经口腔超声在扁桃体周围脓肿的应用

目的：评价经口腔超声对扁桃体周围脓肿的诊断价值。方法：３３例疑诊为扁桃体周围脓肿（ＰＴＡ）患者进行经口腔超声（ＩＯＵ）检查。结果：ＩＯＵ诊断ＰＴＡ２７例,扁桃体周围炎（ＰＴＣ）６例。２８例穿刺或切排抽取脓液,５例穿刺阴性。ＩＯＵ诊断ＰＴＡ的敏感度为９６．４％（２７／２８）,特异度为１００％。阳性预测值为１００％,阴性预测值为８３．３％。结论：ＩＯＵ是一种诊断准确率高,图像直观,非侵入性的诊断技术,是临床诊断ＰＴＡ的有用工具。     

Ultrasound-guided drainage of peritonsillar abscess by the emergency physician

The diagnosis of peritonsillar abscess (PTA) poses a challenge to emergency physicians (EPs). The decision to perform an invasive procedure with potential complications is based on clinical judgment that is often inaccurate. Although there is some mention of intraoral ultrasound in otolaryngology practice, there is none in the emergency medicine (EM) literature. However, this bedside emergency application of ultrasonography has the potential to be of considerable use in EM practice, and could allow EPs who previously deferred blind needle aspiration of a potential abscess to perform the procedure themselves. We report the cases of 6 patients who presented with probable PTA and were evaluated with intraoral ultrasound at the bedside by an EP. All 6 patients then underwent needle aspiration. As diagnosed on ultrasound, 3 of the patients had negative aspirations and were diagnosed with peritonsillar cellulitis. Three others were found to have PTA, with 2 requiring real-time ultrasound needle guidance to accomplish abscess drainage after multiple failures with the blind approach.     

Abscess Management: An Evidence-Based Review for Emergency Medicine Clinicians

BackgroundAbscesses are commonly evaluated and managed in the emergency department. Recent research has evaluated the use of ultrasonography, packing, incision and drainage (I&D), and antibiotics. There are evidence-based nuances to the management of specific types of abscesses, such as Bartholin, breast, dental, hidradenitis suppurativa, peritonsillar, and pilonidal abscesses.ObjectiveThis review provides emergency medicine clinicians with a summary of the current literature regarding abscess management in the emergency department.DiscussionUltrasound is valuable in diagnosing abscesses that are not clinically evident and in guiding I&D procedures. Although I&D is traditionally followed by packing, this practice may be unnecessary for small abscesses. Antibiotics, needle aspiration, and loop drainage are suitable alternatives to I&D of abscesses with certain characteristics. Oral antibiotics can improve outcomes after I&D, although this improvement must be weighed against potential risks. Many strategies are useful in managing Bartholin abscesses, with the Word catheter proving consistently effective. Needle aspiration is the recommended first-line therapy for small breast abscesses. Dental abscesses are often diagnosed with clinical examination alone, but ultrasound may be a useful adjunct. Acute abscess formation caused by hidradenitis suppurativa should be managed surgically by excision when possible, because I&D has a high rate of abscess recurrence. Peritonsillar abscesses can be diagnosed with either intraoral or transcervical ultrasound if clinical examination is inconclusive. Needle aspiration and I&D are both suitable for the management of peritonsillar abscesses. Pilonidal abscesses have traditionally been managed with I&D, but needle aspiration with antibiotics may be a suitable alternative.ConclusionsThis review evaluates the recent literature surrounding abscess management for emergency medicine clinicians.     

Transoral Point-of-Care Ultrasound in the Diagnosis of Parapharyngeal Space Abscess

Background

Parapharyngeal space abscesses (PPSA) are deep-space neck infections that are associated with significant morbidity and, rarely, mortality if not promptly diagnosed and treated. The diagnosis is often difficult, as the clinical presentation can mimic peritonsillar abscesses (PTA). Transoral point-of-care ultrasound (POCUS) may be a useful tool to help distinguish PTAs from other deep-space infections such as PPSAs.

