Abscess incision and drainage in the emergency department (Part 2)

The Journal

of Emergency

Medrone.

Vol 3. pp 295-305,

1985

Prrtled

r the USA

l

Copyright

” 1985 Pergamon

Press 1:d

ABSCESS INCISION AND DRAINAGE IN THE EMERGENCY DEPARTMENT (Part 2) Gary D. Halvorson,

MD,

Jan E. Halvorson,

DMD,

Kenneth V. Iserson,

Section of Emergency Medicine, Department Arizona liealth Sciences Center, Tucson, Reprint address, Kenneth V Iserson.

Abscesses

at Special

Sites

Nasal Septal Abscesses A nasal septal abscess (NSA) is an uncommon entity. It is defined as a collection of pus separating the cartilaginous or bony septum from the mucoperichondrium or mucoperiosteum.’ It usually results from a traumatic nasal septal hematoma.2.3 An NSA presents as nasal congestion, usually with nasal pain, headache, and often fever. One or both sides of the septum are swollen and fluctuant. The abscess can occlude the nares. Externally the nose usually appears normal.1*3 Intracranial extension is possible as a result of an NSA. Multiple complications have been reported including extension to the cavernous sinus, sagittal sinus, and pterygoid plexus. Meningitis may also occur as a result of NSA extension.3-5 In addition, an NSA often causes necrosis of the cartilaginous nasal septum resulting in the “saddle-nose” deformity.2.3 Drainage of an NSA can be performed in the emergency department under local anesthesia, but admission and intravenous antibiotics have been recommended.‘,2 Top-

MD,

FACEP

of Surgery, AZ 85724 MD

ically applied cocaine (4t70) is the anesthesia of choice for these patients. Needle aspiration confirms the diagnosis, and Gram’s stain aids in the choice of antibiotic. Ambrus et al’ recommend parenteral antibiotics to be given one-half to two hours prior to incision and drainage. The incision can be made vertically or horizontally and over the point of maximum fluctuance.‘,3 When the abscess is bilateral, the incisions should be made in a staggered fashion. After evacuation, a small section of mucoperichondrium is excised, a drain is sutured in place, and the nose is then packed with finger cots. The drain and packing are left in place until drainage ceases in two to three days. Intravenous antibiotics are continued for three to five days followed by a course of oral antibiotics.

Odontogenic

Abscesses

In many cases it may be difficult to distinguish between the odontogenic abscesses. They often present with localized pain, with or without swelling and trismus; and, infrequently, with systemic signs. If not recognized and treated properly, an odonto-

Techniques and Procedures features practical, “how-to” articles of interest to all practicing emergency physicians. This section is coordinated by George Sternbach, MD, Stanford University Medical Center. RECEIVED: 16 April 1985; ACCEPTED: 8 May 1985 0736-4679185 $3.00 + 800

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genie infection may spread hematogenously or through direct invasion of anatomic spaces. This can cause serious complications such as cavernous sinus thrombosis, mediastinitis, or airway obstruction.6.7 Odontogenic abscesses most commonly arise from dental pulp, but may also arise from the periodontal (gum) or pericoronal structures overlying a partially erupted tooth.’ A periapical or dentoalveolar abscess begins as inflammation from an infected or necrotic pulp that progresses through the root apex into the alveolar bone. The abscessmay perforate the alveolus and spread into continguous fascial planes. It may appear either intra-orally or extra-orally, depending on the anatomic location of the affected tooth and on the route of abscess spread.8,9 Periodontal disease is a chronic, destructive bacterial process that produces an inflammatory exudate that usually drains freely about the neck of affected teeth. A periodontal abscess results from obstruction of this drainage. It presents as localized swelling of the soft tissues encircling the associated and frequently mobile tooth. The abscess is usually limited to the alveolar process and does not often spread to neighboring anatomic spaces.6 A pericoronal abscess, most frequently associated with mandibular third molars, arises when microorganisms and debris become entrapped under the soft tissues surrounding a partially erupted tooth. This may result in a local infection between the tooth and soft tissues.’ If inflammatory exudate becomes entrapped because of swelling, spread to other anatomic sites, such as the pterygomandibular space, is possible.6 The emergency physician should drain these abscessesonly when fluctuance is palpable. Incisions must be kept superficial, and blunt dissection should be used to open the abscess cavity to avoid neurovascular structures such as the mental or lingual nerves and facial artery.‘O Gauze packing may be used to aid drainage. After incision and drainage, or in cases

