract
Page 683
Manag 1995;2:4345.
Tenenbaum DJ. Shoul d you be doi ng nasopharyngoscopy? Fam Pract
Manag 1995;2:3541.
Wal l ner F, Knoch H. The potenti al uses and l i mi tati ons of fl exi bl e
l aryngoscopy under l ocal anesthesi a i n cl i ni cal practi ce. HNO
1999;47:702705.
Zuber TJ. Offi ce procedures. AAFP Academy col l ecti on qui ck
Wi l ki ns, 1999:5160.
Page 684
> Table of Cont ent s > Ear, Nose, and Throat Procedures > 57 - Cerumen
Impact ion Removal57
Cerumen Impaction Removal
Cerumen (earwax) i s a natural product of the external audi tory
canal . The exact functi on of cerumen i s unknown. It usual l y occurs
as a sti cky, honey-col ored wax that can darken wi th oxi dati on.
Someti mes, however, the cerumen may become hard and scal y.
Accumul ati on of cerumen can resul t i n heari ng l oss, ti nni tus,
otal gi a, verti go, and i nfecti on.
The two common techni ques for removal of i mpacted cerumen are
wi th an ear curette or wi th i rri gati on. The ear curette method i s
most effecti ve for smal l amounts of easi l y vi si bl e wax. Irri gati on
usual l y takes l onger and i s messi er than the curette techni que, but
i t rarel y fai l s. It i s often requi red for dense or l arge ci rcumferenti al
cerumen i mpacti ons and when the curette techni que has fai l ed or
caused pai n. Sucti on al so may be used for very soft cerumen but i s
rarel y adequate for compl ete removal of an i mpacti on.
A cerumen-softeni ng agent such as tri ethanol ami ne (Cerumenex),
carbami de peroxi de (Debrox), or cresyl acetate (Cresyl ate) may be
used to soften or mel t cerumen. These agents may be appl i ed at
home for 3 days before a vi si t for i mpacti on removal . In studi es,
water has surpri si ngl y proved to be an effecti ve softeni ng agent,
whereas ol i ve oi l appears to be al most total l y i neffecti ve as a wax
di spersant. Docusate sodi um sol uti on (Col ace) may be i nsti l l ed
i ntra-aural l y for 15 mi nutes and the ear i rri gated.
Tympani c membrane perforati on and damage to ossi cl es consti tute
the most seri ous potenti al compl i cati on, because they can l ead to
heari ng l oss. Pati ents may experi ence pai n, verti go, nausea, or
vomi ti ng duri ng the procedure. Mi nor canal wal l abrasi ons and
bl eedi ng may occur, especi al l y i f hard adherent wax i s removed by
mechani cal means. Rarel y, oti ti s externa and i di opathi c ti nni tus
Page 685
may occur.
Among al ternati ve methods, ear candl es are the most popul ar
method of cerumen removal . A hol l ow candl e i s burned on one end,
wi th the other end i n the ear canal ; the i ntent i s to create negati ve
pressure and draw cerumen from the ear. Unfortunatel y, studi es
show that ear candl es do not produce negati ve pressure i n the ear
and do not remove cerumen from the external audi tory canal .
Candl e wax has been deposi ted i n some ears, and a survey of
otol aryngol ogi sts i denti fi ed ear i njuri es resul ti ng from ear candl e
use. Insti l l i ng oi l i n the ear has been found to be mi ni mal l y hel pful ,
but not as effecti ve as easi l y avai l abl e over-the-counter and
prescri pti on products.
P.464
After cerumen removal , i nstruct the pati ent to return i f i ncreasi ng
pai n, decreased heari ng, verti go, or purul ent drai nage devel ops i n
the treated ear. Consi der educati ng the pati ent about peri odi c ear
cl eani ng usi ng commerci al l y avai l abl e earwax softeners and a
squeeze bul b. Al so i nform the pati ent that the curved anatomy of
the ear canal makes sel f-i nstrumentati on of the ear canal wi th
cotton-ti pped appl i cators or other wax removal tool s unl i kel y to
hel p, l i kel y to make accumul ati ons worse, and dangerous to the
del i cate heari ng apparatus of the ear.
INDICATIONS
Otal gi a
Decreased heari ng on the affected si de
Obscured vi sual i zati on of the tympani c membrane
External oti ti s associ ated wi th cerumen
CONTRAINDICATIONS
Cl i ni ci an unfami l i ari ty wi th the equi pment
Cl i ni ci an's unfami l i ari ty wi th the anatomy of the external
audi tory canal
Di storted or abnormal anatomy
Page 686
Previ ous scarri ng
Known or suspected chol esteatoma (refer to an
otol aryngol ogi st)
The affected ear i s the onl y heari ng ear (consi der
referral to an otol aryngol ogi st)
For i rri gati on because of known or suspected perforati on
of the tympani c membrane
P.465
PROCEDURE
Posi ti on the pati ent i n a si tti ng posi ti on on a chai r or exami nati on
tabl e. Al l ow chi l dren to si t i n a parent's l ap or l i e on the
exami nati on tabl e wi th a parent or assi stant stabi l i zi ng the head.
Appl y posteri or tracti on on the hel i x as necessary to vi sual i ze the
ear canal and any i mpacted cerumen usi ng an operati ng otoscope.
(1) Have pati ent si t on a chai r or exami nati on tabl e, and appl y
posteri or tracti on on the hel i x as necessary to vi sual i ze the ear
canal and any i mpacted cerumen.
Page 687
Sel ect a curette or ear l oop that easi l y fi ts the canal . Gentl y
remove the i mpacted cerumen by taki ng smal l top-to-bottom scoops
wi th mi ni mal forward pressure. Thi s can be done through the
otoscope or by di rect vi sual i zati on after careful l y exami ni ng the
canal and cerumen wi th the scope.
(2) Usi ng a curette or ear l oop, gentl y remove the i mpacted
cerumen by taki ng smal l top-to-bottom scoops wi th mi ni mal
forward pressure.
P.466
If hardened cerumen i s encountered, the same moti on may be used
to rol l and pul l apart the bal l or extract i t i n toto.
Al ternati vel y, i f hardened cerumen i s encountered, i nsti l l mi neral
oi l , 3% hydrogen peroxi de, or a commerci al l y avai l abl e wax softener
such as Cerumenex or Debrox for 5 to 10 mi nutes to soften the
cerumen and faci l i tate removal .
Page 688
(3) If hardened cerumen i s encountered, the same moti on can be
used to rol l and pul l apart the bal l or extract i t i n toto.
PITFALL: Vigorous removal can be traumatic. Consider
prescribing topical otic antibiotics if the canal epithelium is
disrupted or bleeding is present.
PITFALL: If the cerumen is adherent to the tympanic membrane,
irrigation or suction may be necessary for atraumatic removal.
P.467
Several devi ces for i rri gati ng an ear are shown: a 20- to 50-mL
syri nge wi th a l arge-bore Angi ocath attached (Fi gure 4A), a 20- to
50-mL syri nge wi th attached butterfl y tubi ng wi th needl e cut off
(Fi gure 4B), and a metal i rri gator syri nge (Fi gure 4C). Fi l l the
syri nge wi th body-temperature (37C) water or normal sal i ne.
Al ternati vel y, a jet i rri gator adjusted to i ts l owest pressure setti ng
may be used.
Page 689
(4) Devi ces for i rri gati ng an ear: a 20- to 50-mL syri nge wi th a
l arge-bore Angi ocath attached, a 20- to 50-mL syri nge wi th
attached butterfl y tubi ng wi th the needl e cut off, and a metal
i rri gati on syri nge.
PITFALL: Using water that is too warm or cold increases the risk
of stimulation of the vestibular reflex and associated nystagmus
and nausea.
PITFALL: Using a jet irrigator on any but the lowest setting
increases the risk of perforation of the tympanic membrane.
P.468
Pl ace a gown or towel on the pati ent. Pl ace an ear basi n under the
affected ear and have the pati ent ti l t hi s or her head sl i ghtl y to
that si de.
Page 690
(5) Pl ace a towel on the pati ent, pl ace an ear basi n under the
affected ear, and have the pati ent ti l t hi s or her head sl i ghtl y to
that si de.
P.469
Di rect the water jet toward the superi or part of the i mpacti on to
al l ow space for the outfl ow of water and cerumen. After cerumen
washes out of the canal , reexami ne to determi ne i f any i mpacted
cerumen remai ns. Repeat the process unti l the canal i s cl ear.
Remove the apparatus and drapes, and dry the ear. Rarel y, very
hard i mpacted cerumen does not cl ear after several mi nutes of
i rri gati on. If thi s occurs, termi nate the procedure, and i ni ti ate the
use of a l i qui d earwax softener. Have the pati ent return i n a few
days for cerumen removal .
Page 691
(6) Di rect the water jet toward the superi or part of the i mpacti on
to al l ow space for the outfl ow of water and cerumen.
PITFALL: Avoid direct irrigation on the tympanic membrane that
can cause pain, nausea, or perforation.
PITFALL: Prescribe topical otic antibiotics if canal epithelium is
disrupted or bleeding is present.
P.470
CODING INFORMATION
2002 Average 50th
Percentile Fee
69210 Removal i mpacted cerumen
(separate procedure), one or
both ears
$57
Page 692
Operati ng otoscopes, ear curettes, emesi s or ear basi n, ear
syri nges, and commerci al l y avai l abl e jet i rri gators (Water-Pi k) can
be obtai ned from http://www.Al l Heart.com-Professi onal
Appearances, Inc., 431 Cal l e San Pabl o, Camari l l o, CA 93012 (fax:
805-445-8816; http://www.store.yahoo.com/al l heart/i ndex.html )
and from MD Depot; 7590 Commerce Court; Sarasota, FL 34243
(phone: 888-355-2606; fax: 800-359-8807;
http://www.mddepot.com).
Cerumen-softeni ng agents such as mi neral oi l , tri ethanol ami ne
(Cerumenex), carbami de peroxi de (Debrox), or cresyl acetate
(Cresyl ate) may be obtai ned from pharmaci es.
BIBLIOGRAPHY
Andaz C, Whi ttet HB. An i n vi tro study to determi ne effi cacy of
di fferent wax-di spersi ng agents. ORL J Otorhi nol aryngol Rel at Spec
1993;55:9799.
Bl ake P, Matthews R, Horni brook J. When not to syri nge an ear. N Z
Med J 1998;111:422424.
Carr MM, Smi th RL. Cerumi nol yti c effi cacy i n adul ts versus chi l dren.
J Otol aryngol 2001;30:154156.
Di nsdal e RC, Rol and PS, Manni ng SC, et al . Catastrophi c otol ogi c
i njury from oral jet i rri gati on of the external audi tory canal .
Laryngoscope 1991;101(Pt 1):7578.
Eekhof JA, de Bock GH, Le Cessi e S, et al . A quasi -randomi sed
Page 693
control l ed tri al of water as a qui ck softeni ng agent of persi stent
earwax i n general practi ce. Br J Gen Pract 2001;51:635537.
Grossan M. Cerumen removal current chal l enges. Ear Nose Throat
J 1998;77:541546, 548.
Grossan M. Safe, effecti ve techni ques for cerumen removal .
Geri atri cs 2000;55:80, 8386.
Mackni n ML, Tal o H, Medendrop SV. Effect of cotton-ti pped swab
use on ear-wax occl usi on. Cl i n Pedi atr 1994;33:1418.
Masterson E, Seaton TL. How does l i qui d docusate sodi um (Col ace)
compare wi th tri ethanol ami ne pol ypepti de as a cerumi nol yti c for
acute earwax removal ? J Fam Pract 2000;49:1076.
Seel y DR, Qui gl ey SM, Langman AW. Ear candl eseffi cacy and
safety. Laryngoscope 1996;106:1226-001229.
Si nger AJ, Sauri s E, Vi ccel l i o AW. Cerumi nol yti c effects of docusate
sodi um: a randomi zed, control l ed tri al . Ann Emerg Med
2000;36:228232.
Wi l son PL, Roeser RJ. Cerumen management: professi onal i ssues
and techni ques. J Am Acad Audi ol 1997;8:421430.
Page 694
> Table of Cont ent s > Ear, Nose, and Throat Procedures > 58 - Foreign Body
Removal from t he Audit ory Canal and Nasal Cavit y58
Foreign Body Removal from the
Auditory Canal and Nasal Cavity
Expl orati on i s a normal part of chi l dhood. Unfortunatel y, thi s may
cause the common pedi atri c probl em of smal l forei gn objects pl aced
i n the external audi tory canal or nasal cavi ty. Si mpl e removal
techni ques may be attempted fi rst, such as normal sal i ne i rri gati on
through an 18-gauge catheter or usi ng vasoconstri cti ve nasal
sol uti on to reduce mucosal edema and havi ng the pati ent bl ow
forceful l y. Irri gati on i s contrai ndi cated i f tympani c membrane
perforati on i s suspected.
Attempts to remove forei gn bodi es shoul d be made under di rect
vi sual i zati on. Use care to avoi d pushi ng the object deeper. Hard,
spheri cal objects may be especi al l y di ffi cul t to remove because
they cannot be grasped and may easi l y be pushed deeper. Metal l i c
objects may someti mes be removed wi th a smal l magnet. Other
objects, such as pl ant materi al s or seeds, can swel l over hours i f
l eft i n pl ace or i f sal i ne i s used to fl ush them out.
If l ocal anesthesi a i s needed for removal of an object from the
audi tory canal , pl ace the affected ear i n the nondependent
posi ti on, and i nsti l l 2% l i docai ne or 20% benzocai ne i nto the canal ,
al l owi ng i t to remai n for 10 mi nutes. Thi s i s especi al l y useful wi th
an i nsect i n the ear. Many i nsects, especi al l y cockroaches, grasp
the l i ni ng of the canal to resi st extracti on. Local anestheti c
provi des anesthesi a, and i t ki l l s the i nsect, maki ng i t easi er to
remove. Do not use l ocal anesthesi a i f the tympani c membrane may
be di srupted. Oral , i ntravenous, or general anesthesi a may be
necessary i n i ndi vi dual s who cannot tol erate i nstrumentati on.
Compl i cati ons are usual l y mi nor. Trauma to mucous membranes
wi th or wi thout associ ated i nfecti on or bl eedi ng i s a possi bi l i ty.
Page 695
The cl i ni ci an must al so be careful not to push the object deeper,
maki ng i t harder or i mpossi bl e to extract the forei gn body. Care
must be exerted to prevent seri ous trauma to the tympani c
membrane or mi ddl e ear duri ng removal . Oti ti s externa i s a common
sequel ae of i njury caused by the forei gn body i tsel f or by i ts
removal . The pati ent may experi ence nausea or vomi ti ng before or
after removal of an object i n the ear.
After the procedure, i nstruct the pati ent to watch for si gns of
i nfecti on. If mucous membrane i njury occurs, have the pati ent
return for a fol l ow-up vi si t i n 1 or 2 days. Sal i ne i rri gati ons two to
three ti mes each day for 2 or 3 days may be used after nasal
forei gn body removal s.
P.472
INDICATIONS
Vi si bl e forei gn body i n the audi tory canal or nasal cavi ty
CONTRAINDICATIONS
Cl i ni ci an's l ack of knowl edge of normal anatomy or
removal techni ques
Trauma-i nduced di storti on of the normal anatomy
An uncooperati ve pati ent or unrestrai nabl e i nfant
Irri gati on contrai ndi cated wi th tympani c membrane
perforati on
Previ ous ear surgery because of i ncreased ri sk of
perforati on (rel ati ve contrai ndi cati on)
Known or suspected chol esteatoma
Affected ear i s onl y heari ng-capabl e ear (rel ati ve
contrai ndi cati on; consi der referral )
Inabi l i ty to vi sual i ze the forei gn body
P.473
PROCEDURE
Page 696
If desi red, i nsti l l a topi cal anestheti c. Use sucti on as necessary to
remove l i qui ds or debri s to vi sual i ze the object. Wi th adul ts,
vi sual i zati on of the external audi tory canal i s accompl i shed by
pul l i ng the auri cl e upward and backward to strai ghten the canal
(Fi gure 1A). In chi l dren, the auri cl e i s pul l ed downward to ai d i n
vi sual i zati on (Fi gure 1B). Extendi ng the head and appl yi ng upward
pressure on the ti p of the nose hel ps to vi sual i ze the nasal cavi ty
(Fi gure 1C).
(1) The external audi tory canal i n adul ts can be vi sual i zed by
pul l i ng the auri cl e upward and backward to strai ghten the canal ,
and the external audi tory canal i n chi l dren can be vi sual i zed by
pul l i ng the auri cl e downward.
PITFALL: Suction of the auditory canal produces a loud, scary
stimulus to children.
P.474
Page 697
Grasp fi brous objects (e.g., cotton, cl oth, gum, i nsects) wi th the
al l i gator forceps, and gentl y extract them. Use l ocal anestheti c to
remove i nsects because i t provi des anesthesi a and ki l l s the i nsect.
Al l i gator forceps are val uabl e ai ds i n removi ng nasal cavi ty forei gn
bodi es.
(2) Grasp fi brous objects wi th the al l i gator forceps, and gentl y
extract them.
P.475
Smooth objects that are not ti ghtl y bl ocki ng the canal , such as
beads, beans, seeds, or popcorn kernel s, may be removed usi ng a
smal l hook. Steady the operati ng hand by pl aci ng the wri st or hand
agai nst the pati ent. Pass a ri ght-angl e hook (i .e., atti c hook)
beyond the object (Fi gure 3A), turn the hook 90 degrees (Fi gure
3B), and gentl y wi thdraw the object and the hook (Fi gure 3C). Thi s
same techni que i s useful for nasal cavi ty forei gn bodi es.
Page 698
Al ternati vel y, smal l objects may be fl ushed out as descri bed i n
Chapter 57.
(3) Smooth objects that are not ti ghtl y bl ocki ng the canal may be
removed wi th a smal l (atti c) hook.
A ri ght angl e (atti c) hook may be made by dul l i ng the ti p of an
1-i nch needl e and then bendi ng the l ast 2 mm at a 90-degree
angl e.
(4) An atti c hook can be made by dul l i ng the ti p of a 1-i nch
needl e and bendi ng the l ast 2 mm at a 90-degree angl e.
PITFALL: Remove small batteries quickly, because permanent
damage to the ear can result if they are allowed to remain for
more than a short time.
PITFALL: Insertion of a needle can damage the canal. Make sure
the end has no sharp edges before insertion.
P.476
Page 699
CODING INFORMATION

2002 Average 50th
Percentile Fee

30300* Removal i ntranasal forei gn
body, wi thout general
anesthesi a
$138
69200 Removal forei gn body from
external audi tory canal ,
wi thout general anesthesi a
$108

