Posterior neck abscess

[pinipig523]

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Would you guys drain a posterior neck abscess? Something that is at the base of the skull along the trapezius muscle - a little dorsal to the posterior triangle of the neck?
I can see possibly only one artery that may be nearby - the occipital artery.

That said - I had an interesting case today. Patient came in from the general surgeon's office after being referred by the primary physician. The surgeon refused to I&D the abscess because of its location so he sent the patient to the ER. I took this as a sign that there might be something more than meets the eye. I had the ENT surgeon drain the abscess, which he did very willingly.

The abscess was about 3x4cm.

Non toxic otherwise.

Would you drain it? I think I got spooked by the fact the surgeon didn't feel comfortable with it. I tried to recall if I drained something in this location in residency, but I recall myself being so much more cavalier back then (a couple of years ago)... funny how that goes.

 

[tkim]

Would you guys drain a posterior neck abscess? Something that is at the base of the skull along the trapezius muscle - a little dorsal to the posterior triangle of the neck?
I can see possibly only one artery that may be nearby - the occipital artery.

That said - I had an interesting case today. Patient came in from the general surgeon's office after being referred by the primary physician. The surgeon refused to I&D the abscess because of its location so he sent the patient to the ER. I took this as a sign that there might be something more than meets the eye. I had the ENT surgeon drain the abscess, which he did very willingly.

The abscess was about 3x4cm.

Non toxic otherwise.

Would you drain it? I think I got spooked by the fact the surgeon didn't feel comfortable with it. I tried to recall if I drained something in this location in residency, but I recall myself being so much more cavalier back then (a couple of years ago)... funny how that goes.

I'd bedside sono it then drain if no nearby questionable structures.

 

[Rendar5]

Could always ask the surgeon what spooked him. Its his bread and butter so might learn something, be it medicine or this particular surgeon.

 

[dotcb]

Outside of EM, thinking outside the box, or working outside of your defined discipline is not rewarded. Most surgical disciplines have defined areas of the body that they work in, and there is little to no incentive for them to cross the line.

Example: I sent a patient to the OR w/ ENT last week for a neck abscess from IVDU. Intra-operatively, ENT discovered a small, simple cutaneous abscess on his leg. What did they do about it? Nothing. Consulted surgery after the case was done.

 

[Groove]

Depends on size and location and clinical presentation, etc.. If surgeon refused and sent to ED (red flag for me, in general), I would not touch without a direct conversation to understand his reasoning and good documentation of that conversation. I had one recently over the upper back/C7/T1 area with cellulitic changes overlying, mildly febrile, went down to the spinous processes and close to interspinous ligament. Too deep for my comfort, so I admitted him for cellulitis and had surgery deal with the abscess. Generally, uncomplicated abscesses isolated in muscles, although uncommonly seen by me... I've not had a problem with straightforward I&D in the past unless I'm concerned for adjacent neurovascular damage. You can always at least aspirate, send for culture and IV vs PO abx with good surgery f/u unless they look toxic or it appears worrisome.

That being said Pin... I prob would have had ENT deal with it, as you did. Something about being at the base of the skull, that size, in that location makes me uneasy. It's just not a common location, so I would have been reticent without at least talking to a surgeon about it and having him review the CT.