Cellulitis of the face
Cellulitis following a facial wound carries the risk of cavernous-sinus
thrombosis. Monitor the patient closely during antibiotic treatment
for signs of increasing facial oedema. Keep the patient in
hospital, if necessary. Explain to the patient not to squeeze
or manipulate infected foci on the face, even if small. To
prevent cavernous-sinus thrombosis, administer heparin by continuous
Panophthalmitis is a complication of a neglected penetrating
injury of the eye. When efforts to save the eye have failed
and the eye is useless, consider evisceration or enucleation.
If possible, refer to an ophthalmologist.
Enucleation of the eye is the surgical removal of the entire
globe and requires an ophthalmologist. Evisceration is the
surgical removal of the content of the globe and does not require
a specialist. This procedure involves excision of the anterior
globe and curetting of is contents. If necessary, consider
evisceration for uncontrolled panophthalmitis. The eviscerated
globe is packed open and treated as an abscess cavity. After
healing, refer the patient for a prosthesis.
Middle ear infection presents with chronic drainage of pus
from the external meatus. Clean the ear, place a cotton wick
and apply a gauze dressing. Continue the administration of
antibiotics and give analgesics as needed. Keep the auditory
canal dry and change the dressing when necessary.
Acute mastoiditis is usually a complication of acute otitis
media. The patient complains of fever and pain in the affected
ear, with disturbed hearing. There may be a discharge from
the ear. Characteristically there is a tender swelling in the
mastoid area, which pushes the pinna forward and out. Definitive
treatment is exposure of the mastoid air cells by a qualified
surgeon. When this is not possible, initial treatment is to
relieve immediate pain with an incision and drainage of the
abscess down to the periosteum.
a general or local anaesthetic, make a curved incision
over the most fluctuant part of the abscess or, if
not obvious, at 1.5 cm behind the pinna. Deepen the
incision to the periosteum or until pus is found.
a sample for bacteriological examination and establish
free drainage. Apply petroleum gauze or a small latex
drain and dress the area with gauze.
the administration of antibiotics and analgesics,
and change dressings as necessary.
the drain after 24–48 hours.
Treat dental pain initially by cleaning the painful socket
or cavity and then packing it with cotton wool soaked in oil
of cloves or a paste of oil of cloves and zinc oxide.
Tooth extraction is the best way to drain an apical abscess
when there are no facilities for root canal treatment. Remove
a tooth if it cannot be preserved, is loose and tender, or
causes uncontrollable pain.
Explain the procedure to the patient and obtain permission
to remove the tooth. Dental forceps are designed to fit the
shape of the teeth including their roots. The inexperienced
operator will find it simpler to rely on one pair of universal
forceps for the upper jaw and one for the lower (Figure
The upper molars have three roots, two buccal and one palatal,
whereas the lower molars have two, one medial and one distal.
The upper first premolars have two roots side by side, one
buccal and one palatal. All the other teeth are single-rooted.
Use local infiltration analgesia for extraction of all but
the lower molars, which may require a mandibular nerve block.
Occasionally, general anaesthesia is appropriate.
the patient in a chair with a high back to support
the head. After the patient has rinsed the mouth,
swab the gum with 70% ethanol. Insert a 25-gauge,
25 mm needle at the junction of the mucoperiosteum
of the gum and the cheek, parallel to the axis of
the tooth (Figure 5.33).
Advance the needle 0.5 to 1 cm, level with the apex of the tooth, just above
the periosteum. The bevel of the needle should face the tooth. Infiltrate the
tissues with 1 ml of 1% lidocaine with adrenaline (epinephrine) and repeat the
procedure on the other side of the tooth. Confirm the onset of numbness before
handling the tooth.
you are right-handed, stand behind and to the right
of the patient when extracting lower right molar
or premolar teeth. Face the patient, to the patient’s
right, when working on all other teeth. Separate
the gum from the tooth with a straight elevator.
While supporting the alveolus with your thumb and
finger of your other hand, apply the forceps to either
side of the crown, parallel with the long axis of
the root. Position the palatal or lingual blade first.
Push the blades of the forceps up or down the periodontal
membrane on either side of the tooth, depending on
which jaw you are working on (Figure
extraction occurs if you drive the blades of the
forceps as far along the periodontal membrane as
Firmly grip the root of the tooth with the forceps and loosen the tooth with
gentle rocking movements from buccal to lingual or palatal side. If the tooth
does not begin to move, loosen the forceps, push them deeper, and repeat the
rocking movements. Avoid excessive lateral force on a tooth, as this can lead
to its fracture.
inspect the extracted tooth to confirm its complete
removal. A broken root is best removed by loosening
the tissue between the root and the bone with a curved
elevator. After the tooth has been completely removed,
squeeze the sides of the socket together for a minute
or two and place a dental roll over the socket. Instruct
the patient to bite on it for a short while. After
the patient has rinsed the mouth, inspect the cavity
for bleeding. Arrest profuse bleeding that will not
stop, even when pressure is applied, with mattress
sutures of absorbable suture across the cavity.
the patient not to rinse the mouth again for the first
24 hours or the blood clot may be washed out, leaving
a dry socket. Have the patient rinse the mouth frequently
with saline during the next few days. Analgesia may
be needed. Warn the patient against exploring the cavity
with a finger. If gross dental sepsis occurs, administer
penicillin for 48 hours and consider giving tetanus
Throat and neck abscesses
Non-emergency operations on the throat, including tonsillectomy, should be performed
only by qualified surgeons.
