Inflamed breast — lactational triage, aspiration fences, fistula ducts and granulomatous restraint

Examiner prompts with model answers

Lactational mastitis — diagnose clinically, empty, feed through. Mastitis is usually clinical with focal tenderness plus fever and malaise, emptying and technique correction are treatment, anti-staphylococcal cover follows when needed, and continued feeding is encouraged with no infant risk — the abscess prevented by early treatment and continued feeding never reaches theatre.^[1]

Abscess — aspirate first with fences. Ultrasound-guided aspiration resolves 85 to 92% with shorter healing and better reported outcomes than drainage, while surgery stays preferred for collections over 5 cm, multiloculated or recurrent disease especially outside lactation — and the French line agrees with needle plus antibiotics under 5 cm (grade C) and no evidence-based first choice above it.^[3][18]

Microbiology — culture every collection, cover MRSA by prevalence. Abscesses traditionally reflect sensitive staphylococci but MRSA now dominates some cohorts (74.5% of isolates, 88.7% lactational, mean 29.4 years), all vancomycin-susceptible with low clindamycin and co-trimoxazole resistance — so culture routinely, cover MRSA empirically where prevalent, aspirate first, and keep feeding after treatment.^[16]

Periductal fistula — ducts plus smoke. Peripheral non-lactational abscesses resolve with drainage and antibiotics, but subareolar disease recurs and fistulises from keratin-plugged terminal ducts in smokers — requiring terminal-duct excision with nipple correction, not repeat drainage.^[4]

Granulomatous disease — mimic, then combine locally. Granulomatous mastitis mimics inflammatory cancer, affects younger recently parous women (median 36 versus 52 years, 56% recent birth versus 5%), runs 11 to 105 weeks regardless of modality, and rewards steroid-based combination — triple therapy ranking best — with local steroids improving response (RR 1.35) and halving toxicity (RR 0.24).^[19][12][13]