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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 163-166

Ultrasound-guided aspiration compared to incision and drainage in the management of breast abscess


1 Department of Surgery, Government Medical College, Kozhikode, Kerala, India
2 Department of Radiodiagnosis, Government Medical College, Kozhikode, Kerala, India

Date of Submission03-Aug-2020
Date of Decision17-Aug-2020
Date of Acceptance13-Sep-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Dr. Roben Sebastian
Department of General Surgery, Government Medical College, Kozhikode - 673 008, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_20_20

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  Abstract 


Introduction: Breast abscess is a common cause of morbidity in women. Ultrasound-guided needle aspiration, as opposed to formal I&D, is becoming the standard of care for most breast abscesses. This study aimed to establish whether ultrasound-guided aspiration is a comparable option to incision and drainage for breast abscess and to study the microbiological profile and antibiotic sensitivity pattern observed in breast abscess. Materials and Methods: Fifty females aged 20–40 years with breast abscess were analysed, of these 25 patients had ultrasound-guided needle aspiration (Group A) and 25 patients had incision and drainage (Group B). Group A patients were followed up on days 3, 7 and 14 by both clinically and radiologically (US), with repeated aspirations done on day 3 and 7. The presence of breast abscess on day 14 was considered as treatment failure, for whom incision and drainage was performed. Group B had incision and drainage done, followed up at 2 weeks. Scar length was assessed at 12 weeks for Group A and B. The results were statistically analysed. Results: The mean age of Group A was 31 and Group B was 30. Out of the 25 in Group A, 88% underwent resolution with no scar and 12% had failure. 100% of the patients in Group B had resolution, but had a definitive scar. Conclusions: US-guided aspiration of breast abscess is a comparable treatment option in the management of breast abscess as opposed to incision and drainage with the added advantage of minimal or no scar.

Keywords: Breast abscess, incision and drainage, methicillin resistant Staphylococcus aureus, ultrasound-guided aspiration


How to cite this article:
Sebastian R, Ragesh K V, Mani A, Subramaniam G. Ultrasound-guided aspiration compared to incision and drainage in the management of breast abscess. Kerala Surg J 2020;26:163-6

How to cite this URL:
Sebastian R, Ragesh K V, Mani A, Subramaniam G. Ultrasound-guided aspiration compared to incision and drainage in the management of breast abscess. Kerala Surg J [serial online] 2020 [cited 2020 Nov 26];26:163-6. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/163/300229




  Introduction Top


Breast abscess is a common cause of morbidity in women. While they are less common in developed countries as a result of improved maternal hygiene, nutrition, standard of living and early administration of antibiotics, breast abscess remains a problem among women in developing countries.[1],[2] Breast abscess is commonly seen in lactating women.[3] Mastitis and proliferation of glandular tissue during lactation are predisposing factors.[4],[5],[6] Out of total breast diseases, the incidence of breast abscess is 10.2%.[7],[8],[9],[10]

Patients with mastitis present with a tender, focally or diffusely swollen breast. There is associated skin thickening and oedema in the breast parenchyma, and there may be a focal fluctuant palpable mass when abscess is present.[11] Breast abscesses can be broadly classified as puerperal and nonpuerperal, with nonpuerperal abscesses subclassified as peripheral or central subareolar.[12],[13] This broad classification is important for the radiologist and surgeon to be aware of, because patient demographics, inciting organisms and clinical outcomes may be different between these groups.[11]

Ultrasound-guided needle aspiration, as opposed to formal I&D, is becoming the standard of care for most breast abscesses. Multiple aspirations may be required. When repeat aspirations are required, hospitalisation may be the best way to facilitate treatment. When compared with I&D, aspiration causes less scarring, does not interfere with breastfeeding and does not require procedural sedation.[9] Christensen and associates recommended that ultrasound-guided needle drainage replaces surgery as first-line treatment of uncomplicated puerperal and nonpuerperal breast abscesses.[14]

The traditional treatment of breast abscesses is by surgical incision, digital disruption of septa, evacuation of contents with occasional placement of surgical drains and administration of systemic antibiotics. This strategy often requires general anaesthesia, may leave unpleasant scars, is more expensive than aspiration, requires regular postoperative changes of dressing and interferes with lactation. In addition, 10%–38% of abscesses recur and need additional surgical drainage.[15],[16],[17] This study was designed to prospectively assess the efficacy of incision and drainage with that of repeated needle aspiration in the management of breast abscesses in conjunction with antibiotic therapy in terms of cure rate and scar length and to study the microbiological profile and antibiotic sensitivity pattern.


  Materials and Methods Top


Our study was a randomised controlled trial on 50 females aged 20–40 years during March 2018 to September 2019 in a government hospital, diagnosed to have breast abscess with a diameter of 2–8 cm by ultrasound. Patients with recurrent or chronic breast abscess, immunosuppressed patients (diabetes, on steroids, with malignancies, autoimmune diseases, receiving immunosuppressants, on anticancer drugs), patients with necrotic skin over the abscess, draining abscess and patients whose ultrasound report came as generalised inflammation, skin thickening, soft tissue oedema, cellulitis, mastitis, but without focal collection were excluded from the study. Clinical diagnosis was made based on the presence of breast pain, swelling with or without fever and presence of a fluctuant tender breast swelling. The patients diagnosed clinically were subjected to ultrasound scan in the radiology department.

