Matitis/Breast Abscesses

Question 1

Define mastitis

Answer 1

Inflammation of the breast
• Infectious
- Lactational (puerperal) – milk stasis/overproduction and bacterial infection
- Non-lactational (duct ectasia) – dilated ducts associated with inflammation
• Non-infectious
- Idiopathic granulomatous inflammation
- Foreign material e.g. nipple piercing, breast implant

Question 2

Define breast abscess

Answer 2

Localised area of infection with a walled off collection of pus

Question 3

What are the causes/risk factors of mastitis/breast abscesses?

Answer 3

Bacterial skin commensal infection
• Staphylococcus aureus
• Streptococcus pyogenes
• Staphylococcus epidermis

Risk factors
• Broken skin e.g. piercing,
breastfeeding, eczema
• Lactation
• Milk stasis
• Previous mastitis

Question 4

What are the symptoms of mastitis/breast abscesses?

Answer 4

• Malaise
• Myalgia
• Fever
• Breast pain
• Decreased milk flow

Question 5

What are the signs of mastitis/breast abscesses?

Answer 5

• Warmth/erythema
• Firmness
• Swelling
• Mass
• Nipple discharge
• smooth surface
• distinct borders
• firm/lax consistency
• fluctuant mobility
• no fixity
• lymphadenopathy

Question 6

What investigations are carried out for mastitis/breast abscesses?

Answer 6

Triplle assessment
• Clinical Examination
• Radiological Examination:
- USS if the patient < 35 - well circumcised black masses.
- View Mammography if the patient > 35 - Hypoechoic lesion (abscess); may be well circumscribed, irregular, or ill defined with septae.
• FNA or Core Biopsy
- Before you do this you need to do inflmamtory markers, clotting and platelets. And you should do a blood culture aswell.
- Purulent fluid on fine needle biopsy indicates a breast abscess.
- Microbiology: Microscopy, culture and sensitivity of pus samples.

• Bloods – CRP, FBC etc to identify inflammation, WCC

Question 7

What is the management for mastitis/breast abscesses?

Answer 7

Medical:
• Lactational: Early, cellulitic phase may be treated with flucloxacillin.
• Nonpuerperal: Flucloxaclillin with the addition of metronidazole for anaerobes.
• Give them analgesia as they will still be breast feeding and check if it is safe in brastfeeding.

Surgical:
• Lactational: Daily needle aspiration with antibiotic cover may be successful, but in most cases, formal incision and drainage is carried out.
• Incision should allow full drainage and be cosmetically acceptable
• Loculi are explored and broken down with a finger.
• Breastfeeding should continue from the non-affected breast and the affected side emptied either manually or with a breast pump.
• Advice on avoiding cracked nipples.

Non-puerperal: Open drainage should be avoided, or carried out through a small incision.
• Definitive treatment should be carried out once the infection has settled by the excision of the involved duct system.

Question 8

What are the complications of mastitis/breast abscesses?

Answer 8

• Mammary fistula formation.
• Rarely, the overlying skin undergoes necrosis.
• You want to carry on breastfeeding as milk may block the ducts more so.
• Can lead to sepsis, pain, fistula, scarring –especially if you need biopsy done of the area. You can also get extra-mammary skin infections as a result.