Abscess incision and drainage

Definition

An abscess is an infected skin nodule containing pus. It may need to be drained via an incision (cut) if the pus does not resolve with treatment by antibiotics . This allows the pus to escape, the infection to be treated, and the abscess to heal.

Purpose

An abscess is a pus-filled sore, usually caused by a bacterial infection. The pus is comprised of both living and dead organisms. It also contains destroyed tissue due to the action of white blood cells that were carried to the area to fight the infection. Abscesses are often found in the soft tissue under the skin such as the armpit or the groin. However, they may develop in any organ, and are commonly found in the breast and gums. Abscesses are far more serious and call for more specific treatment if they are located in deep organs such as the lung, liver, or brain.

Because the lining of an abscess cavity tends to interfere with the amount of drug that can penetrate the source of infection from the blood, the cavity itself may require draining. Once an abscess has fully formed, it often does not respond to antibiotics. Even if the antibiotic does penetrate into the abscess, it does not function as well in that environment.

Demographics

Abcess drainage is a minor and common surgical procedure that is often performed in a professional medical office. Accurate records concerning the number of procedures are kept in private medical office rather than hospital records. For these reasons, it is impossible to accurately tally the number of abscess incision and drainage procedures performed in a year. The procedure increases in frequency with increasing age.

This lung abscess is a build-up of fluid near the lung (A). To drain it, the patient is placed on his or her side, and an incision is made (B). A rib is exposed (C) and cut (D). The fluid in the abscess is suctioned (E), and the incision is closed around a temporary drainage tube (F). (

Illustration by GGS Inc.

)

Description

A doctor will cut into the lining of an abscess, allowing the pus to escape either through a drainage tube or by leaving the cavity open to the skin. The size of the incision depends on the volume of the abscess and how quickly the pus is encountered.

Cells normally formed for the surface of the skin often migrate into an abscess. They line the abscess cavity. This process is called epithelialization. This lining prevents drugs from reaching an abscess. It also promotes recurrence of the abscess. The lining must be removed when an abscess is drained to prevent recurrence.

Once an abscess is opened, the pus drained, and the epithelial lining removed, the doctor will clean and irrigate the wound thoroughly with saline. If it is not too large or deep, the doctor may simply pack the abscess wound with gauze for 24–48 hours to absorb the pus and discharge.

If it is a deeper abscess, the doctor or surgeon may insert a drainage tube after cleaning out the wound. Once the tube is in place, the surgeon closes the incision with simple stitches and applies a sterile dressing. Drainage is maintained for several days to help prevent the abscess from reforming. The tube is removed, and the abscess allowed to finish closing and healing.

Diagnosis/Preparation

An abscess can usually be diagnosed visually, although an imaging technique such as a computed tomography (CT) scan or ultrasound may be used to confirm the extent of the abscess before drainage. Such procedures may also be needed to localize internal abscesses such as those in the abdominal cavity or brain.

Prior to incision, the skin over an abscess will be cleansed by swabbing gently with an antiseptic solution.

Aftercare

Much of the pain around an abscess will be gone after the surgery. Healing is usually very rapid. After the drainage tube is removed, antibiotics may be continued for several days. Applying heat and keeping the affected area elevated may help relieve inflammation.

Risks

Any scarring is likely to become much less noticeable as time goes on, and eventually become almost invisible. Occasionally, an abscess within a vital organ (such as the brain) damages enough surrounding tissue that there is some permanent loss of normal function.

Other risks include incomplete drainage and prolonged infection. Occasionally, an abscess may require a second incision and drainage procedure. This is frequently due to retained epithelial cells that line the abscess cavity.

Normal results

Most abscesses heal after drainage alone. Others may require more prolonged drainage and antibiotic drug treatment.

Morbidity and mortality rates

Morbidity associated with an abscess incision and drainage is very uncommon. Post-surgical problems are usually associated with infection or an adverse reaction to antibiotic drugs prescribed. Mortality is virtually unknown.

Alternatives

There is no reliable alternative to surgical incision and drainage of an abscess. Heat alone may cause small superficial abscesses to resolve. The degree of epithelialization usually determines if the abscess reappears.

See also Incision care ; Wound care .