Instruments such as sucti on ti ps, al l i gator forceps, ear curettes,
atti c hooks, ear specul ums, or nasal specul ums may be obtai ned
from most nati onal suppl y houses, such as http://www.Al l Heart.com
-Professi onal Appearances, Inc., 431 Cal l e San Pabl o, Camari l l o, CA
93012 (fax: 805-445-8816;
http://www.store.yahoo.com/al l heart/i ndex.html ) or MD Depot,
7590 Commerce Court, Sarasota, FL 34243 (phone: 888-355-2606;
fax: 800-359-8807; http://www.mddepot.com).
BIBLIOGRAPHY
Antonel l i PJ, Ahmadi A, Prevatt A. Insecti ci dal acti vi ty of common
reagents for i nsect forei gn bodi es of the ear. Laryngoscope
2001;111:1520.
Benger JR, Davi es PH. Forei gn bodi es i n the nasal cavi ti es.
Postgrad Med J 2001;77:359.
D'Cruz O, Lakshman R. A sol uti on for the forei gn body i n nose
probl em. Pedi atri cs 1988;81:174.
Dougl as SA, Mi rza S, Stafford FW. Magneti c removal of a nasal
forei gn body. I nt J Pedi atr Otorhi nol aryngol 2002;62:165167.
Handl er SD. Nasal wash techni que for nasal forei gn body removal .
Pedi atr Emerg Care 2000;16:307.
Hon SK, Izam TM, Koay CB, et al . A prospecti ve eval uati on of
Page 700
forei gn bodi es presenti ng to the Ear, Nose and Throat Cl i ni c,
Hospi tal Kual a Lumpur. Med J Mal aysi a 2001;56:463467.
Jensen JH. Techni que for removi ng a spheri cal forei gn body from the
nose or ear. Ear Nose Throat J 1976;55:46.
Mi shra A, Shukl a GK, Bhati a N. Aural forei gn bodi es. I ndi an J
Pedi atr 2000;67:267269.
Peacock WF. Otol aryngol ogi c emergenci es. In: Ti nti nal l i JE, Rui z E,
Krome RL, eds. Emergency medi ci ne: a comprehensi ve study gui de.
New York: McGraw-Hi l l , 1985:10711072.
Reddy IS. Forei gn bodi es i n the nose and ear. Emerg Med J
2001;18:523.
Page 701
> Table of Cont ent s > Musculoskelet al Procedures > 59 - Great er Trochant eric
Bursa Inject ion59
Greater Trochanteric Bursa
Injection
Greater trochanteri c bursi ti s i s a common condi ti on that often
produces hi p, l ateral thi gh, or referred knee pai n. The pati ent often
compl ai ns of ni ghtti me pai n when l yi ng i n bed on the affected si de.
Characteri sti c l ocal tenderness can be el i ci ted by pal pati on from
over the greater trochanter of the femur when the pati ent l i es on
the exami nati on tabl e wi th the affected si de up.
Greater trochanteri c bursi ti s occurs predomi nantl y i n mi ddl e-aged to
el derl y i ndi vi dual s, wi th women affected more often than men.
Onset tends to be gradual , and symptoms tend to l ast for months.
Indi vi dual s wi th l onger-l asti ng symptoms may fai l to l ocal i ze thei r
pai n, often descri bi ng di ffuse pai n over the enti re thi gh wi th
wal ki ng.
Two major bursae overl yi ng the greater trochanter have cl i ni cal
si gni fi cance, al though i t i s bel i eved that at l east three di sti nct
bursae exi st at thi s si te. The superfi ci al bursa rests between the
l ateral aspects of the trochanter and the ski n and subcutaneous
ti ssue. The deep bursa l i es above the tendi nous i nserti on of the
gl uteus maxi mus muscl e and extends behi nd the trochanter. Ei ther
of these bursa may become i nfl amed and can produce swel l i ng or
pai n i n the area. Swel l i ng and erythema i s more apparent when the
superfi ci al bursa i s i nfl amed, and pai n i s produced wi th marked
abducti on of the hi p. Pai n from the deep bursa may be produced by
passi ve i nternal rotati on when the hi p i s adducted or by passi ve
external rotati on when the hi p i s abducted.
The di fferenti al di agnosi s i ncl udes osteoarthri ti s of the hi p,
i l i oti bi al band syndrome, or adductor tendoni ti s (and bursi ti s) of
the hi p. The l ocal i zed, l ateral tenderness of greater trochanteri c
Page 702
bursi ti s hel ps to di fferenti ate the condi ti on. The di scomfort of hi p
arthri ti s general l y i s fel t i n the groi n, wi th pai n produced by
i nternal and external rotati on of the hi p.
One presentati on for trochanteri c bursi ti s i s the snappi ng hi p
syndrome. Excessi ve ti ghteni ng of the i l i oti bi al band over the
trochanter can produce fri cti on, bursi ti s, and poppi ng as i t snaps
over the bony promi nence duri ng fl exi on and extensi on of the hi p.
Steroi d i njecti ons reduce l ocal i nfl ammati on and may soften and
stretch the i l i oti bi al band. Thi s syndrome al so appears to i mprove
wi th exerci ses that stretch the i l i oti bi al band.
P.480
INDICATIONS
Symptomati c i ndi vi dual s wi th characteri sti c l ocal i zed
tenderness over the trochanter
Bl eedi ng di athesi s
Bacteremi a or cel l ul i ti s of the proxi mal , l ateral thi gh
P.481
PROCEDURE
The two major bursa are i l l ustrated.
Page 703
(1) Anatomy of the l ateral hi p.
Posi ti on the pati ent on the exami nati on tabl e wi th the unaffected
hi p down and the affected hi p up. Drapes can be used to keep the
surroundi ng body areas covered.
(2) Posi ti on the pati ent on the exami nati on tabl e wi th the
unaffected hi p down and the affected hi p up.
P.482
Page 704
Pal pate over the greater trochanter to reveal the characteri sti c
l ocal i zed tenderness.
(3) Pal pate over the greater trochanter to reveal the characteri sti c
l ocal i zed tenderness.
After ski n preparati on, i nsert a 1- or 1-i nch needl e to the
hub. The needl e ti p shoul d reach the greater trochanter. If the
needl e i s too short, i t may be l engthened by pressi ng i t
i nto the ski n.
(4) Insert a l ong needl e to the hub unti l the ti p reaches the greater
trochanter.
P.483
A 10-mL syri nge wi th 1 mL of steroi d (e.g., 6 mg of Cel estone, 40
Page 705
mg of tri amci nol one) and 6 to 9 mL of 1% l i docai ne i s used.
Injecti ng a l arger vol ume of fl ui d appears to be benefi ci al i n the
treatment of greater trochanteri c bursi ti s. Inject a smal l amount
just over the i ni ti al contact poi nt wi th trochanter (Fi gure 5A).
Redi rect the needl e around the i ni ti al si te, and admi ni ster
addi ti onal sol uti on i n a wi de or fan-shaped pattern. Redi rect the
needl e posteri orl y, maki ng sure that the needl e ti p wal ks'' off
the end of the bone, to del i ver sol uti on to the porti on of the bursa
posteri or to the trochanter (Fi gure 5B).
(5) Inject a smal l amount of steroi d and 1% l i docai ne just over the
i ni ti al contact poi nt wi th the trochanter, redi rect the needl e around
the i ni ti al si te, and admi ni ster addi ti onal sol uti on i n a wi de or
fan-shaped pattern.
Page 706
P.484
CODING INFORMATION
C
P
T
C
o
d
e
D
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sc
ri
pt
io
n
2
0
0
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Page 707
aj
or
jo
i n
t
or
b
ur
sa
(h
i p
)
CPT
i s a
tradem
ark of
the
Ameri c
an
Medi ca
l
Associ
ati on.
Consul t the orderi ng i nformati on that appears i n Chapter 65. It i s
easi er to perform thi s procedure and reach the posteri or porti on of
the bursa wi th a 22-gauge, 3-i nch (spi nal ) needl e. These speci al
needl es can be ordered through l ocal surgi cal suppl y houses. A
suggested tray for performi ng soft ti ssue aspi rati ons and i njecti ons
i s l i sted i n Appendi x D. Ski n preparati on recommendati ons appear
i n Appendi x H.
BIBLIOGRAPHY
Adki ns SB, Fi gl er RA. Hi p pai n i n athl etes. Am Fam Physi ci an
Page 708
2000;61: 210918.
Anderson LG. Aspi rati ng and i njecti ng the acutel y pai nful joi nt.
Emerg Med 1991;23:7794.
Bi undo JJ. Regi onal rheumati c pai n syndromes. In: Kl i ppel JH,
Weyand CM, Wortmann RL, eds. Pri mer on the rheumati c di seases,
11th ed. Atl anta: Arthri ti s Foundati on, 1997:136148.
Bl ackburn WD. Approach to the pati ent wi th a muscul oskel etal
di sorder. Caddo, OK: Professi onal Communi cati ons, 1997.
& Hal l , 1997:12.
Hol l ander JL. Arthrocentesi s and i ntrasynovi al therapy. In: McCarty
DJ, ed. Arthri ti s, 9th ed. London: Henry Ki mpton Publ i shers,
1979:402414.
Owen DS, Irby R. Intra-arti cul ar and soft-ti ssue aspi rati on and
i njecti on. Cl i n Rheum Pract 1986;Mar-May:5263.
Pando JA, Kl i ppel JH. Arthrocentesi s and corti costeroi d i njecti on: an
i l l ustrated gui de to techni que. Consul tant 1996;36:21372148.
Pronchi k D, Hel l er MB. Local i njecti on therapy: rapi d, effecti ve
treatment of tendoni ti s/bursi ti s syndromes. Consul tant
1997;37:13771389.
Schapi ra D, Nahi r M, Scharf Y. Trochanteri c bursi ti s: a common
cl i ni cal probl em. Arch Phys Med Rehab 1986;67:815817.
Scopp JM, Moorman CT. The assessment of athl eti c hi p i njury. Cl i n
Sports Med 2001;20:647659.
Wi l son FC, Li n PC. General orthopedi cs. New York: McGraw-Hi l l ,
1997.
Page 709
> Table of Cont ent s > Musculoskelet al Procedures > 60 - Shoulder Inject ion60
Shoulder Injection
The shoul der compri ses a seri es of joi nts and muscul oskel etal
ti ssues that affords the extraordi nary range of moti on to the arm.
Speci fi c i njecti ons have been advocated for a vari ety of shoul der
ai l ments, but pri mary care physi ci ans may not have the opportuni ty
or desi re to perform some of the l ess common and more di ffi cul t
techni ques. For i nstance, i njecti on i nto the acromi ocl avi cul ar joi nt
can rel i eve symptoms of degenerati ve arthri ti s, but the opportuni ty
to perform the i njecti on i s i nfrequentl y encountered i n a general i st
practi ce. The gl enohumeral , acromi ocl avi cul ar, sternocl avi cul ar, and
scapul othoraci c joi nts can be di ffi cul t to enter and may be best
i njected by experi enced physi ci ans.
Thi s chapter descri bes aspi rati on and i njecti on techni ques i n the
l ateral rotator cuff and subacromi al bursa. Commonl y cal l ed a
shoul der i njecti on, thi s procedure general l y does not i nvol ve
enteri ng the shoul der joi nt. Shoul der i njecti ons are easy to perform
and frequentl y provi de benefi ci al i nterventi on for a number of
shoul der condi ti ons. Four of the more common shoul der di sorders
that benefi t from thi s aspi rati on and i njecti on techni que i ncl ude
cal ci fi c tendi ni ti s, i mpi ngement syndrome, supraspi natus
tendoni ti s, and subacromi al bursi ti s. Anatomi c proxi mi ty of the
rotator cuff tendons and the bursa creates overl ap among these
condi ti ons, al l owi ng for a si mi l ar i njecti on techni que for three
condi ti ons.
CALCIFIC TENDINITIS
Cal ci fi c tendi ni ti s i s a degenerati ve condi ti on of the tendons of the
rotator cuff. The supraspi natus tendon i s most commonl y i nvol ved,
wi th l ocal i zed deposi ts of cal ci um i denti fi ed i n the tendon sheath.
It i s esti mated that 2% to 3% of the U.S. adul t popul ati on suffers
from thi s di sorder, al though many wi th the di sorder are
Page 710
asymptomati c. The di sorder i s more common i n mi ddl e-aged men i n
the domi nant shoul der, and i t may be connected to use and
acti vi ty. More than 25% of i ndi vi dual s have bi l ateral shoul der
i nvol vement. Cal ci fi c tendoni ti s usual l y i s characteri zed by an acute
onset of i ntense shoul der pai n that i s not rel ated to posi ti on or
acti vi ty.
Because the subacromi al bursa i s adjacent to the supraspi natus
tendon, most of the pai n from cal ci fi c tendi ni ti s i s rel ated to bursal
i nfl ammati on. Poi nt tenderness
P.486
i s i denti fi ed over the l ateral shoul der, and pai n can be produced
wi th acti ve abducti on from 60 to 120 degrees. Cal ci um can be
detected on x-ray fi l ms (i n external rotati on); acute deposi ts are
sharpl y del i neated, whereas chroni c cal ci um deposi ts are hazy and
i l l defi ned as they are bei ng resorbed. Symptoms tend to resol ve
over a peri od of 2 weeks. Greater degrees of i nfl ammati on (i .e.,
greater pai n) tend to resul t i n rupture of the cal ci um deposi t i nto
the overl yi ng bursa, wi th more rapi d resol uti on of symptoms.
Persi stentl y l arge deposi ts may l ead to di suse and eventual l y to
frozen shoul der.
Acutel y pai nful deposi ts are treated wi th i njecti on of a l ocal
anestheti c and steroi d. Repeated i njecti on of steroi d can i nhi bi t
repai r, and some physi ci ans recommend cauti on after two
i njecti ons. Aspi rati on of cal ci um-contai ni ng (toothpaste-l i ke)
tendon fl ui d has been recommended by some physi ci ans. Removal
of cal ci um requi res l arger (and more uncomfortabl e) needl es, and
the techni que can be di ffi cul t for pati ents and practi ti oners. Some
physi ci ans bel i eve that the greatest benefi t from i njecti on comes
from the needl e puncture hol es made i n the di seased tendon
sheath. The hol es al l ow cal ci um and thi ck i nfl ammatory fl ui d to
fl ow i nto the adjacent bursa, hasteni ng resol uti on of the tendi ni ti s.
The techni que that al l ows for redi recti ng the needl e or fan-shaped
appl i cati on of steroi d i s l i kel y to produce mul ti pl e hol es i n the
sheath.
Page 711
IMPINGEMENT SYNDROME
Impi ngement syndrome descri bes mechani cal compressi on of the
rotator cuff between the humeral head and the overl yi ng acromi on.
Narrowi ng i n thi s regi on i s often attri buted to spur formati on on the
anteroi nferi or acromi on and may be rel ated to excessi ve overhead
use of the l i mb i n certai n sports and occupati ons. Unl i ke cal ci fi c
tendi ni ti s, the major component of di scomfort i s tendoni ti s. Three
stages of i mpi ngement have been descri bed: stage 1, edema and
hemorrhage; stage 2, tendi ni ti s and fi brosi s; and stage 3, tendon
rupture and bony changes.
Pati ents wi th i mpi ngement commonl y compl ai n earl y of chroni c
achi ng i n the shoul der. Acute onset of symptoms i s much more
suggesti ve of cal ci fi c tendi ni ti s. The di scomfort of i mpi ngement i s
frequentl y experi enced at ni ght when reachi ng over the head to
grasp the pi l l ow and when abducti ng the shoul der between 60 and
120 degrees. A posi ti ve i mpi ngement si gn i ndi cates pai n just di stal
to the anteri or acromi on when passi vel y el evati ng the arm 30
degrees forward of the coronal pl ane of the body, wi th the el bow
bent to 90 degrees and the shoul der i nternal l y rotated.
Impi ngement syndrome general l y i s treated wi th exerci ses to
restore fl exi bi l i ty and strength. Avoi dance of pai nful acti vi ti es i s
i mportant earl y i n the course of thi s di sorder, and nonsteroi dal
anti i nfl ammatory drugs (NSAIDs) and i ce therapy can be added to
rest and physi cal therapy. Steroi d i njecti on may provi de symptom
rel i ef. Surgi cal procedures are advocated for stage 3 di sease.
SUPRASPINATUS TENDINITIS AND
SUBACROMIAL BURSITIS
Supraspi natus tendi ni ti s and subacromi al bursi ti s are consi dered
together, because they usual l y coexi st i n these adjacent structures.
Many physi ci ans bel i eve that these di sorders al most al ways occur
as part of the two previ ousl y di scussed condi ti ons. Pri mary bursi ti s
i n the absence of tendoni ti s probabl y i s rare, but not al l
P.487
Page 712
tendoni ti s need be cal ci fi c. If cal ci um cannot be i denti fi ed on x-ray
fi l ms or after i nserti on of the needl e ti p i nto the tendon sheath,
noncal ci fi c tendi ni ti s i s possi bl e.
The poi nt of the shoul der (just under the acromi on) i s the l ocati on
of maxi mal tenderness from supraspi natus tendi ni ti s. Soft ti ssue
di sorders of the shoul der are di ffi cul t to di fferenti ate cl i ni cal l y,
because these condi ti ons produce remarkabl y si mi l ar si gns and
symptoms. Injecti on therapy often i s a val uabl e adjunct, unl ess
there i s evi dence of compl ete rotator cuff tear or l oss of motor
functi on.
Bl eedi ng di athesi s or coagul opathym
Bacteremi a or cel l ul i ti s overl yi ng the l ateral shoul der
Evi dence of compl ete rotator cuff tear
P.488
PROCEDURE
Anatomy of the shoul der i s i l l ustrated.
(1) Anatomy of the shoul der.
Page 713
The subacromi al bursa l i es between the del toi d muscl e and the
supraspi natus muscl e.
(2) Locati on of the subacromi al bursa.
P.489
Ci rcumscri bed, di sti nct margi ns of the cal ci um deposi t i n the
supraspi natus tendon suggests an acute process.
(3) X-ray appearance of acute cal ci fi c tendoni ti s.
The exami ner stands behi nd the seated pati ent. The pati ent's
el bow i s fl exed to 90 degrees, and the shoul der i s i nternal l y
Page 714
rotated so that the pati ent's hand l i es over the trunk. The arm i s
el evated and abducted to about 30 degrees anteri or (sl i ghtl y
forward) of the coronal pl ane of the body. A posi ti ve i mpi ngement
si gn i s accentuati on of the pai n wi th thi s techni que and tenderness
just bel ow the acromi on.
(4) The i mpi ngement si gn.
P.490
One techni que for l ocati ng the poi nt of maxi mal tenderness uses
the pal pati on of mul ti pl e si tes wi th the i ndex fi nger, aski ng the
pati ent to di fferenti ate between si tes 1 and 2. Thi s i s repeated
unti l the si te i s i denti fi ed, and the ski n i s marked by i ndentati on
wi th a fi ngernai l or capped needl e.
(5) The poi nt of maxi mal tenderness i s l ocated.
Page 715
After ski n preparati on, a 22- to 25-gauge needl e i s i nserted
hori zontal l y under the acromi on unti l the supraspi natus tendon i s
reached. If cal ci um exi sts i n the tendon sheath, i t often creates a
gri tty feel on the needl e ti p.
(6) A 22- to 25-gauge needl e i s i nserted hori zontal l y under the
acromi on unti l the supraspi natus tendon i s reached.
Between 4 and 8 mL of 1% l i docai ne i s added to the steroi d i n the
syri nge, as admi ni steri ng the added vol ume of fl ui d appears to
i mprove symptom resol uti on. The added vol ume al so faci l i tates a
fan-shaped admi ni strati on of the sol uti on. Mul ti pl e punctures can
be made i n the tendon sheath, and admi ni strati on of sol uti on i s
made around the tendon and i n several si tes i n the bursa. A
bandage i s appl i ed to the ski n after removal of the needl e.
(7) Between 4 and 8 mL of 1% l i docai ne i s added to the steroi d i n
the syri nge, because the addi ti onal vol ume of fl ui d i mproves
symptom resol uti on.
P.491
Page 716
CODING INFORMATION
C
P
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C
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d
e
D
e
sc
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pt
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n
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Page 717
d
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e
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g
a
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nt
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0
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ct
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m
aj
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i n
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or
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(s
h
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Page 718
d
er
)
2
0
6
0
5
*
In
je
ct
i o
n
of
i n
te
r
m
e
di
at
e
jo
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t
(a
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o
m
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cl
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i c
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)
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ur
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9
7
Page 719
sa
CPT
i s a
tradem
ark of
the
Ameri c
an
Medi ca
l
Associ
ati on.
81
Consul t the orderi ng i nformati on i n Chapter 65. A suggested tray
for performi ng soft ti ssue aspi rati ons and i njecti ons i s l i sted i n
Appendi x D. Ski n preparati on recommendati ons appear i n Appendi x
H.
BIBLIOGRAPHY
Emerg Med 1991;23:7794.
Bl ake R, Hoffman J. Emergency department eval uati on and
treatment of the shoul der and humerus. Emerg Med Cl i n North Am
1999;17:859876.
& Hal l , 1997.
Ike RW. Therapeuti c i njecti on of joi nts and soft ti ssues. In: Kl i ppel
JH, Weyand CM, Wortmann RL, eds. Pri mer on the rheumati c
di seases, 11th ed. Atl anta: Arthri ti s Foundati on, 1997:419421.
Jacobs LG, Barton MA, Wal l ace WA, et al . Intra-arti cul ar di stensi on
and steroi ds i n the management of capsul i ti s of the shoul der. BMJ
1991;302:14981501.
Leversee JH. Aspi rati on of joi nts and soft ti ssue i njecti ons. Pri m
Page 720
Care 1986;13:579599.
Mani L, Gerr F. Work-rel ated upper extremi ty muscul oskel etal
di sorders. Pri m Care Cl i n Offi ce Pract 2000;27:845-64.
Merci er LR, Petti d FJ, Tami si ea DF, et al . Practi cal orthopedi cs, 4th
ed. St. Loui s: Mosby, 1995.
Pronchi k D, Hel l er MB. Local i njecti on therapy: rapi d, effecti ve
treatment of tendoni ti s/bursi ti s syndromes. Consul tant
1997;37:13771389.
Rowe CR. Injecti on techni que for the shoul der and el bow. Orthop
Cl i n North Am 1988;19:773777.
Wi l son FC, Li n PP. General orthopedi cs. New York: McGraw-Hi l l ,
1997.
Wol f WB. Cal ci fi c tendoni ti s of the shoul der: di agnosi s and si mpl e,
effecti ve treatment. Phys Sportsmed 1999;27:2733.
Woodward TW, Best TM. The pai nful shoul der. Part II. Acute and
chroni c di sorders. Am Fam Physi ci an 2000;61:32913300.
Page 721
> Table of Cont ent s > Musculoskelet al Procedures > 61 - Knee Joint Aspirat ion
and Inject ion61
Knee Joint Aspiration and Injection
Aspi rati on and i njecti on of the knee joi nt i s commonl y i ndi cated i n
pri mary care practi ce. Arthrocentesi s may be requi red to establ i sh a
di agnosi s, rel i eve di scomfort, eval uate a hemarthrosi s, drai n off
i nfected fl ui d, or i nsti l l medi cati on. Because prompt di agnosi s and
treatment of a monoarthri ti s can provi de si gni fi cant pati ent benefi t,
thi s easy techni que shoul d be consi dered a fi rst-l i ne i nterventi on.
Effusi on of the knee often produces a detectabl e suprapatel l ar or
parapatel l ar swel l i ng and may be more evi dent i f the ti ssues
surroundi ng the knee are compressed duri ng exami nati on. Large
effusi ons can be confi rmed by bal l ottement of the patel l a. A vari ety
of needl e entry techni ques have been descri bed for the knee joi nt,
and al most al l are successful when l arge effusi ons are present.
Smal l er effusi ons are best approached from beneath the patel l a
wi th the knee extended (i .e., pati ent i s supi ne) to al l ow for greater
ease i n aspi rati on. Thi s chapter descri bes the commonl y used
superol ateral approach.
Corti costeroi ds appear to l i mi t the acti on of i nfl ammatory cel l s and
i nhi bi t destructi ve enzymes wi thi n the joi nt. Steroi d i njecti ons can
provi de si gni fi cant symptom rel i ef and assi st i n the resol uti on of
exacerbati ons of osteoarthri ti s (Tabl e 61-1). Intrasynovi al
admi ni strati on i s desi gned to maxi mi ze l ocal medi cati on benefi ts
whi l e mi ni mi zi ng systemi c effects. Di l uti ng the steroi d sol uti on
wi th a l ocal anestheti c (usual l y 1% l i docai ne) i ncreases the
benefi ts from added vol ume, and the anestheti c provi des i nstant
rel i ef.
TABLE 61-1. CRITERIA FOR THE CLASSIFICATION OF OSTEOARTHRITIS OF THE KNEE USING CLINICAL AND LABORATORY
FINDINGS
Page 722

The pati ent shoul d compl ai n of knee pai n and at l east 5 of the fol l owi ng 9 features:
Age >50 yr
Sti ffness <30 mi n
Crepi tus
Bony tenderness
Bony enl argement
No pal pabl e warmth
Erythrocyte sedi mentati on rate <40 mm/hr
Rheumatoi d factor <1:40
Synovi al fl ui d si gns of osteoarthri ti s (cl ear to straw-col ored, hi gh vi scosi ty, 1,0007,500 whi te bl ood cel l s/L, 2.95.5 g of
protei n/dL)

Adapted from Bl ackburn WD. Approach to the pati ent wi th a muscul oskel etal di sorder. Caddo, OK: Professi onal Communi cati on,
2000:126.
Steroi ds shoul d not be i njected i nto a joi nt wi th cl oudy fl ui d or i f
i nfecti on i s suspected or confi rmed. The total whi te bl ood cel l count
(WBC) can hel p cl assi fy the type of effusi on (Tabl e 61-2). A WBC of
l ess than 2,500/mm
3
i s found i n noni nfl ammatory fl ui d, a WBC
between 2,500 and 25,000/mm
3
i s found i n i nfl ammatory fl ui d, and
a WBC greater than 50,000/mm
3
i s found i n i nfecti ous fl ui d. The
i ntroducti on of i nfecti on from arthrocentesi s i s a rare phenomenon
and i s bel i eved to occur i n l ess than 1 i n 10,000 procedures.
Despi te thi s reassuri ng i nformati on, practi ti oners shoul d use steri l e
gl oves and steri l e techni que when enteri ng joi nts.
TABLE 61-2. RECOMMENDED TESTS FOR SYNOVIAL FLUID
Page 723

Always perform:
Note the vol ume and gross appearance of the fl ui d
Total WBC and di fferenti al
Conduct pol ari zed l i ght exami nati on
Wet preparati on
Gram stai n and cul ture (i f i ndi cated by the cl i ni cal si tuati on or previ ous exami nati ons)
Defer these tests (unlikely to yield useful information):
Vi scosi ty or muci n cl ot
Red bl ood cel l count
Protei n, gl ucose
Compl ement, i mmune compl exes, rheumatoi d factor, anti nucl ear anti body

