Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Abscesses and Other Infections Treated by Surgery
Figure 5. Ludwig’s angina.
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1 million units q4h I-V, should be started and chewing gum used to stimulate salivation.
If these fail to bring improvement in 48 hours, multiple incisions through
the capsule of the parotid gland should be made to drain abscesses. Fluctuance may
not be present due to the tough parotid capsule. Surgeons not familiar with parotid
surgery should refer such cases to a surgeon who is experienced, if possible, because
of the risk of damage to the facial nerve. If referral is not possible, incise the skin
vertically just anterior to the ear and extend well down over the mandible. The
parotid capsule is incised transversely in line with the nerve branches and a hemostat
inserted and opened to allow drainage of pus if present. This should be done in
several sites over the gland and the wound packed open.
Deep Cervical Abscess and Ludwig’s Angina
Often caused by abscessed teeth (Ludwig’s angina) or lymph nodes, deep cervical
abscesses may become large enough to obstruct breathing. Drainage is by incision
with a scalpel and insertion of a Kelly forceps to open a drainage tract (Fig. 5).
A soft drain is inserted if the cavity is large.
Mastoiditis
Mastoiditis is now rare in developed countries but continues to be relatively
common in poorer societies where treatment of middle ear infections is late or not
available. Differentiating acute or chronic mastoiditis from post-auricular node infection
or from a furuncle in the external canal can be difficult. In mastoiditis, there
is often hearing loss and pulling on the ear may not be painful as it is in acute otitis.
In chronic mastoiditis, there is often a cholesteatoma in the external canal. This is a
stinky white mass of desquamated epithelium protruding from the antrum through
the perforated ear drum. If the infection has perforated the cranial cortex producing
a subperiosteal abscess, the abscess can be drained using local anesthetic. Complete
clearance of the mastoid air cells of pus and debris requires experience as there is
danger of perforating the dura or the sigmoid sinus or damaging the facial nerve.
Scalp
The scalp is remarkably resistant to infection. However, boils, carbuncles, and
ulcers may occur as well as infected wounds. These may require drainage or debridement
which can usually be performed using local anesthetic.
Skin and Subcutaneous
Skin infections are often related to trauma. Boils and carbuncles (see above) may
occur in any part of the body.
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