超声引导下置管引流与穿刺抽吸在肝脓肿治疗中的比较

目的:比较超声引导下穿刺抽吸与置管引流在肝脓肿治疗中优劣。方法:33例置管引流与87例穿刺抽吸两组患者,术后比较体温及白细胞下降至正常的时间,平均住院时间以及并发症。两种方法均同时采用静脉内给抗生素治疗。结果:两组方法在疗效及安全性上无显著差异(包括体温及白细胞降至正常时间,平均住院时间以及并发症)。结论:超声引导下穿刺抽吸或置管引流在治疗肝脓肿的疗效与安全性均无显著差异。     

A novel approach to enhance visualization during drainage of peritonsillar abscess

Routine emergency department care for uncomplicated peritonsillar abscess involves needle aspiration or incision and drainage. Standard technique involves use of a tongue blade and auxiliary light source. We describe the novel use of a disassembled disposable vaginal speculum with fiberoptic light, a device becoming commonplace in many emergency departments. This novel approach to managing peritonsillar abscess greatly enhances visualization and facilitates peritonsillar abscess drainage.     

Adult Patients With Peritonsillar Abscess: What Nurse Practitioners in Primary Care Need to Know

Background and purposeA peritonsillar abscess (PTA) is the most common deep neck space infection. Surprisingly, there are no clinical practice guidelines to guide nurse practitioners (NPs) caring for patients with a PTA. This risks inconsistencies in practice and the potential for poor patient outcomes. The purpose of this article is to equip NPs with information to accurately diagnose and appropriately manage patients with a PTA. This article describes the most common characteristics of the patient who presents to outpatient providers with unilateral throat pain consistent with a diagnosis of PTA. Accurate diagnosis improves patient safety and prevents inadequate care by implementing research-based management.MethodsAs part of a quality improvement project, a retrospective analysis was performed on medical record data of 100 patients aged 19 to 59 diagnosed with PTAs at a private outpatient otolaryngology practice. The data were analyzed to look at the most common characteristics of PTA.ConclusionsFindings demonstrated that patients with PTA experienced difficulty controlling oral secretions, where patients with phlegmon did not. A larger number of patients with PTA also experienced lymphadenopathy.Implications for practiceIntervening early with accurate diagnosis and initiation of antibiotics and steroids is essential in the treatment of PTA. When symptoms suggest surgical intervention, the NP should promptly refer the patient to otolaryngology to improve outcomes. Close monitoring of the patient with a PTA improves patient safety by decreasing the likelihood of further airway obstruction and to ensure symptoms continue to improve.     

Role of bedside transvaginal ultrasonography in the diagnosis of tubo-ovarian abscess in the emergency department

Tubo-ovarian Abscess (TOA) is a complication of pelvic inflammatory disease (PID) requiring admission, i.v. antibiotics and, possibly, aspiration or surgery. The purpose of this study was to describe the role of emergency department (ED) bedside transvaginal ultrasonography (US) in the diagnosis of TOA. This was a retrospective review of non-pregnant ED patients presenting with pelvic pain who were diagnosed with TOA using bedside transvaginal US. ED US examinations were performed by emergency medicine residents and ultrasound-credentialed attending physicians within 1 h after clinical assessment. ED US logs were reviewed for the diagnosis of TOA. Medical records were reviewed for risk factors, medical and sexual history, physical examination findings, laboratory results, additional diagnostic testing, hospital course, and a discharge diagnosis of TOA by the admitting gynecology service. A total of 20 patients with TOA were identified over a 3-year period. Ages ranged from 14 to 45 years (mean 27 years). Seven (35%) patients reported a prior history of PID or sexually transmitted disease, and 1 (5%) was febrile. All had lower abdominal tenderness and 9 (45%) had cervical motion or adnexal tenderness. The sonographic abnormalities included 14 (70%) with a complex adnexal mass, 5 (25%) with echogenic fluid in the cul-de-sac, and 3 (15%) patients with pyosalpinx. The discharge diagnosis was TOA by the admitting gynecology service for all patients. Our study illustrates the limitations of clinical criteria in diagnosing TOA and supports the use of bedside US when evaluating patients with pelvic pain and symptoms that do not meet classic Centers for Disease Control and Prevention criteria for PID.     