Jan E. Halvorson,

Kenneth

V. lserson

not drained in the emergency department, warm saline rinses, analgesics, and an antibiotic effective against oral flora (penicillin, erythromycin, or clindamycin) are indicated.“‘I4 Dental referral is mandatory since extraction, root canal, or periodontal treatment may be required to best treat the source of infection.

Feritonsillar Abscesses Peritonsillitis is an acute infection of the peritonsillar space. This can be in the form of cellulitis or peritonsillar abscess (PTA).15 The patient, usually an adolescent or young adult, presents three to five days after the onset of a sore throat with worsening of unilateral pharyngeal pain radiating to the ipsilateral ear.16-2r On examination, the patient is usually mildly toxic with some degree of trismus and drooling. The involved tonsil is displaced medially, and the anterior tonsillar pillar is swollen.L6.18-23Pointing or fluctuance may or may not be present.24.25 If pus is demonstrable in the peritonsillar space, by visual examination or by needle aspiration, drainage is indicated. A PTA, if not drained, may progress to involve the parapharyngeal space, which is occupied by the carotid artery, jugular vein, sympathetic chain, and cranial nerves IX, X, XI, and XII.*6~23 Severe toxicity, medial displacement of the entire lateral pharyngeal wall, torticollis, diffuse brawny edema at the angle of the jaw, or signs of involvement of the contained neurovascular structures all suggest a parapharyngeaI abscess.“*U.z6*27 Otolaryngologic consultation should be obtained whenever this is suspected. A carotid artery aneurysm may masquerade as a PTA, the incision of which could be disasterous.28-32 Therefore, needle aspiration should always be performed, prior to drainage, to rule out this possibility.32 With cooperative patients, incision and drainage of a PTA may be performed under local anesthesia in the emergency department. Small children will often require general anesthesia for incision and drain-

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age.33 Topical application of 10% cocaine to the site of incision with or without intravenous opiates is usually sufficient anesthesia.24.33Ipsilateral intranasal cocainization will usually overcome severe trismus.24.33.34 The patient should be sitting upright with head support and lighting provided via a head mirror or head light.2**33 Needle aspiration should first be performed with an 18gauge needle at the site of maximum bulging.” Adhesive tape may be wrapped around the needle approximately 1 cm from the tip as a guard to prevent advancing the needle too deeply (Fig 1). If unsuccessful, a second attempt may be tried 1 cm lower.3s.36 If no pus can be aspirated, the diagnosis of cellulitis should be made, and the patient treated conservatively, without incision.‘9.25.35-37 If an incision needs to be made, it should be at the site of successful aspiration.*’ A no. 11 blade is used, tiith tape guarding all but the tip of the blade, as with needle aspiration, to make a small incision just through the mucosa21*33(Fig 2). If the anterior pillar is involved, the blade should be directed posterolaterally, remaining anterior to the tonsil.24 If the posterior pillar is involved, the blade should be directed laterally.22 A small hemostat is used to enlarge the incision, and a suction tip is held near the site to prevent aspiration of pus by the patient.16 No drain is used. For patients with PTA or cellulitis, analgesics, warm saline pharyngeal douches, and a lO-to-14&y course of penicillin or other appropriate antibiotic should be prescribed.25*3a.39Follow-up should be daily in the beginning, watching for new accumulation of pus. Patients unable to swallow will require admission for parenteral fluids and antibiotics.19,m Many otolaryngologists have begun to advocate immediate tonsillectomy as the drainage procedure of choice. This is because PTA is considered, by some, an absolute indication for tonsillectomy.i6~19~22 Therefore, the emergency physician should be aware of the approach used by the local otolaryngologists. A third approach recently studied in-

Figuro1.AspWbonotrperMaWb~ss.