Adapted from Hassel bacher P. Arthrocentesi s, synovi al fl ui d anal ysi s and synovi al bi opsy. In: Kl i ppel JH, Weyand CM, Wortmann RL,
eds. Pri mer on rheumati c di seases, 11th ed. Atl anta: Arthri ti s Foundati on, 1997:98104.
Several adverse events can occur after steroi d and l i docai ne
i njecti on of the knee. The anestheti zed knee i s vul nerabl e to
i njury, and strenuous acti vi ty shoul d
P.493
be avoi ded i n the fi rst 24 hours after i njecti on, whi ch al so prevents
a washout effect of the i njected medi cati ons. The posti njecti on
fl are i s a worseni ng of joi nt pai n 12 to 72 hours after a steroi d
i njecti on. The posti njecti on fl are i s caused by a reacti on to the
steroi d crystal s and occurs after 1% to 2% of al l joi nt i njecti ons.
The posti njecti on fl are can be di mi ni shed or avoi ded by
recommendi ng nonsteroi dal anti i nfl ammatory drug (NSAID) therapy
for 72 hours after steroi d i njecti on.
The fl are reacti on i s di fferent from the wi ndow peri od. The wi ndow
peri od represents the ti me duri ng whi ch symptoms may recur; the
l i docai ne wears off i n 1 to 3 hours, and the steroi d effect begi ns i n
6 to 24 hours. Pati ent sati sfacti on i s enhanced by adequate
educati on about these i ssues before and after the procedure.
Steroi ds can produce l ong-term degenerati on of the arti cul ar
surface i f repeatedl y admi ni stered. Al though some physi ci ans
advi se no more than three i njecti ons per year, more conservati ve
Page 724
recommendati ons i ncl ude no more than three or four i njecti ons i n
any wei ght-beari ng joi nt i n an i ndi vi dual 's l i feti me. Injecti on of
vi scous agents such as hyal uroni c aci d have i ncreased the
therapeuti c opti ons for pati ents wi th degenerati ve di sease.
P.494
INDICATIONS
Di agnosti c eval uati on of the cause of an effusi on or an
unexpl ai ned monoarthri ti s
Di agnosti c eval uati on of traumati c effusi on (eval uate for
hemarthrosi s or fat i n the effusi on)
To l i mi t joi nt damage from i nfected or i nfl amed joi nt
fl ui d by seri al removal of fl ui d
Symptomati c rel i ef by removi ng a l arge effusi on or
treatment of joi nt pai n or i nfl ammati on
Di agnosi s or treatment of a crystal -i nduced arthropathy
Admi ni strati on of vi scous agents for symptomati c
i mprovement of osteoarthri ti s
Bacteremi a or overl yi ng cel l ul i ti s over the joi nt
Injecti on of steroi ds i f septi c arthri ti s i s suspected or
present
Cl i ni ci an i s unfami l i ar wi th the correct approach to any
joi nt
Presence of a joi nt prosthesi s
P.495
PROCEDURE
The anatomi c structure of the knee i s detai l ed.
Page 725
(1) Anatomi c structure of the knee.
P.496
Wi th the pati ent l yi ng supi ne, the suprapatel l ar pouch can be
mi l ked wi th downward pressure to reveal fl ui d that may not be
apparent duri ng the i ni ti al exami nati on (Fi gure 2A). Al ternatel y, the
patel l a can be bal l oted wi th di rect downward pressure (Fi gure 2B).
Page 726
(2) Checki ng for a joi nt effusi on.
P.497
Di rect i njecti on i nto the joi nt can be achi eved under the patel l a
wi th the knee fl exed 90 degrees.
Page 727
(3) Di rect i njecti on i nto the joi nt can be achi eved under the patel l a
wi th the knee fl exed 90 degrees.
PITFALL: This technique is discouraged, because the needle tip
may cause damage to the articular surfaces or the menisci. This
direct approach may be acceptable when administering
therapeutic viscous solutions (e.g., hyaluronic acid), because
the knee cartilage has previously received significant wear.
The superol ateral techni que uses an entry poi nt 1 cm l ateral and 1
cm superi or to the upper l ateral poi nt on the patel l a (Fi gure 4A).
Thi s entry si te can be approxi mated by measuri ng 1 fi ngerbreadth
l ateral l y and superi orl y.
Page 728
(4) The superol ateral techni que uses an entry poi nt 1 cm l ateral
and 1 cm superi or to the upper l ateral poi nt on the patel l a.
P.498
The needl e i s i nserted through ski n stretched wi th the nondomi nant
hand to reduce the pati ent's di scomfort. Al ternatel y, some
physi ci ans i nfi l trate 1% l i docai ne (wi thout steroi d) to the ski n
entry si te before the arthrocentesi s needl e i s i nserted.
(5) The needl e i s i nserted through ski n stretched wi th the
physi ci an's nondomi nant hand to reduce the pati ent's di scomfort.
The aspi rati ng syri nge (60, 20, or 10 mL) i s attached to a 20- or
Page 729
22-gauge, 1-i nch needl e. The needl e i s cross-cl amped wi th a
steri l e hemostat (i .e., perpendi cul ar to the l ong axi s of the needl e)
at the needl e base.
(6) The needl e i s cross-cl amped wi th a steri l e hemostat.
P.499
The needl e i s gentl y i nserted beneath the patel l a at a 45-degree
angl e to the axi s of the extremi ty, ai mi ng the needl e to the center
of the joi nt at the i nferi or porti on of the patel l a.
(7) Insert the needl e gentl y beneath the patel l a at a 45-degree
Page 730
angl e to the axi s of the extremi ty.
PITFALL: The needle tip should pass easily and not touch nearby
structures. Touching the needle to any structures within the
joint can cause significant discomfort.
P.500
After aspi rati on of fl ui d, the needl e i s hel d steady wi th the
hemostat. The Luer-l ock syri nge i s detached from the needl e usi ng
counter-cl ockwi se rotati on (Fi gure 8A), and the syri nge wi th steroi d
and l i docai ne i s rei nserted rapi dl y wi thout contami nati ng the
needl e. The i njecti ng syri nge i s l ocked onto the needl e usi ng a
cl ockwi se rotati on (Fi gure 8B). Inject the 1 mL of steroi d (6 mg of
betamethasone or 40 mg of tri amci nol one) wi th 3 to 7 mL of 1%
l i docai ne. The needl e i s then removed, and a steri l e bandage i s
appl i ed to the i njecti on si te.
Page 731
(8) The Luer-l ock syri nge i s detached from the needl e, and the
syri nge wi th steroi d and l i docai ne i s rei nserted rapi dl y wi thout
contami nati ng the needl e.
PITFALL: Avoid movement of the needle when removing or
reapplying a syringe. Movement of the needle is very painful.
P.501
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Page 732
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Steri l e gl oves
Steri l e fenestrated drape
10-mL syri nge (for admi ni steri ng l i docai ne and steroi d)
60-mL syri nge (for aspi rati ng effusi on; can use a second
10-mL syri nge i f the effusi on i s smal l )
Two 21-gauge, i nch needl es (one to draw up
i njecti ng sol uti ons, one for performi ng arthrocentesi s)
1 i nch of 4 4 gauze soaked wi th povi done-i odi ne
Page 734
sol uti on for ski n preparati on
Hemostat for stabi l i zi ng the needl e when exchangi ng
medi cati on syri nge for aspi rati on syri nge
Postprocedure bandage
Al l materi al s can be ordered through l ocal surgi cal suppl y houses.
Li docai ne sol uti on, i njectabl e steroi d sol uti on (e.g., Cel estone),
and i njectabl e vi scous agents (e.g., Hyal gan) are avai l abl e from
l ocal pharmaci es or surgi cal suppl y houses. Consul t the orderi ng
i nformati on i n Chapter 65. A suggested tray for performi ng soft
ti ssue aspi rati ons and i njecti ons i s l i sted i n Appendi x D. Ski n
BIBLIOGRAPHY
Al tman RD, Moskowi tz R. Intraarti cul ar sodi um hyal uronate
(Hyal gan) i n the treatment of pati ents wi th osteoarthri ti s of the
knee: a randomi zed control l ed tri al . J Rheumatol
1998;25:22032212.
Emerg Med 1991;23:7794.
Bl ackburn WD. Approach to the pati ent wi th a muscul oskel etal
di sorder. Caddo, OK: Professi onal Communi cati ons, 1999.
Loui s: Mosby, 2000:309313.
Goss JA, Adams RF. Local i njecti on of corti costeroi ds i n rheumati c
di seases. J Muscul oskel Med 1993;10:8392.
Gray RG, Gottl i eb NL. Intra-arti cul ar corti costeroi ds: an updated
assessment. Cl i n Orthop 1983;177:235263.
Hassel bacher P. Arthrocentesi s, synovi al fl ui d anal ysi s and synovi al
bi opsy. In: Kl i ppel JH, Weyand CM, Wortmann RL, eds. Pri mer on
the rheumati c di seases, 11th ed. Atl anta: Arthri ti s Foundati on,
1997:98104.
Hi nton R, Moody RL, Davi s AW, et al . Osteoarthri ti s: di agnosi s and
therapeuti c consi derati ons. Am Fam Physi ci an 2002;65:841848.
P.502
Page 735
Johnson MW. Acute knee effusi ons: a systemati c approach to
di agnosi s. Am Fam Physi ci an 2000;61:23912400.
Care 1986;13:579599.
ed. St. Loui s: Mosby, 1995;207232.
Owen DS, Wei ss JJ, Wi l ke WS. When to aspi rate and i nject joi nts.
Pati ent Care 1990;24:128145.
Renner JB, Wi l son FC. Di agnosti c modal i ti es: i magi ng, joi nt
aspi rati on, and arthroscopy. In: Wi l son FC, Li n PP, eds. General
orthopedi cs. New York: McGraw-Hi l l , 1997:105128.
Schumacher HR. Arthrocentesi s of the knee. Hosp Med
1997;33:6064.
Wen DY. Intra-arti cul ar hyal uroni c aci d i njecti ons for knee
osteoarthri ti s. Am Fam Physi ci an 2000;62:565570, 572.
Zuber TJ. Knee joi nt aspi rati on and i njecti on. Am Fam Physi ci an
2002;66:14971500, 15031504, 1507, 15111512.
Wi l ki ns, 1999:187194.
Page 736
> Table of Cont ent s > Musculoskelet al Procedures > 62 - Reduct ion of Radial Head
Subluxat ion (Nursemaid's Elbow)62
Reduction of Radial Head
Subluxation (Nursemaid's Elbow)
Subl uxati on of the radi al head (nursemai d's el bow) i s a common
chi l dhood i njury, whi ch i s seen most often between 6 months and 5
years of age. The radi al head normal l y rotates agai nst the ul na and
capi tel l um (i .e., humerus), permi tti ng forearm pronati on and
supi nati on. The radi al head i s hel d i n pl ace agai nst the proxi mal
ul na and capi tel l um by l i gaments and the joi nt capsul e. Radi al head
subl uxati on usual l y i s caused by the appl i cati on of l i near tracti on
to a hand or wri st (i .e., l ongi tudi nal tracti on i njury), such as by
l i fti ng a chi l d by an outstretched hand. It may al so be caused by an
i nci dental fal l i n whi ch the arm, el bow, and forearm are i mpacted
between the ground and the chi l d's trunk. Rarel y, there i s no known
hi story of trauma, but the parents noti ce that the chi l d i s not usi ng
the affected l i mb.
Approach a chi l d wi th suspected subl uxati on sl owl y and cal ml y to
al l ay anxi ety. The chi l d i s often best seated i n the parent's l ap.
The affected arm i s parti al l y fl exed at the el bow and i n forearm
pronati on. Typi cal l y, the chi l d keeps the arm cl ose to the trunk and
appears contented and pl ayful but decl i nes to acti vel y move the
affected arm. There i s no tenderness to pal pati on of the cl avi cl e,
shoul der, humerus, el bow, forearm, wri st, or hand, and passi ve
range of moti on of the shoul der, hand, and wri st i s usual l y
pai nl ess. However, even modest attempts to supi nate the forearm
or to move the el bow el i ci t pai n and angui sh.
Radi ographs are usual l y unnecessary, because there are no
radi ographi c abnormal i ti es associ ated wi th thi s condi ti on and
physi cal exami nati on effecti vel y di agnoses the probl em.
Radi ographs shoul d be consi dered i f the chi l d exhi bi ts poi nt
Page 737
tenderness, soft ti ssue swel l i ng, or ecchymosi s of the el bow.
After a reducti on attempt, the chi l d usual l y cri es for a few seconds
but then i s easi l y comforted. Observe for 15 mi nutes for a ful l
return to normal use. If functi on and use have not normal i zed
wi thi n 15 mi nutes, a repeated attempt at reducti on i s
recommended. Consi der al ternati ve di agnoses i f the chi l d's arm
does not return to normal . Neurovascul ar compromi se i s rare wi th
thi s i njury. For chi l dren who recover ful l use after one or two
reducti on maneuvers, further therapy i s unnecessary. A sl i ng may
be offered to the chi l d whose functi on has i mproved but i s not
compl ete. Sl i ngs typi cal l y are usel ess i n toddl ers because they are
easi l y di scarded. Consi der recommendi ng that they wear a
l ong-sl eeved shi rt and attach
P.504
the cuff buttonhol e to an upper shi rt button to hel p provi de some
i mmobi l i zati on.
Gentl y remi nd parents to avoi d l i fti ng the chi l d by the hand, wri st,
or forearm. Inform the parents that there i s an i ncreased ri sk of
recurrence unti l the chi l d reaches 5 to 6 years of age. Recurrent
subl uxati on occurs i n nearl y one fourth of pati ents, and those 24
months or younger are at greatest ri sk.
INDICATIONS
Reducti on of a subl uxed radi al head.
CONTRAINDICATIONS
Uncertai nty about the di agnosi s or possi bi l i ty of occul t
fracture (i .e., further workup i ndi cated)
P.505
PROCEDURE
Pl ace the chi l d's el bow i n the fi ngers of your hand and your thumb
over the chi l d's radi al head (i .e., l ateral aspect of the proxi mal
forearm). Grasp the chi l d's affected hand wi th your other hand.
Page 738
(1) Pl ace the chi l d's el bow i n the fi ngers of your hand wi th your
thumb over the chi l d's radi al head, and grasp the chi l d's affected
hand wi th your other hand.
Rapi dl y appl y downward pressure on the radi al head wi th your
thumb, qui ckl y fol l owed by ful l supi nati on and then ful l fl exi on of
the chi l d's el bow. A cl i ck i s often pal pated by the
physi ci an's thumb as reducti on i s accompl i shed.
Page 739
(2) Rapi dl y appl y downward pressure on the radi al head wi th your
thumb, qui ckl y fol l owed by ful l supi nati on and then ful l fl exi on of
the chi l d's el bow.
P.506
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Page 742
an
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No speci al equi pment i s needed for reducti on of a radi al head
subl uxati on.
BIBLIOGRAPHY
Davi d ML. Radi al head subl uxati on. Am Fam Physi ci an
1987;35:143146.
Jongschaap HC, Youngson GG, Beatti e TF. The epi demi ol ogy of
radi al head subl uxati on (pul l ed el bow ) i n the Aberdeen ci ty
area. Heal th Bul l 1990;48:5861.
McDonal d J, Whi tel aw C, Gol dsmi th LJ. Radi al head subl uxati on:
compari ng two methods of reducti on. Acad Emerg Med
1999;6:715718.
Quan L, Marcuse EK. The epi demi ol ogy and treatment of radi al head
subl uxati on. Am J Di s Chi l d 1985;139:11941197.
Sacchetti A, Ramoska EE, Gl ascow C. Noncl assi c hi story i n chi l dren
wi th radi al head subl uxati ons. J Emerg Med 1990;8:151153.
Sal ter RB, Zal tz C. Anatomi c i nvesti gati ons of the mechani sm of
i njury and pathol ogi c anatomy of pul l ed el bow i n young
chi l dren. Cl i n Orthop 1971;77:134.
Schunk JE. Radi al head subl uxati on: epi demi ol ogy and treatment of
87 epi sodes. Ann Emerg Med 1990;19:10191023.
Snyder HS. Radi ographi c changes wi th radi al head subl uxati on i n
chi l dren. J Emerg Med 1990;8:265269.
Teach SJ, Schutzman SA. Prospecti ve study of recurrent radi al head
Page 743
subl uxati on. Arch Pedi atr Adol esc Med 1996;150:164166.
Woo CC. Traumati c radi al head subl uxati on i n young chi l dren: a
case report and l i terature revi ew. J Mani pul ati ve Physi ol Ther
1987;10:191200.
Page 744
> Table of Cont ent s > Musculoskelet al Procedures > 63 - Plant ar Fascia Inject ion
63
Plantar Fascia Injection
Proxi mal pl antar fasci i ti s i s a common cause of heel pai n i n adul ts.
The pl antar fasci a i s a fi brous aponeurosi s that ori gi nates from the
medi al tubercl e of the cal caneus and provi des dynami c shock
absorpti on and stati c support to the l ongi tudi nal arch. Indi vi dual s
wi th pes pl anus (i .e., fl at feet) or pes cavus (i .e., hi gh arches) are
at i ncreased ri sk for devel opi ng pl antar fasci i ti s. In athl etes,
overuse i s the most common cause of pl antar fasci i ti s. The pai n of
proxi mal pl antar fasci i ti s i s usual l y caused by col l agen
degenerati on at the medi al tubercl e of the cal caneus (i .e., ori gi n of
the pl antar fasci a). It i s caused by repeti ti ve mi crotears of the
pl antar fasci a that overcome the body's abi l i ty to repai r i tsel f.
Cl assi cal l y, the defi ni ng si gn of pl antar fasci i ti s i s that the worst
pai n occurs wi th the fi rst few steps i n the morni ng. Pati ents often
noti ce pai n wi th the i ni ti ati on of acti vi ty that l essens as acti vi ty
conti nues. Pai n may al so be associ ated wi th prol onged standi ng. In
more severe cases, the pai n wi l l al so worsen toward the end of the
day. A hi story of an i ncrease i n wei ght-beari ng acti vi ti es i s
common, especi al l y those i nvol vi ng runni ng, whi ch causes
mi crotrauma to the pl antar fasci a.
On exami nati on, the pati ent i s maxi mal l y tender at the
anteromedi al regi on of the cal caneus. The pati ent may al so have
pai n al ong the proxi mal pl antar fasci a. The pai n i s often
exacerbated by passi ve dorsi fl exi on of the toes or by havi ng the
pati ent stand on the ti ps of the toes. Di agnosti c testi ng i s usual l y
not i ndi cated. Pl antar fasci i ti s i s often cal l ed heel spurs because of
the commonl y associ ated x-ray fi ndi ngs, but 15% to 25% of the
asymptomati c popul ati on has heel spurs, and many symptomati c
i ndi vi dual s do not. Di agnosti c testi ng i s i ndi cated i n atypi cal cases
Page 745
of heel pai n (Tabl e 63-1), or i n pati ents who are not respondi ng to
appropri ate treatment.
TABLE 63-1. DIFFERENTIAL DIAGNOSIS OF HEEL PAIN

Problem Differentiating Clinical Features

Entrapment syndromes Radi ati ng burni ng pai n, or numbness and ti ngl i ng, mai nl y at ni ght
on the pl antar surface of the foot
Cal caneal stress fracture Pai n wi th wei ght beari ng; worsens wi th prol onged wei ght beari ng
Paget's di sease Bowed ti bi as, kyphosi s, headaches
Bone tumor Deep bone pai n; consti tuti onal symptoms l ate i n the course
Cal caneal apophysi ti s (Sever's di sease) Posteri or heel pai n i n adol escents
Fat pad syndrome Atrophy of heel pad
Heel brui se Hi story of acute i mpact i njury
Bursi ti s Usual l y retrocal caneal ; swel l i ng, pai n, and erythema of posteri or
heel
Pl antar fasci a rupture Sudden, acute, kni fel i ke pai n, ecchymosi s
Tendoni ti s Pai n mai nl y wi th resi sted moti ons