The Effect of Soft-tissue Ultrasound on the Management of Cellulitis in the Emergency Department

Objectives: To evaluate the effect of diagnostic soft-tissue ultrasound (US) on management of emergency department (ED) patients with clinical cellulitis.
Methods: This was a prospective observational study in an urban ED of adult patients with clinical soft-tissue infection without obvious abscess. The treating physician's pretest opinions regarding the need for further drainage procedures and the probability of subcutaneous fluid collection were determined. Emergency sonologists then performed US of the infected area, and the effect on management plan was recorded.
Results: Ultrasound changed the management of patients with cellulitis in 71/126 (56%) of cases. In the pretest group that was believed not to need further drainage, US changed the management in 39/82 (48%), with 33 receiving drainage and 6 receiving further diagnostics or consultation. In the pretest group in which further drainage was believed to be needed, US changed the management in 32/44 (73%), including 16 in whom drainage was eliminated and 16 who had further diagnostic interventions. US had a management effect in all pretest probabilities for fluid from 10% to 90%.
Conclusions: Soft-tissue US changes physician management in approximately half of patients in the ED with clinical cellulitis. US may guide management of cellulitis by detection of occult abscess, prevention of invasive procedures, and guidance for further imaging or consultation.     

彩色多普勒超声引导下经皮穿刺留置中心静脉导管引流并反复抗生素冲洗治疗老年肺脓肿

目的探讨彩色多普勒超声引导下经皮穿刺留置中心静脉导管引流并反复抗生素冲洗治疗老年肺脓肿的治疗方法和临床应用价值。方法对58例老年肺脓肿患者进行了彩色多普勒超声引导经皮穿刺留置中心静脉导管引流并反复抗生素冲洗法治疗。结果所有患者均一次性穿刺成功,成功率100%,术后使用氯化钠和抗生素稀释后反复抽洗脓腔,直至脓液相对减小或闭合时,拔出引流导管,随访0.5～3年,56个肺脓肿治愈,治愈率96.6%,均未出现出血与气胸等并发症。结论彩色多普勒超声引导下经皮穿刺留置中心静脉导管引流并反复抗生素冲洗治疗老年肺脓肿,成功率和治愈率高,并发症少。     

Splenic abscess: Sonographic diagnosis and percutaneous drainage or aspiration

During a recent 5-year period, 12 patients with splenic abscesses were evaluated by abdominal ultrasound (US) examination. Multifocal abscesses were noted in seven patients, three of them were secondary to infectious endocarditis, three were in immunosuppressed state, and one was caused by tuberculosis. The latter four patients had developed splenic microabscesses with a diameter of <1.5 cm. The larger abscesses showed an irregular wall, weak or no internal echoes, ovoid or round in shape, and accompanied by mild to moderate distal acoustic enhancement. Wedge-shaped abscesses were typically noted in patients with infectious endocarditis and septic embolism. US-guided percutaneous drainage was done in five patients (abscesses > 4 cm). Simple aspiration in conjunction with antibiotic administration was done for seven smaller abscesses (diameter <3.5 cm) in five patients. A second drainage, either for a dislodged catheter or a recurrent abscess, was performed in two cases. All patients had uneventful clinical course following this therapeutic approach.     

