ABSCESS : Types and Methods of Treatment

An abscess is a cavity filled with pus and lined by a pyogenic membrane. There are three varieties of abscess :

  • Pyogenic abscess (commonest)
  • Pyaemic abscess
  • Cold abscess

Sometimes, the abscess cavity persists, which becomes firm and contains sterile pus. The firmness is due to thickness of its wall. This is known as 'antibioma'. This is due to continuous administration of antibiotics. The lump may even be hard, when it may mimic a carcinomatous lump.

Basic principle of treatment of an abscess is:

  • to drain the pus
  • to send the pus for culture and sensitivity test, and
  • to give proper antibiotic
Drainage of a pus can be obtained by free incision or by Hilton's method. Hilton's method is chosen when there are plenty of important structures like nerves and vessels around the abscess cavity, which are liable to be injured. 

Incision should be made parallel to important structures like nerves and vessels, while the muscle should be incised along the line of the fibers.

Counter incision : When the most prominent part is not the most dependent part, complete drainage of the pus is not possible with single incision. So, counter incision is required at the most dependent part to facilitate the drainage by gravity.

A corrugated rubber drain is usually used for drainage of an abscess cavity. When counter incision is used, the drain extends from the first incision to the counter incision.

Pyaemic Abscess : In this condition, multiple abscesses develop from infected emboli in pyaemia. Pyaemia is a condition characterized by formation of secondary foci of suppuration in various parts of the body. These foci are caused by lodgement of septic emboli formed as a result of  breaking up of an infected thrombus.

Pyaemia  is also seen in acute appendicitis when the infective emboli pass in to the portal venous system and cause portal vein pyaemia. (forming multiple pyaemic liver abscesses) 

Bacteremia Vs Septicemia : 
Bacteremia is the condition in which bacteria circulate in the blood stream. The organisms are usually very rapidly destroyed.
Septicemia is the development of certain clinical manifestations due to liberations of toxins by the bacteria in the blood stream. The manifestations include pyrexia, rigors, hypotension, petechial hemorrhages, etc. In absence of  systemic disease, B hemolytic streptococci. 

Toxaemia : Condition in which toxins, either chemical or bacterial blood circulate in the blood stream

Cold Abscess: This abscess is cold and non reacting in nature. It does not produce hot and painful abscess as seen in pyogenic abscess. It is almost always a sequel of tubercular infection anywhere in the body, commonly in the lymph nodes, bone and joint. Caseation of the lymph nodes forms the cold abscess. The commonest sites are the neck and axilla.

Once the diagnosis is established, full antitubercular regime should be started. An incision should not be made on a cold abscess for drainage, as it almost always invites secondary infection and forms a persistent sinus. Aspiration may be attempted through the normal surrounding skin and not the most prominent and most dependent part as this will innvariably cause sinus formation.