Abscess Evaluation using Bedside

Ultrasonography
Updated: Jul 10, 2013
Author
Lars J Grimm, MD, MHS House Staff, Department of Diagnostic Radiology, Duke University
Medical Center
Disclosure: Nothing to disclose.
Coauthor(s)
Kristin A Carmody, MD Assistant Professor of Emergency Medicine, Boston University
Medical School; Director of Emergency Ultrasound, Boston Medical Center
Kristin A Carmody, MD is a member of the following medical societies: American College of
Emergency Physicians, American Institute of Ultrasound in Medicine, and Society for Academic
Emergency Medicine
Disclosure: Nothing to disclose.
Multimedia Library
References

Overview
Abscesses and other superficial soft tissue infections are common presentations to the emergency
department (ED). In a subset of patients, the physical examination reveals a grossly fluctuant
subcutaneous collection that is indicative of an abscess. In many cases, however, the clinical
presentation is not that clear. Physical examination alone is often inadequate when differentiating
between simple cellulitis and deeper soft tissue infections.[1] These 2 disease entities are managed
differently, and misdiagnosis can lead to unnecessary painful procedures or an increase in
morbidity, time lost, or cost to the patient.[2, 3]
Ultrasonography has emerged as an increasingly valuable diagnostic tool to help with decisionmaking. Several recent ED studies have demonstrated that bedside ultrasonography significantly
improves clinicians ability to differentiate between cellulitis and abscess and, thus, to initiate the
most appropriate treatment from the outset.[4, 5] The advantages of bedside ultrasonography
include low cost, portability, patient comfort, speed of detection (usually < 1 min), and wide

availability. Additionally, if a fluid collection is detected, ultrasonography can better localize the
fluid for subsequent aspiration or incision and drainage.

Indications

Patients who present with localized signs of swelling, pain, and erythema, and in whom
cellulitis and abscess might be present, are excellent candidates for bedside
ultrasonography.

Contraindications

No contraindications exist to using bedside ultrasonography to differentiate between

simple cellulitis and abscess.

Anesthesia

No anesthesia is required, although analgesia should be considered to increase patient

comfort and ease of scanning.

Equipment

Portable bedside ultrasonography machine with a high-resolution linear transducer

Conducting gel

Nonsterile gloves

Standoff pad (optional)

Positioning

The patient should be positioned so that the full area of interest is exposed and readily
accessible to the examiner.

While dressings and clothing should be removed for complete visualization, optimal
exposure must be balanced with appropriate draping of potentially sensitive areas.

Technique
Setup

Set up needed equipment at the bedside. Start with the linear transducer set at a frequency
between 5.0 and 7.5 MHz. If a deeper collection is suspected, consider switching to a curvilinear
probe set at 3.5 MHz.
Position the patient as described above and clear the area of examination.

Procedure
Place the probe at the border of the region of interest and begin scanning the length of the
affected area. This should allow for transition from normal to affected tissue for comparison.
Extend the area scanned to completely visualize the edges of the infection in one plane.
Repeat the scan in an orthogonal plane to form a mental 3-dimensional image of the area of
interest.
Identify normal subcutaneous tissue, fascial planes, and muscle as landmarks for comparison.
Also be sure to identify any adjacent structures of interest, such as blood vessels or peripheral
nerves (which can have a honeycomb appearance, see below).

Ultrasound image of normal soft tissue.

Continue scanning the region of interest to characterize the presence of fluid collection, the
extent of collection, the depth of collection, echogenicity, and heterogeneity.
Consider using a skin marker while scanning to mark sites for subsequent aspiration or incision
and drainage.
The video below depicts demonstration of ultrasonographic abscess evaluation.
Demonstration and explanation of ultrasonographic abscess evaluation using a linear probe.
Video courtesy of Meghan Kelly Herbst, MD. Also courtesy of Yale School of Medicine,
Emergency Medicine.

Image interpretation

Normal subcutaneous tissue is hypoechoic with strands of hyperechoic connective tissue. Fascial
planes are highly hyperechoic, and muscle tissue demonstrates a characteristic striated
appearance. Vascular structures are anechoic and usually compressible with the transducer.
Cellulitis results in hyperechoic subcutaneous fat lobules floating in edematous fluid. This is
classically described as cobblestoning, and is shown below.

Ultrasound image of cellulitis with cobblestoning.