Hepatic abscesses in immunocompromised patients: Ultrasonically guided percutaneous drainage

Ultrasonically guided percutaneous drainage (US-PD) is considered first-line therapy for hepatic abscesses, but no data are available on its efficacy in severely immunocompromised patients. Therefore, we examined 15 such patients in whom one or more hepatic abcesses of different etiology were treated with US-PD. Eleven patients underwent needle aspiration and four had catheter drainage under US guidance. In 12 cases we achieved complete healing of the abscesses. In one case, clinical improvement was obtained but surgery was required for cure. In another case (fungal abscess in AIDS), we had no improvement and the patient died. No procedural complications were observed. Seven patients died during the follow-up periods of up to 49 months from their underlying disease. We conclude that US-PD must be considered the therapy of choice for hepatic abscess (except the fungal lesions) in severely immunocompromised patients.     

Interventional ultrasound for adrenal masses

Purpose To determine the value of interventional ultrasound (US) for adrenal masses, especially incidentally discovered adrenal masses. Methods Demographic, clinical, and pathological data were reviewed for eight patients who underwent percutaneous US-guided puncture or biopsy for adrenal masses from September 1994 through March 2002 in our institute. Results US-guided intervention was successfully performed for seven patients: two with adrenal cysts, two with adrenocortical adenomas, and three with metastatic adrenal tumors (one from prostate cancer, one from lung cancer, and one from renal cell carcinoma). The remaining patient had bilateral adrenal masses, and a biopsy specimen could not be obtained because safe puncture was difficult. For all patients there was no postoperative hemorrhage or pain, and no major complications were observed during the procedure. Conclusions Interventional US using the color Doppler method for adrenal masses is a useful procedure for safe puncture to reveal the orientation of adjacent viscera and blood vessels at the puncture site and to avoid complications including hemorrhage and pneumothorax. US, including color Doppler US, is also useful for detection of complications and follow-up studies because it is noninvasive and can be used for real-time examinations. In addition, pathological examination of specimens obtained by percutaneous biopsy or fine needle aspiration is useful for avoiding unnecessary surgery in patients with metastatic adrenal masses.     

Ultrasound-guided drainage of deep pelvic abscesses: experience with 33 cases

The aim of this study was to demonstrate and evaluate the ultrasound-guided drainage of deep pelvic abscesses in which transabdominal percutaneous access could not be performed because of overlying structures. A retrospective analysis of 32 consecutive patients with 33 deep pelvic abscesses was performed. The underlying causes of the abscesses included postsurgical fluid collection or surgical complications in 18 of the 32 patients, and 11 of these patients underwent recent rectal cancer surgery. The locations of the abscesses, which had a median diameter of 6 cm (range 2-10 cm), were as follows: perirectal (n = 13), presacral (n = 9), pouch of Douglas (n = 7), internal genitals (n = 2) and between the bowel loops (n = 2). The abscesses were all drained using ultrasound (US) guidance with a transrectal (n = 18), transvaginal (n = 11), transperineal (n = 2) or transgluteal (n = 2) approach. Of the larger abscesses (median diameter 7 cm), 19 were treated with catheter drainage and 18 of these cases resulted in favorable clinical outcomes. Of the smaller abscesses (median diameter 4 cm), 14 were treated with needle drainage. In two of these cases, follow-up US showed that a repeat puncture and drainage was necessary. All needle drainages resulted in favorable clinical outcomes. Sixteen of the 29 transrectal or transvaginal drainage procedures were performed without any anesthesia (10 were performed with a needle and six were performed with a catheter). Apart from minor discomfort during the drainage procedure and the subsequent in-dwelling catheter period, there were no serious complications related to the drainage procedures. We conclude that ultrasound-guided transrectal, transvaginal, transperineal and transgluteal drainage of deep pelvic abscesses are safe and effective treatment approaches. Based on our findings, needle drainage will be our most common first-line treatment approach because of the simplicity of the procedure, improved patient comfort and reduced costs. Catheter drainage will be reserved for large multiloculated abscesses.(E-mail: tlo@dadlnet.dk)     

US-guided percutaneous needle biopsy of the spleen using 18-gauge versus 21-gauge needles

