Abscess in neck due to suspected stick penetration - any ideas?

RE: Abscess in neck due to suspected stick penetration - any ideas?

Anthony Dennison — Tue, 01 Sep 2020 14:08:16 GMT

I've dealt with a couple of these, and normally after repeated course of antibiotics and other treatment by colleagues.

Similar approach as to Beats described, and they are a right bugger to remove. All wrapped around all the large, pulsing vessels in the neck! Perhaps it's because they've had previous treatments that most of the local inflammatory reaction has settled, and there is just a pocket of pus around the offending item, as this is what I have experienced

RE: Abscess in neck due to suspected stick penetration - any ideas?

Gillian Mostyn — Mon, 24 Aug 2020 13:20:00 GMT

OK... so that wasn't fun!

Opened midline, dissected down ok, identified carotid sheath, recurrent laryngeal etc so no concerns there. However, the 'mass' wasn't discrete - lots of hard bands of fibrous scar tissue and thickened tissue (that kept tricking me into thinking I'd found a stick) with multiple small pockets of pus and bruising, with no one discrete pocket or FB found. Therefore even though I opened up whatever areas and pockets i could, it would have been impossible for me to either 'open up' or remove the entire extent of the affected tissue. So the dog has recovered fine but still has a 'lump' palpable in its neck - albeit significantly smaller.

I'm suspecting this is more chronic than the owner thought.

Anyway, it has been copiously flushed and so far it has recovered fine - so it isn't all bad. I guess it is wait and see time....

RE: Abscess in neck due to suspected stick penetration - any ideas?

Rob Davis — Mon, 24 Aug 2020 07:48:09 GMT

[quote userid="10320" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/29304/abscess-in-neck-due-to-suspected-stick-penetration---any-ideas/225038#225038"]I'm very much a GP (and not a cutter) but I would have thought keeping off abs would be better, as easier to follow and explore a proper, pus-filled tract...[/quote]

This is usually my approach.

RE: Abscess in neck due to suspected stick penetration - any ideas?

Lucy Fleming — Sat, 22 Aug 2020 21:50:16 GMT

[quote userid="2457" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/29304/abscess-in-neck-due-to-suspected-stick-penetration---any-ideas/225028#225028"] I haven't started antibiotics and wasn't planning to until surgery - hoping the culture results are back by then. Is that the right plan?[/quote]

I'm very much a GP (and not a cutter) but I would have thought keeping off abs would be better, as easier to follow and explore a proper, pus-filled tract... I did see one case a few years ago where we had the dog on antibiotics and that actually settled inflammation down enough that the huge hunk of stick became palpable through the skin, but I think that would probably be an exception!

Best of luck with it

RE: Abscess in neck due to suspected stick penetration - any ideas?

Gillian Mostyn — Sat, 22 Aug 2020 07:35:47 GMT

Malcolm Ness, Beats, Rob, ... I haven't started antibiotics and wasn't planning to until surgery - hoping the culture results are back by then. Is that the right plan? I assumed starting them before, or trying a course first, could make the situation worse? Happy to put on an antibiotic course if you think that's right .... Apart from anything else, my locum job will be over and it becomes someone else's problem

Edit.... culture has just come back...no growth!

RE: Abscess in neck due to suspected stick penetration - any ideas?

Rob Davis — Fri, 21 Aug 2020 14:28:00 GMT

[quote userid="3607" url="~/001/veterinary-clinical/small-animal/soft-tissue-surgery/f/discussions/29304/abscess-in-neck-due-to-suspected-stick-penetration---any-ideas/225014#225014"]Gelpis are invaluable[/quote]

If you have a ring retractor it can be really useful for this sort of dissection.

RE: Abscess in neck due to suspected stick penetration - any ideas?

Gillian Mostyn — Fri, 21 Aug 2020 09:35:50 GMT

Many thanks Malcolm Ness ... but gulp!

I am happy with thyroidectomies but that's as much neck surgery as I've done. I have made the client very well aware of the risk of iatrogenic damage but I am working in an area where costs are a big factor so I'm afraid their choices are limited to..me!

I don't think cadaver surgery is an option unfortunately but I will refresh my anatomy knowledge over the weekend!

RE: Abscess in neck due to suspected stick penetration - any ideas?

Malcolm Ness — Fri, 21 Aug 2020 08:35:38 GMT

Agree completely with Beats.