T8p8ku88dtopwnmld88pp8n8mtMof~ luledk.

volves needle aspiration and antibiotics, without incision and drainage.3s~37~40~4’ Herzon has shown that the majority of patients with PTA can be treated successfully as outpatients by nonotolaryngologists with this method.j6 Aspiration should be performed as described for diagnosis, but aspirating as much pus as possible. Complications of PTA are largely a result of extension into other deep neck spaces and their contained structures.24.27 Extension can continue to include the intrathoracic or intracranial spaces.*6~24~42 Failure to diagnose a carotid artery aneurysm, either accompanying or masquerading as a PTA, can result in exsanguinating hemorrhage upon incision.30-32 Aspiration of pus by the patient during drainage can be prevented by having the patient sit upright, emptying the cavity with a needle prior to incision, and by using suction as the abscess is incised.16

Hidradenitis

Suppurativa

Hidradenitis suppurativa is an acute and chronic disorder of the apocrine sweat glands located in the axillary, genital, and perianal regions.43 The glands become obstructed with keratinous debris, resulting in recurrent abscesses, eventually with subcutaneous spreading and multiple-draining sinuses. In the acute phase, treatment consists of appropriate antibiotics, with or without incision and drainage, moist heat, impeccable

298

Gary D. Halvorson,

Figum2.lndsbnofr~lkuabsce.s.Tspe

Is used here, as wall, to prevent the Made from

advancing

too deeply.

axillary hygiene, and topical antiseptics.“.45 Shaving, deodorants, antiperspirants, and depilatories should be discontinued. The chronic phase of this disease is notoriously resistant to conservative therapy, and radical surgical excision of the apocrine sweat glands is required for cure.45-47 Thus, anyone with recurrent axillary or perineal abscesses should be given surgical referral.

Fingertip Abscesses Although most suppurative infections of the hand require the expertise of an experienced hand surgeon, those in the fingertip can often be effectively treated by the emergency physician. The term “paronychia” refers specifically to an infection of the nail fold on the radial or ulnar side, but is also often used to refer to nailbed infections in genera1.4*-so A felon, or whitlow, is an infection of the pulp space of the finger. These common infections are usually amenable to treatment in the emergency department. An acute paronychia may present as swelling and pain of the nail fold, the subungual space, or both. Although some very early paronychias can be treated conservatively with heat, elevation, and antibiotics alone, nearly all will require some form of drainage.SL-53 For small amounts of pus restricted to the nail fold, blunt dissection of the nail fold from the nail with small scis-

Jan E. Halvorson,

Kenneth

V. lserson

sors may be successful in draining one or two drops of pus (Fig 3). This usually provides sufficient drainage without anesthesia.48.54Alternatively, a no. 11 blade may be used for dissection if held flat against the nail49,50,55,56 (Fig 4). When pus is present beneath a portion of the nail, that portion must be removed in a minimally traumatic manner .48.so.54The involved nail can be bluntly dissected from the nailbed, and then removed with sharp tissue scissors5’ (Fig 5). If the proximal nail is removed, the nail fold must be packed with a nonadherent dressing to prevent adhesions and resulting nail deformity.50 The entire nail should be removed only when completely separated from the nailbed by pus since removal leaves the fingertip unprotected.54.s5 A felon presents as a painful, red, warm, tensely swollen fingerpad. Diagnosis must be made and surgical therapy instituted early, before impairment of blood supply or involvement of the tendon occurs.52.57Throbbing pain and tense swelling implies pus formation under pressure, mandating immediate surgical intervention.48.4g~58~sgLate signs include fluctuance, pointing, draining, sinus formation, skin necrosis, and finger pad anesthesia. Herpetic whitlow, a fingertip infection caused by herpes virus, may simulate a felon, but should not be surgically drained. It can be distinguished by lack of tenseness, presence of vesicles, and a positive Tzanck test, wherein giant cells are seen on light microscopy of stained vesicular fluid.60-62 The surgical treatment of felons is controversial. Classically, various forms of dorsal incisions have been advocated. This includes making the incision parallel and just volar to the nailbed, breaking up the fibrous septae to allow for drainage and avoiding the finger pad itself. The “fishmouth” incision has been almost entirely abandoned, and the “J” or “hockeystick” is used much less frequently. Unilateral and bilateral incisions have become frequently adv~ated50~5’~54~57~63~64 (Fig 6A-D). With this approach, a no. 11 blade is used to incise only the skin, being very careful to remain