Incision and drainage of peritonsillar abscess
Peritonsillar abscess (quinsy) is a complication of acute tonsillitis. The patient
develops progressive pain in the throat which radiates to the ear. The neck is
rigid, and there is fever, dysarthria, dysphagia, drooling, trismus, foul breath
and lymphadenopathy. Local swelling causes the anterior tonsillar pillar to bulge
and displaces the soft palate and uvula. The overlying mucosa is inflamed, sometimes
with a small spot discharging pus. The differential diagnosis includes diphtheria
antibiotics and analgesics and place the patient
in a sitting position with the head supported. Spray
the region of the abscess with 2–4% lidocaine.
A local anaesthetic is safer than general anaesthesia
because of the potential for aspiration with general
the tongue with a large tongue depressor or have
an assistant hold it out between a gauze-covered
finger and thumb. Perform a preliminary needle aspiration
(Figure 5.35) and then incise the most prominent
part of the swelling near the anterior pillar (Figure
5.36). Introduce the point of a pair of artery forceps
or sinus forceps into the incision, and open the
jaws of the forceps to improve drainage (Figure
Aspirate the cavity with suction and lavage it with
the patient to gargle with warm salt water several times
a day for about 5 days. Continue antibiotics for one week
and give analgesics as necessary.
Retropharyngeal abscesses occur in children and may compromise the airway. They
result from infection of the adenoids or the nasopharynx and must be differentiated
from cellulitis. The child cannot eat, has a voice change, is irritable and has
croup and fever. The neck is rigid and breathing is noisy. In the early stages
of the abscess the pharynx may look normal but, with progression, swelling appears
in the back of the pharynx.
A lateral X-ray reveals widening of the retropharyngeal space. The differential
diagnosis includes tuberculosis. Obtain a white-cell count and differential,
determine the erythrocyte sedimentation rate and test the skin reaction to tuberculin
(Mantoux test). Administer antibiotics and analgesics. Treat a patient with tuberculosis
with specific antituberculous medication.
Spray the back of the throat with local anaesthetic. While an assistant
steadies the patient’s head, retract the tongue with a depressor.
Incise the summit of the bulge vertically. Introduce the tip of an artery
forceps and open the jaws to facilitate drainage. Remove the pus with suction.
Instruct the patient to gargle regularly with warm salt water. Administer
antibiotics and analgesics.
Acute abscess of the neck
Deep abscesses in the neck arise in lymph nodes. Differentiate abscesses
from lymphadenopathy. Examine the patient’s mouth and throat, particularly
the tonsils and teeth to identify a primary focus. If the abscess is acute
and clearly pointing, perform a simple incision and drainage. In children,
treat an abscess of the neck by repeated aspiration. For small, superficial
abscesses, aspirate the cavity using a syringe with a wide-bore needle.
Perform incision and drainage under general anaesthesia for large abscess
cavities. Because of the complexity of the neck, surgical intervention
requires a qualified surgeon with adequate support. Place the incision
in a skin crease centred over the most prominent or fluctuant part of the
abscess. Spread the wound edges with a pair of sinus or artery forceps
to facilitate drainage. Take a sample of pus for bacteriological tests,
including an examination for tuberculosis. Remove necrotic tissue, but
avoid undue probing or dissection. Insert a soft latex drain. Remove the
drain after 24–48 hours. Hold
gauze dressings in place with tape.
Mastitis and breast abscess
Breast infections, common during lactation, are most often caused by penicillin
resistant staphylococcus aureus. The bacteria gain entrance through a cracked
nipple causing mastitis (breast cellulitis) which may progress to abscess formation.
The features of a breast abscess are pain, tender swelling and fever. The skin
becomes shiny and tight but, in the early stages, fluctuation is unusual. Failure
of mastitis to respond to antibiotics suggests abscess formation even in the
absence of fluctuation. When in doubt about the diagnosis, perform a needle aspiration
to confirm the presence of pus.
The differential diagnosis of mastitis includes the rare but aggressive inflammatory
carcinoma of the breast. Patients present with an advanced abscess in which the
overlying skin has broken down and the pus is discharging. If the woman is not
lactating, a neglected carcinoma should not be excluded.
Successful drainage of a breast abscess requires adequate anaesthesia; ketamine,
a wide field block or a general anaesthetic. Prepare the skin with antiseptic
and drape the area. Make a radial incision over the most prominent part of the
abscess or the site of the needle aspiration (Figure
Introduce the tip of a pair of artery forceps or a pair of scissors to widen
the opening and allow the pus to escape (Figure 5.39). Extend the incision if
necessary. Obtain cultures for bacteria, fungus and tuberculosis. Break down
all loculi with a finger to result in a single cavity (Figure
the cavity with saline and then either pack with damp saline gauze or insert
a latex drain through the wound (Figure 5.41).