Make a long incision from the larynx all the way back to the sternum. Gelpis are invaluable. Use a sandbag or two under the neck, especially caudally to improve access. Position the dog in PERFECT dorsal recumbency - absolutely straight and symmetrical. Stick to the midline until you are 'in'. If you are unfamiliar with this area, I would very strongly suggest that you do a trial-run on a cadaver. There are lots of very important structures that will need to be moved aside. Rather than trying to dissect past the major anatomical structures (nerves, carotids etc) go looking for them, positively identify then retract them. An assistant with Penrose drain tubing wrapped around whatever you don't want to cut can be helpful. Finally, once you are in there, explore primarily by touch/palpation to find the FB.

RE: Abscess in neck due to suspected stick penetration - any ideas?

Gillian Mostyn — Fri, 21 Aug 2020 06:44:52 GMT

Thank you Beats. I was wondering how to approach, as the mass is close the the skin on the left but goes much deeper - your advice to go midline sounds sensible and is appreciated.

I've already done FNA and am awaiting culture results.

I have certainly warned the owner about all the worst case scenarios!

RE: Abscess in neck due to suspected stick penetration - any ideas?

Beats — Thu, 20 Aug 2020 23:01:42 GMT

Usual caveat that I am in no way an expert on anything, consider my musings in light of that.

I would open the neck ventral midline in well positioned paitent (like doing a thyroidectomy / parathyroidectomy but incision going much more caudally - rolled up towel (or sandbags dependent on size) under neck in dorsal recumbency with forelimbs invididually drawn caudally and body straight from nose to tail) rather than on left most likely - I find the anatomy easier this way.

Separate muscles down midline until reach trachea, then blunt dissection towards mass which is likely deep to ventral neck strap muscles. Stick a needle in it and see if getting pus out - if so, then follow through inflammed tissue (breaking down any separate pockets) to pus and explore and then simply flush well [swab for cytology / culture optional] and stick a penrose drain in if nothing plant-like found there.

While it sounds like it is, be prepared for this not to be an abscess (eg a thyroid mass or cervical lymph node or botryomycosis or something of that ilk) and make a judgement on whether can safely dissect out (ideally) or biopsy and close with discretion being the better part of valour in an otherwise happy patient if that is the case.

Don't cut the recurrent laryngeal nerve (is lateral and deep-ish when approaching from ventral midline), otherwise important structures are obvious.

Cotton buds and fingers can make excellent dissection tools.

Patience and mosquito forceps and ligating anything that might bleed before cutting during a dissection of a neck mass helps to keep your field of view blood free.

Give yourself longer than you expect you'll need when organising surgery time.

Use a capnograph and continuous heart rate monitor (and in the absence of the latter, then a shot of atropine is a consideration assuming premed is methadone alone).

Remember that the neck can communicate with the thoracic cavity.

Put on antibiotics afterwards/during: amox/clav in the presence of pus and absence of cytology/culture.

Advise owners of all that can go wrong pre-emptively.

Be prepared to operate again a second time, but with the knowledge you probably won't have to really in all likelihood.

I would not expect this to be simple, but don't think you need dread it either.

I think you are more than up to this task and will in all likelihood be pleasantly surprised.

Oh, and check the gelpis are autoclaved.

RE: Abscess in neck due to suspected stick penetration - any ideas?

Gillian Mostyn — Thu, 20 Aug 2020 22:06:33 GMT

Do you think so Neil? I thought starting antibiotics could make things more difficult rather than easier - allowing further migration of a potential FB? Wouldn't the abscess indicate where to look? Plus, I suppose I couldn't imagine an abscess so large clearing fully with just medical treatment? But I don't know.....

RE: Abscess in neck due to suspected stick penetration - any ideas?

Neil Wheadon — Thu, 20 Aug 2020 21:57:11 GMT

They are a needle in a haystack in a difficult place and dealing with one at the moment.

Is it worth a prolonged course of antibiotics first to really shrink it down to a particular size. At this point you can explore or wait and see. Some of these do cure and if you can avoid a surgical problem it may be worth taking a chance

Neil

RE: Abscess in neck due to suspected stick penetration - any ideas?

Gillian Mostyn — Thu, 20 Aug 2020 20:57:09 GMT

Thanks Joyce Whitehead , good idea with the ultrasound especially!

RE: Abscess in neck due to suspected stick penetration - any ideas?

Joyce Whitehead — Thu, 20 Aug 2020 19:04:01 GMT

Can you ultrasound? Sometimes we have found sticks this way, and at least you visualise where there are pockets of pus/fluid, avoid big blood vessels etc. I must say some of these I’ve just very gently kept following tracts till you get to something. Had one on the wing of the atlas once many years ago with the tiniest splinter, came out as I was flushing but never returned! Good luck.