Abscess

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and Dramage

Figure3.Bkmt dbecuonwlthcuwedkhacieaom meybeaHthetkrequh-edfordrehmgeofaemall paronychia. Aneethesia may not be necessary.

dorsal and barely volar to the nailbed. This avoids digital nerve or artery injury.57 Blunt dissection should be carried out volar to the distal phaiynx. A unilateral incision should be made on the radial side of a thumb or little finger, or on the ulnar side of the remaining digits.S’*54 The wound should be packed open with gauze, and when using a bilateral incision, a gauze wick may be passed from one side to the other to facilitate drainage. An alternative approach involves a longitudinal, midvolar incision (Fig 6E). With this approach, the incision is made through the skin over the area of maximum tenderness, and blunt dissection is carried to the distal phalynx.48*49.65~66No attempt is made to disrupt the fibrous bands of the fingertip. Zinc oxide may be used to keep the wound open, but the wound is not packed. When late signs of abscess formation are present, thii is the procedure of choice, since a dorsal incision is more likely to contribute to skin slough. Some authors advocate this incision in ah cases of fe10ns.49.53.56*s9Opponents of this method express concern about painful scar formation, whereas its advocates maintain that this is not a problem.48*66 For felons seen late in their course or where there is concern about bone or tendon involvement, a hand surgeon should be consulted and inpatient care considered. When managed as an outpatient, followup should be daily until clear progress to-

F&fure4.Aeea@elbbdeieueedto~tbe nefl fold from the nell in an acute pwny&fe.

ward resolution is evident. Persistence or return of throbbing pain implies inadequate drainage, and further surgical intervention is needed.56,67 For all hand infections care must include heat, elevation, appropriate antibiotics, and plaster immobilization.48.49.62.67 Heat should be applied with hot packs, since soaking precludes elevation. Antibiotics shouid be chosen empiricahy to include staphylococcal coverage until culture and sensitivity rest&s are available.6*-‘0 The efficacy of antlbiotits, however, has been demonstrated only in older studies with parenteral penicillin. ‘I-” Digital or metacarpal block anesthesia should be used for drainage of all felons and all but the most minor of paronychia.49

Perkectel Abscesses Controversy surrounds the classification, etiology, and treatment of perirectal abscesses. Although usually associated with only minor morbidity, perirectal abscesses require adequate drainage for healing, since they have the potential for mortality and severe morbidity. Usually perirectal abscessesare classified as perianal, ischiorectal, intersphincteric,

