Breast Abscess

DEFINITION
See also Mastitis.

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INCIDENCE
Age
Usually of lactating age.

Risk Factors
Lactation.
Retracted nipple.
Mammary duct ectasia (see below)
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AETIOLOGY

Infecive
Staph is major agent.
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BIOLOGICAL BEHAVIOUR

Pathogenesis

Lactating breast
The nipple and areolar complex contain secretor ducts exposed to environment
- chronic inflammation, duct dilation and obstruction combine to favour infection.
Often one or more breast ducts become blocked by sloughing of epithelial debris.
- "subareolar duct ectasia"
- obstruction of major ducts leads to bacterial proliferation and abscess.
--> further destruction of duct openings can also lead to fistula formation
--> chronic recurrent abscess.

Baby influence
With a sore and cracked nipple, a baby may introduce the infective agent.
This sets up the acute inflammatory response.

Non-lactating breast
Inquire deeper
- ?suspicious cause
- or:

Mammary duct ectasia
Inflammatory condition
- distortion / dilation of lactiferous sinuses under nipple.
- frequently responsible for nipple inversion in older women.

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MANIFESTATIONS

Symptoms
Local
Pain, tenderness, heat, redness, swelling.
Inability to breast feed.
Often spreads in size, gradually involving larger areas of breast.
Can become chronic (walled off).
Systemic
Possibly general unwellness, fever on and off.

Signs
Observe
Classic features of acute inflammation.
Palpate
Tense induration of overlying skin.
Clear symmetrical edges.
Tense consistence, fluctuance is a late sign.
Mobility in breast planes.
Painful, tender and may have swollen lymph nodes up.

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INVESTIGATIONS

Diagnostic treatment.
Biopsy of abscess wall may be required
- especially if a lump
- or generally in the non-lactating breast.
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MANAGEMENT

Non-operative
Antibiotics ineffective alone.
Continue breast-feeding

Operative
Ultrasound-guided aspiration is now preferred and is almost always effective.
Incision and drainage.
- insert finger to disrupt remaining septa in the abscess cavity (usually loculated)
- +/- a dependent drainage tube.
Peri-areolar abscess
Conservative if possible
Small incision if necessary
Excision of the involved ducts can help prevent recurrence
- but recurrence is still common and leads to chronic infection and fistulation.
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References
Sabiston 17th.