Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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360 Surgery and Healing in the Developing World
Figure 1. Wall rack for vials of local anesthetics.
Body Regions and Surgically Treated Infections
Head and Neck
Nodal Infections
These conditions are more common in children than in adults. A primary site
should be sought especially in the tonsils, teeth, and skin of the head, face and neck.
Management of infected cervical lymph nodes depends on whether the nodes have
developed abscesses or not. If not, antibiotic treatment is indicated. If the nodes
have formed an abscess, surgical drainage is necessary. Signs of acute abscessed bacterial
adenitis include the usual four signs but these may be present without abscess
formation. Careful examination should be made for fluctuance. Fluctuance is detected
by palpation with the fingers of both hands gently pressing on the swelling to
determine a site of shifting softness in the overall zone of induration. Treatment
then involves infiltrating local anesthetic into the skin overlying the region or regions
of fluctuance and performing incision and drainage of the abscessed node or
nodes. Be careful to avoid being squirted by pus under high pressure: wear glasses
and keep your mouth closed. The incision need not be very large and a cruciate
incision is not necessary unless the cavity admits more than the tip of the little
finger. Keep in mind that a superficial neck abscess may communicate with a deep
subfascial abscess (collar-button abscess) in which case the deeper component should
be evacuated by careful dilatation of the communicating tract using a Kelly forceps.
A soft drain should be inserted into the deeper cavity for several days. Attempts
should not be made to excise abscessed cervical nodes.
Tuberculous Cervical Adenitis
Tuberculous cervical adenitis (old term: “scrofula”) should be distinguished from
non-specific cervical adenitis as the treatment is different. Usually, there are signs of
pulmonary tuberculosis to help make the diagnosis. Most tuberculous abscesses are
“cold”, i.e., they do not manifest heat, redness nor tenderness. These latter signs
occur when the tuberculous nodes become secondarily infected by pyogenic bacteria.
For tuberculous adenitis, the treatment is appropriate antituberculous chemo-