300

Gary D. Halvorson,

Jan E. Halvorson,

flgur.6. vwiouai-u8odto~~ (A) “fjshmouth”i-,

Kenneth

V. lserson

(B)“J” or “hOCkey-

swellingis morelateralanddiffuse.” Fever and leukocytosismay bepresent.87**9.w An intersphinctericabscessusuallypresentsas exquisitetenderness andswellingposteriorintermuscular(submucosal), or supralevator ly on rectal examinationwithout external (pelvirectal).The largestmajority of peri- signs.9’The uncommonintermuscularand rectalabscesses areperianaland ischiorec- supralevatorabscesses presentwith auteal, tal, which are, fortunately, the most easily pelvic,or perianalpainand swellingevident treated.74-78 high in the rectum on digital examination. Accordingto theanalglandularhypoth- IILdefti pain,fever,leukocyto&s,andconesis,ail perirectalabscesses beginasinter- stitutional symptomsarecommon, andthe sphinctericabscesses that arise from anal diagnosismay be difficult to make.9z-93 In glandularinfectionsand spreadin different addition,entitiessuchashidrade&s suppudireakm.“.w Althoughoriginauyproposed ratiq fUrundes,andBartholincyStabsceWs in 1929,no definitive evidencefor this the- may mimic perirectalabscesses.77.7*.89.94 ory of origin is available.81 Indirectevidence While many perirectalabscesses can be existswhich suggeststhat intersphincteric drainedin theemergencydepartmentunder abscesses are not involved in a significant localanesthesia, thepatientsmustbechosen percentageof cases.~*8z-*4 with care. In general,most perianal and A wide variety of organismshavebeen ischiorectalabscesses areamenableto outisolatedfrom perirectalabscesses, but Ewhpatient treatment, but nearly all of those ericia coii, Staphybcoccus aureus, and fecal morecephaladshouldbe drainedunderananaerobes arefoundin themajority.82.U.m-“’esthesiain the operatingroom.75.‘7When A perianalabscesspresentsas a tender patient discomfort precludesan adequate swellingimmediatelyadjacentto the anus, rectalexamination,or whenfor any reason without indurationof theanalcanalon rec- the extentof theabscess is unclear,spinalor tal examination.74.88 Constitutional signs generalanesthesiais indicated.‘sAlthough and symptoms are usually absent.An is- beliedby commonexperience, someauthors chiorectalabscessalso presentsasperianal suggestthat local anesthesiaaloneis never pain, but induration is palpable on rec- sufficient to allow for adequateexaminatal examination,and the externalperianal tion or drainage.87.W,94.95 Inadequatedrain-

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Abscess incision and Drainage age under local anesthesia has been followed by death in some case~~.~ In addition, admission and drainage in the operating room should be elected for patients who are toxic, debilitated, or who have underlying iksses rendering them at risk for complications. Incision and drainage should be made with the patient in the prone or jackknife position and with the buttocks taped apart. The incision for p&anal or ischiorectal abscessesshould be radial and can in&de elliptical excision, with or without deroofmg. Packing, usually iodoform or Et&-soaked gauze, should be removed at 24 to 48 hours and sitz baths begun. Antibiotics am not required for the uncomplicated case.“.M Incision, currettage, and primary suture with antibiotic coverage has been used successfully for per&W a&essesg** Others have advocated primary ftiulotomy, citing the anal glandular hypothesis as rationale. 97-100 Most authorities disagree with these procedures. complications of ptrinctal abscessescan include extension into the adjacent soft tissues, including fascia, muscle, genitalia, and abdomen. This can cause septicemia, tissue necrosis, and sometimes de&~.~~-‘~ Factors associated with a poor outcome are patient delay, inadequate treatment, and, nearly always, significant concomitant dise~e.87.90.102

Pilonidal (Postanal) Abscess Pilonidal sinus disease includes the formation of sinus tracts, pits, and abscesses in the midline presacral region. The etiology remains controversial. Some authors maintain the sinus tracts are congenital in origin, whereas the majority feel the disease is acquired, resulting from the ingrowth of hair into follicles.103-‘07 The bacteria responsible for abscess formation are predominently fecal flora with a high proportion of anaerobes.Lo8.109 The disease nearly always affects postpubertal white people under the age of 30. It lasts less than 4 years, even without de-

finitive therapy.“O.“’ A pilonidal abscess presents as a tender swelling in the presacral area, accompanied by a central sinus and lateral fktuias. Systemic symptoms are uncommon. ’ a* Care must be taken to differentiate a pilonidal abscess from hidradenitis suppurativa since the surgical treatment is different. A great variety of smgical ope&ons for pilonidal sinus disease have been prqosed. ThOS4?WhOSt?beIiewiIlthe~theory

of origin genera@ reammmdmoreextensive operations than those ascribing to the acquired theory.‘i* Nonsurgical methods including sclerosis, cautery, and radiation therapy have met with partial, temporary success. surgery ranges from mcksion, curettagc,andprimarysuturctowide~ & flep ~~llblf3 sjmpk drainage without antibiotics foliowed by a definitive operation seven to tar days Iater

