Incision and Drainage

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17 Incision and Drainage

Daniel L. Stulberg, MD, and Patrick Moran, DO

Incision and drainage (I&D) is a simple in-office procedure that in most cases is curative for superficial abscesses and related infections including uncomplicated methicillin-resistant Staphylococcus aureus (MRSA) abscesses. Commonly, patients will present with the acute onset of localized pain, swelling, and erythema indicating abscess formation (Figure 17-1). These can be the result of trauma, injection drug use, insect stings or bites, a secondary infection or inflammation of an epidermoid cyst, or paronychia from nail biting or manipulation, or they may arise without a clear inciting event.

image

FIGURE 17-1 Abscess with raised fluctuant center on the arm.

(Copyright Richard P. Usatine, MD.)

The most common pathogens are Staphylococcus aureus and Streptococcus bacteria. Systemic antibiotics should usually only be given if there is surrounding cellulitis (Figure 17-2) or other signs or symptoms of further infection. There is no clear need for antibiotics even if localized MRSA is present, and there is also no clear indication for antibiotics in a patient with diabetes or an immune-compromised patient as long as the infection is a localized one that can be drained.1,2 Some patients may be colonized with MRSA and develop recurrent abscesses. In this situation, treatment with systemic antibiotics such as trimethoprim/sulfamethoxazole, doxycycline, or clindamycin based on local sensitivity patterns may help. Mupirocin is applied inside the nares twice daily for 5 days and topical chlorhexidine skin washing is commonly used to try to clear the carrier state, although the literature does not clearly support these practices.3,4

image

FIGURE 17-2 Abscess with cellulitis. Note the erythema around this breast abscess. This presentation prompted an investigation for underlying breast cancer.

(Copyright Richard P. Usatine, MD.)

Indications

The following lesions should be treated with incision and drainage:

• Abscess
• Abscessed epidermoid cyst
• Furuncle—abscess related to the hair follicle
• Carbuncle—coalescence of furuncles
• Paronychia—abscess at the nail margin.

Contraindications and Cautions

• This chapter deals with superficial abscesses seen in routine office practice. Deep abscesses and those of body compartments including the palm of the hand require more extensive surgical intervention.
• Perirectal abscesses should be approached cautiously. They may be associated with deep disease or underlying inflammatory bowel disease and care should be taken not to damage the anal sphincter, which can cause incontinence.5
• Incision and drainage of abscesses of the face can lead to scarring, so choose the line of incision along skin tension lines, wrinkles, or other structures to minimize the prominence of the scar. Needle aspiration and antibiotics can be tried as initial treatment with close follow-up and an informed patient understanding that incision and drainage may ultimately be necessary.
• Be cautious to avoid damage to underlying structures including nerves and blood vessels.
• Abscesses and infections in closed spaces including the hand, foot, and orbits require additional intervention and consultation.
• Crepitus or gas seen on imaging suggests a more serious infection such as necrotizing fasciitis. This is a surgical emergency requiring a STAT surgical consult.
• Breast abscesses in a nonlactating woman should prompt evaluation for possible cancer (Figure 17-2).
• Abscesses of the central face in the “danger triangle” between the bridge of the nose and the angles of the mouth may lead to further complications such as a cavernous sinus thrombosis. These are best treated with antibiotics and warm compresses early to prevent a cavernous sinus thrombosis.6

Advantages of Incision and Drainage

The advantages of I&D can be categorized into those for the clinician and those for the patient. Advantages for the clinician include the following:

• Patient results are usually excellent.
• The procedure is simple to perform.
• Most are amenable to being performed in the office setting.

 

Advantages for the patient include:

• Results are usually excellent.
• Reduction in pain may occur quickly.
• This is an office procedure that can save a patient the higher copays and bills that result from an emergency department or surgical center visit.
• Family member or friend can be instructed to do the repacking when needed.

Disadvantages Of Incision And Drainage

As with the advantages of I&D, the disadvantages can also be categorized into those for the clinician and those for the patient. Disadvantages for the clinician include the following:

• Time to collect supplies and perform the procedure
• Possibility of body fluid exposure.

 

Disadvantages for the patient include:

• Pain of procedure
• Scarring.

Equipment

• Alcohol, povidone-iodine, and/or chlorhexidine for skin preparation
• Lidocaine, plain or with epinephrine
• Ethyl chloride spray (This is an optional topical anesthesia that is used to drain a paronychia or prior to a lidocaine injection.)
• 3- to 10-mL syringe based on size of abscess
• 18-gauge or large needle to draw up anesthesia
• 27-gauge 1.5-inch needle for anesthesia injections
• Clean gloves
• No. 11 blade with disposable or nondisposable scalpel handle
• Hemostat (Many clinicians prefer a curved hemostat to more easily get to loculations.)
• Scissors
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