Surgical Incision and Drainage

Dr Reena Talwar
Authored by:
Dr Reena Talwar

Introduction

Surgical incision and drainage is a common procedure performed by a trained clinician in order to drain a collection of exudates (pus) from a fascial space in the head and neck region. The procedure involves both sharp and blunt surgical dissection, irrigation, possible placement of a drainage tube and suturing. In some instances sterile collection of exudates prior to sharp dissection is recommended for culture and sensitivity analysis of the exudates.

Background

The surgical incision and drainage technique is performed by clinicians with a surgical background. The complexity of the procedure is often the determining factor for whether it should be performed by a general practitioner or a surgeon. A thorough understanding of the local anatomy, knowledge of the patient’s medical and dental related issues, radiographic interpretation and surgical ability are necessary modalities for proper patient management. If any of these areas are limited or compromised, the risk and complications to the patient may be severe. For instance, making a buccal vestibular incision adjacent to the mandibular first and second premolar region without considering the location of the mental foramen and neurovascular bundle, could lead to anesthesia (complete numbness) of the patient’s lip, chin and gingiva on that side.

Research

In an article by Martin et al 1, the authors found that drainage of an odontogenic abscess can reduce the duration of antibiotic therapy in most patients to approximately 2 to 3 days. This study helps to strengthen the concept that “removal of the source” of the infection, by surgical incision and drainage (possibly combined with extraction) allows for faster resolution of the infection with reduced need for long term antibiotic therapy.

Procedure

Prior to performing surgical incision and drainage on a patient, a thorough medical and clinical history as well as a detailed clinical examination should be performed. 2 Radiographs are helpful to determine the potential dental origin of the lesion. If plain films are unclear or not diagnostic for the source of the infection, more detailed radiography may be necessary. Knowledge of regional anatomy is crucial to avoid iatrogenic complications (caused by the clinician) as a result of performing the incision and drainage procedure.

The overall procedure can be summarized in the following order:

  1. Creating a surgical plan for drainage of the lesion in the most “dependent” position (apex of the abscess formation).
  2. Proper suctioning must be performed throughout the procedure.
  3. Palpation of the site of exudates collection or abscess formation.
  4. Administration of local anesthetic should involve regional blocks, avoiding the site of exudates collection initially and then superficial injection at the planned incision site. It is not necessary to inject local anesthetic into the abscess.
  5. Using a new/sterile # 15 surgical blade, create a 1 cm (or less) sharp incision at the most dependent site of exudates collection, through both mucosa and submucosal tissue layers.
  6. Next, using a straight or slightly curved hemostat, perform blunt dissection into the lesion, entering and exiting the wound with the beaks of the hemostats in a “closed” position and with constant suctioning to avoid aspiration of the exudates.
  7. Irrigate the open surgical wound with approximately 50 cc of sterile saline solution and constant suctioning to avoid aspiration.
  8. If necessary, insert a 0.5 cm Penrose drain into the surgical site and secure it to the mucosa using a 3.0 silk suture to allow for residual drainage. Cut the Penrose drain to the appropriate length to avoid occlusal interference.
  9. If a drain is placed, it must be monitored with daily follow-up and removed when no evidence of residual drainage is present – generally between 24 to 72 hours.
  10. Place gauze at the surgical site and provide the patient with extra sterile gauze to be used until hemostasis is achieved post-operatively.

Note: In some instances in which a culture and sensitivity test is required (i.e., for resistant chronic abscess refractory to empiric antibiotic therapy), aspiration of the lesion may be necessary. This is done using a sterile 16 or 18 Ga needle attached to a 5 cc syringe. Steps 1 through 4 are performed, followed by insertion of the needle into the site of exudates collection and aspiration of a small sample for testing.

Contentious Issues

One of the most common areas of contention associated with this procedure is whether to first initiate empirical antibiotic therapy and delay extraction of the tooth or surgical incision and drainage. The goal of every clinician, when dealing with a patient who has an odontogenic abscess, should be to remove the source of infection.2 This does not always entail the extraction of tooth, but may involve a pulpectomy procedure combined with local incision and drainage. Appropriate antibiotic therapy – including adequate dosage and interval of administration – is also an important addition to the overall success of therapy.

 

References: 

Martin MV, Longman LP, Hill JB, Hardy P. Acute Dentoalveolar Infections: an Investigation of the Duration of Antibiotic Therapy. Br Dent J 1997;183(4):135-7.

Peterson LJ, Hupp JR, Ellis E III, Tucker MR. Contemporary Oral and Maxillofacial Surgery. 4th ed. St. Louis: Mosby, 2005