Oftheseveralpmoetkures~for aprimarynue,oneoftbesafeHICLbOdDrequiringolllylod-iawrivcsshavingthearea,unroof~oftiaec&rc& sinustractaadaulateral~,asKlthorOUghlydeaajllgd~OpUJOfthCcntire Iesion.‘05-“4-1*C Ha&ng by this method usually requires three to six weeks. Therefore, the emergency physician who treats the patient in this manner should discuss therapy with the surgeon who will provide follow-up care. This care mvolves sit2 barbs, localhy~,andthebrc&.ingupofbridge formation, which keeps the wound edges apart while healing occurs. Antibiotics are usually unnecessary.

Bartholin ‘s Cyst Abscesses The Bartholin’s glands are located posterolaterally to the orifice on either side of the vaginal canal.“’ When the duct of the gland becomes obstructed, a cyst may form, which

302

Flgure

(conrw)

Gary D. Halvorson,

7.

Mamupll&atlon of a Bartholln’r the cyrs wall Is inclaod, ovtied

Jan E. Halvorson,

Kenneth

V. lserson

gland oy8t: (left) an ellipn is mmoved from the ep&hdum, and (rfg/ft) sutured to the epithelium.

is evident as a painless swelling in the region of Bartholin’s gland. These cysts can become infected, giving rise to an abscess that presents as a warm, tender swelling with erythema. *18 Treatment consists of simple incision and drainage with referral for marsupialization when the abscess has healed, primary marsupialization, or treatment by the Word catheter technique. Incision and drainage alone lead to a high recurrence rate.L”.119 Excision of the gland is only performed for recurrent cases and is never performed in the presence of infection.‘20 Incision and drainage or marsupialization may be performed under local, regional (ipsilteral pudendal block), or general anesthesia.lzO With the patient in the lithotomy position, the incision is made on the mucosal surface over the abscess and parallel to the hymenal ring. For simple incision and drainage, the abscess is then packed with iodoform or petroleum gauze and removed in 48 hours, at which time sitz baths are begun.

To perform marsupialization, an elipse of vestibular epithelium should be excised over the abscess parallel to the hymenal ring. The cyst is incised, the contents evacuated, and the edges of the cyst everted. They are then sutured to the vestibular epithelium with 2-O or 3-O chromic or polyglycolic acid sutures (Fig 7). In the presence of an abscess, the cyst lining may not be well defined. Marsupialization creates a large opening that will eventually shrink to pinhead size. Sitz baths are begun on the third or fourth postoperative day. Neither packing nor antibiotics are required in most cases. A less commonly employed method involves the use of a specialized catheter developed by Word. 1X*.121After a small incision, the catheter is inserted, the balloon inflated with 2 to 5 mL water, and the distal end tucked into the vagina. It is left in place for 4 to 6 weeks. During this time a fistula is formed and epithelialized. Recurrence appears uncommon with this technique and discomfort is not a problem.‘L*~‘22

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Baker AS, et al: Manabscess. Luryngoscope Eliachar I, et al: Nasal origin. Arch OtolarynParker

