Aspirations of cysts and bursae

Breast cyst

Equipment, patient’s positioning and main details of the procedure are generally the same as for FNAB (see Fine-needle aspiration biopsy (FNAB) ). It is vitally important to make an accurate clinical diagnosis before attempting aspiration (Bull MJV, Gardiner P, 1995)

The following steps should be taken:

1. Examination of the breast: the breast should be palpated with the flat of the hand to identify the lump.
2. The lump should be palpated between the thumb and fingers to identify the characteristics of a cyst (Fig. 1). The cyst is discrete, mobile, rounded and attached neither to the skin nor to the pectoral muscle (Bull MJV, Gardiner P, 1995) .

enlarge | info

Fig. 1. Breast cyst palpation

Technique (Bull MJV, Gardiner P, 1995) , (Chen H, Sonnenday CJ, Lillemoe KD (eds), 2000) , (Cracknell ID, Mead MG, 1997)

• The skin over the lump is cleansed with an alcohol swab
• The cyst is immobilized between two fingers of one (non-dominant) hand (see Fig. 1)
• A 22-gauge needle attached to a well-fitted 20 ml syringe is advanced into the cyst (see Fig. 2). Resistance will be felt as the needle penetrates the wall of the cyst
• Once the cyst is entered, a full 20 ml of suction is applied to the syringe and maintained until the cyst is drained as thoroughly as possible, and can no longer be felt.

enlarge | info

Fig.2. Aspiration of the breast cyst

• The needle is withdrawn, and pressure is applied to the puncture site with a gauze pad
• The operator should palpate the area again to ensure that he/she has fully aspirated the cyst. If the cyst is still palpable, the patient should be referred for consultant opinion. Even if the cyst is not palpable, and a negative cytology is obtained, the patient should be seen again in 3-4 weeks to check that the cyst has not reformed (Brown JS, 1989)

The typical fluid obtained from a breast cyst is a dark green colour, yellow, yellow-brown or even inky. The fluid should be transferred from the syringe to a pot containing an alcohol-based fixative/preservative (as for FNAB aspirates) or universal specimen container, and sent for cytology. NOTE: Bloody or bloodstained fluid is a sign that the cyst may not be benign.

Olecranon bursitis

Before proceeding, be certain to differentiate olecranon bursitis (that does not involve the elbow joint) from bulging synovium (Stone CK, Humphries R (eds), 2004) , and establish that the bursa is not infected (Bull MJV, Gardiner P, 1995) .

Equipment

• Alcohol prep pads
• 2 ml syringes (2)
• 20 ml syringe
• 1½-inch 21 gauge needles (3)
• 1% lidocaine with adrenaline (2 ml ampoule)
• Long-acting methylprednisolone (40 mg in 1 ml) or equivalent (e.g. triamcinolone) (NOTE: to be injected only if the fluid withdrawn is a clear, straw yellow colour) (Cracknell ID, Mead MG, 1997)
• Universal specimen container
• Dressing, gauze, elastic bandage

Patient’s positioning

• The elbow is resting on table in flex position with forearm pronated

Technique

• The skin surface should be cleansed with alcohol pad
• The skin over the apex of the elbow should be infiltrated with 1% lidocaine + adrenaline (0.5-2.0 ml)
• Using the 20 ml syringe with a 21 G needle the bursa can be entered through the anaesthetised skin area
• The contents of the bursa is aspirated and a sample sent for laboratory examination in the universal container
• The needle is removed and the puncture wound sealed with a sterile dressing
• To prevent recurrence the elbow should be immobilized in a firmly compressive dressing (e.g. such as elastic bandage) for at least 72 hrs following aspiration; the patient should also be encouraged to gently move the arm within this restraint (Cracknell ID, Mead MG, 1997)
• The alternative way of preventing recurrence of the bursa is an instillation of 20-40 mg of long-acting methylprednisolone or triamcinolone into the site after aspiration. The injection may be repeated after 2-4 weeks if the results of the first injection are not satisfactory and the bursa recurs (Cracknell ID, Mead MG, 1997) , (Kunnamo I (ed), 2005) . It is desirable to obtain a negative culture or Gram’s stain smear prior to injection

Septic bursitis

See alsoClinical scenario in:'Minor Surgery' > Organ > Diagnostic and therapeutic procedures > Aspiration of cysts and bursae

Many patients with bursitis have definable infection. Some patients have very few signs of infection though there are no reports that correlate clinical findings with microbiological diagnosis (Choudaray V., 2004) . No comparative studies could be found regarding the usefulness of diagnostic aspiration in improving outcome (Choudaray V., 2004) .

Evidence:

• If septic bursitis is suspected the bursa should be punctured and the sample should be cultured in a blood culture bottle (one aerobic culture bottle sufficesor a bacterial culture test tube can be used) [Evidence level III] (Kunnamo I (ed), 2005) .
• The cells in the bursa fluid are mostly granulocytes with a leukocyte count over 2000 x 10⁶/l, but the absolute cell count is not reliable in distinguishing between septic and aseptic bursitis (in emerging bursitis very few cells may be found) [Evidence level III] (Kunnamo I (ed), 2005) .
• If septic bursitis is suspected then antibiotics (anti-staphylococcal) should be started. Initial aspiration may be useful in determining whether sepsis is the underlying cause and in defining when to stop treatment [Evidence level II] (Choudaray V., 2004) .

Treatment with antibiotics

An antibiotic against Staphylococcus (a cephalosporin derivative, cloxacillin, etc.) should be initiated parenterally (e.g. cefuroxime 750 mg i.v. or i.m. three times daily or ceftriaxone 1 g i.m. once daily). The injections can be administered on an outpatient basis. The treatment is continued with cephalexin or cefadroxil 500 mg three times daily (Kunnamo I (ed), 2005) .<

Glossary

breast

Either of the two fleshy organs on the front of a woman\'s chest, which contain the mammary glands; also the analogous organs in men.