Resources

BOOKS

Bland, K. I., W. G. Cioffi, and M. G. Sarr. Practice of General Surgery. Philadelphia: Saunders, 2001.

Braunwald, E., Longo, D. L., and J. L. Jameson. Harrison's Principles of Internal Medicine, 15th Edition. New York: McGraw-Hill, 2001.

Goldman, L., and J. C. Bennett. Cecil Textbook of Medicine, 21st Edition. Philadelphia: Saunders, 1999.

Schwartz, S. I., J. E. Fischer, F. C. Spencer, G. T. Shires, and J. M. Daly. Principles of Surgery, 7th Edition. New York: McGraw Hill, 1998.

Townsend, C., K. L. Mattox, R. D. Beauchamp, B. M. Evers, and D. C. Sabiston. Sabiston's Review of Surgery, 3rd Edition. Philadelphia: Saunders, 2001.

PERIODICALS

Cmejrek, R. C., J. M. Coticchia, and J. E. Arnold. "Presentation, Diagnosis, and Management of Deep-neck Abscesses in Infants." Archives of Otolaryngology Head and Neck Surgery, 128(12) 2002: 1361–1364.

Douglass, A. B., and J. M. Douglass. "Common Dental Emergencies." American Family Physician, 67(3) 2003: 511–516.

Usdan, L. S., and C. Massinople. "Multiple Pyogenic Liver Abscesses Associated with Occult Appendicitis and Possible Crohn's Disease." Tennessee Medicine, 95(11) 2002: 463–464.

Wang, L. F., W. R. Kuo, C. S. Lin, K. W. Lee, and K. J. Huang. "Space Infection of the Head and Neck." Kaohsiung Journal of Medical Sciences, 18(8) 2002: 386–392.

ORGANIZATIONS

American Academy of Otolaryngology-Head and Neck Surgery. One Prince St., Alexandria, VA 22314-3357. (703) 836-4444. http://www.entnet.org/index2.cfm .

American College of Surgeons. 633 North St. Clair Street, Chicago, IL 60611-32311. (312) 202-5000; Fax: (312) 202-5001. Web site: http://www.facs.org . E-mail: http://post master@facs.org.

American Medical Association. 515 N. State Street, Chicago, IL 60610. (312) 464-5000. http://www.ama-assn.org .

American Osteopathic College of Otolaryngology-Head and Neck Surgery. 405 W. Grand Avenue, Dayton, OH 45405. (937) 222-8820 or (800) 455-9404; Fax (937) 222-8840. Email: info@aocoohns.org.

American Society of Colon and Rectal Surgeons. 85 W. Algonquin Rd., Suite 550, Arlington Heights, IL 60005. (847) 290-9184; Fax: (847) 290-9203. http://www.fascrs.org . Email: ascrs@fascrs.org.

OTHER

American Society of Colon and Rectal Surgeons, (April 4, 2003). http://www.fascrs.org/brochures/anal-abscess.html .

Merck Manual, (April 5, 2003). <http://www.merck.com/pubs/mmanual/section6/chapter74/74a.htm� 3E; .

National Library of Medicine, (April 4, 2003). <http://www.nlm.nih.gov/medlineplus/ency/article/001353.htm ; .

Oregon Health and Science University, (April 4, 2003). http://www.ohsu.edu/cliniweb/C1/C1.539.830.25.html .

Vanderbilt University Medical Center, (April 4, 2003). <http://www.mc.vanderbilt.edu/peds/pidl/neuro/brainabs.htm> .

L. Fleming Fallon, Jr, MD, DrPH

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Abscesses are most commonly incised and drained by general surgeons. Occasionally, a family physician or dermatologist may drain a superficial abscess. These procedures may be performed in a professional office or in an outpatient facility. The skin and surrounding area may be numbed by a topical anesthetic.

Brain abscesses are usually drained by neurosurgeons. Thoracic surgeons drain abscesses in the lung. Otolaryngologists drain abscesses in the neck. These procedures are performed in a hospital operating room. General anesthesia is used.

QUESTIONS TO ASK THE DOCTOR

• How many abscess incision and drainage procedures has the physician performed?
• What is the physician's complication rate?