Cobblestone appearance. Video courtesy of Meghan Kelly Herbst, MD. Also courtesy of Yale
School of Medicine, Emergency Medicine.
Abscesses have a wide range of sonographic appearances. Typically, they appear as anechoic or
hypoechoic spherical collections of echogenic fluid with poorly defined borders. Additionally,
septae, sediment, or even gas may be present within the fluid collection. Compression with the
transducer may induce movement or swirling of the contained pus. See the images below.

Ultrasound image of a typical spherical abscess.

Ultrasound image of a typical spherical abscess.

Ultrasound image of
an abscess. Note the heterogenous appearance.
Cine loop of an abscess. Video courtesy of Meghan Kelly Herbst, MD. Also courtesy of Yale
School of Medicine, Emergency Medicine.
If an abscess is identified, thorough characterization of its location, size, and extent helps dictate
further management.

Pearls

A standoff pad may be useful to elevate the transducer, as this improves image resolution
by moving the region of interest into the focal zone. This is particularly helpful when
evaluating superficial structures such as the hands and feet. Commercial pads can be
purchased and customized to a given situation. Alternatively, bags of saline, water-filled
gloves, or water baths may be substituted.

Color flow Doppler sonography, shown below, is useful in identifying adjacent vascular
structures prior to performing any percutaneous interventions. This modality can also
help identify lymph nodes, which can easily be mistaken for fluid collections. Lymph
nodes are highly vascular and demonstrate strong color flow signals, while abscesses do
not. In addition, compressing lymph nodes does not result in the typical swirling flow of

fluid that is often seen with abscesses.

Ultrasound image
of a lymph node with its characteristic hyperechoic center and hypoechoic rim.

Ultrasound image of a blood vessel lying deep to a lymph node.

Ultrasound image of a lymph node demonstrating color

Doppler flow.

Computed tomography (CT) remains the criterion standard for abscess evaluation. CT
may still be necessary if the ultrasound is indeterminate or unable to adequately delineate
the full extent of the abscess.

Herniated bowel, shown below, may be confused for an abscess but can be differentiated

by the presence of peristalsis.

herniated bowel.

Ultrasound image of

Scanning the contralateral side of the body for comparison is always helpful when trying
to differentiate normal tissue from abnormal tissue.

If complicated, percutaneous interventions should be ultrasound-guided to ensure proper

positioning and complete drainage.

Probe covers can help reduce the risk of spreading infectious agents and should be
considered.[6, 7]

Complications

The use of bedside ultrasonography in the evaluation of soft tissue infections presents no
appreciable risks.

Pitfalls

Like any ultrasound study, be sure to consider the operator's skill and training. Some
sonographers have had more experience than others in evaluating and assessing soft
tissue infections.

References
1. Abrahamian FM, Talan DA, Moran GJ. Management of skin and soft-tissue infections in
the emergency department. Infect Dis Clin North Am. Mar 2008;22(1):89-116, vi.
[Medline].
2. Pallin DJ, Egan DJ, Pelletier AJ, Espinola JA, Hooper DC, Camargo CA Jr. Increased US
emergency department visits for skin and soft tissue infections, and changes in antibiotic
choices, during the emergence of community-associated methicillin-resistant
Staphylococcus aureus. Ann Emerg Med. Mar 2008;51(3):291-8. [Medline].
3. Rogers RL, Perkins J. Skin and soft tissue infections. Prim Care. Sep 2006;33(3):697710. [Medline].
4. Tayal VS, Hasan N, Norton HJ, et al. The effect of soft-tissue ultrasound on the
management of cellulitis in the emergency department. Acad Emerg Med. Apr
2006;13(4):384-8. [Medline].
5. Squire BT, Fox JC, Anderson C. ABSCESS: applied bedside sonography for convenient
evaluation of superficial soft tissue infections. Acad Emerg Med. Jul 2005;12(7):601-6.
[Medline].
6. Cohen PR. Community-acquired methicillin-resistant Staphylococcus aureus skin
infections: implications for patients and practitioners. Am J Clin Dermatol.
2007;8(5):259-70. [Medline].

7. Cohen PR. Community-acquired methicillin-resistant Staphylococcus aureus skin

infections: a review of epidemiology, clinical features, management, and prevention. Int J
Dermatol. Jan 2007;46(1):1-11. [Medline].
8. Cosby KS, Kendall JL. Practical Guide to Emergency Ultrasound. 1st. Philadelphia, Pa:
Lippincott Williams & Wilkins; 2006.