Dress the wound with gauze. Give analgesics as required, but antibiotic treatment
is unnecessary unless there is cellulitis. Change dressings as necessary, and
remove the drain when the discharge is minimal.
Have the patient continue breastfeeding, unless she is HIV
positive. The child may feed from both breasts but, if this is
too painful for the mother, she may express the milk from the affected
Thoracic empyema is the presence of pus in the pleural cavity. It can complicate
lung, mediastinal or chest-wall infections and injuries. Rarely the source is
a liver abscess. The infection results from mixed flora including staphylococci,
streptococci, coliform bacteria, tuberculosis.
An empyema is either acute or chronic. It can invade adjacent tissues or cause
abscesses to form in other organs.
Characteristic features are chest pain, fever and an
irritating, dry cough. The affected area is dull
to percussion, with an absence of, or markedly
reduced, breath sounds. Diagnostic aids include
a chest X-ray, white cell count, haemoglobin and
urinalysis. A chest X-ray shows evidence of fluid
in the pleural cavity, often with features of the
Needle aspiration of the chest is diagnostic. Examine the pus for the
infecting organisms. Small acute empyema should be treated by repeated
aspiration. Treat a moderate or large collection by placement of a chest
tube attached to an underwater seal (see Unit 16: Acute Trauma Management).
Indications for underwater seal chest drainage at the district hospital
are pneumothorax, haemothorax, haemopneumothorax and acute empyema.
Give systemic antibiotics (do not instil them into the pleural cavity)
and analgesics. If there is evidence of loculation or failure of lung
expansion, refer the patient.
Patients with chronic empyema present with minimal signs and symptoms.
Features include finger clubbing, mild chest discomfort and cough. Patients
are generally in poor health and may have chronic sepsis, including metastatic
abscesses, and malnutrition. The inflamed pleura is thickened and loculated
and it is not possible to drain the pleural cavity adequately using underwater
seal intercostal drainage. Refer for specialized surgical care.
Pyomyositis is an intramuscular abscess occurring in the large muscles
of the limbs and trunk, most commonly in adolescent males. It presents
with tender, painful muscles and fever. It is usually single but can
occur in multiple distantly separated muscle groups. Staphylococcus aureus
is the causative organism in over 90% of immune competent patients. Blood
cultures are often negative and leukocytosis may be absent. In immune
compromised patients, including those who are HIV positive or diabetic,
gram negative and fungal pyomyositis may occur.
Aspiration of pus with a large bore needle (14 or 16 gauge) is diagnostic.
Treat with incision and drainage. Leave a latex drain in place at least
Infections of the hand
Staphylococci are the organisms commonly responsible for acute infections
of the hand. An early infection may resolve with antibiotics alone but
incision and drainage are usually needed. Antibiotics should be given
until sepsis is controlled.
Patients present with a history of throbbing pain, warm, tender swelling,
a flexion deformity of the finger and pain on movement. Confirm the abscess
with needle aspiration. Obtain an X-ray of the hand to determine if there
is bone involvement and perform a Gram stain on the pus.
Give general or regional anaesthesia and proceed with incision and drainage.
Make an adequate, but not extensive, incision along a skin crease at
the site of maximum tenderness and swelling (Figure
Aspirate or irrigate away all pus. Open up deeper loculi with artery
forceps and insert a latex drain. Obtain a culture. Dress the wound loosely
with dry gauze, administer antibiotics and elevate the hand.
Marked swelling on the dorsum of the hand is often due to lymphoedema,
which does not require drainage. Infection of the nail bed may necessitate
excision of a portion of the nail for effective drainage of pus.
Treat paronychia of the middle finger with an incision over the involved
area (Figure 5.43) or excise a portion of the nail (Figure
Treat finger tip abscesses with a “hockey stick” incision
Treat acute septic contracture of an involved digit with antibiotics
and prompt surgical drainage of the flexor tendon sheath through incisions
along the lateral or medial borders of the fingers, preferably the junctional
area between the palmar and dorsal skin (Figure
5.46). Infection of the
tendon sheaths of the thumb or little finger may spread to the radial
or ulnar bursa, respectively (Figure 5.47), necessitating drainage by
short, transverse incisions in the distal palmar crease and/or at the
base of the palm.
Infections of fascial palmar spaces result from extensions of infections
of a web-space or a tendon sheath. Drain the affected fascial space through
skin incisions directly over the area of maximum swelling and tenderness.
Open deeper parts of the abscess with forceps. In general, place incisions
for drainage along creases of the palm, along the lateral or medial borders
of the fingers, or along the ulnar or radial borders of the forearm (Figure
Splint the hand in position of function. Encourage active
exercises as soon as possible. Give antibiotics
and analgesics and remove the drain in 24–48