Pl antar fasci i ti s i s usual l y a sel f-l i mi ti ng condi ti on, but i t may take
6 to 18 months to resol ve. Rest al one i s an effecti ve treatment,
but i t i s poorl y accepted as a treatment modal i ty by athl etes,
acti ve adul ts, and persons whose occupati ons requi re extensi ve
wal ki ng. Often, a pl anned peri od of rel ati ve rest that
substi tutes l ess damagi ng al ternati ve forms of acti vi ty can i ncrease
the compl i ance wi th treatment. For l ong-term therapy, correct the
probl ems that pl ace i ndi vi dual s at i ncreased ri sk for pl antar
fasci i ti s, such as i ncreased wei ght-beari ng acti vi ty, hi gh i ntensi ty
of acti vi ty, hard wal ki ng or runni ng surfaces, and worn shoes.
The most common conservati ve treatment for pl antar fasci i ti s i s
stretchi ng and strengtheni ng programs to correct functi onal ri sk
factors such as ti ghtness of
P.508
the gastrocsol eus compl ex and weakness of the i ntri nsi c foot
Page 746
muscl es. Other commonl y used treatments i ncl ude use of orthoti cs,
nonsteroi dal anti i nfl ammatory drugs (NSAIDs), i ontophoresi s, i ce,
heat, heel cups, ni ght spl i nts, and pl antar strappi ng. For
i ndi vi dual s wi th fl at feet, shoes wi th better l ongi tudi nal arch
support may hel p.
Corti costeroi d i njecti ons work best when admi ni stered earl y i n the
course of pl antar fasci i ti s but are often reserved for recal ci trant
cases. Some authori ti es recommend a foot radi ograph before
i njecti ng steroi ds to rul e out a tumor. Steroi ds can be i njected
through pl antar or medi al approaches wi th or wi thout ul trasound
gui dance. Studi es have found that steroi d treatments have a
success rate of at l east 70%.
Rupture of the pl antar fasci a i s a treatment ri sk found i n up to 10%
of pati ents after i njecti on. Long-term pl antar fasci a rupture may be
common. However, most i ndi vi dual s wi th rupture of the pl antar
fasci a have resol uti on of symptoms wi th rest and rehabi l i tati on.
Other possi bl e ri sks i ncl ude fat pad atrophy, ecchymosi s, and
i nfecti on.
INDICATIONS
Pl antar fasci i ti s
ABSOLUTE CONTRAINDICATIONS
Local cel l ul i ti s
Septi c arthri ti s
Acute fracture
Bacteremi a
Joi nt prosthesi s
Achi l l es or patel l a tendi nopathi es
Tumor
Hi story of al l ergy to the medi cati ons
P.509
Mi ni mal rel i ef after two previ ous corti costeroi d
Page 747
i njecti ons
Coagul opathy or anti coagul ati on therapy
Evi dence of surroundi ng joi nt osteoporosi s
Uncontrol l ed di abetes mel l i tus
P.510
PROCEDURE
Pl ace the pati ent i n a comfortabl e posi ti on. Cl ean the i njecti on
area wi th al cohol . Choose a 21- or 22-gauge needl e that i s 1 i nches
l ong. Fi nd the poi nt of maxi mal tenderness, whi ch i s usual l y at or
near the pl antar fasci a i nserti on on the cal caneus.
(1) Fi nd the poi nt of maxi mal tenderness, whi ch i s usual l y at or
near the pl antar fasci a i nserti on on the cal caneus.
PITFALL: Use of a short, smaller-diameter needle may cause
less discomfort, but it may fail to reach the intended area at the
fascia insertion.
Usi ng steri l e techni que, i nsert the needl e 1 to 2 cm above the sol e,
just past the end of the pl antar fasci a i nserti on on the cal caneus,
ai mi ng for the end of the bone. The needl e i s wal ked down
the bone, successi vel y redi rected toward the toes, unti l the di stal
Page 748
end i s reached. When the di stal end bone or mi dl i ne of the foot i s
reached, i nject about 0.5 mL of Cel estone or si mi l ar steroi d 23
mL of di l uted, wi th 1% l i docai ne i nto the aponeurosi s i n a fan
shape just di stal to the i nserti on.
(2) Medi al approach.
P.511
Usi ng steri l e techni que, i nsert the needl e at a 30-degree angl e i nto
the tendon at the poi nt of maxi mal tenderness. Inject about 1 to 4
mL of di l uted Cel estone i nto the aponeurosi s i n a fan shape just
di stal to the i nserti on.
Page 749
(3) Pl antar approach.
PITFALL: Do not allow any steroid to leak into the fat pads on
the plantar aspect of the foot, because this may cause fat
atrophy or necrosis. If the specialized plantar fat pad atrophies,
it is gone forever. Some authorities recommend against the
direct plantar approach to avoid injury to this specialized
cushioning fat beneath the heel.
Fol l owi ng the i njecti on, hol d pressure for 2 mi nutes to decrease
brui si ng and prevent steroi d spread.
(4) Appl y pressure to the i njecti on si te for 2 mi nutes to decrease
Page 750
brui si ng and prevent the steroi d from spreadi ng.
P.512
CODING INFORMATION
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Page 751
te
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ati on.
Common materi al s for pl antar fasci i ti s i njecti on, i ncl udi ng a 3- or
5-mL syri nge, 1% l i docai ne wi thout epi nephri ne, or 1% procai ne,
and 22-, 25-, or 27-gauge needl es of vari ous l engths. Injectabl e
steroi ds can be found i n l ocal pharmaci es. Consul t the orderi ng
i nformati on i n Chapter 65. A suggested tray for performi ng
soft-ti ssue aspi rati ons and i njecti ons i s l i sted i n Appendi x D. Ski n
Page 752
BIBLIOGRAPHY
Acevedo JI, Beski n JL. Compl i cati ons of pl antar fasci a rupture
associ ated wi th corti costeroi d i njecti on. Foot Ankl e I nt
1998;19:9197.
Furey JG. Pl antar fasci i ti s: the pai nful heel syndrome. J Bone Joi nt
Surg 1975;57:672673.
Gi l l LH, Ki ebzak GM. Outcome of nonsurgi cal treatment for pl antar
fasci i ti s. Foot Ankl e I nt 1996;17:527532.
Kane D, Greaney T, Bresni han B, et al . Ul trasound gui ded i njecti on
of recal ci trant pl antar fasci i ti s. Ann Rheum Di s 1998;57:383384.
Khan KM, Cook JL, Taunton JE, et al . Overuse tendi nosi s, not
tendi ni ti s: a new paradi gm for a di ffi cul t cl i ni cal probl em (part 1).
Phys Sports Med 2000;28:3848.
Kwong PK, Kay D, Voner RT, et al . Pl antar fasci i ti s: mechani cs and
pathomechani cs of treatment. Cl i n Sports Med 1988;7:119126.
Marti n RL, Irrgang JJ, Conti SF. Outcome study of subjects wi th
i nserti onal pl antar fasci i ti s. Foot Ankl e I nt 1998;19:803811.
Sel l man JR. Pl antar fasci a rupture associ ated wi th corti costeroi d
i njecti on. Foot Ankl e I nt 1994;15:376381.
Si ngh D, Angel J, Bentl ey G, et al . Pl antar fasci i ti s. BMJ
1997;315:172175.
Stanl ey KL, Weaver JE. Pharmacol ogi c management of pai n and
i nfl ammati on i n athl etes. Cl i n Sports Med 1998;17:375392.
Taunton JE, Ryan MB, Cl ement DB, et al . A retrospecti ve
case-control anal ysi s of 2002 runni ng i njuri es. Br J Sports Med
2002;36:95101.
Wol gi n M, Cook C, Graham C, et al . Conservati ve treatment of
pl antar heel pai n: l ong-term fol l ow-up. Foot Ankl e I nt
1994;15:97102.
Young CC, Rutherford DS, Ni edfel dt MW. Treatment of pl antar
fasci i ti s. Am Fam Physi ci an 2001;63:467474, 477478.
Page 753
> Table of Cont ent s > Musculoskelet al Procedures > 64 - Trigger Point Inject ion
64
Trigger Point Injection
Tri gger poi nts are di screte, focal , hyperi rri tabl e si tes l ocated wi thi n
bands of skel etal muscl e. The poi nts are pai nful on compressi on
and can produce referred pai n, referred tenderness, motor
dysfuncti on, and autonomi c phenomena. A l ocal twi tch
response can usual l y be produced when fi rm snappi ng
pressure i s appl i ed perpendi cul ar to the muscl e over the tri gger
poi nt. Tri gger poi nts often accompany chroni c muscul oskel etal
di sorders.
An acti ve tri gger poi nt often causes pai n at rest and produces a
referred pai n pattern that i s si mi l ar to the pati ent's pai n compl ai nt.
Thi s referred pai n i s fel t not at the si te of the tri gger poi nt ori gi n,
but remote from i t, and i t i s often descri bed as spreadi ng or
radi ati ng. Referred pai n di fferenti ates a tri gger poi nt from a tender
poi nt, whi ch i s associ ated wi th pai n at the si te of pal pati on onl y. A
l atent tri gger poi nt does not cause spontaneous pai n but may
restri ct movement or cause muscl e weakness. The pati ent
commonl y presents wi th muscl e restri cti ons or weakness and may
become aware of pai n ori gi nati ng from a l atent tri gger poi nt onl y
when pressure i s appl i ed di rectl y over the poi nt.
Acute trauma or repeti ti ve mi crotrauma may l ead to the
devel opment of a tri gger poi nt. Lack of exerci se, prol onged poor
posture, vi tami n defi ci enci es, sl eep di sturbances, and joi nt
probl ems may al l predi spose to the devel opment of mi crotrauma.
Acti vi ti es that produce repeti ti ve stress on speci fi c muscl es may
l ead to tri gger poi nts. Acute sports i njuri es, repeti ti ve stress,
surgi cal scars, and ti ssues under tensi on after surgery may al so
predi spose a pati ent to the devel opment of tri gger poi nts.
Pati ents wi th tri gger poi nts often report regi onal , persi stent pai n
Page 754
that usual l y resul ts i n a decreased range of moti on. Often, the
postural muscl es of the neck, shoul ders, and pel vi c gi rdl e are
affected. The pai n may be rel ated to muscl e acti vi ty, or i t may be
constant. It i s reproduci bl e and does not fol l ow a dermatomal or
nerve root di stri buti on. Joi nt swel l i ng and neurol ogi c defi ci ts are
general l y absent on physi cal exami nati on. In the head and neck
regi on, myofasci al pai n syndrome wi th tri gger poi nts can mani fest
as tensi on headache, ti nni tus, temporomandi bul ar joi nt pai n, eye
symptoms, and torti col l i s.
Tri gger poi nts are di agnosed by pal pati on of a hard, hypersensi ti ve
nodul e wi thi n a muscl e. Local i zati on of a tri gger poi nt i s based on
the exami ners sense of feel . Common l ocati ons of tri gger poi nts are
shown i n Fi gure 1. No l aboratory test or i magi ng techni que i s
hel pful for di agnosi ng tri gger poi nts.
Page 755
(1) Exami ne the pati ent for tri gger poi nts.
P.514
When treati ng myofasci al pai n syndromes, try to el i mi nate
predi sposi ng and perpetuati ng factors. Pharmacol ogi c treatment
i ncl udes anal gesi cs and medi cati ons, such as anti depressants, to
Page 756
hel p sl eep. Nonpharmacol ogi c treatment modal i ti es i ncl ude
massage, ul trasonography, appl i cati on of heat or i ce, di athermy,
transcutaneous el ectri cal nerve sti mul ati on, ethyl chl ori de spray
and stretch techni que, and dry needl i ng. These methods are more
l i kel y to requi re several treatments, and the benefi ts may not be as
ful l y apparent for days.
Tri gger poi nt i njecti on wi th l ocal anestheti c can effecti vel y
i nacti vate tri gger poi nts and provi de prompt, symptomati c rel i ef. It
i s the most studi ed, effecti ve, and commonl y used treatment
modal i ty. It has a nal oxone-reversi bl e mechani sm of acti on,
suggesti ng an endogenous opi oi d system as a medi ator for the
decreased pai n and i mproved physi cal fi ndi ngs after i njecti on wi th
l ocal anestheti c.
In comparati ve studi es, dry needl i ng was found to be as effecti ve
as i njecti ng an anestheti c sol uti on. However, soreness resul ti ng
from dry needl i ng was found to be more i ntense and of l onger
durati on than that experi enced by pati ents i njected wi th l i docai ne.
An i njectabl e sol uti on of 1% l i docai ne or 1% procai ne typi cal l y i s
used, al though sal i ne i s al so used. Di cl ofenac (Vol taren) and
botul i num toxi n type A (Botox) have been used, but these
substances may have si gni fi cant myotoxi ci ty. Procai ne has the
di sti ncti on of bei ng the l east myotoxi c of al l l ocal i njectabl e
anestheti cs. Injectabl e corti costeroi ds may al so be added to the
l ocal anestheti c, but data supporti ng added effi cacy for steroi ds are
l i mi ted.
Posti njecti on soreness i s common, but the pati ent's rel i ef of the
referred pai n pattern measures the success of the i njecti on.
Rei njecti on of the tri gger poi nts i s not recommended unti l the
posti njecti on soreness resol ves, usual l y after 3 or 4 days. If two or
three previ ous attempts have been unsuccessful , do not conti nue
i njecti ng a si te. Encourage pati ents to remai n acti ve, putti ng
muscl es through thei r ful l range of moti on for a week after
i njecti on, but advi se them to avoi d strenuous acti vi ty, especi al l y
for 3 or 4 days.
Compl i cati ons of tri gger poi nt i njecti ons i ncl ude vasovagal syncope,
Page 757
l ocal pai n, needl e breakage, hematoma formati on, and ski n
i nfecti on. Al l needl e i njecti ons have the ri sk of enteri ng or
admi ni steri ng medi cati on to an i nappropri ate or uni ntended area.
Pneumothorax may be avoi ded by never ai mi ng a needl e at an
i ntercostal space. Ask about bl eedi ng tendenci es, because capi l l ary
hemorrhage i ncreases posti njecti on soreness and ecchymosi s. Have
pati ents refrai n from dai l y aspi ri n for at l east 3 days before the
procedure.
INDICATIONS
Symptomati c tri gger poi nts
CONTRAINDICATIONS
Anti coagul ati on or bl eedi ng di sorders
Aspi ri n i ngesti on wi thi n 3 days of i njecti on
The presence of l ocal or systemi c i nfecti on
Al l ergy to anestheti c agents
Acute muscl e trauma
Extreme fear of needl es
P.515
PROCEDURE
Common l ocati ons of tri gger poi nts. Pl ace the pati ent i n a
comfortabl e posi ti on to assi st wi th muscl e rel axati on. The prone or
supi ne posi ti on i s usual l y most effecti ve and may al so hel p to
avoi d i njury i f a vasovagal reacti on occurs. Exami ne the pati ent for
tri gger poi nts, especi al l y i n the areas where they most frequentl y
occur. Choose a 23- to 25-gauge needl e that i s l ong enough to
reach the tri gger poi nt; a - to 1-i nch needl e usual l y i s
adequate.
PITFALL: Using a smaller-diameter needle may cause less
discomfort, but it may be deflected away from a very taut
muscular band.
PITFALL: Never insert the needle to its hub to minimize the risk
of needle breakage.
Page 758
P.516
Cl eanse the ski n overl yi ng the tri gger poi nt wi th al cohol . Use
al ternati ng pressure between i ndex and mi ddl e fi nger to i sol ate the
l ocati on of the tri gger poi nt (Fi gure 2A and 2B). Posi ti on the tri gger
poi nt hal fway between the fi ngers to keep i t from sl i di ng to one
si de duri ng the i njecti on (Fi gure 2C).
(2) Cl eanse the ski n overl yi ng the tri gger poi nt wi th al cohol , and
i sol ate the l ocati on of the tri gger poi nt by al ternati ng pressure
Page 759
between the i ndex and mi ddl e fi ngers.
P.517
Usi ng steri l e techni que, i nject wi th the needl e paral l el to the
fi ngers and away from the hand. Press fi rml y downward and apart
wi th the fi ngers to mai ntai n pressure for hemostasi s and to ensure
adequate tensi on of the muscl e fi bers to al l ow penetrati on of the
tri gger poi nt.
(3) Inject wi th the needl e paral l el to the fi ngers and away from the
hand.
PITFALL: Before advancing the needle into the trigger point,
warn the patient of the possibility of pain or muscle twitching
when the needle enters the muscle.
Insert the needl e so that i t may enter the tri gger poi nt at an angl e
of 30 degrees. Wi thdraw the pl unger before i njecti on to ensure that
the needl e i s not wi thi n a bl ood vessel .
Page 760
(4) The needl e shoul d enter the tri gger poi nt at a 30-degree angl e.
PITFALL: Never aim a needle at an intercostal space to prevent
the risk of pneumothorax.
P.518
Inject a smal l amount (0.2 mL) of sol uti on i nto the tri gger poi nt.
Wi thdraw the needl e to the l evel of the subcutaneous ti ssue, and
then repeat the i njecti on process superi orl y, i nferi orl y, l ateral l y,
and medi al l y unti l the l ocal twi tch response i s el i mi nated or
resi sti ng muscl e tautness i s rel i eved. Immedi atel y have the pati ent
acti vel y move each i njected muscl e through i ts ful l range of moti on
three ti mes to stretch the i njecti on si te.
(5) Inject a smal l amount of sol uti on i nto the tri gger poi nt,
wi thdraw the needl e to the subcutaneous ti ssue, and then repeat
i njecti ons superi orl y, i nferi orl y, l ateral l y, and medi al l y unti l the
l ocal twi tch response has stopped or the resi sti ng muscl e tautness
i s rel i eved.
After i njecti on, pal pate the area for other tri gger poi nts. If found,
they shoul d be i sol ated and i njected. Appl y pressure to the i njected
area for 2 mi nutes to promote hemostasi s. Appl y an adhesi ve
bandage.
Page 761
(6) Appl y pressure to the i njected area for 2 mi nutes to promote
hemostasi s, and appl y an adhesi ve bandage.
PITFALL: Failing to apply direct pressure for at least 2 minutes
after injection makes hematoma formation much more likely.
P.519
CODING INFORMATION
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Page 762
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Page 764
p
oi
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s,
th
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CPT
i s a
tradem
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the
Ameri c
an
Medi ca
l
Associ
ati on.
Common materi al s for tri gger poi nt i njecti on, i ncl udi ng a 3- or 5-mL
syri nge, 1% l i docai ne wi thout epi nephri ne, or 1% procai ne, and 22-,
25-, or 27-gauge needl es of vari ous l engths. A suggested tray for
Page 765
performi ng soft ti ssue aspi rati ons and i njecti ons i s l i sted i n
H.
BIBLIOGRAPHY
Al varez DJ, Rockwel l PG. Tri gger poi nts: di agnosi s and
management. Am Fam Physi ci an 2002;65:653660.
Cri scuol o CM. Interventi onal approaches to the management of
myofasci al pai n syndrome. Curr Pai n Headache Rep
2001;5:407411.
El i as M. Reducti on of pai n and EMG acti vi ty i n the masseter regi on
by trapezi us tri gger poi nt i njecti on. Pai n 1993;55:397400.
Fi ne PG, Mi l ano R, Hare BD. The effects of myofasci al tri gger poi nt
i njecti ons are nal oxone reversi bl e. Pai n 1988;32:1520.
Fi scher AA. Injecti on techni ques i n the management of l ocal pai n. J
Back Muscul oskel et Rehabi l 1996;7:107117.
Fri cton JR, Kroeni ng R, Hal ey D, et al . Myofasci al pai n syndrome of
the head and neck: a revi ew of cl i ni cal characteri sti cs of 164
pati ents. Oral Surg Oral Med Oral Pathol 1985;60:615623.
Garvey T, Marks MR, Wi esel SW. A prospecti ve, randomi zed,
doubl e-bl i nd eval uati on of tri gger-poi nt i njecti on therapy for
l ow-back pai n. Spi ne 1989;14:962964.
Han SC, Harri son P. Myofasci al pai n syndrome and tri gger-poi nt
management. Reg Anesth 1997;22:89101.
Hong CZ. Li docai ne i njecti on versus dry needl i ng to myofasci al
tri gger poi nt: the i mportance of the l ocal twi tch response. Am J
Phys Med Rehabi l 1994;73:256263.
Hong CZ, Hsueh TC. Di fference i n pai n rel i ef after tri gger poi nt
i njecti ons i n myofasci al pai n pati ents wi th and wi thout
fi bromyal gi a. Arch Phys Med Rehabi l 1996;77:11611166.
Hopwood MB, Abram SE. Factors associ ated wi th fai l ure of tri gger
poi nt i njecti ons. Cl i n J Pai n 1994;10:227234.
Li ng FW, Sl ocumb JC. Use of tri gger poi nt i njecti ons i n chroni c
pel vi c pai n. Obstet Gynecol Cl i n North Am 1993;20:809815.
McMi l l an A, Bl asberg B. Pai n-pressure threshol d i n pai nful jaw
muscl es fol l owi ng tri gger poi nt i njecti on. J Orofac Pai n
Page 766
1994;8:384390.
Padamsee M, Mehta N, Whi te GE. Tri gger poi nt i njecti on: a
negl ected modal i ty i n the treatment of TMJ dysfuncti on. J Pedod
1987;12:7292.
Page 767
> Table of Cont ent s > Musculoskelet al Procedures > 65 - Trigger Finger Inject ion
65
Trigger Finger Injection
Fl exor tendon entrapment of the di gi ts i s a common condi ti on
encountered i n pri mary care practi ce. Thi s pai nful condi ti on i s
known as a tri gger fi nger, and i t can produce l ocki ng of the fi nger
i n the posi ti on of fl exi on. Locki ng i s rel eased by forced extensi on of
the di gi t, whi ch may produce a cl i ck that can be fel t and
occasi onal l y heard. Al though the fourth fi nger i s most commonl y
i nvol ved, mul ti pl e fi ngers and the thumb are al so commonl y
reported as tri gger fi ngers. Tenderness i s common but not al ways
present. Most di agnoses are made from the cl assi c physi cal
fi ndi ngs.
The probl em wi th a tri gger di gi t i s mechani cal . A nodul ar expansi on
of the tendon can devel op, movi ng wi th fi nger moti on and catchi ng
wi thi n the annul ar A1 pul l ey over the metacarpophal angeal joi nt.
Al ternatel y, the pul l ey can become too ti ght, constri cti ng a
normal -si zed tendon. Tri gger fi ngers occur i n chi l dren, usual l y on
the thumb, and probabl y represent a congeni tal di screpancy
between the si ze of the tendon and that of the tendon sheath.
Tri gger fi ngers were hi stori cal l y referred to as stenosi ng
tenosynovi ti s, but hi stol ogi c studi es fai l to document i nfl ammati on.
Pri mary di sease occurs more often i n mi ddl e-aged women and i s
bel i eved to devel op from degenerati ve changes i n the fl exor
tendons and A1 pul l eys. Secondary tri gger fi ngers devel op from
condi ti ons that affect the connecti ve ti ssues, such as rheumatoi d
arthri ti s, di abetes mel l i tus, and gout.
In-offi ce surgi cal rel ease of the pul l ey i s hi ghl y effecti ve but may
be beyond the purvi ew of pri mary care physi ci ans. Corti costeroi d
i njecti on (0.5 mL of tri amci nol one [10 mg/mL] mi xed wi th 0.5 to 1.5
mL of 1% l i docai ne) can be hi ghl y successful , especi al l y earl y i n
Page 768
the course of the di sorder. Injecti on i s performed i nto the tendon
sheath, not i nto the tendon. Steroi d therapy may rel i eve di scomfort
and produces a cure i n up to 85% of i ndi vi dual s wi th the di sorder.
If two or three i njecti ons fai l to resul t i n compl ete resol uti on,
consul tati on wi th a hand surgeon shoul d be sought.
INDICATIONS
Locki ng of fl exor tendon of fi nger or thumb (i .e., fl exor
tendon entrapment syndrome)
P.521
Fai l ure to respond to mul ti pl e i njecti ons
Bl eedi ng di athesi s
Bacteremi a or cel l ul i ti s of the pal m or thumb
Congeni tal tri ggeri ng i n thumb i n i nfants
P.522
PROCEDURE
The fourth fi nger i s commonl y i nvol ved. The condi ti on causes
l ocki ng of the fl exor tendon i n a posi ti on of fl exi on.
Page 769
(1) Tri gger fi nger most commonl y i nvol ves the fourth fi nger.
P.523
Pl ace the supi ne hand fl at on a fi rm surface. After steri l e
preparati on of the ski n, the needl e i s i nserted verti cal l y i nto the
ski n (Fi gure 2A). The correct i nserti on si te general l y i s i n the pal m,
where the tendon crosses the di stal pal mar crease (Fi gure 2B).
Page 770
(2) The needl e i s i nserted verti cal l y i nto the pal m where the
tendon crosses the di stal pal mar crease.
PITFALL: Novice physicians frequently inject at the base of the
digit (i.e., crease where the digit meets the palm). This is well
above the metacarpophalangeal joint and above the A1 pulley.
The joint can be palpated through the palm; it is at least 1 cm
proximal to the crease at the base of the finger.
P.524
Insert the needl e unti l the ti p reaches the tendon. Back out the
needl e 1 to 2 mm to faci l i tate i njecti on i nto the sheath (Fi gure 3A).
Some experts advocate i nserti on of the needl e ti p at a 45-degree
angl e (rather than verti cal or 90 degrees) wi th the bevel downward
to faci l i tate i njecti on i nto the sheath (Fi gure 3B). Pal pate the si te
wi th the nondomi nant (noni njecti ng) hand to confi rm i njecti on i nto
the sheath.
Page 771
(3) Insert the needl e unti l the ti p reaches the tendon, and then
back out the needl e 1 to 2 mm to faci l i tate i njecti on i nto the
sheath.
P.525
Move the fi nger i mmedi atel y after i njecti on to di stri bute the
steroi d. A bandage can be appl i ed over the i njecti on si te.
Nonsteroi dal anti i nfl ammatory medi cati on i s prescri bed for at l east
72 hours to reduce the chance of posti njecti on fl are (i .e., i ncreased
Page 772
pai n i nduced by the steroi d crystal s).
(4) Move the fi nger i mmedi atel y after i njecti on to di stri bute the
steroi d.
P.526
CODING INFORMATION
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Page 773
h
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Page 774
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Syri nges (1 or 3 mL), needl es (25 or 27 gauge, 5/8 i nch), and
al cohol swabs are avai l abl e from l ocal surgi cal suppl y houses or
pharmaci es. Steroi d sol uti ons are avai l abl e from manufacturers or
l ocal pharmaci es. Cel estone Sol uspan (betamethasone sodi um) i s
produced by Scheri ng-Pl ough, Keni l worth, NJ (
http://www.scheri ng-pl ough.com), Ari stocort (tri amci nol one
di acetate) and Ari stospan (tri amci nol one hexacetoni de) can be
obtai ned from Baxter-Lederl e, Deerfi el d, IL (http://www.baxter.com
); and Depo-Medrol (methyl predni sol one acetate) i s avai l abl e from
Pharmaci a Upjohn, Baski ng Ri dge, NJ (http://www.pharmaci a.com).
A suggested tray for performi ng soft ti ssue aspi rati ons and
i njecti ons i s l i sted i n Appendi x D Ski n preparati on recommendati ons
appear i n Appendi x H.
BIBLIOGRAPHY
Anderson B, Kaye S. Treatment of fl exor tenosynovi ti s of the hand
(tri gger fi nger ) wi th corti costeroi ds. Arch I ntern Med
1991;151:153156.
& Hal l Medi cal , 1997:164165.
Hol l ander JL. Arthrocentesi s and i ntrasynovi al therapy. In: McCarthy
DJ, ed. Arthri ti s, 9th ed. London: Henry Ki mptom Publ i shers,
Page 775
1979:402414.
Care 1986;13:579599.
Moore JS. Fl exor tendon entrapment of the di gi ts (tri gger fi nger and
tri gger thumb). J Occup Envi ron Med 2000;42:526545.
i njecti on. Cl i n Rheumatol Pract 1986;Mar-May:5263.
Rei sdorf GE, Hadl ey RN. Treatment of tri gger fi ngers and thumbs.
In: Benjami n RB, ed. Atl as of outpati ent and offi ce surgery, 2nd ed.
Phi l adel phi a: Lea & Febi ger, 1994:9296.
Retti g AC. Wri st and hand overuse syndromes. Cl i n Sports Med
2001;20:591611.
Sal dana MJ. Tri gger di gi ts: di agnosi s and treatment. J Am Acad
Orthop Surg 2001;9:246252.
Page 776
> Table of Cont ent s > Musculoskelet al Procedures > 66 - De Quervain's
Tenosynovit is Inject ion66
De Quervain's Tenosynovitis
Injection
Stenosi ng tenosynovi ti s of the short and l ong thumb abductor
tendons (i .e., abductor pol l i ci s l ongus and extensor pol l i ci s brevi s)
i s a common cause of dorsal wri st pai n near the radi al styl oi d.
Commonl y known as de Quervai n's tenosynovi ti s or di sease, the
condi ti on probabl y i s rel ated to overuse and chroni c mi crotrauma to
the fi rst dorsal compartment tendons as they pass through a
fi bro-osseous tunnel . Jobs that requi re repeti ti ve hand and wri st
moti on, especi al l y those wi th frequent thumb extensi on and
extreme l ateral wri st devi ati ons, i ncrease the ri sk of thi s di sorder.
Certai n sports (e.g., gol f, racquet sports, fi shi ng) have al so been
commonl y associ ated wi th the condi ti on. Gonococcal i nfecti on
hi stori cal l y was a cause of de Quervai n's di sease, but thi s i s a very
uncommon cause today.
De Quervai n's di sease produces marked di scomfort on gri ppi ng.
Ul nar devi ati on, as reproduced wi th Fi nkel stei n's test, causes
marked pai n. Vi si bl e swel l i ng often can be observed over the
abductor tendons, and pal pabl e crepi tus may be observed. Pai n,
tenderness, swel l i ng, and warmth over the dorsal wri st are common
features on exami nati on. Fi nkel stei n's test i s the cl assi c di agnosti c
maneuver to uncover the di sorder. The di fferenti al di agnosi s
i ncl udes wri st arthri ti s, Wartenberg's syndrome (i .e., radi al nerve
compressi on at the wri st), and i ntersecti on syndrome (i .e.,
tendoni ti s and associ ated bursi ti s of the dorsal wri st extensors).
Corti costeroi d i njecti on can resol ve or cure the condi ti on, especi al l y
i f gi ven earl y i n the course of the di sease. Some physi ci ans bel i eve
that i njecti on therapy offers the best prognosi s for i mprovement i n
symptoms. Many physi ci ans prefer to postpone i njecti ons unti l a
Page 777
tri al of physi cal therapy, anti i nfl ammatory medi cati on, and rest
(wi th or wi thout spl i nti ng or casti ng) have been prescri bed. Up to
three i njecti ons, gi ven at monthl y i nterval s, can be tri ed before
surgi cal referral for rel ease of the dorsal compartment.
INDICATIONS
Cl i ni cal l y apparent de Quervai n's di sease
P.528
Steroi d admi ni strati on i f cl i ni cal appearance of
gonococcal tenosynovi ti s
Bacteremi a or l ocal i zed cel l ul i ti s of wri st area
Uncontrol l ed di abetes
P.529
PROCEDURE
The two abductor tendons of the thumb can be observed outl i ni ng
the radi al border of the anatomi c snuff box. The tendons appear
promi nentl y when the thumb i s ful l y abducted.
Page 778
(1) Locati on of the two abductor tendons of the thumb: abductor
pol l i ci s l ongus tendon and extensor pol l i ci s brevi s tendon.
The thumb i s fl exed fi rml y i nto the pal m (Fi gure 2A). The remai ni ng
four fi ngers cl ose over the thumb, and then the wri st i s devi ated to
the ul nar si de (Fi gure 2B). Fi nkel stei n's test produces marked
di scomfort for most i ndi vi dual s wi th de Quervai n's di sease.
(2) Fi nkel stei n's test.
P.530
Identi fy the poi nt of maxi mal tenderness. After ski n preparati on,
the needl e enters the ski n at a 45-degree angl e (Fi gure 3A). The
needl e can enter the tendon sheath angl ed toward or away from the
hand. Insert the needl e unti l the ti p i s fel t to touch the tendon;
then wi thdraw the needl e ti p 1 to 2 mm. If the needl e ti p i s wi thi n
the tendon sheath, i njecti on wi l l offer no resi stance, and the
sheath can often be observed to di stend wi th fl ui d (Fi gure 3B).
Page 779
(3) Insert the needl e at a 45-degree angl e unti l the ti p i s fel t to
touch the tendon and then wi thdraw the needl e ti p 1 to 2 mm.
PITFALL: The tendon can be weakened by intratendinous
injection. Avoid injecting directly into the tendon. If the
physician is uncertain about the position of the needle tip, ask
the patient to abduct the thumb; slight movement of the tendon
produces marked movement of the syringe and needle.
A bandage i s pl aced over the i njecti on si te. Some physi ci ans
advocate l i mi ted acti vi ty and ni ghtti me spl i nti ng for 1 to 2 weeks
fol l owi ng the i njecti on. Nonsteroi dal anti i nfl ammatory medi cati ons
shoul d be taken for at l east 72 hours to reduce the i nci dence of
posti njecti on fl are (i .e., i ncreased pai n i nduced by the steroi d
crystal s).
Page 780
(4) Pl ace a bandage over the i njecti on si te, and ask pati ent to l i mi t
acti vi ty and appl y a spl i nt at ni ghtti me for 1 to 2 weeks fol l owi ng
the i njecti on.
P.531
CODING INFORMATION
C
P
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Page 781
nt
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Page 782
Ameri c
an
Medi ca
l
Associ
ati on.
Consul t the orderi ng i nformati on that appears i n Chapter 65. A
suggested tray for performi ng soft ti ssue aspi rati ons and i njecti ons
i s l i sted i n Appendi x D. Ski n preparati on recommendati ons appear
i n Appendi x H.
BIBLIOGRAPHY
Emerg Med 1991;23:7794.
Brown JS. Mi nor surgery: a text and atl as. London: Chapman & Hal l
Medi cal , 1997:165.
Hanl on DP. Intersecti on syndrome: a case report and revi ew of the
l i terature. J Emerg Med 1999;17:969971.
Kay NR. De Quervai n's di sease: changi ng pathol ogy or changi ng
percepti on? J Hand Surg Br 2000;25:6569.
Care 1986;13:579599.
Mani L, Gerr F. Work-rel ated upper extremi ty muscul oskel etal
di sorders. Pri m Care Cl i n Offi ce Pract 2000;27:845864.
Marx RG, Sperl i ng JW, Cordasco FA. Overuse i njuri es of the upper
extremi ty i n tenni s pl ayers. Cl i n Sports Med 2001;20:439451.
Retti g AC. Wri st and hand overuse syndromes. Cl i n Sports Med
2001;20:591611.
Page 783
Ri tchi e JV, Munter DW. Emergency department eval uati on and
treatment of wri st i njuri es. Emerg Med Cl i n North Am
1999;17:823842.
Wei ss AP, Akel man E, Tabatabai M. Treatment of DeQuervai n's
di sease. J Hand Surg Am 1994;19:595598.
Page 784
> Table of Cont ent s > Musculoskelet al Procedures > 67 - The Short Arm Cast 67
The Short Arm Cast
Pri mary care physi ci ans often have the opportuni ty to pl ace casts.
Pati ents wi th orthopedi c i njuri es commonl y present to pri mary care
offi ces, and casti ng may be performed i n the management of
uncompl i cated i njuri es spl i nted i n the emergency department.
Al though most di spl aced fractures are managed wi th orthopedi c
consul tati on, pri mary care physi ci ans manage many uncompl i cated
or nondi spl aced fractures. Properl y trai ned general i sts may al so
perform reducti ons and some i nternal fi xati on procedures.
Hi stori cal l y, the treatment of muscul oskel etal i njury i nvol ved rest
and i mmobi l i zati on of the i njured part. Over the past several
decades, studi es have demonstrated that bones and soft ti ssues
heal better wi th functi onal treatment, al l owi ng normal movement
whi l e preventi ng abnormal movement. Osteoporosi s of i mmobi l i zed
bone may be reduced or prevented by axi al l oadi ng or sti mul ati on
of the fracture as heal i ng occurs, and carti l age and l i gaments heal
better i f al l owed to move. The objecti ve of earl y fracture
management i s i mmobi l i zati on of the fracture fragments wi th
si mul taneous axi al l oadi ng and movement of nearby joi nts. Internal
fi xati on accompl i shes thi s goal , but the costs and ri sks of i nternal
fi xati on may be unreasonabl e for some fractures that can be
effecti vel y treated wi th external devi ces such as casts.
Casts are ci rcumferenti al , ri gi d, mol ded to fi t a body part, and do
not accommodate swel l i ng. Casts shoul d be appl i ed onl y after a
peri od of spl i nti ng, usual l y 2 to 14 days, to al l ow resol uti on of
swel l i ng. Casts can be appl i ed i mmedi atel y for a cl i ni cal si tuati on
i n whi ch swel l i ng i s i nsi gni fi cant, such as wi th a suspected
scaphoi d fracture. A cast never compl etel y i mmobi l i zes a fracture,
but i t provi des enough rel ati ve i mmobi l i zati on to al l ow a fracture to
heal . Casts provi de the addi ti onal benefi ts of pai n rel i ef, protecti on
Page 785
of surroundi ng ti ssues (e.g., vessel s, nerves) and mai ntenance of
posi ti on after reducti on of fracture fragments.
Pl aster of Pari s has been extremel y popul ar as a cast materi al
because of i ts ease of use, l ong shel f-l i fe, and l ow cost. Syntheti c
materi al s such as fi bergl ass provi de the benefi t of l i ght wei ght and
added strength, but at addi ti onal cost. The shel f-l i fe of some
syntheti c materi al s can be l ess than 6 months; the shel f-l i fe can be
extended by turni ng over the packages every few months to prevent
dryi ng. Two rol l s of 4-i nch pl aster or two rol l s of 2- or 3-i nch
fi bergl ass materi al are usual l y adequate for pl acement of a short
arm cast.
P.533
One of the most common i ndi cati ons for pl acement of a short arm
cast i s to i mmobi l i ze a suspected or occul t scaphoi d fracture or to
treat a nondi spl aced fracture. The potenti al harm and l ong-term
consequences of a mi ssed scaphoi d (navi cul ar) fracture are great.
Ini ti al radi ographs often are negati ve for scaphoi d fractures.
Casti ng for 10 to 14 days al l ows adequate ti me for earl y cal l us
formati on, whi ch can be seen on a fol l ow-up radi ograph.
Documented fractures hi stori cal l y have been treated wi th short
arm-thumb spi ca casts or l ong arm casts. New evi dence suggests
that si mpl e short arm casts may provi de better outcomes for
nondi spl aced scaphoi d fractures.
PRIMARY CARE INDICATIONS FOR A
GAUNTLET OR SHORT ARM CAST
Col l es' fracture (nondi spl aced or after reducti on)
Nondi spl aced metacarpal fractures
Torus (buckl e) or greensti ck fracture of the di stal radi us
Nondi spl aced or suspected scaphoi d fracture (refer i f
more than 1 mm of di spl acement)
Unfami l i ari ty wi th appropri ate methods or techni ques
Page 786
Fractures best managed by speci al ty referral or surgi cal
reducti on or i nterventi on
Improperl y functi oni ng equi pment (e.g., cast saw)
Infecti on i n ti ssues to be covered by a cast
Open fractures
Physi ci ans woul d be wi se to heed the 2001 gui del i nes for
physi otherapi sts i n Austral i a for the appl i cati on and removal of
casts
(http://www.physi oreg.heatl h.nsw.gov.au/hprb/physi o_web/pdf/pl as
ter.pdf).
P.534
PROCEDURE
When appl yi ng a cast, pl ace the i njured part i n a posi ti on of
functi on, unl ess al ternate posi ti oni ng i s requi red by the cl i ni cal
si tuati on. The posi ti on of functi on for the forearm and hand i nvol ve
pl aci ng the arm i n a handshake posi ti on; pronate the wri st about
20 degrees, fl ex the wri st 20 to 30 degrees, and fl ex the
metacarpophal angeal and phal angeal joi nts as i f hol di ng a 1- or
2-i nch pol e i n the pal m.
(1) When appl yi ng a cast, pl ace the i njured part i n a posi ti on of
functi on unl ess al ternate posi ti oni ng i s requi red by the cl i ni cal
Page 787
si tuati on.
P.535
A si ngl e l ayer of stocki nette i s appl i ed. Cut the stocki nette l ong
enough so that i t goes from the el bow to the di stal i nterphal angeal
joi nt of the thi rd fi nger (Fi gure 2A). The extra l ength on each end
hel ps to create smooth edges on the cast. Cut a hol e for the thumb
(Fi gure 2B).
(2) Appl y a si ngl e l ayer of stocki nette from the el bow to the di stal
i nterphal angeal joi nt of the thi rd fi nger, and cut a hol e for the
thumb.
P.536
Appl y the cast paddi ng, begi nni ng i nch i nsi de one end of the
Page 788
stocki nette and proceedi ng to wi thi n 1 i nch of the other end (Fi gure
3A). The cast paddi ng i s appl i ed to a doubl e thi ckness by
overl appi ng the rol l 50% each turn (Fi gure 3B). Appl y the paddi ng
and cast materi al wi th the thenar emi nence, keepi ng the rol l fl at
(l i ke unrol l i ng carpet) and not reversed to avoi d droppi ng the rol l
duri ng appl i cati on (Fi gure 3C). Appl y the paddi ng hal fway onto the
thumb; the excess i s fol ded back i nto the cast, provi di ng paddi ng
at the base of the thumb.
Page 789
(3) Appl y the cast paddi ng, begi nni ng i nch i nsi de one end of
the stocki nette and proceedi ng to wi thi n an i nch of the other end.
Page 790
PITFALL: Do not overpad, because this makes the cast loose.
PITFALL: Some extra padding should be applied over bony
prominences to avoid injury under the cast. An extra roll over
the ulnar styloid can avoid problems at this site.
P.537
As an al ternate opti on, a waterproof cast l i ner made up of mul ti pl e
square cushi ons can be appl i ed under fi bergl ass casts. Thi s l i ner
al l ows i ndi vi dual s to bathe or swi m wi th a short arm fi bergl ass
cast. The waterproof cast l i ner repl aces the stocki nette and cast
paddi ng and i s rol l ed di rectl y on the ski n wi th overl appi ng rol l s.
After swi mmi ng i n chl ori nated pool s or sal t water, the cast i s
ri nsed, and i t dri es i n 30 to 60 mi nutes.
(4) A waterproof cast l i ner made up of mul ti pl e square cushi ons can
be appl i ed under fi bergl ass casts, whi ch al l ows the pati ent to swi m
or bathe.
Pl ace the pl aster or fi bergl ass rol l i n l ukewarm or room temperature
water. Al l ow the pl aster to si t i n the water a few seconds, unti l the
bubbl i ng ceases. Remove the rol l , and gentl y twi st or gentl y
squeeze the rol l to remove excess water.
Page 791
(5) Pl ace the pl aster or fi bergl ass rol l i n l ukewarm water, and al l ow
i t to si t for a few seconds unti l the bubbl i ng ceases.
PITFALL: Never use hot water, which can cause an excess
thermochemical reaction and extremely rapid setting of the cast
material. The cast material should never be wrung out.
P.538
Begi n at the proxi mal end of the forearm, at l east 2 i nches from
the el bow to avoi d compromi se of el bow fl exi on (Fi gure 6A). After
the fi rst ci rcumferenti al rol l around the forearm, fol d back the
excess stocki nette and paddi ng over the cast materi al . Rerol l over
thi s fol ded materi al , i nch from the edge of the fol ded paddi ng,
to create a smooth edge of cast materi al and soft edge of paddi ng
above the cast materi al (Fi gure 6B).
Page 792
(6) Begi n appl yi ng the fi bergl ass rol l at the proxi mal end of the
forearm at l east 2 i nches from the el bow to avoi d compromi se of
el bow fl exi on.
P.539
Rol l the cast materi al wi th moderate tensi on, appl yi ng i t i n the
same manner as the cast paddi ng, from one end to the other and
overl appi ng 50% of the pri or turn. When appl yi ng pl aster over
Page 793
tapered parts, tucks or pl eats may be needed to avoi d ri dges or
creases.
(7) Rol l the cast materi al wi th moderate tensi on, appl yi ng i t i n the
same manner as the cast paddi ng, from one end to the other and
overl appi ng 50% of the pri or turn.
P.540
Appl y the materi al to the l evel of the pati ent's mi d-pal m, over the
proxi mal pal mar crease. Fol d back the stocki nette and paddi ng, and
then rerol l a smooth edge that angl es across the pal m. To al l ow
movement of the fi fth fi nger, the cast edge must angl e downward
across the pal m, not strai ght across. Do not appl y the cast materi al
onto the thumb.
Page 794
(8) Appl y the materi al to the l evel of the pati ent's mi d-pal m over
the proxi mal pal mar crease.
PITFALL: The most common mistake made by novice physicians
is to apply the cast to the metacarpophalangeal joints. All
fingers need to be able to flex 90 degrees, and this means that
the cast should end well short of the metacarpophalangeal
joints.
PITFALL: If the cast material creates a sharp edge at the base
of the thumb, trim the edge with casting scissors or the cast
saw.
P.541
Whi l e the pl aster or fi bergl ass i s setti ng, contour and mol d the
materi al wi th the pal ms of the hands (Fi gure 9A). After the materi al
Page 795
sets, make sure a fi nger can be i nserted easi l y under the cast edge
at each end (Fi gure 9B). Make sure the cast edge i s padded at the
base of the thumb. Gi ve the pati ent adequate fol l ow-up
i nstructi ons (Tabl e 67-1).
(9) Contour and mol d the casti ng materi al wi th the pal ms of your hands whi l e the pl aster or fi bergl ass i s setti ng, maki ng sure that a
fi nger can be easi l y i nserted under each end of the cast.
TABLE 67-1. INSTRUCTIONS FOR CAST CARE
Page 796

