February 2003

A 15-month-old girl presents to the clinic with a painful neck mass and fever. There has always been fullness in the same area, but there has been a sudden increase in size. There is also a past history of this happening before, requiring a surgical procedure. Her past medical history is otherwise normal, and immunizations are up to date.

Examination revealed a healthy 15-month-old girl with a fever of 102.3°F and a mid-line neck mass as shown in figures 1 through 3. No lab tests were done. The rest of her examination was normal.

Part 1. What’s your diagnosis?

1. Submental adenitis
2. Thyroglossal duct abscess
3. Branchial cleft cyst
4. Actinomycosis

Part 2. Which of the following would you use?

1. Ampicillin
2. Nafcillin
3. Ampicillin-sulbactam (Unasyn, Pfizer)
4. Ceftriaxone (Rocephin, Roche)

Part 1 - Answer

The answer is B, thyroglossal duct abscess. The clue is in its low, midline location (figure 4). The thyroglossal duct cyst is by far the most common midline neck mass. An additional clue is that these masses will move with swallowing. They can obviously get infected, becoming an abscess. Infections are usually mixed with aerobic gram-positive cocci, such as staphylococcus, predominating along with anaerobic organisms from the mouth and upper respiratory tract. While a submental adenitis may be midline, it will be just under the chin, and would not likely be recurrent. A branchial cleft cyst is also a congenital defect, but will be in a lateral cervical location, at a point along the anterior aspect of the sternocleidomastoid muscle. These can also be recurrent and infected.

Cervicofacial actinomycosis is an infection usually caused by Actinomyces israelii, a gram-positive anaerobic bacillus that may be part of the normal flora. It is fairly uncommon in children. When it is seen, it is usually manifested as a firm, nodular swelling anywhere along the mandibular area. It is usually associated with poor dental hygiene and or trauma.

Part 2 - Answer

Therapy recommendations are always tricky, but out of these choices, I feel ampicillin-sulbactam is the best selection. As previously noted, head and neck infections are often mixed, with aerobes and anaerobes being recovered. Ampicillin covers most of these organisms, and the sulbactam molecule makes it resistant to those producing beta-lactamase. Nafcillin is too narrow in its spectrum and ceftriaxone is not reliable against staphylococcus. Neither would have the respiratory anaerobic activity of ampicillin-sulbactam. High-dose ampicillin or penicillin would be the drug of choice if this were actinomycosis.

After the infection was drained (figures 5-8) and cleared up with a course of antibiotics, she was to return to have a definitive procedure to close the defect to prevent it from occurring again.

Is there anything in medicine that provides more instant gratification than draining an abscess? I think it was at the moment of my first real abscess experience that turned my interest to infectious diseases. I was an intern working my shift in the emergency room at Fitzsimons Army Medical Center in Denver in 19xx, well, let’s just say a while back, when a patient came in with an axillary abscess. After incising it, there was some initial drainage, but I could tell there was a lot more where that came from. Apparently, there was a large loculation of pus that gave way as I applied a little pressure to the lesion. It shot a stream of foul-smelling, brownish exudate across the room, hitting the wall. The patient felt an instant sense of relief from the pain that she had on presentation. The culture grew Pseudomonas aeruginosa; less likely than Staphylococcus aureus, but not too unusual. It probably got there by way of shaving under her arms, initially resulting in folliculitis. It is hard to remember the details of the case, but the site of that pus flying across the room is as fresh in my memory as if it happened yesterday, in slow motion. During the course of my residency, I gravitated toward this “art form” of using pus as a liquid missile. I recall as a chief resident, I was showing an intern (my old friend Ed Eitzen) how to drain an abscess on the buttock of a child who was admitted to the hospital. Dr. Eitzen was positioned at the foot of the table, in the direct line of fire. I got him right in the chest with a stream of the typical yellowish exudate of S. aureus. I’ve grown up since then and certainly don’t condone this type of foolish behavior of youth. However, Dr. Eitzen learned a valuable lesson on the dynamics of fluid under pressure. I’ve drained a lot of abscesses since then — but I never find it boring.

Drainage of the abscess is one of the oldest described surgical procedures. A quote from The Ebers Papyrus, from about 1550 B.C., reads, “When thou findest a purulent swelling with the apex elevated, sharply defined and of a rounded form, then sayest thou, ‘it is a purulent tumor which is growing in the flesh … I must treat the disease with the knife’” (Mettler CC and Mettler FA. History of Medicine. Blakiston;1947:797). This basic principle has not changed in over three millennia.

Of course, the patient presented did not have a simple furuncle or carbuncle that could simply be incised and drained. She had an abnormal anatomic space that got infected and reinfected, requiring more expert surgical drainage and repair. No pathogen ever grew from the culture, probably because of the several doses of antibiotics she received prior to drainage. Even though nothing grew, never be misled, antibiotics alone will not fix a well-formed abscess.