PURPOSE: To compare the techniques of sonographically (US)-guided percutaneous needle biopsy of the spleen using 18-gauge and 21-gauge needles. METHODS: Forty-two patients undergoing 43 spleen biopsy procedures for focal lesions (n = 27 [16 single, 11 multiple]) or diffuse splenomegaly (n = 15) were analyzed. Two groups were divided randomly according to needle type: group 1 comprised 25 patients biopsied with an 18-gauge cutting needle for histologic examination; group 2 comprised 17 patients biopsied with a 21-gauge needle for histologic and cytologic examinations. Diagnostic accuracy, complication rate, and number of needle passes were compared between the 2 groups. RESULTS: Correct histopathologic diagnosis was obtained in 36 cases, whereas incorrect diagnosis occurred in 6 cases. The accuracy of US-guided spleen biopsy in this series was 85.7%, with 1 patient (2.4%) having postprocedural hemorrhage. Compared with the 21-gauge needle, the 18-gauge needle had higher diagnostic accuracy (P < 0.05), required fewer needle passes (P < 0.05), and there was no significant difference in overall complication rate. CONCLUSION: Because biopsy with an 18-gauge needle yields larger and unfragmented samples with higher diagnostic rate compared with a 21-gauge needle, and no increased rate of major complication requiring surgical intervention, it may be advantageous to use an 18-gauge cutting needle in the US-guided needle biopsy of splenic lesions.     

Abscess incision and drainage in the emergency department--Part I

Superficial abscesses are commonly seen in the emergency department. In most cases, they can be adequately treated by the emergency physician without hospital admission. Treatment consists of surgical drainage with the addition of antibiotics in selected cases. Incision is generally performed using local anesthesia, with intraoperative and postoperative systemic analgesia. Care must be taken to make a surgically appropriate incision that allows adequate drainage without injuring important structures. Postoperative care includes warm soaks, drains or wicks, analgesia, and close follow-up. Antibiotics are usually unnecessary. Complications of incision and drainage include damage to adjacent structures, bacteremic complications, misdiagnosis of such entities as mycotic aneurysms, and spread of infection owing to inadequate drainage. The infectious agents responsible for abscess formation are numerous and depend largely on the anatomic location of the abscess. Staphylococcus aureus accounts for less than half of all cutaneous abscesses. Anaerobic bacteria are common etiologic agents in the perineum and account for the majority of all cutaneous abscesses. Abscesses at specific locations involve special consideration for diagnosis and treatment and may require specialty consultation.     

Bedside ultrasound performed by novices for the detection of abscess in ED patients with soft tissue infections

Objective

The objective was to compare bedside ultrasound (US) to clinical examination for the detection of abscess.

Methods

This is a 24-month prospective, observational emergency department (ED) study. Adults with suspected nondraining abscess with planned incision and drainage (I&;D) are included in the study. Exclusion criteria are spontaneous drainage and perineal, perirectal, or intraoral location. Before I&;D, a second ED physician conducts an US and records the presence or absence of findings suggestive of abscess. A positive I&;D of the suspected abscess is the criterion standard. The treating practitioner is blinded to the US results. Ultrasound is performed by novice ED physicians. The findings of the US, the prediction of pus from the clinician and the ultrasonographer in 3 strata (low, indeterminate, definite), and the results of the I&;D (pus/no pus) are recorded onto data sheets. Measures of association are reported and Fisher's Exact test is used.

Results

Forty patients were enrolled. The sensitivity of novice sonographers to predict a positive I&;D with US was 0.97 (0.83-1.00), the specificity was 0.67 (0.24-0.94), the positive likelihood ratio was 2.90, the negative likelihood ratio was 0.04, and the area under the receiver operating characteristic curve was 0.85 (0.66-1.00). Clinical examination yielded a sensitivity of 0.76 (0.58-0.89), specificity of 0.83 (0.36-0.99), positive likelihood ratio of 4.50, negative likelihood ratio of 0.29, and area under the receiver operating characteristic curve of 0.75 (0.50-1.00).