1.
El evate the cast for 24 to 48 hours to reduce swel l i ng beneath the cast. Avoi d grabbi ng or damagi ng the cast i n the fi rst 24
hours.
2.
Watch for si gns of swel l i ng or probl ems beneath the cast. Pai n i s usual l y an earl y i ndi cati on of a probl em. To watch for
ci rcul ati on probl ems, exami ne the fi ngernai l s. If the nai l s appear pal e or bl ue or fai l to bl anch (i .e., turn whi te and then pi nk
after bl ood returns) when squeezed, cal l your physi ci an.
3.
Keep the cast dry i f i t i s a pl aster cast. If a waterproof cast l i ner i s appl i ed beneath a fi bergl ass cast, swi mmi ng or bathi ng i s
permi tted. However, dry out the cast (i .e., use a bl ow dri er set on cool or l ow, di rected beneath each end) soon after to prevent
ski n trauma or macerati on.
4.
Do not pl ace anythi ng i nsi de the cast. Many i ndi vi dual s i ncorrectl y try to rel i eve i tchi ng wi th penci l s, pens, coat hangers, or
ki tchen utensi l s. Bl ow warm ai r wi th a hai rdryer, appl y an i ce pack, or take Benadryl (25 mg) to hel p al l evi ate i tchi ng.
5.
Do not damage the cast, cut i nto the cast, or modi fy the cast. If the cast i nadvertentl y breaks or becomes too l oose, report ri ght
away to your physi ci an for cast repai r.