Radiological diagnosis was confirmed by the presence of a thick walled echo complex mass, predominantly cystic with internal echoes and septations with sometimes fluid debris levels or loculations and posterior acoustic enhancement could also be seen. The size of the abscess was estimated along with the details of loculations. The patients were randomised into Group A and B, in such a way that every alternate patient falls in the same study group.

In Group A, after painting the area with povidone iodine, local anaesthesia using 2% lignocaine was infiltrated into the site using 23G needle. This was followed by aspiration using 10 ml syringe and large bore needle under direct ultrasound guidance. The amount of pus aspirated was recorded. The needle was introduced into each loculi using ultrasound guidance and aspirated until there was no significant residual pus on ultrasound. The aspirate amount was recorded and samples was sent for routine and anaerobic cultures. Sterile dressings were given. Post-procedure, the patient was discharged on antibiotics (oral cloxacillin 500 mg QID) and analgesics. The antibiotic was changed according to the result of culture. Follow-up was done on days 3 and 7 clinically and radiologically and aspiration was done as necessary. On day 14, if abscess still persisted, it was considered as treatment failure, hence converted to traditional incision and drainage. The patients were followed up after 12 weeks to assess scar size.

In Group B patients, incision and drainage was done using sinus forceps to reach the abscess cavity. Pus was taken for routine and anaerobic cultures and given appropriate antibiotic. Follow-up was done at 2 and 12 weeks to assess the scar length.


  Results Top


The mean age of Group A was 31 and Group B 30.8. 60% belonged to 30–40 years' age group and 40% 20–30 years. 32% (8) of the patients in Group A and 20% (5) in Group B had staphylococcus sensitive to cloxacillin. 24% (6) in Group A and 20% (5) in Group B had methicillin-resistant staphylococcus aureus (MRSA) sensitive to vancomycin, linezolid and cotrimoxazole. 4% (1) in Group A and 4% (1) in Group B had pseudomonas sensitive to ciprofloxacin. 8% (2) in Group A were sterile. None of the cultures were positive for fungal or anaerobic growth. The P value of the test was > 0.05, hence insignificant [Figure 1] and [Figure 2].
Figure 1: Distribution of culture characteristics in the two groups

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Figure 2: Distribution of antibiotic sensitivity characteristic between the groups

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When the mean size of abscess aspirated was plotted between different time intervals, it was found to be statistically significant. There was significant reduction in the size of abscess over the course of 14 days [Figure 3].
Figure 3: Mean size of abscess (in cm) between different time intervals in Group A

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The mean volume of abscess aspirated in the initial day was 13.92 ml. This reduced to 9.20 ml by day 3 and further reduced to 5.44 ml by day 7 [Figure 4].
Figure 4: Mean volume of abscess aspirated (in ml) between different time intervals in Group A

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Out of the 25 patients in Group A, 22 (88%) underwent resolution according to operational definition. 3 (12%) of them had failure and hence were converted to incision and drainage. All the patients in Group B were cured. When the scar length was compared between Group A and B, 88% had minimal or no scar in Group A, whereas all the patients in Group B had a definitive scar.


  Discussion Top


In our study, the mean age group was 31 for Group A and 30.8 for Group B. The mean size of abscess was 0.86 cm. The mean size of the abscess was 6.36 cm in Group A and 6.56 cm in group B. Failure occurred in three patients in Group A and none in Group B. In a similar randomised controlled study by Javed et al.[6] on 60 female patients, the mean age of patients in Group A was 30.83 and in Group B was 31.53. Twenty-one patients in Group A had recurrence, whereas none was found in patients in Group B. They concluded that recurrence rate is less after incision and drainage as compared to multiple needle aspiration, whereas we concluded that ultrasound-guided aspiration is a comparable treatment option for breast abscess with the added advantage of minimal scar.

Elagili et al.[16] studied 30 patients and found the size range to be 1–15 cm with a mean size of 9 cm as against our range was 2–8 cm with mean size of 6.46 cm. This study analysed only ultrasound-guided aspiration and concluded that needle aspiration with ultrasound guided is an effective treatment for breast abscess irrespective of abscess size and volume.

Bing and Jie [18] did a meta-analysis and concluded that compared with incision and drainage, ultrasound-guided aspiration has more cure rate, more effective rate, less healing time and scar as well as complications. Post-operative scar formation and even deformation of breast are main reasons for psychological anxiety. 70% of women were not satisfied with scar. The scar formation by ultrasound-guided aspiration was significantly lower than by incision and drainage. Our study also concluded that in patients who were successfully treated by ultrasound-guided aspiration, there was minimal/no scar.