Conclusion

Novice ED sonographers can identify abscesses with only minimal US training. Identification of abscess on US may change management of cutaneous abscesses.     

Percutaneous management of breast abscesses. An experience of 39 cases

This is a review of our experience with percutaneous drainage by means of needle aspiration or catheter drainage of breast abscesses under ultrasound (US) guidance, and a suggested management algorithm. A retrospective study of the 39 patients (36 women, 3 men; mean age: 28.9 years) with breast abscesses who were treated by percutaneous US-guided procedures over a period of 13 years (1989 to 2002) was carried out. Of the 36 women, 34 were nonlactating and two lactating. Needle aspiration was used in the cases of fluid collections < or = 3 cm and catheter drainage in fluid collections of > 3 cm. Postdrainage care and US evolutive controls were carried out on an outpatient basis. Fine-needle aspiration cytology was performed in masses unresolved after postdrainage. Mammography was performed in patients over 30 years old. In all cases, US examination revealed images of fluid collection. A single needle aspiration was sufficient in 19 cases; 3 patients needed a second aspiration to resolve the breast abscess. A total of 15 cases were resolved by means of percutaneous catheter drainage. In 2 of the 17 patients who underwent catheter drainage, the mass persisted postdrainage; histologic findings showed a chronic abscess requiring surgical intervention in one and a breast carcinoma in the second. Mean follow-up was 8.4 months. Recurrence of breast abscess occurred in 4 patients, and these were resolved by surgical excision. Percutaneous drainage procedures in breast abscesses are a safe and effective alternative to incision and drainage. Needle aspiration is employed in cases of small abscesses and catheter drainage in abscesses larger than 3 cm. Although, in chronic abscesses, the treatment of choice is surgical excision, percutaneous drainage remains as an intermediate therapeutic option.     

Point of Care Ultrasound Use by Associate Providers for Differentiating Abscess Versus Cellulitis Skin and Soft Tissue Infection in the Emergency Department

BackgroundSkin and soft tissue infections (SSTIs) are a common complaint in the ambulatory setting and pose a significant burden on the health care system.ObjectivesWe sought to determine the accuracy of ultrasound for detecting soft tissue abscesses by emergency medicine associate providers (APs).MethodsThis was a prospective observational study of adult patients with suspected SSTI in the emergency department of a rural tertiary care academic medical center. The AP performed and interpreted point-of-care ultrasound (POCUS) of the suspected infected area. Ultrasound images and interpretation were reviewed by the attending emergency physician with either rejection or agreement of the image interpretation, diagnosis, and management. If incision and drainage was performed, presence or absence of purulent drainage was recorded.ResultsSixty-four patients with suspected SSTI were enrolled: 29 had POCUS-proven abscesses and 33 had cellulitis; 2 were excluded. AP clinical evaluation alone for identifying abscess revealed sensitivity of 92.3 (74.9–99.1), specificity of 67.7 (49.5–82.6), positive predictive value of 68.6 (57.0–78.2), and negative predictive value of 92.0 (81.4–100). The use of POCUS by APs in addition to clinical examination demonstrated sensitivity of 96.2 (80.4–99.9), specificity of 93.9 (79.8–99.3), positive predictive value of 92.6 (76.5–98.0), and negative predictive value of 96.9 (81.9–99.5). p values were <0.05 for test characteristics. Ultrasound results changed SSTI management decisions in 10 of 62 (16.1%) patients, with the most common change being a new incision and drainage or needle aspiration. Agreement of the POCUS interpretation between APs and attending physicians was 96.8% with a κ of 0.94 (0.85–1.00).ConclusionWith modest training, APs can successfully use POCUS to identify abscesses in patients in the emergency department with SSTIs. POCUS increases the ability to rule in the diagnosis and changes management in a clinically relevant number of patients with SSTIs.