P.542
Cast removal i s performed wi th a vi brati ng cast saw. The serrated
edge on the cast saw (Fi gure 10A) can i njure the ski n beneath the
cast or burn the pati ent. The bl ade heats up as i t vi brates through
cast materi al ; i t gets warmer wi th thi cker casts or fi bergl ass
materi al . The cast saw cuts by up-and-down moti on as i t moves
from one end of the cast to the other (Fi gure 10B). Make a cut
al ong the ul nar si de of the cast; enl arge the openi ng wi th a cast
spreader (Fi gure 10C). Careful l y cut the paddi ng beneath the cast
usi ng cast sci ssors, avoi di ng i njury to underl yi ng ski n. (Fi gure 10D).
If the arm cannot easi l y sl i p out of the cast, a second cut may be
requi red down the radi al si de of the cast.
Page 797
(10) Removal of the cast i s accompl i shed by usi ng a vi brati ng cast
saw.
P.543
Page 798
CODING INFORMATION
These codes are used onl y for cast or spl i nt reappl i cati ons duri ng a
fol l ow-up peri od. The i ni ti al casti ng or spl i nti ng i s consi dered part
of the fracture management code. If no management code i s
reported, the cast appl i cati on can be reported at the i ni ti al servi ce.
A suppl y code (99070) may be reported i n addi ti on to the cast code
to hel p defray the cost of materi al s (esti mated at $12 to $20 for
pl aster casts, $20 to $50 for fi bergl ass casts). Insurance such as
Medi cai d may not cover the cost of materi al s.
C
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Page 799
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The 2-, 3-, or 4-i nch rol l s of cotton or acryl i c cast paddi ng, cotton
or acryl i c stocki net, pl aster bandages, and fi bergl ass cast tape can
be ordered from DePuy OrthoTech, Tracy, CA (
http://www.depuy.com); Ray-Tek Inc. fracture management suppl i es
(http://www.ray-tek.com); and 3M Heal th Care, St. Paul , MN
(phone: 800-228-3957; http://www.3M.com/heal thcare). Cast
removal tool s such as sci ssors, cast spreaders, and Stryker cast
saws can be obtai ned from Appl i es Medi cal Servi ce, Inc, Knoxvi l l e,
TN (http://www.appl i edmedi cal i nc.com). Procel l cast l i ner (formerl y
Gore cast l i ner) i s a waterproof, breathabl e, qui l ted cast paddi ng
that al l ows i ndi vi dual s to bathe and swi m whi l e the fracture heal s.
De-fl ex Protecti ve Stri p i s a cut-resi stant removal ai d that provi des
protecti on from the cuts and burns from cast saws. It can be
ordered from W.L. Gore & Associ ates, Fl agstaff, AZ (phone:
800-248-8489; http://www.goremedi cal .com).
Page 801
BIBLIOGRAPHY
Burge P. Cl osed case treatment of scaphoi d fractures. Hand Cl i n
2001;17:541552.
Byl NN, Kohl hase W, Engel G. Functi onal l i mi tati on i mmedi atel y
after cast i mmobi l i zati on and cl osed reducti on of di stal radi us
fractures: prel i mi nary report. J Hand Ther 1999;12:201211.
Dahners LE, Al meki nders LC, Di rschl DR. Traumati c di sorders. In:
Wi l son FC, Li n PP, eds. General orthopedi cs. New York:
McGraw-Hi l l , 1997:327391.
Davi dson JS. Si mpl e treatment for torus fractures of the di stal
radi us. J Bone Joi nt Surg Br 2001;83:11731175.
Gei ssl er WB. Carpal fractures i n athl etes. Cl i n Sports Med
2001;20:167188.
Hanel DP, Jones MD, Trumbl e TE. Wri st fractures. Orthop Cl i n North
Am 2002;33:3557.
Kal b RL. Offi ce management of di stal radi al fractures. Hosp Pract
1999;34:131137.
Ki l l i an JT, Whi te S, Lenni ng L. Cast-saw burns: compari son of
techni que versus materi al versus saws. J Pedi atr Orthop
1999;19:683687.
Lewi s DM, Osterman AL. Scaphol unate i nstabi l i ty i n athl etes. Cl i n
Sports Med 2001;20:131140.
P.544
Medl ey ES, Shi rl ey SM, Bri l l i ant HL. Fracture management by fami l y
physi ci ans and gui del i nes for referral . J Fam Pract
1979;8:701710.
ed. St. Loui s: Mosby, 1995:1419.
Phi l bi n TM. Hybri d casts: a compari son of di fferent casti ng
materi al s. J Am Osteopath Assoc 1999;99:311312.
Ri tchi e JV, Munter DW. Emergency department eval uati on and
treatment of wri st i njuri es. Emerg Med Cl i n North Am
1999;17:823842.
Page 802
Spai n D. Casti ng acute fractures. Part 1. Commonl y asked
questi ons. Aust Fam Physi ci an 2000;29:853856.
Vi l l ari n LA, Bel k KE, Frei d R. Emergency department eval uati on and
treatment of el bow and forearm i njuri es. Emerg Med Cl i n North Am
1999;17:843858.
Zemel NP. Pi npoi nti ng the cause of wri st i njuri es i n athl etes. J
Muscul oskel et Med 1996;13:5666.
Page 803
> Table of Cont ent s > Musculoskelet al Procedures > 68 - The Short Leg Cast 68
The Short Leg Cast
Pri mary care physi ci ans frequentl y encounter fractures of the l ower
extremi ty. Improved orthoti c braci ng, surgi cal procedures, and
nonsurgi cal techni ques have transformed the treatment of l ower
extremi ty fractures. Despi te these advances, pl acement of short l eg
casts i s a cost-effecti ve i nterventi on for many l ower extremi ty
fractures and muscul oskel etal di sorders i n pri mary care practi ce.
Improved fracture heal i ng occurs wi th functi onal treatment,
al l owi ng normal movement of the l ower extremi ty whi l e l i mi ti ng
abnormal movement. Functi onal treatment provi des i mproved and
more rapi d heal i ng of the fracture si te through the sti mul ati on of
axi al l oadi ng (i .e., ambul ati on). Functi onal treatment al so produces
i mproved carti l age repai r from joi nt moti on and i mproved tendon
functi on, and i t reduces the osteoporosi s i nduced by
i mmobi l i zati on.
Immobi l i zati on i s the major benefi t of casti ng, al l owi ng for
stabi l i zati on and bone cal l us formati on. Casts al so provi de pai n
rel i ef, mai ntai n posi ti on after reducti on of a fracture, and protect
the soft ti ssues surroundi ng the fracture si te. Because casts are
ri gi d and ci rcumferenti al , they general l y shoul d not be appl i ed
i mmedi atel y after a fracture. Fractures can produce a si gni fi cant
amount of bl eedi ng and swel l i ng, and the cast can compromi se
vascul ar fl ow to the ti ssues i f si gni fi cant swel l i ng i ncreases i n the
ti ssues beneath a ri gi d cast. Most l ower extremi ty fractures shoul d
be spl i nted for at l east 72 hours before cast pl acement i s
attempted.
Pl aster of Pari s has been extensi vel y used hi stori cal l y to achi eve
i mmobi l i zati on. Pl aster i s easy to use and i nexpensi ve. Wal ki ng
short l eg casts experi ence extensi ve stress from wei ght beari ng,
and when composed of pl aster, these casts requi re added spl i nt
Page 804
materi al i ncorporated wi thi n the cast to enhance durabi l i ty. Spl i nt
enhancement can be i ncorporated wi thi n fi bergl ass casts, but the
i ncreased strength of the fi bergl ass materi al usual l y i s adequate.
A waterproof cast l i ner made of mul ti pl e square cushi ons can be
used i n pl ace of stocki nette and gauze beneath fi bergl ass casts
(see Chapter 67). The cast l i ner al l ows i ndi vi dual s to shower,
bathe, and swi m when weari ng the cast. The l i ner works wel l i n
forearm casts but can bunch up i n the heel i n short l eg wal ki ng
casts. Seal -ti ght cast covers may provi de a better opti on to permi t
bathi ng for i ndi vi dual s wi th short l eg casts.
Three rol l s of 4- to 6-i nch pl aster or 4-i nch fi bergl ass materi al are
usual l y adequate for a short l eg casts. The extra cast materi al
i ncorporated i nto a short l eg
P.546
cast requi res addi ti onal ti me duri ng removal . The cast saw bl ade
al so generates addi ti onal heat when cutti ng through thi cker
materi al , especi al l y fi bergl ass. The practi ti oner shoul d avoi d tryi ng
to cut off the cast posteri orl y where the addi ti onal spl i nti ng i s
pl aced and shoul d al l ow addi ti onal ti me for the cast saw bl ade to
cool to avoi d pati ent burns. A protecti ve stri p can be pl aced
beneath the cast to protect the pati ent's ski n duri ng cast removal .
The stri ps do not add bul k to the cast and shoul d be consi dered i n
chi l dren's casts.
PRIMARY CARE INDICATIONS FOR A SHORT
LEG CAST
Nondi spl aced, stabl e ankl e (uni mal l eol ar) fractures
Metatarsal fractures
Proxi mal fi fth metatarsal fractures, arti cul ar (avul si on;
usual l y wei ght-beari ng cast)
Proxi mal fi fth metatarsal fractures, nonarti cul ar (Jones'
fractures; usual l y non-wei ght-beari ng cast)
Tarsal fractures (not tal ar neck fractures)
Stabl e, nondi spl aced di stal fi bul ar fractures
Page 805
Hi gh ankl e sprai n (torn di stal ti bi ofi bul ar l i gament)
Nondi spl aced fractures of the body of the cal caneus
Unfami l i ari ty wi th appropri ate methods or techni ques
Fractures that are outsi de the experti se of the treati ng
physi ci an (best managed by speci al ty referral or surgi cal
reducti on or i nterventi on)
Improperl y functi oni ng equi pment (e.g., cast saw)
Infecti on i n the ti ssues to be covered by the cast
Open fractures
Practi ti oners woul d be wi se to heed the 2001 gui del i nes for
physi otherapi sts i n Austral i a for the appl i cati on and removal of
casts (
http://www.physi oreg.heal th.nsw.gov.au/hprb/physi o_web/pdf/pl ast
er.pdf).
P.547
PROCEDURE
When appl yi ng a cast, pl ace the i njured part i n the posi ti on of
functi on, unl ess al ternate posi ti oni ng i s requi red by the cl i ni cal
si tuati on. The posi ti on of functi on for the foot i s wi th the toes hel d
hori zontal and the ankl e i n neutral dorsi fl exi on and pl antar fl exi on
(i .e., foot i s 90 degrees to the l ower l eg) and i n neutral eversi on
and i nversi on (Fi gure 1A). Thi s posi ti oni ng i s cri ti cal to mai ntai n
throughout cast appl i cati on; pai n and swel l i ng may cause the foot
to dangl e. An assi stant can grasp the toes duri ng cast appl i cati on
to mai ntai n the ankl e-foot posi ti on (Fi gure 1B). Al ternatel y, the
practi ti oner can wear a pl asti c apron and l ean agai nst the foot wi th
the torso to mai ntai n posi ti on of the foot whi l e l eavi ng the hands
free to appl y the cast (Fi gure 1C).
Page 806
(1) Pl ace the i njured part i n the posi ti on of functi on whi l e appl yi ng
the cast unl ess the cl i ni cal posi ti on requi res al ternate posi ti oni ng.
PITFALL: Do not let the foot dangle. If the cast is placed and the
foot is not 90 degrees to the lower leg, the heel will be elevated.
Weeks in a cast in this position can cause significant shortening
of the Achilles' tendon.
P.548
Page 807
Appl y a si ngl e l ayer of stocki nette from the end of the toes to the
knee (Fi gure 2A). The extra l ength on each end hel ps to smooth the
ends of the cast. Because the stocki nette i s i n di rect contact wi th
ski n, do not l eave any bunched-up stocki nette. Cut out a thi n oval
of overl appi ng stocki nette where the dorsal foot meets the l ower
l eg (Fi gure 2B).
(2) Appl y a si ngl e l ayer of stocki nette from the end of the toes to
Page 808
the knee, and cut out a thi n oval of overl appi ng stocki nette where
the dorsal foot meets the l ower l eg.
P.549
Appl y the cast paddi ng. Begi n i nch i nsi de one end of the
stocki nette and proceed to wi thi n an i nch of the other end. The
cast paddi ng i s appl i ed to a doubl e thi ckness by overl appi ng the
rol l 50% on each turn (Fi gure 3A). If desi red, appl y the paddi ng
(and cast materi al ) wi th the thenar emi nence, keepi ng the rol l fl at
(l i ke unrol l i ng carpet) and not reversed to avoi d droppi ng the rol l
duri ng appl i cati on (Fi gure 3B). Appl y the protecti ve stri ps down one
or both l ateral si des of the cast at thi s ti me (Fi gure 3C).
Page 809
(3) Begi n by appl yi ng the cast paddi ng.
PITFALL: Do not overpad, because this makes the cast too
loose.
PITFALL: Extra padding should be applied over bony
prominences to avoid injury to these sites under the cast. Break
off two 6-inch sections of padding, and place them over the
Page 810
malleoli and over the metatarsal heads on the plantar surface.
P.550
Pl ace the pl aster or fi bergl ass rol l i n l ukewarm or room temperature
water. Al l ow the pl aster to si t i n the water for a few seconds unti l
the bubbl i ng ceases. Remove the rol l , and gentl y twi st or gentl y
squeeze the rol l to remove excess water.
(4) Pl ace the pl aster or fi bergl ass rol l i n l ukewarm water, and al l ow
i t to si t for a few seconds unti l the bubbl i ng ceases.
PITFALL: Never use hot water, which can cause an exaggerated
thermochemical reaction and extremely rapid setting of the cast
material. The cast material should never be wrung out.
P.551
Page 811
Begi n on the upper porti on of the l ower l eg at l east 2 to 3
fi ngerbreadths bel ow the fi bul ar head (Fi gure 5A). The upper
porti on of the cast shoul d be wel l bel ow the knee joi nt. Rol l the
cast materi al wi th moderate tensi on, appl yi ng i t i n si mi l ar fashi on
to the cast paddi ng, from one end to the other. Overl ap 50% of
each pri or rol l . The cast materi al i s rol l ed to just proxi mal to the
toes. Angl e the appl i cati on so that the toes can al l fl ex and move
but al l metatarsal heads are covered (Fi gure 5B).
(5) Begi n appl yi ng the pl aster or fi bergl ass rol l at l east 2 to 3
fi ngerbreadths bel ow the fi bul ar head, and rol l the materi al wi th
Page 812
moderate tensi on, appl yi ng i t i n a si mi l ar fashi on to the cast
paddi ng, from one end to the other.
PITFALL: A common and dangerous mistake is to apply the cast
too high, so that the upper edge of the cast impinges on the
peroneal nerve as it passes behind the fibular head. The upper
edge of the cast must be well below the fibular head.
P.552
Appl y the extra posteri or spl i nt materi al at thi s ti me i f the cast wi l l
be a wei ght-beari ng cast, and certai nl y i f pl aster i s used. Si x-i nch
spl i nt materi al that i s about i nch thi ck i s used for adul ts. Pl ace
the spl i nt materi al from the metatarsal heads, over the back of the
ankl e, and up the posteri or cal f. Mol d the spl i nt so that i t adheres
and conforms to the fi rst appl i ed rol l .
(6) If the cast wi l l be wei ght beari ng or i f pl aster i s bei ng used,
appl y extra posteri or spl i t materi al from the metatarsal heads, over
the back of the ankl e, and up the posteri or cal f.
PITFALL: The ankle must be maintained in dorsiflexion to keep
the 90-degree angle for the foot. The first roll of cast material is
rapidly setting, and if the correct position is not maintained at
this stage, the cast will maintain the foot in an incorrect
position.
P.553
Page 813
Appl y a second rol l over the previ ous rol l on the upper porti on of
the l ower l eg and spl i nt materi al (Fi gure 7A). After the fi rst
ci rcumferenti al rol l , fol d back the excess stocki nette and paddi ng
over the cast materi al . Rerol l over thi s fol ded materi al -1i nch
from the edge of the fol ded paddi ng to create a smooth edge of
cast materi al and soft edge of paddi ng above the cast materi al
(Fi gure 7B).
(7) Appl y a second rol l over the upper porti on of the l ower l eg and
spl i nt materi al .
P.554
Page 814
Rol l down the l eg. Make sure the cast materi al adequatel y covers
the heel area (Fi gure 8A). Excess materi al can be fol ded back wi th
tucks or pl eats to avoi d ri dges or creases (Fi gure 8B).
(8) Rol l down the l eg, maki ng sure the cast materi al adequatel y
covers the heel area.
P.555
Page 815
On reachi ng the di stal end of the cast, rol l the materi al over the
metatarsal heads to cover the pri or rol l and spl i nt materi al . Fol d
back the cast paddi ng and stocki nette to reveal the toes, and then
rerol l to create a smooth di stal end to the cast.
(9) Rol l the materi al over the metatarsal heads to cover the pri or
rol l and spl i nt materi al .
Whi l e the cast materi al i s setti ng, contour or mol d the materi al
wi th the pal ms of the hands posi ti oned on opposi te si des of the
cast. After the materi al sets, make sure a fi nger can be i nserted
easi l y under the cast edge at each end. Gi ve the pati ent adequate
fol l ow-up i nstructi ons (see Chapter 67). The pati ent shoul d wear a
cast shoe. Crutches shoul d be used for 24 hours to al l ow pl aster
cast materi al to set and achi eve adequate strength for ambul ati on.
Page 816
(10) Contour the cast materi al whi l e i t i s setti ng, maki ng sure a
fi nger can be easi l y i nserted under each end of the cast edge.
P.556
Cast removal i s performed wi th a vi brati ng saw. Appl i cati on of a
protecti ve stri p down one or both l ateral si des of the cast can hel p
prevent i njury. The saw i s i nserted wi th up-and-down moti on as i t
cuts through the cast materi al (Fi gure 11A). After the cast i s cut
from one end to the other, a cast spreader wi dens the openi ng
(Fi gure 11B). Cast sci ssors can be used to cut the underl i ng
stocki nette and paddi ng, wi th extra care used to avoi d i njuri ng the
pati ent's ski n. If the ankl e cannot easi l y sl i p out of the cast,
perform a cut on the opposi te surface to faci l i tate removal (Fi gure
11C).
Page 817
Page 818
(11) Use a vi brati ng saw to remove the cast.
P.557
CODING INFORMATION
These codes are used onl y for cast or spl i nt reappl i cati on duri ng a
peri od of fol l ow-up. The i ni ti al casti ng or spl i nti ng i s consi dered
part of the fracture management code. If no management code i s
reported, the cast appl i cati on can be reported at the i ni ti al servi ce.
A suppl y code (99070) may be reported i n addi ti on to the cast code
to hel p defray the cost of materi al s (esti mated at $12 to $20 for
pl aster casts, $20 to $50 for fi bergl ass casts, and $5 to $12 for
cast shoes). Insurance such as Medi cai d may not cover the cost of
materi al s.
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Page 819
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Page 821
ark of
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Cast care i nstructi ons and cast materi al s orderi ng i nformati on
appears i n Chapter 67.
Speci fi c materi al s rel ated to short l eg casts i ncl ude cast shoes
(vari ous materi al s, si zes, col ors) at an acqui si ti on cost of $5 to $15
from Darby Drug Co, Inc., Westbury, NY (http://www.darbydrug.com
). Seal -ti ght cast covers, creati ng a waterproof seal usi ng a
nonl atex di aphragm that fi ts over the upper l eg and attaches to a
pol yvi nyl bag, al l ow dai l y bathi ng and showeri ng whi l e preventi ng
water penetrati on. The acqui si ti on cost i s approxi matel y $21 for a
reusabl e cover, whi ch can be obtai ned from Brown Medi cal
Industri es, Spi ri t Lake, IA (http://www.brownmed.com). De-fl ex
protecti ve stri p i s a cut-resi stant removal ai d that provi des
protecti on from the cuts and burns from cast saws. The stri p does
not add bul k to the cast and can be ordered from W. L. Gore &
Associ ates, Fl agstaff, AZ (http://www.goremedi cal .com).
BIBLIOGRAPHY
Dabezi es E, D'Ambrosi a RD, Shoji H. Cl assi fi cati on and treatment of
ankl e fractures. Orthopedi cs 1978;1:365373.
Dahners LE, Al meki nders LC, Di rschl DR. Traumati c di sorders. In:
Wi l son FC, Li n PP, eds. General orthopedi cs. New York:
McGraw-Hi l l , 1997:327391.
Hough DO. Ankl e fractures. In: Rakel RE, ed. Saunders manual of
medi cal practi ce. Phi l adel phi a: WB Saunders, 1996:833834.
Page 822
Ki l l i an JT, Whi te S, Lenni ng L. Cast-saw burns: compari son of
techni que versus materi al versus saws. J Pedi atr Orthop
1999;19:683687.
Medl ey ES, Shi rl ey SM, Bri l l i ant HL. Fracture management by fami l y
physi ci ans and gui del i nes for referral . J Fam Pract
1979;8:701710.
Neyl an VD. The pai nful foot: a pri mer. Emerg Med
1998;30:72103.
P.558
Ni ehoff JM. Casti ng techni ques. In: Rakel RE, ed. Saunders manual
of medi cal practi ce. Phi l adel phi a: WB Saunders, 1996:835837.
Sammarco GJ. Be al ert for Jones fractures. Phys Sportsmed
1992;20:101110.
Steel e PM, Bush-Joseph C, Bach B. Management of acute fractures
around the knee, ankl e, and foot. Cl i n Fam Pract 2000;2:661705.
Wedmore IS, Charette J. Emergency department eval uati on and
treatment of ankl e and foot i njuri es. Emerg Med Cl i n North Am
2000;18:85113.
Yu WD, Shapi ro MS. Fractures of the fi fth metatarsal : careful
i denti fi cati on for opti mal treatment. Phys Sportsmed
1998;26:4764.
Page 823
> Table of Cont ent s > Musculoskelet al Procedures > 69 - Ext ensor Tendon Repair
69
Extensor Tendon Repair
Al l l acerati ons to the hands or feet must be careful l y exami ned for
underl yi ng tendon i njury. To fi nd such i njuri es, exami ne the pati ent
for a functi onal defi ci t of the anatomi c part. Fl exor tendon i njuri es
of the hand requi re compl ex speci al i zed repai rs and shoul d be
promptl y referred to a surgi cal hand speci al i st. Al though many
extensor tendon i njuri es may al so requi re speci al i zed repai r,
extensor i njuri es to the dorsum of the hand (Verdan cl assi fi cati on
zone VI) may often be treated i n the offi ce or emergency
department.
Even wi th normal functi on on fi nger exami nati on, a tendon may be
parti al l y l acerated. Unrepai red parti al tendon l acerati ons can resul t
i n del ayed rupture 1 to 2 days after the i ni ti al i njury. Repai r any
tendon that i s more than 50% transected. If onl y a mi ni mal
l acerati on i s di scovered, appl y a spl i nt for 3 weeks, fol l owed by
passi ve moti on exerci ses for 2 to 3 weeks.
A tendon that angl es around curves, pul l eys, or joi nts i s surrounded
by a thi n tendon sheath. A l acerated tendon wi thi n an i ntact sheath
often wi l l not heal . If the sheath i s absent or severed, the proxi mal
part of the tendon wi l l grow i n an attempt to reattach to the di stal
porti on, often resul ti ng i n adherence to surroundi ng structures.
Adhesi ons are part of the repai r process, and they occasi onal l y may
i nterfere wi th functi on. Pati ents who are compl i ant wi th
i nstructi ons and moti vated toward rehabi l i tati on usual l y have a
greater chance of a good outcome after tendon repai r.
When the tendon i s cut compl etel y through, the ends may retract a
si gni fi cant di stance from the si te of trauma. Careful exami nati on
and extensi on of the i nci si on may be necessary to i denti fy both
ends. However, extensor tendons on the dorsum of the hand are
Page 824
cross-l i nked and usual l y do not retract to the same degree as fl exor
tendons. Duri ng the fi rst 2 weeks of heal i ng, a repai red tendon
devel ops a fi brobl asti c bul bous connecti on. Organi zed tendon
col l agen usual l y does not begi n to form unti l the thi rd week. By the
end of the fourth week, swel l i ng and vascul ari ty markedl y decrease.
After the swel l i ng has abated and the juncti on becomes strong, the
tendon can ful l y perform i ts gl i di ng moti on.
For tendon repai rs to be successful , the tendons must be covered
wi th heal thy ski n. Ski n grafti ng shoul d be performed when there i s
a si gni fi cant area of ski n avul si on or necrosi s. Tendon i njuri es that
are compl i cated by ti ssue macerati on, contami nati on, or passage of
more than 8 hours shoul d be treated i n the operati ng room.
P.560
Uncontrol l ed moti on of the hand duri ng the fi rst 3 weeks after
repai r often resul ts i n rupture or attenuati on of the repai r.
Cl assi cal l y, the repai red tendons are i mmobi l i zed for 1 week to
prevent rupture and to promote heal i ng. Pl ace a pl aster spl i nt on
the pal mar surface from the forearm to the fi ngerti ps. Pl ace the
wri st i n 30 degrees of extensi on, the metacarpophal angeal joi nts i n
20 degrees of fl exi on, and the fi ngers i n sl i ght fl exi on. Keep the
fi ngers from fl exi ng duri ng spl i nt changes. Acti ve moti on i s started
after 5 to 14 days to i mprove the fi nal strength of the repai r.
Physi cal and occupati onal therapy consul tati on i s usual l y hel pful .
Strong heal i ng can be observed as earl y as 6 weeks after the
tendon repai r. Some centers have shown that earl y, l i mi ted,
control l ed moti on usi ng speci al i zed orthoti cs may i mprove
outcomes (see Chow et al ., 1989).
Extensor tendon i njuri es over fi ngers (Verdan cl assi fi cati on zones I
through IV) i nvol ve compl ex structures and often resul t i n poor
heal i ng wi th offi ce repai r. Because these tendons l i e cl ose to the
joi nt capsul e, any compl ete tendon l acerati on over a joi nt shoul d
rai se the suspi ci on of joi nt capsul e i njury and shoul d be treated i n
the operati ng room. Lacerati ons di rectl y over the
Page 825
metacarpophal angeal joi nts (zone V) may be successful l y repai red
i n the offi ce by ski l l ed surgeons. Zone VI repai rs are the most
commonl y performed repai rs by pri mary care physi ci ans.
Possi bl e compl i cati ons of tendon repai r i ncl ude l ocal i nfecti on,
fi nger contracture, del ayed tendon rupture, or l ocal adhesi ons.
Pati ents wi th associ ated di gi tal fractures or wi th ragged l acerati ons
tend to have poorer resul ts.
INDICATIONS
Parti al l y l acerated extensor tendon i n the dorsum of the
hand
Transected extensor tendon i n the dorsum of the hand
CONTRAINDICATIONS
Tendon i njuri es associ ated wi th ti ssue macerati on
Tendon i njuri es associ ated wi th contami nati on
Tendon i njuri es more than 8 hours ol d
Extensor tendon i njuri es over the dorsum of the fi ngers,
and fl exor tendon i njuri es (referred to hand surgeon)
P.561
PROCEDURE
Exami ne the hand l acerati on, and i denti fy the ends of the tendon.
If the ends of the tendon have retracted from the ski n i nci si on,
extend the fi ngers to push the tendon ends back to the i nci si on
si te.
Page 826
(1) Exami ne the l acerati on, and i denti fy the ends of the tendon.
P.562
Perform a di rect end-to-end repai r of extensor tendon. The Kessl er
techni que i nvol ves passi ng a 4-0 nyl on, stai nl ess steel , or Dacron
suture i nto the cut end and exi ti ng on the proxi mal si de (Fi gure
2A). An external i zed l oop i s then made; the suture traverses the
tendon (Fi gure 2B), makes another external l oop, and fi nal l y exi ts
the proxi mal cut end (Fi gure 2C). The opposi te (di stal ) end of the
cut tendon i s sutured i n a l i ke manner (Fi gure 2D, expl oded vi ew).
Pl ace the knot i nsi de the repai red tendon. Fi ni sh the repai r wi th a
runni ng 6-0 nyl on suture to provi de addi ti onal stabi l i ty (Fi gure 2E).
The approxi mated tendon ends shoul d not be buckl ed or excessi vel y
compressed. A fl at end-to-end repai r promotes proper heal i ng and a
return of the proper gl i di ng acti on of the tendon.
Page 827
(2) The Kessl er techni que.
PITFALL: Do not use this technique to repair extensor tendons
injuries of the fingers.
P.563
The modi fi ed Bunnel l techni que uses 5-0 nonabsorbabl e suture that
enters the cut porti on of the tendon. It exi ts the opposi te si de of
Page 828
the tendon (Fi gure 3A), transverses to the near si de (Fi gure 3B),
and exi ts the proxi mal cut si de (Fi gure 3C). The other (di stal ) si de
of the tendon i s sutured i n a l i ke manner (Fi gure 3D, expl oded
vi ew). Fi ni sh the repai r wi th a runni ng 6-0 nyl on suture (Fi gure 3E).
(3) The modi fi ed Bunnel l techni que.
P.564
Parti al or compl ete l acerati ons may al so be repai red wi th
Page 829
i nterrupted hori zontal mattress sutures usi ng 5-0 nyl on.
(4) Interrupted mattress sutures wi th 5-0 nyl on can be used to
repai r parti al or compl ete l acerati ons.
Repai r the ski n i n a normal fashi on.
(5) Repai r the ski n.
P.565
CODING INFORMATION
Chapter 14 contai ns the Current Procedural Termi nol ogy (CPT)
codes (1200112020) for si mpl e repai r cl osures of the ski n.
C
P
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Page 830
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Page 831
or
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Page 832
tradem
ark of
the
Ameri c
an
Medi ca
l
Associ
ati on.
Appendi x A l i sts the suggested i nstruments and materi al s i n an
offi ce surgery tray. A suggested anesthesi a tray that can be used
for thi s procedure i s l i sted i n Appendi x G. Ski n preparati on
BIBLIOGRAPHY
Cal abro JJ, Hoi dal CR, Susi ni LM. Extensor tendon repai r i n the
emergency department. J Emerg Med 1986;4:217225.
Chow JA, Dovel l e S, Thomes LJ, et al . A compari son of resul ts of
extensor tendon repai r fol l owed by earl y control l ed mobi l i sati on
versus stati c i mmobi l i sati on. J Hand Surg Br 1989;14:1820.
Evans JD, Wi gnakumar V, Davi s TR, Dove A. Resul ts of extensor
tendon repai r performed by juni or acci dent and emergency staff.
I njury 1995;26:107109.
Ip WY, Chow SP. Resul ts of dynami c spl i ntage fol l owi ng extensor
tendon repai r. J Hand Surg Br 1997;22:283287.
Kerr CD, Burczak JR. Dynami c tracti on after extensor tendon repai r
i n zones 6, 7, and 8: a retrospecti ve study. J Hand Surg Br
1989;14:2122.
Ki nni nmonth AWG. A compl i cati on of the buri ed suture. J Hand Surg
Am 1990;15:959.
Kl ei nert HE. Report of the commi ttee on tendon i njuri es. J Hand
Surg Am 1989;14:381.
Lee H. Doubl e l oop l ocki ng suture: a techni que of tendon repai r for
Page 833
earl y acti ve mobi l i zati on, parts I and II. J Hand Sung Am
1990;15:945.
Newport ML, Bl ai r WF, Steyers CM. Long-term resul ts of extensor
tendon repai r. J Hand Surg Am 1990;15:961.
Purcel l T, Eadi e PA, Murugan S, et al . Stati c spl i nti ng of extensor
tendon repai rs. J Hand Surg Br 2000;25:180182.
Thomas D, Moutet F, Gui nard D. Postoperati ve management of
extensor tendon repai rs i n zones V, VI, and VII. J Hand Ther
1996;9:309314.
Wol ock BS, Moore JR, Wei l and AJ. Extensor tendon repai r: a
reconstructi ve techni que. Orthopedi cs 1987;10:13871389.
Page 834
> Table of Cont ent s > Musculoskelet al Procedures > 70 - Carpal Tunnel Syndrome
Inject ion70
Carpal Tunnel Syndrome Injection
Carpal tunnel syndrome i s the most common entrapment
neuropathy. The syndrome i s produced by compressi on of the
medi an nerve wi thi n the carpal canal . The canal i s an unyi el di ng
space bounded by the carpal bones i nferi orl y and the transverse
carpal l i gament superi orl y. Condi ti ons that enl arge structures
wi thi n the canal or that shri nk the canal can produce medi an nerve
compressi on. Tumors, gangl i a, or tenosynovi ti s of the fl exor
tendons al l reduce the space wi thi n the canal . Edema can resul t
from general medi cal condi ti ons such as thyroi d dysfuncti on or
amyl oi dosi s.
Carpal tunnel syndrome i s more common i n women (3:1
femal e-to-mal e rati o). Pregnant women and those i n the l ater
reproducti ve years appear to have the hi ghest i nci dence. Underl yi ng
causes for tenosynovi ti s, such as repeti ti ve work acti vi ti es, gout, or
rheumatoi d arthri ti s shoul d be corrected or treated. Improved
control of di abetes or hypothyroi di sm al so appears to benefi t
i ndi vi dual s wi th the di sorder.
Most pati ents wi th carpal tunnel syndrome exhi bi t paresthesi as and
pai n i n the di stri buti on of the medi an nerve. The nerve suppl i es
sensati on to the vol ar aspect of the fi rst three fi ngers and the
radi al hal f of the fourth fi nger. Symptoms are worse wi th acti vi ty or
at ni ght, when i ndi vi dual s tend to sl eep on the wri st or mai ntai n
the hand i n fl exi on. More establ i shed cases may exhi bi t pai n i nto
the wri st or forearm, weakness i n the hand, and atrophy of the
thumb abductor muscl es.
Provocati ve testi ng i ncl udes Ti nel 's test and Phal en's test. Ti nel 's
test i nduces paresthesi as by tappi ng over the medi an nerve at the
wri st. Phal en's test i s performed by maxi mal l y fl exi ng the wri sts
Page 835
(pal mar fl exed to 90 degrees) by pl aci ng the wri sts together for 30
to 60 seconds, produci ng numbness, paresthesi as, or reproduci ng
the pati ent's symptoms. Poor sensi ti vi ty of these tests (tests are
posi ti ve i n 20% and 46% of normal i ndi vi dual s, respecti vel y) l i mi ts
thei r val ue. El ectrophysi ol ogi c studi es provi de objecti ve data. Nerve
conducti on tests reveal l atency across the carpal canal , and
el ectromyography of the thenar muscl es can establ i sh the presence
of axonal damage. El ectrophysi ol ogi c testi ng does not appear to
i denti fy those who wi l l benefi t from surgi cal i nterventi on and may
be unnecessary when the di agnosi s i s cl i ni cal l y apparent.
P.567
Thenar muscl e atrophy suggests the presence of severe,
l ong-standi ng di sease. Surgi cal decompressi on i s i ndi cated for
severe di sease or for severe, di sabl i ng pai n. Mi l der di sease can be
treated wi th rest, i ce, avoi dance of offendi ng acti vi ti es, ni ghtti me
spl i nti ng, nonsteroi dal anti i nfl ammatory drugs (NSAIDs), and oral
or i njected corti costeroi ds.
The l i terature has confi rmed the val ue of steroi ds i njected i nto the
canal . Sl ow and careful needl e ti p posi ti oni ng avoi ds damage to the
medi an nerve. Most studi es document that more than 70% of
pati ents recei ve si gni fi cant short-term benefi t from i njecti on
therapy. Pati ents wi th symptom recurrence can be rei njected, but a
l i mi t of two or three i njecti ons i s advocated to l i mi t the amount of
crystal l i ne substance i n the canal , whi ch can serve as an i rri tant. If
a second i njecti on fai l s, most authors recommend that the pati ent
be referred for surgi cal i nterventi on.
INDICATIONS
Si gns and symptoms suggesti ng medi an nerve
compressi on i n the carpal canal wi th the absence of
severe symptoms or pai n and absence of severe si gns
such as thenar muscl e wasti ng
Page 836
Si gns and symptoms of carpal tunnel syndrome i n the
thi rd tri mester of pregnancy (spontaneous i mprovement
after del i very i s l i kel y)
Evi dence of cel l ul i tes or bacteremi a
Presence of a mass i n the carpal canal
P.568
PROCEDURE
Note the l ocati on of the carpal tunnel i n the proxi mal porti on of the
hand, not over the wri st.
(1) Passage of the medi an nerve through the carpal tunnel .
The sensory di stri buti on of the medi an nerve i s shown i n Fi gure 2A.
Long-term compressi on of the medi an nerve can resul t i n thenar
Page 837
muscl e weakness and atrophy (Fi gure 2B).
(2) The sensory di stri buti on of the medi an nerve.
P.569
Ti nel 's si gn i s produced by tappi ng over the medi an nerve at the
wri st (Fi gure 3A). Phal en's si gn i s performed by hol di ng the wri sts
together for up to 60 seconds (Fi gure 3B).
Page 838
(3) Provocati ve maneuvers for carpal tunnel syndrome: Ti nel 's si gn
(A) and Phal en's si gn (B).
PITFALL: Limit Phalen' s test to 60 seconds. Severe disease often
manifests with symptoms in less than 30 seconds. Phalen' s test
often is positive in normal individuals if the wrists are palmar
flexed to 90 degrees for more than 60 seconds.
P.570
Page 839
The pati ent i s l ai d supi ne, and the affected arm i s ful l y extended.
The practi ti oner must turn to face the pati ent's feet (Fi gure 4A).
Ask the pati ent to make a fi st and sl i ghtl y fl ex the wri st agai nst
resi stance. Most i ndi vi dual s have a pal mari s l ongus tendon that
el evates at the wri st (Fi gure 4B). The needl e i s i nserted on ei ther
si de (radi al or ul nar) of the pal mari s l ongus tendon.
Page 840
Page 841
(4) In most i ndi vi dual s, the pal mari s l ongus tendon el evates at the
wri st.
P.571
Identi fy the second wri st crease on the vol ar surface (Fi gure 5A).
Prepare a 5- to 6-mL syri nge wi th i njecti on sol uti on, such as 0.5 mL
of Cel estone and 3 to 4 mL of 1% l i docai ne wi thout epi nephri ne.
Lay the syri nge fl at on the forearm, wi th the needl e di rected toward
the ti p of the thi rd fi nger (Fi gure 5B). Angl e the needl e sl i ghtl y
downward. The needl e ti p wi l l l i e approxi matel y 1 cm bel ow the
surface of the hand overl yi ng the carpal canal (Fi gure 5C).
Page 842
(5) Identi fy the second wri st crease on the vol ar surface, and i nsert
ti p of a 5- to 6-mL syri nge fi l l ed wi th i njecti on sol uti on
approxi matel y 1 cm bel ow the surface of the hand underl yi ng the
carpal canal .
P.572
Many authors recommend i nserti on of the needl e ti p to the proxi mal
canal ; thi s means the needl e i s i nserted onl y about 1 to 1.5 cm
Page 843
(Fi gure 6A). An al ternate techni que attempts to i nsert the needl e
wi thi n the canal , i nserti ng the needl e 2.0 to 2.5 cm (Fi gure 6B).
Both techni ques appear effi caci ous. After i njecti on, the pati ent
shoul d experi ence i mmedi ate numbness from the l i docai ne. NSAIDs
and ni ghtti me spl i nti ng shoul d be prescri bed i n addi ti on to the
i njecti on, unl ess NSAIDs are contrai ndi cated.
(6) Two recommended i nserti on techni ques: i nsert the needl e ti p
1.0 to 1.5 cm to the proxi mal canal (A), and i nsert the needl e 2.0
to 2.5 cm wi thi n the canal (B).
PITFALL: Insert the needle slowly and gently. The needle should
pass easily. If resistance is met, withdraw the needle, and
redirect the tip, still aiming for the tip of the third finger.
PITFALL: The needle tip can touch or penetrate the median
nerve. If the insertion is slow, magnified symptoms appear in
the fingertips when the needle tip touches the nerve. Ask
patients to report pain or numbness in the fingertips as the
needle is inserted. If the needle tip touches the median nerve,
withdraw the needle and then redirect slightly, still aiming for
the tip of the third finger.
P.573
CODING INFORMATION
Page 844
C
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Page 845
i o
n
of
th
e
ca
rp
al
tu
n
n
el
CPT
i s a
tradem
ark of
the
Ameri c
an
Medi ca
l
Associ
ati on.
Consul t the orderi ng i nformati on that appears i n Chapter 65.
Needl es, syri nges, and spl i nts are avai l abl e from l ocal surgi cal
suppl y houses. A suggested tray for performi ng soft ti ssue
aspi rati ons and i njecti ons i s l i sted i n Appendi x D. Ski n preparati on
BIBLIOGRAPHY
11th ed. Atl anta, Arthri ti s Foundati on, 1997:136148.
Page 846
Loui s: Mosby, 2000:267270.
Dammers JW, Veeri ng MM, Vermeul en M. Injecti on wi th
methyl predni sol one proxi mal to the carpal tunnel : randomi zed
doubl e bl i nd tri al . BMJ 1999;319:884886.
Kasten SJ, Loui s DS. Carpal tunnel syndrome: a case of medi an
nerve i njecti on i njury and a safe and effecti ve method for i njecti ng
the carpal tunnel . J Fam Pract 1996;43:7982.
Katz RT. Carpal tunnel syndrome: a practi cal revi ew. Am Fam
Physi ci an 1994;49:13711379.
Lee D, van Hol sbeeck MT, Janevski PK, et al . Di agnosi s of carpal
tunnel syndrome: ul trasound versus el ectromyography. Radi ol Cl i n
North Am 1999;37:859872.
Mi l l er RS, Iverson DC, Fri ed RA, et al . Carpal tunnel syndrome i n
pri mary care: a report from ASPN. J Fam Pract 1994;38:337344.
Murphy MS, Amadi o PC. Carpal tunnel syndrome: eval uati on and
treatment. Fam Pract Recert 1992;14:2340.
Ol ney RK. Carpal tunnel syndrome: compl ex i ssues wi th a
si mpl e condi ti on [Edi tori al ]. Neurol ogy
2001;56:14311432.
Sei l er JG. Carpal tunnel syndrome: update on di agnosti c testi ng and
treatment opti ons. Consul tant 1997;37:12331242.
Szabo RM. A management gui de to carpal tunnel syndrome. Hosp
Med 1994;30:2633.
von Schroeder HP. Revi ew fi nds l i mi ted evi dence for
el ectrodi agnosi s to predi ct surgi cal outcomes i n peopl e wi th carpal
tunnel syndrome. Evi d Based Heal thcare Sci Appr Heal th Pol
2000;4:92.
1997:259260.
Wong SM, Hui AC, Tang A, et al . Local vs. systemi c corti costeroi ds
i n the treatment of carpal tunnel syndrome. Neurol ogy
2001;56:15651567.
Page 847
> Table of Cont ent s > Musculoskelet al Procedures > 71 - Aspirat ion and Inject ion
of Olecranon Bursit is71
Aspiration and Injection of
Olecranon Bursitis
The ol ecranon bursa i s si tuated between the ti p of the ol ecranon
and the ski n, and i t i s best exami ned wi th the el bow ful l y
extended. Thi s l ocati on over the el bow frequentl y i s subjected to
repeti ti ve fri cti on and trauma. The bursa most often becomes
i nfl amed from acti vi ti es or occupati ons that i nvol ve chroni c l eani ng
on the el bow, or i nfl ammati on may be produced from a si ngl e
i njury. Infl ammatory ol ecranon bursi ti s may resul t from gout,
rheumatoi d arthri ti s, or cal ci um pyrophosphate deposi ti on di sease.
Uremi c pati ents undergoi ng hemodi al ysi s may al so experi ence
i nfl ammatory ol ecranon bursi ti s.
Ol ecranon bursi ti s i s di agnosed by the appearance of a fl uctuant
swel l i ng over the el bow. The bursa frequentl y becomes i nfected,
and the presence of erythema, warmth, and tenderness shoul d al ert
the practi ti oner to the possi bi l i ty of septi c bursi ti s. However, many
posi ti ve cul tures can be obtai ned from di stended bursae that do not
exhi bi t the cl assi c physi cal fi ndi ngs of i nfecti on. Some physi ci ans
advocate testi ng to excl ude i nfecti on before i njecti on of
corti costeroi ds i n the ol ecranon bursa, especi al l y i f turbi d fl ui d i s
present on aspi rati on.
Chroni c i nfl ammatory reacti ons often produce a nontender, rubbery
bursa. Vi l l ous thi ckeni ng i n chroni c bursi ti s can produce mul ti pl e,
smal l nodul es that can be mi staken for bone fragments. Drai nage of
chroni c bursi ti s often i s fol l owed by reaccumul ati on. Fortunatel y,
the fl ui d tends to resol ve over several months. Chroni cal l y pai nful
bursae may requi re total exci si on for symptom resol uti on.
After epi sodi c i njury, the bursa fi l l s wi th bl ood or cl ear fl ui d to
produce a tender, pai nful swel l i ng over the el bow. Aspi rati on of
Page 848
fl ui d fol l owed by appl i cati on of a support wrap over the el bow may
be successful i n resol vi ng an acute bursi ti s. Acute bursi ti s usual l y
spontaneousl y resol ves over a few weeks. If i nfecti on devel ops
after an acute i njury, treatment consi sts of anti bi oti cs (usual l y
cephal ospori ns or peni ci l l i nase-resi stant peni ci l l i ns such as
di cl oxaci l l i n), moi st heat, and spl i nti ng. A whi te bl ood cel l count of
10,000 cel l s/mm
3
i s consi stent wi th i nfecti ous bursi ti s, and
traumati c bursi ti s that i s not i nfected usual l y has a count of l ess
than 1000 cel l s/mm
3
. Repeated aspi rati on or occasi onal l y i nci si on
and drai nage may be requi red to resol ve the condi ti on.
P.575
INDICATIONS
Symptomati c or cosmeti c concerns over di stenti on of the
ol ecranon bursa
Suspi ci on of septi c bursi ti s of the ol ecranon bursa
P.576
PROCEDURE
Ol ecranon bursi ti s i s depi cted.
Page 849
(1) Ol ecranon bursi ti s.
The el bow i s fl exed to 90 degrees for the aspi rati on. Most
physi ci ans prefer a l ateral approach to avoi d the ul nar nerve. A 20-
to 25-gauge, 1-i nch needl e i s i nserted, and fl ui d i s removed.
Some physi ci ans recommend performance of a Gram stai n, cul ture
and sensi ti vi ty tests, whi te bl ood cel l count and di fferenti al count,
and crystal anal ysi s on al l fl ui d before steroi ds are admi ni stered.
(2) Have the pati ent fl ex hi s or her el bow 90 degrees, and i nsert a
Page 850
20- to 25-gauge, 1-i nch needl e l ateral l y to remove fl ui d.
PITFALL: Two procedures generally are needed to perform the
bacteriologic studies after aspiration and then to inject
corticosteroid. The injection can be performed on the same date
or at a later visit. Avoid injecting steroid into a bursa with a
subacute infection.
P.577
After the i njecti on, the pati ent can recei ve nonsteroi dal
anti i nfl ammatory drugs (NSAIDs), i mmobi l i zati on, and compressi on
dressi ng. If corti costeroi d i s admi ni stered, 0.5 mL of Cel estone and
2.5 mL of 1% l i docai ne can be admi ni stered.
(3) Pati ents can recei ve NSAIDs, i mmobi l i zati on, and compressi on
dressi ng after aspi rati on.
Acutel y occurri ng bursi ti s that i s i nfected may benefi t from an
i ndwel l i ng catheter pl aced i n the bursa whi l e i ntravenous,
i ntramuscul ar, or oral anti bi oti cs are admi ni stered.
Page 851
(4) For acutel y occurri ng bursi ti s that i s i nfected, pl ace an
i ndwel l i ng catheter i n the bursa whi l e i ntravenous, i ntramuscul ar,
or oral anti bi oti cs are admi ni stered.
P.578
CODING INFORMATION
C
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Page 852
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Page 853
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CPT
i s a
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Needl es, syri nges, and corti costeroi d preparati ons may be ordered
from surgi cal suppl y houses or l ocal pharmaci es. A suggested tray
for performi ng soft ti ssue aspi rati ons and i njecti ons i s l i sted i n
H.
BIBLIOGRAPHY
Baker CL, Jones GL. Arthroscopy of the el bow. Am J Sports Med
1999;27:251264.
Beetham WP, Pol l ey HF, Sl ocumb CH, et al . Physi cal exami nati on of
the joi nts. Phi l adel phi a: WB Saunders, 1965:4448.
Page 854
11th ed. Atl anta: Arthri ti s Foundati on, 1997:136148.
Loui s: Mosby, 2000:265266.
Kraay MJ. The pai nful el bow: causes to consi der. Hosp Med
1994;30:2534.
Matfi n G, Luchsi nger A, Marti nez J, et al . An i nfl amed el bow after
an i nsect sti ng. Hosp Pract 1998;33:4144.
Vi l l ari n LA, Bel k KE, Frei d R. Emergency department eval uati on and
treatment of el bow and forearm i njuri es. Emerg Med Cl i n North Am
1999;17:843858.
Wi l son FC, Li n PP. General orthopaedi cs. New York: McGraw-Hi l l ,
1997:424.
Page 855
> Table of Cont ent s > Musculoskelet al Procedures > 72 - Aspirat ion and Inject ion
of Wrist Ganglia72
Aspiration and Injection of Wrist
Ganglia
Gangl i on cysts are common tumors that ari se from joi nt capsul es or
synovi al sheaths of tendons. When gangl i a mai ntai n thei r
connecti on to the synovi al sheath, they can be mobi l e and vary i n
si ze. Gangl i a occur at al l ages, but most commonl y appear i n
women between the ages of 20 and 40 years. The dorsal or vol ar
aspects of the wri st are the most common si tes.
Gangl i a may be obvi ous or occul t. Obvi ous gangl i a may sl owl y
enl arge or devel op suddenl y after trauma. Obvi ous gangl i a often
appear as fi rm, nontender, pea- to marbl e-si zed l esi ons beneath
the ski n. Occul t gangl i a may compress superfi ci al nerves and cause
dul l achi ng. Gangl i a al so frequentl y produce weakness and al tered
range of moti on i n the wri st and fi ngers. Imagi ng methods such as
ul trasonography or magneti c resonance i magi ng may hel p to
i denti fy a suspected gangl i a.
Hi tti ng a dorsal wri st gangl i a wi th a l arge Bi bl e has been a
treatment used for centuri es. If the cyst ruptures, the body absorbs
the fl ui d, and the l esi on can be cured i n 30% of i ndi vi dual s. In
addi ti on to the hi gh recurrence rate, thi s techni ques carri es a
si gni fi cant ri sk of fracture and other i njury to surroundi ng ti ssues.
Aspi rati on and steroi d i njecti on has become the most commonl y
performed nonsurgi cal i nterventi on for gangl i a. A l arge-bore needl e
can be pl aced wi thi n a gangl i a to remove the thi ck, vi scous fl ui d.
Si mpl e aspi rati on i s associ ated wi th hi gh rates of recurrence
(>50%). Injecti on of corti costeroi d after aspi rati on can hel p to
shri nk or resol ve the l esi ons and reduces recurrences to between
13% and 50%.
Hyal uroni dase i s a natural l y occurri ng enzyme that l i quefi es the
Page 856
contents of the gangl i on and permi ts compl ete removal of gangl i on
contents and penetrati on of the steroi d to the cyst wal l . Gangl i a
recurrence can be reduced by i njecti ng 1500 uni ts (10 mL
reconsti tuted) of hyal uroni dase for 20 mi nutes before the i njecti on
of the steroi d. The vol ume, cost, and addi ti onal compl exi ty of thi s
step has di scouraged many practi ti oners from hyal uroni dase
i njecti on. The onl y U.S. manufacturer of hyal uroni dase di sconti nued
producti on i n 2002.
Surgi cal i nterventi on may be needed for recurrent or symptomati c
l esi ons, but even surgi cal exci si on has recurrence rates hi gher than
5% to 10%. Most gangl i a i n chi l dren resol ve wi thout i nterventi on.
The rate of spontaneous resol uti on
P.580
i n adul ts appears to be l ess but i s sti l l si gni fi cant enough to
counsel pati ents about the opti on of observati on.
INDICATIONS
Symptomati c gangl i a over the wri st (or other
non-wei ght-beari ng joi nts)
Gangl i a for whi ch pati ents sel ect nonsurgi cal
i nterventi on
Uncooperati ve pati ents
Gangl i a overl yi ng arti fi ci al joi nts
Presence of septi c arthri ti s or bacteremi a
P.581
PROCEDURE
A l arge gangl i on i s depi cted on the dorsum of the wri st.
Page 857
(1) A l arge gangl i on on the dorsum of a wri st.
P.582
Enter the gangl i on from the si de (hori zontal l y) usi ng a 16- or
18-gauge, 1-i nch needl e (Fi gure 2A). The needl e i s cross-cl amped
near i ts base wi th a strai ght hemostat (Fi gure 2B). After the
aspi rati ng syri nge fi l l s wi th the thi ck gel -l i ke contents, the
hemostat i s used to stabi l i ze the needl e. The aspi rati ng syri nge i s
removed, and the i njecti ng syri nge that contai ns corti costeroi d i s
attached to the needl e (Fi gure 2C). The steroi d-l i docai ne sol uti on
(e.g., 0.4 mL of Cel estone and 1.6 mL of 1% l i docai ne) i s i njected
i nto the gangl i on, and the cyst enl arges wi th the fl ui d.
Page 858
(2) Aspi rati on and i njecti on of a gangl i on usi ng a 16- to 18-gauge,
1-i nch needl e.
PITFALL: Insertion of a large-bore needle can be
uncomfortable. Stretch the skin before needle insertion.
Consider intradermal injection of 1% lidocaine at the needle
insertion site before the procedure.
PITFALL: Movement of the large needle when replacing syringes
can make the procedure very uncomfortable and dislodge the
needle tip from inside the cyst. Keep the tip immobile by
maintaining firm grasp of the hemostat and bracing (anchoring)
this hand on the patient' s wrist or forearm.
P.583
Spl i nti ng or compressi on i s advocated by many physi ci ans after
Page 859
aspi rati on and i njecti on. An ace wrap can be used over the si te.
(3) Spl i nt or compress the si te after aspi rati on and i njecti on.
P.584
CODING INFORMATION
C
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Page 860
il
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Page 861
Becaus
e thi s
i s a
new
code
for
2003,
there
i s no
2002
fee
avai l a
bl e.
CPT
i s a
tradem
ark of
the
Ameri c
an
Medi ca
l
Associ
ati on.
Gangl i on cysts are best aspi rated wi th 16- or 18-gauge, 1-i nch
needl es. A hemostat may be used to exchange the i njecti on syri nge
for the aspi rati on syri nge. Needl es, syri nges, and ace wraps may be
ordered from l ocal surgi cal suppl y houses. Hemostats may be
ordered from i nstrument deal ers. The onl y U.S. manufacturer of
hyal uroni dase has been Wyeth, but Wyeth di sconti nued producti on
of hyal uroni dase i n 2002. A suggested tray for performi ng soft
ti ssue aspi rati ons and i njecti ons i s l i sted i n Appendi x D. Ski n
Page 862
BIBLIOGRAPHY
Beetham WP, Pol l ey HF, Sl ocumb CH, et al . Physi cal exami nati on of
the joi nts. Phi l adel phi a: WB Saunders, 1965:5657.
Loui s: Mosby, 2000:290291.
Ho PC, Gri ffi ths J, Lo WN, et al . Current treatment of gangl i on of
the wri st. Hand Surg 2001;6:4958.
Jones JG. Sel ected di sorders of the muscul oskel etal system. In:
Tayl or RB, ed. Fami l y medi ci ne pri nci pl es and practi ce,5th ed. New
York: Spri nger, 1998:10051015.
Kl i ppel JH, Weyand CM, Wortmann RL. Pri mer on the rheumati c
di seases, 11th ed. Atl anta: Arthri ti s Foundati on, 1997:141.
Care 1986;13:579599.
Osterman AL, Raphael J. Arthroscopi c resecti on of dorsal gangl i on
of the wri st. Hand Cl i n 1995;11:712.
Paul AS, Sochart DH. Improvi ng the resul ts of gangl i on aspi rati on
by the use of hyal uroni dase. J Hand Surg Br 1997;22:219221.
Wang AA, Hutchi nson DT. Longi tudi nal observati on of pedi atri c
hand and wri st gangl i a. J Hand Surg Am 2001;26:599602.
1997:424425.
Page 863
> Back of Book > Resources > AppendicesAppendices
P.586
P.587
Appendix A: Instruments and
Materials in the Office Surgery Tray
The fol l owi ng i nstruments and materi al s are i ncl uded i n the
suggested offi ce surgery tray:
No. 15 scal pel bl ade
Scal pel bl ade handl e
Webster needl e hol der
Metzenbaum ti ssue sci ssors
Strai ght i ri s sci ssors
Adson forceps wi th teeth
Adson forceps wi thout teeth
2 mosqui to hemostats
2 i nches of 4 4 gauze
Fenestrated di sposabl e drape
21-gauge, 1-i nch needl e (bent i nto a ski n hook)
These materi al s are dropped onto a steri l e di sposabl e drape l ai d
across a metal stand. Anestheti c i s appl i ed wi th nonsteri l e gl oves
and a syri nge not pl aced on the tray. Steri l e gl oves are then
appl i ed away from thi s steri l e tray. Added to the tray are steri l e
suture materi al s (e.g., 4-0 nyl on suture) that are requi red for the
parti cul ar procedure.
Gl oves, materi al s, and i nstruments can be ordered from the
fol l owi ng sources:
Del asco, Counci l Bl uffs, IA (http://www.del asco.com)
Page 864
Robbi ns Instruments, Chatham, NJ (
http://www.robbi nsi nstruments.com)
Skl ar Instruments, West Chester, PA (
http://www.skl arcorp.com)
Surgi cal 911.com, Ol d Saybrook, CT (
http://www.surgi cal 911.com)
P.588
Appendix B: Instruments and
Materials in a Standard Gynecologic
Tray
The fol l owi ng i nstruments and materi al s are i ncl uded i n the
standard gynecol ogi c tray:
Gl oves
Graves metal specul um
Tenacul um
Uteri ne sound
Ri ng or sponge forceps
Basi n wi th cotton bal l s and povi done-i odi ne
Add scal pel or sci ssors i f needed
Add cervi cal di l ators i f needed
These i tems shoul d be steri l e for most procedures, except for
removal of cervi cal pol yps and treatment of Barthol i n's gl and
abscesses.
The i nstruments can be ordered from the fol l owi ng sources:
Skl ar Instruments, West Chester, PA (
http://www.skl arcorp.com)
Surgi cal 911.com, Ol d Saybrook, CT (
http://www.surgi cal 911.com)
Wal l ach Surgi cal Devi ces, Inc., Orange, CT (phone:
800-243-2463; http://www.wal l achsurgi cal .com)
P.589
Page 865
Appendix C: Recommended Suture
Removal Times
The fol l owi ng ti mes for suture removal are approxi mate. Pati ent
factors such as age, presence of vascul ar or chroni c di sease, and
nutri ti onal status i nfl uence heal i ng ti mes and suture removal
ti mes.
Fac
e
3
to
5
day
s
Ne
ck
5
to
7
day
s
Sca
l p
7
day
s
Tru
nk
10
to
14
day
s
Up
per
ext
re
mi t
y
10
to
14
day
s
Ext
ens
or
sur
14
day
s
Page 866
fac
e
of
the
ha
nds
Lo
wer
ext
re
mi t
y
14
to
28
day
s
P.590
Appendix D: Suggested Tray for Soft
Tissue Aspiration and Injection
Procedures
The fol l owi ng i nstruments and materi al s can be pl aced on a
nonsteri l e sheet on the Mayo stand:
Fenestrated drape, i f desi red
Two 10-mL syri nges
20- or 21-gauge, 1-i nch needl e for drawi ng up i njecti ng
sol uti on
21-, 22-, or 25-gauge, 1 i nch needl e for aspi rati on or
i njecti on
1 i nch of 4 4 gauze soaked wi th povi done-i odi ne
sol uti on
Hemostat for stabi l i zi ng the needl e when exchangi ng the
medi cati on syri nge for the aspi rati on syri nge
1% l i docai ne hydrochl ori de stock bottl e (20 mL)
Steroi d of choi ce (e.g., betamethasone sodi um
Page 867
phosphate and acetate, 5-mL mul ti use bottl e)
Band-Ai d or steri l e bandage
For i ntraarti cul ar i njecti ons and certai n soft-ti ssue i njecti ons, i t
may be preferabl e to use steri l e gl oves, drapes, and tray. An
assi stant shoul d assi st i n drawi ng up the i njecti ng sol uti on to al l ow
the practi ti oner to avoi d contami nati on.
When usi ng mul ti use stock bottl es, i t i s preferabl e to draw up the
l i docai ne fi rst and then the steroi d sol uti on. Thi s order prevents
contami nati on of the l i docai ne wi th steroi d that may be on the
needl e. Li docai ne on the needl e does not si gni fi cantl y al ter the
steroi d sol uti on.
P.591
Appendix E: Recommendations for
Endoscope Disinfection
The fol l owi ng recommendati ons are offered for di si nfecti on of
endoscopes:
Every endoscopy shoul d be performed wi th a cl ean,
di si nfected endoscope. Use of di sposabl e-component
systems (i .e., sheathed endoscopes) can el i mi nate
i nfecti ous transmi ssi on from endoscopes.
Manual cl eani ng of the endoscope's surface, val ves, and
channel s i s the most i mportant step for preventi ng the
transmi ssi on of i nfecti ons duri ng endoscopy. Manual
cl eani ng shoul d occur i mmedi atel y after each procedure
to prevent dryi ng of secreti ons or formati on of a bi ofi l m,
both of whi ch may be di ffi cul t to remove. The endoscope
shoul d be i mmersed i n warm water and detergent,
washed on the outsi de wi th di sposabl e sponges or
swabs, and brushed on the di stal end wi th a smal l
toothbrush. Val ves shoul d be removed and cl eaned by
brushi ng away adherent debri s, and the hol l ow porti ons
shoul d be fl ushed wi th detergent sol uti on. The
bi opsy-sucti on channel shoul d be thoroughl y cl eaned
Page 868
wi th a brush that i s appropri ate for the i nstrument and
channel si ze. Automati c washi ng devi ces can be used
but do not repl ace manual cl eani ng.
Di si nfecti on can be achi eved by soaki ng the endoscope,
val ves, and al l i nternal channel s for at l east 10 mi nutes
i n 2% gl utaral dehyde. Many authori ti es prefer a
mi ni mum of 20 mi nutes. Al ternatel y, newer systems that
use aci di c el ectrol yti c water (AEW) may achi eve
di si nfecti on wi th l ess potenti al for subsequent ti ssue
i rri tati on or toxi ci ty.
Endoscope channel s shoul d be ri nsed wi th 70% al cohol ,
dri ed wi th compressed ai r, and hung verti cal l y overni ght
to reduce bacteri al col oni zati on when the endoscopes
are not i n use.
Accessori es such as bi opsy forceps shoul d be
mechani cal l y cl eaned and autocl aved after each use.
BIBLIOGRAPHY
Axon AT. Worki ng party report to the Worl d Congresses.
Di si nfecti on and endoscopy: summary and recommendati ons. J
Gastroenterol Hepatol 1991;6:2324.
P.592
Nel son D. Newer technol ogi es for endoscope di si nfecti on:
el ectrol yzed aci d water and di sposabl e-component endoscope
systems. Gastroi ntest Endosc Cl i n North Am 2000;10: 319328.
Spach DH, Si l verstei n FE, Stamm WE. Transmi ssi on of i nfecti on by
gastroi ntesti nal endoscopy and bronchoscopy. Ann I ntern Med
1993;118:117128.
Tandon RK. Di si nfecti on of gastroi ntesti nal endoscopes and
accessori es. J Gastroenterol Hepatol 2000;15(Suppl ):S69S72.
P.593
Appendix F: Guidelines for
Page 869
Monitoring the Patient Receiving
Conscious Sedation for
Gastrointestinal Endoscopy
The fol l owi ng gui del i nes are provi ded for moni tori ng pati ents who
recei ve consci ous sedati on whi l e undergoi ng gastroi ntesti nal
endoscopy:
Moni tori ng of pati ents i s one part of an overal l qual i ty
assessment program for the endoscopy uni t. Moni tori ng
pol i ci es shoul d be peri odi cal l y eval uated and updated.
A wel l -trai ned gastroi ntesti nal assi stant, worki ng cl osel y
wi th the endoscopi st, i s the most i mportant part of the
moni tori ng process. The assi stant and endoscopi st
shoul d work as a team i n assessi ng the pati ent's status
and i n respondi ng to changes i n cl i ni cal parameters.
The use of moni tori ng equi pment i s a useful adjunct to
pati ent survei l l ance but i s never a substi tute for
consci enti ous cl i ni cal assessment. Rapi d vi sual
assessment of the pati ent's ski n col or, breathi ng
pattern, and l evel of comfort wi th the procedure may
provi de useful i nformati on duri ng the procedure.
The amount of moni tori ng shoul d be proporti onal to the
percei ved ri sk to the pati ent from the procedure. Mi ni mal
cl i ni cal moni tori ng for al l sedated pati ents i ncl udes
peri odi c eval uati on of bl ood pressure, heart rate, and
respi ratory rate before, duri ng, and after the procedure,
as wel l as at the ti me of di scharge from the endoscopy
uni t. Consensus does not exi st for moni tori ng cardi ac
rhythm and oxygen saturati on. Routi ne moni tori ng wi th
el ectrocardi ograms and oxi metry i s recommended by
many authori ti es, but sel ecti ve use of these moni tori ng
modal i ti es can be performed for pati ents wi th known
comorbi di ti es (e.g., cardi ac di sease).
Oxygen admi ni strati on before and duri ng consci ous
sedati on reduces the i nci dence of desaturati on epi sodes
duri ng the procedure. Oxygen admi ni strati on i s
Page 870
advocated for i ndi vi dual s wi th cardi ovascul ar or
pul monary compromi se and may be of val ue when
routi nel y admi ni stered to el derl y i ndi vi dual s (>65 years
ol d).
The pri mary modi fi cati on i n consci ous sedati on practi ces
requi red for the geri atri c popul ati on i s admi ni strati on of
fewer agents at a sl ower rate and to a
P.594
l ower cumul ati ve dose. Reversal agents (e.g., fl umazeni l ,
nal oxone) shoul d be readi l y avai l abl e i n the endoscopy uni t.
BIBLIOGRAPHY
Ei sen GM, Chutkan R, Gol dstei n JL, et al . Modi fi cati ons i n
endoscopi c practi ce for the el derl y. Gastroi ntest Endosc
2000;52:849851.
Fl ei sher D. Moni tori ng the pati ent recei vi ng consci ous sedati on for
gastroi ntesti nal endoscopy: i ssues and gui del i nes. Gastroi ntest
Endosc 1989;35:262266.
P.595
Appendix G: Suggested Anesthesia
Tray for Administration of Local
Anesthesia, Nerve Blocks, Field
Blocks, or Digital Blocks
The fol l owi ng i tems are pl aced on a nonsteri l e sheet coveri ng the
Mayo stand:
Povi done-i odi ne sol uti on soaked i nto a 4 4 gauze (or
i n a steri l e basi n)
5- or 10-mL syri nge
20- or 21-gauge, 1-i nch needl e for drawi ng anestheti c
from the stock bottl e
Page 871
25-, 27-, or 30-gauge, i nch or 1-i nch needl e for
admi ni steri ng anestheti c
1 i nch of nonsteri l e 4 4 gauze
1% l i docai ne hydrochl ori de wi th or wi thout epi nephri ne
(choi ce determi ned by procedure and si te of
admi ni strati on)
Anti bi oti c oi ntment and Band-Ai d i f no procedure wi l l
fol l ow at the i njecti on si te
Al l of the i tems are readi l y avai l abl e through l ocal pharmaci es,
hospi tal purchasi ng groups, or surgi cal suppl y houses.
P.596
Appendix H: Skin Preparation
Recommendations
Pati ent characteri sti cs associ ated wi th an i ncreased ri sk of surgi cal
si te i nfecti ons i ncl ude remote si te i nfecti ons, col oni zati on,
di abetes, ci garette smoki ng, systemi c steroi d use, obesi ty,
extremes of age, poor nutri ti onal status, and preoperati ve
transfusi on of certai n bl ood products. Appl y greater vi gi l ance when
performi ng offi ce procedures on pati ents wi th these ri sk factors.
Preoperati ve shavi ng for hai r removal i s associ ated wi th hi gher
rates of surgi cal si te i nfecti ons. Cl i ppi ng hai r i mmedi atel y before a
surgi cal procedure has the l owest rates of associ ated i nfecti on and
shoul d be consi dered the preferred preparatory acti vi ty for hai r
removal .
Several effecti ve anti septi c agents are avai l abl e for preoperati ve
ski n preparati on, i ncl udi ng al cohol -contai ni ng products, the
i odophors (e.g., povi done-i odi ne), and chl orhexi di ne gl uconate:
Al cohol i s readi l y avai l abl e, i nexpensi ve, and the most
rapi d-acti ng ski n anti septi c. Di sadvantages i ncl ude
potenti al for spores to be resi stant, and potenti al for
fl ammabl e reacti ons
I odophors provi de broad-spectrum coverage, are
associ ated wi th l ack of mi crobi al resi stance, and provi de
Page 872
a bacteri ostati c effect as l ong as i t exi sts on the ski n
Chl orhexi di ne gl uconate offers broad-spectrum coverage,
appears to provi de greater reducti ons i n ski n mi crofl ora
than povi done-i odi ne, and has greater resi dual acti vi ty
after a si ngl e appl i cati on
The fol l owi ng recommendati ons are provi ded for appl yi ng ski n
preparati on agents:
Remove gross contami nati on from the ski n, i ncl udi ng
soi l , debri s, or devi tal i zed ti ssue.
Appl y the ski n-cl eansi ng agent i n concentri c ci rcl es,
starti ng from the i ntended surgi cal si te.
Extend the area of ski n cl eansi ng to a wi de enough area
to cover the proposed operati on, al l owi ng for extensi on
of the surgi cal fi el d for the creati on of addi ti onal
i nci si ons or drai ns.
P.597
Do not rub or scrub the ski n duri ng appl i cati on of the
anti septi c agent. Damagi ng the ski n duri ng appl i cati on
can l ead to i ncreased surgi cal si te i nfecti ons.
BIBLIOGRAPHY
Kaye ET. Topi cal anti bacteri al agents. I nfect Di s Cl i n North Am
2000;14:321339.
Mangram AJ. Gui del i nes for preventi on of surgi cal si te i nfecti on,
1999. Centers for Di sease Control and Preventi on (CDC) Hospi tal
Infecti on Control Practi ces Advi sory Commi ttee. Am J I nfect Control
1999;27:97132.
P.598
Appendix I: Bacterial Endocarditis
Prevention Recommendations
Endocardi ti s i s a rel ati vel y uncommon, l i fe-threateni ng di sease that
Page 873
may resul t i n substanti al morbi di ty and mortal i ty. Endocardi ti s
usual l y devel ops i n i ndi vi dual s wi th underl yi ng structural cardi ac
defects who devel op bacteremi a (Tabl e 1). Al though bacteremi a i s
common after many i nvasi ve procedures, onl y certai n bacteri a
commonl y cause endocardi ti s. Most cases of endocardi ti s are not
attri butabl e to an i nvasi ve procedure.
Pri mary preventi on of endocardi ti s shoul d be attempted, whenever
possi bl e. If pati ents have a cardi ac condi ti on that puts them at
moderate or hi gh ri sk for endocardi ti s and undergo a procedure that
puts them at ri sk for bacteremi a (Tabl e 2), the Ameri can Heart
Associ ati on recommends prophyl acti c anti bi oti cs (Tabl e 3). To
reduce the l i kel i hood of mi crobi al resi stance, i t i s i mportant that
prophyl acti c anti bi oti cs be used onl y duri ng the peri operati ve
peri od. They shoul d be i ni ti ated shortl y before a procedure and
shoul d not be conti nued for more than 6 to 8 hours afterward. In
the case of del ayed heal i ng or of a procedure that i nvol ves i nfected
ti ssue, i t may be necessary to provi de addi ti onal doses of
anti bi oti cs for treatment of the establ i shed i nfecti on.
P.599
TABLE 1. CARDIAC CONDITIONS ASSOCIATED WITH RISK
FOR BACTERIAL ENDOCARDITIS