  Conclusions Top


Our study concluded that ultrasound-guided aspiration of breast abscess as an initial option prior to embarking on drainage had very good results. However, there was a small risk of conversion to incision and drainage if the abscess persists after repeated aspiration. All lactating females who underwent USG-guided aspiration could continue lactating from the affected breast. There was minimal/no scar in patients who were successfully treated by USG-guided aspiration whereas a definite scar was seen in the I&D group.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ioannis H, Nigel JB. Acute infection of the breast. In: Surgery on CD-ROM-1997-2002-Rassmussen NR: Medicine publishing company Ltd.; 2002.p. 1997-2002.  Back to cited text no. 1
    
2.
Chandika AB, Gakwaya AM, Kiguli-Malwadde E, Chalya PL. Ultrasound guided needle aspiration versus surgical drainage in the management of breast abscesses: A Ugandan experience. BMC Res Notes 2012;5:12.  Back to cited text no. 2
    
3.
Afridi SP, Alam SN, Ainuddin S. Aspiration of breast abscess through wide bore 14-gauge intravenous cannula. J Coll Physicians Surg Pak 2014;24:719-21.  Back to cited text no. 3
    
4.
Hagiya H, Shiota S, Sugiyama W, Otsuka F. Postpartum breast abscess caused by community-acquired methicillin-resistant Staphylococcus aureus in Japan. Breastfeed Med 2014;9:45-6.  Back to cited text no. 4
    
5.
Leibman AJ, Misra M, Castaldi M. Breast abscess after nipple piercing: sonographic findings with clinical correlation. J Ultrasound Med 2011;30:1303-8.  Back to cited text no. 5
    
6.
Javed MU, Aleem S, Asif SJ, Iqbal J. Breast abscess; comparison of recurrence rate between incision drainage and multiple needle aspiration. Prof Med J 2017;24: 89-94A.  Back to cited text no. 6
    
7.
Jamal S, Khaliq T, Shabbir S. The frequency of various causes of breast lumps in females presenting to surgical OPD in a tertiary care hospital. Ann Pak Inst Med Sci 2013;9:26-9.  Back to cited text no. 7
    
8.
Kandi AJ, Gite VA, Varudkar AS. Management of breast abscess by ultrasound guided needle aspiration against incision and drainage. Int Med J 2014;1:655-9.  Back to cited text no. 8
    
9.
Suthar KD, Mewada BN, Surati KN, Shah JK. Comparison of percutaneous ultrasound guided needle aspiration and open surgical drainage in management of puerperal breast abscess. Int J Med Sci Public Health 2013;2:69-72.  Back to cited text no. 9
    
10.
King TA, Morrow M. Breast disease. In: Mulhouand MW, Lillemoe KD, Doherty GM, Maier RV, Simeone DM, editors. Greenfield's Surgery-Scientific Principles and Practice. 5th ed.. Philadelphia: Lippincott Williams & Wilkins; 2011. p. 1241-81.  Back to cited text no. 10
    
11.
Giess CS, Golshan M, Flaherty K, Birdwell RL. Clinical experience with aspiration of breast abscesses based on size and etiology at an academic medical center. J Clin Ultrasound 2014;42:513-21.  Back to cited text no. 11
    
12.
Trop I, Dugas A, David J, El Khoury M, Boileau JF, Larouche N, et al. Breast abscesses: Evidence-based algorithms for diagnosis, management, and follow-up. Radiographics 2011;31:1683-99.  Back to cited text no. 12
    
13.
Meguid MM, Kort KC, Numann PJ. Subareolar breast abscess: The penultimate stage of the mammary duct-associated inflammatory disease sequence. In: Bland KI, Copeland EM 3rd, editors. The Breast: Comprehensive Management of Benign and Malignant Disorders. 3rd ed.. Philadelphia: Saunders; 2004. p. 93.  Back to cited text no. 13
    
14.
Christensen AF, Al-Suliman N, Nielsen KR, Vejborg I, Severinsen N, Christensen H, et al. Ultrasound-guided drainage of breast abscesses: results in 151 patients. Br J Radiol 2005;78:186-8.  Back to cited text no. 14
    
15.
Benson EA, Goodman MA. Incision with primary suture in the treatment of acute puerperal breast abscess. Br J Surg 1970;57:55-8.  Back to cited text no. 15
    
16.
Elagili F, Abdullah N, Fong L, Pei T. Aspiration of breast abscess under ultrasound guidance: outcome obtained and factors affecting success. Asian J Surg 2007;30:40-4.  Back to cited text no. 16
    
17.
Osterman KL, Rahm VA. Lactation mastitis: bacterial cultivation of breast milk, symptoms, treatment, and outcome. J Hum Lact 2000;16:297-302.  Back to cited text no. 17
    
18.
Bing F, Jie L. Ultrasound guided needle aspiration and cavity washing verses incision and drainage to treat breast abcess: Meta analysis. Int J Exp Med 2017;10:8656-65.  Back to cited text no. 18
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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