J: Abscesses

of

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28. McCall JW, Stover WG: Recurrent retrotonsiilar hemorrhage. Laryngoscope 1944; 54:616-618. 29. Metson BF: Hemorrhage of the internal carotid artery secondary to deep neck abscess: report of a case. Ann Otol Rhino1 Laryngol1956; 65:218224. 30. Saiinger S, Pearlman SJ: Hemorrhage from pharyngeal and peritonsiilar abscesses:report of cases, resume of the literature and discussion of ligation of the carotid artery. Arch Otolaryngol 1933; 18464-509. 31. Blum DJ, McCaffrey TV: Septic necrosis of the internal carotid artery: a complication of perisonsiilar abscess. Otolaryngol Head Neck Surg 1983: 91:114-118. 32. Henry RC: Aneurysm of the internal carotid artery presenting as a peritonsiliar abscess. J Laryngol Otol 1974; 88:379-384. 33. Kornblut AD: Non-neopiastic diseasesof the tonsils and adenoids in Papareila MM, Shumrick DA (eds): Otolaryngology, voi 3, Philadelphia, WB Saunders, 1980, pp 2271-2273. 34. Kveton JF, Pillsbury HC: Breaking trismus to faciiitate drainage of peritonsiiiar abscess. Lar.vneoscooe 1980: 90: 1892- 1893. 35. Herr&t FS, Aidridge HJ: Peritonsillar abscess: needle aspiration. Otolaryngol Head Neck Surg 1981; 89:910-911. 36. Herzon FS: Permucosal needle drainage of peritonsillar abscesses.Arch Otolaryngoli985; 110: 104-105. 37. Elisbury KE: Therapeutic alternatives and clinical outcomes in peritonsiititis. J Fam Pratt 1984; 18:69-73. 38. Fiodstrom A, Hailander HO: Microbiological aspects of peritonsiliar abscesses. Stand J Infect Dis 1976; 8:157-160. 39. Brook I: Aerobic and anaerobic bacteriology of peritonsillar abscess in children. Acfa Paediatr Stand 1981; 70:831-835. 40. Schechter GL, Sly DE, Roper AL, et al: Changing face of treatment of peritonsitiar abscess. Laryngoscope 1962; 92:657-659. 41. Cantreil RW: Proper treatment of peritonsiliar abscess: an exercise in cost containment (letter). Arch Otoiaryngol 1984; 110: 103. 42. Lee KJ. Traxier JH. Smith HW. et ai: Tonsillectomy; treatment of peritonsillar abscess. Trans Am Acad Ophthalmoi Otolaryngoll973; 77:417423. 43. Rutherford WH, Calderwood JW, Hart D, et al: Antibiotics in surgicai treatment of septic lesions. Lancet 1970; 1:1077-1080. 44. Simmons RL, Ahrenhoiz DH: infections of the skin and soft tissues, in Simmons RL, Howard RJ (eds): Su@cali@ctious D&~uw, New York, Appleton-Century-Crofts 1982, pp 524-532. 45. Anderson DK, Perry AW: Axillary hidrandenitis. Arch Surg 1975; 110:69-72. 46. Leach RD. Eykyn SJ, PhilPps I, et al: Anaerobic axillary abscess. Br Med J 1979; 2~5-7. 47. Hyland WT, Neale HW: Surgical management of chronic hidradenitis suppurativa of the perineum. South Med J 1976; 69:1002-1004. 48. Sneddon J: Infections, in Pulvenaft RG (ed): The Hand, from Rob C, Smith R, Dudley H

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(eds): Operative Surgery, 3rd ed, Boston, Butterworth & Co, 1977, pp 340-351. 49. Conolly WB. Carter S: Infections, in Kilgore ES, Graham WP (eds): The Hand: Surgical and NonsurgicalManagement, Philadelphia, Lea & Febiger, 1977, pp 307-315. 50. Crandon JH: Infections of the hand, in Simmons RL. Howard RJ @Is): Surgical Infectious Distutus, New York, Appleton-Century-Crofts, 1982, pp 1032-1037. 5 1. Neviaser RJ: Infections, in Green DP (ed): Operative Hand Surgery, vol 1, New York, Churchill Livingstone, 1982, pp 771-777. 52. Carter P: Common Hand Injuries and Infections: A Practical

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60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70.

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to Early

Treatment,

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