High-risk individualsprophylaxis recommended
Prostheti c heart val ves
Hi story of endocardi ti s (even i n the absence of other
heart di sease)
Compl ex cyanoti c congeni tal heart di sease
Surgi cal l y constructed systemi c pul monary shunts or
condui ts
Moderate-risk individualsprophylaxis recommended
Congeni tal cardi ac condi ti ons, i ncl udi ng patent ductus
arteri osus, ventri cul ar septal defect, pri mum atri al septal
Page 874
defect, coarctati on of the aorta, and bi cuspi d aorti c val ve
Acqui red val var dysfuncti on (rheumati c heart di sease or
col l agen vascul ar di sease)
Hypertrophi c cardi omyopathy
Mi tral val ve prol apse (MVP) wi th prol apsi ng and l eaki ng
mi tral val ves, evi denced by audi bl e cl i cks and murmurs of
mi tral regurgi tati on or by Doppl er-demonstrated mi tral
i nsuffi ci ency
Careful eval uati on i s requi red i n chi l dren who have
i sol ated cl i ni cal fi ndi ngs, such as nonejecti on systol i c
cl i ck, si nce thi s may be the onl y i ndi cator of i mportant
mi tral val ve abnormal i ty requi ri ng prophyl axi s
Negligible-risk individualsprophylaxis not
recommended
MVP wi th normal mi tral val ves, prol apse wi thout
l eaki ng, no murmurs, or mi ni mal Doppl er-demonstrated
mi tral regurgi tati on
Pedi atri c pati ents wi th i nnocent heart murmurs
Isol ated secundum atri al septal defect
Surgi cal repai r of atri al septal defect, ventri cul ar septal
defect, or patent ductus arteri osus (wi thout resi dual
beyond 6 months)
Previ ous coronary artery bypass graft surgery
Previ ous Kawasaki di sease wi thout val var dysfuncti on
Previ ous rheumati c fever wi thout val var dysfuncti on
Cardi ac pacemakers (i ntravascul ar and epi cardi al and
i mpl anted defi bri l l ators)
P.600
TABLE 2. BACTEREMIA-PRODUCING PROCEDURES AND
AMERICAN HEART ASSOCIATION RECOMMENDATIONS FOR
BACTERIAL ENDOCARDITIS PROPHYLAXIS
Page 875

Bacterial Endocarditis Prophylaxis Recommended

Respi ratory tract procedures
Tonsi l l ectomy or adenoi dectomy
Operati ons i nvol vi ng respi ratory mucosa
Ri gi d bronchoscopy
Gastroi ntesti nal tract procedures
Esophageal stri cture di l atati on
Endoscopi c retrograde chol angi ography
Scl erotherapy for esophageal vari ces
Bi l i ary tract surgery
Surgery that i nvol ves i ntesti nal mucosa
Geni touri nary tract procedures
Cystoscopy
Prostati c procedures or surgery
Urethral di l atati on
Removal of an i nfected i ntrauteri ne devi ce

Bacterial Endocarditis Prophylaxis Not Recommended

Respi ratory tract procedures
Endotracheal i ntubati on
Fl exi bl e bronchoscopy
Tympanostomy tube i nserti on
Gastroi ntesti nal tract procedures
Endoscopi c l i gati on (bandi ng) of vari ces
Transesophageal echocardi ography
Endoscopy wi th or wi thout gastroi ntesti nal bi opsy
Geni touri nary tract procedures
Vagi nal hysterectomy
Normal vagi nal del i very
Cervi cal bi opsy
Cesarean secti on
Urethral catheteri zati on i n uni nfected ti ssue
Uteri ne di l ati on and curettage i n uni nfected ti ssue
Therapeuti c aborti on i n uni nfected ti ssue
Steri l i zati on procedures i n uni nfected ti ssue
Page 876
Inserti on or removal of i ntrauteri ne devi ces i n
uni nfected ti ssue
Ci rcumci si on
Cardi ac procedures
Cardi ac catheteri zati on, i ncl udi ng bal l oon angi opl asty
Impl anted cardi ac pacemakers, defi bri l l ators, and
coronary stents
Dermatol ogi c procedures
Inci si on or bi opsy of surgi cal l y scrubbed ski n

P.601
TABLE 3. RECOMMENDED PROPHYLACTIC ANTIBIOTIC
REGIMENS

Condition Prophylactic Antibiotic
Regimens

Standard, general
prophyl axi s
Amoxi ci l l i n: adul ts, 2.0 g;
chi l dren, 50 mg/kg PO 1 hr
before procedure
Pati ent unabl e to take oral
medi cati ons
Ampi ci l l i n: adul ts, 2.0 g IM
or IV; chi l dren, 50 mg/kg IM
or IV wi thi n 30 mi n before
procedure
Al l ergi c to peni ci l l i n Cl i ndamyci n: adul ts, 600
mg; chi l dren, 20 mg/kg PO 1
hr before procedure
Cephal exi n or cefadroxi l :
adul ts, 2.0 g; chi l dren, 50
mg/kg PO 1 hr before
procedure
Azi thromyci n or
Page 877
cl ari thromyci n: adul ts, 500
mg; chi l dren, 15 mg/kg PO 1
hr before procedure
Cl i ndamyci n: adul ts, 600
mg; chi l dren 20 mg/kg IV
wi thi n 30 mi n before
procedure
Cefazol i n: adul ts, 1.0 g;
chi l dren, 25 mg/kg IM or IV
procedure
Hi gh-ri sk pati ent undergoi ng
GI or GU procedure
Adul ts: 2.0 g of ampi ci l l i n IM
or IV pl us 1.5 mg/kg of
gentami ci n (not to exceed
120 mg) wi thi n 30 mi n
before procedure; 6 hr l ater,
1 g of ampi ci l l i n IM or IV or
1 g of amoxi ci l l i n PO
Chi l dren: 50 mg/kg of
ampi ci l l i n IM or IV (not to
exceed 2.0 g) pl us 1.5 mg/kg
of gentami ci n wi thi n 30 mi n
before the procedure; 6 hr
l ater, 25 mg/kg of ampi ci l l i n
or 25 mg/kg of amoxi ci l l i n
PO
Hi gh-ri sk pati ent undergoi ng
GI or GU procedure and
al l ergi c to ampi ci l l i n or
amoxi ci l l i n
Adul ts: 1.0 g of vancomyci n
IV over 1-2 hr pl us 1.5
mg/kg of gentami ci n IV or IM
(not to exceed 120 mg), wi th
compl ete i njecti on or
i nfusi on wi thi n 30 mi n
before procedure
Page 878
vancomyci n IV over 12 hr
pl us 1.5 mg/kg of gentami ci n
IV or IM, wi th compl ete
i njecti on or i nfusi on wi thi n
30 mi n before procedure
Moderate-ri sk pati ent
undergoi ng GI or GU
procedure and al l ergi c to
ampi ci l l i n or amoxi ci l l i n
Adul ts: 1.0 g of vancomyci n
IV over 12 hr, wi th
compl ete i nfusi on wi thi n 30
mi n before procedure
vancomyci n IV over 12 hr,
wi th compl ete i nfusi on
procedure

GI, gastroi ntesti nal ; GU, geni touri nary.
Adapted from Dajani AS, Taubert KA, Wi l son W, et al .
Preventi on of bacteri al endocardi ti s. JAMA
1991;227:17941801.
P.602
Appendix J: Informed Consent
The pri nci pl e of sel f-determi nati on i s the cornerstone of the
Ameri can l egal system. Rooted wi thi n thi s pri nci pl e i s the doctri ne
of i nformed consent, whi ch posi ts that an i ndi vi dual has the ri ght
to recei ve adequate i nformati on to form an i ntel l i gent deci si on
regardi ng a proposed procedure. Al though the i nformati on i ncl uded
i n i nformed consent vari es from state to state, the key component
that must be i ncl uded i s what a reasonabl e pati ent woul d need to
know about the ri sks of a proposed procedure that woul d cause the
pati ent not to undergo that treatment.
There are several key i ssues:
The medi cal record i s consi dered a fai thful
documentati on of what i nformati on was transmi tted to
Page 879
the pati ent; the medi cal professi onal must provi de
compl ete notes.
Courts assume that i f i t's not wri tten, i t di dn't
happen.
The physi ci an's word that i nformed consent occurred i s
not suffi ci ent.
Al l preoperati ve di scussi ons about a procedure shoul d be
documented, i ncl udi ng phone cal l s the ni ght before a
procedure.
There are excepti ons to the need to obtai n i nformed
consent, i ncl udi ng emergency care when i mmedi ate
treatment i s requi red to prevent death or seri ous harm
to the pati ent.
To prevai l i n a negl i gence acti on, a pati ent must prove each of the
fol l owi ng cl ai ms:
The physi ci an had a duty to di scl ose certai n i nformati on
to the pati ent.
The physi ci an di d not di scl ose the i nformati on (i .e.,
breach of duty).
The pati ent was harmed by the treatment.
The harm was the resul t of undi scl osed ri sk.
The pati ent woul d have refused the procedure had the
ri sk been di scl osed.
BIBLIOGRAPHY
Moskop JC. Informed consent i n the emergency department. Emerg
Med Cl i n North Am 1999;17:327340.
Wei ntraub MI. Documentati on and i nformed consent. Neurol Cl i n
1999;17:371381.
Page 880

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