Treatment of lymphadenitis

Rishi kashyapJSSMC

In patients with lymphadenitis, treatment depends on the causative agent and may include expectant management, antimicrobial therapy, or chemotherapy and radiation (for malignancy).

Expectant management is used when lymph nodes are smaller than 3 cm, without overlying erythema, not exquisitely tender, and present for 2 weeks or less.

• Antimicrobial therapy is used when nodes are greater than 2-3 cm, are unilateral, have overlying erythema, and are tender. Antibiotics should target common infectious causes of lymphadenopathy.

• Chemotherapy and radiotherapy are used for treatment of malignancies.

TUBERCULOUS LYMPHADENITIS

• Drugs Antitubercular drugs has to be started: Rifampicin 450 mg OD on empty stomach.INH: 300 mg OD.Ethambutol 800 mg OD.Pyrazinamide 1500 mg OD (or 750 mg BD).Duration of treatment is usually 6-9 months.

Contd…

• Aspiration• When there is cold abscess, initially it is

aspirated. (Widebore needle is introduced into the cold abscess in a nondependentsite along a “Z” track (in zig-zag pathway) so as to prevent sinus formation.)

• Incision and drainage• If it recurs, then it should be drained. Drainage

is done through a nondependent incision. After draining the caseating material, wound is closed without placing a drain.

• Surgical removal• Surgical removal of tubercular lymph nodes

are indicated when• 1. There is no local response to drugs or• 2. When sinus persists.• It is done by raising skin flaps and removing all

caseating material and lymph nodes. Care is taken not to injure major structures.

• Excision of the sinus track is often essential when sinus develops.

Treatment of lymphoedema

• Conservative• a. Elevation of the limb, exercise, weight reduction.• b. Static isometric activities like prolonged standing or

carrying weights should be avoided; rhythmic isotonic movements like swimming/massaging should be encouraged.

• c. Diuretics to reduce the oedema is controversial. • d. Benzopyrones are protienolytic agents/lympedim.

They increase the lymphatic peristalsis and pumping mechanism along with proteolysis.

Contd…• e. Daily wearing of below knee stockings.• f. Avoid trauma and infection.• g. Intermittent pneumatic compression devices (Pressure > 50• mmHg); multilayered lymphoedema bandaging (MLLB)—

nonelastic type is preferred method; graded stockings.• h. Antibiotics—fl ucloxacillin, erythromycin, long acting penicillins.• i. Topical antifungal 1% clotrimazole and systemic griseofulvin

250-1000 mg.• j. Regular washing and keeping the limb clean is very important.• k. Diethyl carbamazine citrate (DEC) 100 mg TID for 3 weeks.• l. Pain relief—by suitable means.

• m. Skin care.• n. Complex decongestive therapy is a

comprehensive two phase program of elevation, exercise, massaging, and compression wraps. First phase is intensive therapy and second phase is maintenance therapy.

Surgery• Surgeries for lymphoedema has been classifi ed as:• a. Excisional• Charle’s operation.• Homan’s operation.• b. Physiological• Omentoplasty.• Nodovenous shunt (Neibulowitz).• Lymphovenous shunt (O’Brien’s).• Ileal mucosal patch. Here either communication between superfi cial and deep lymphatics are created

or new lymphatic channels are mobilised to the site.• Omentoplasty (Omental pedicle): As omentum contains plenty of lymphatics, omental transfer with pedicle will facilitate lymph drainage.

• c. Combined: Both excision + creation of communication between superfi cial and deep lymphatics.

Sistrunk operation Thompson’s operation. Kondolean’s operation..

• d. Bypass procedure:• Handley’s (1908) silk threads.• Skin bridge across the thigh and abdomen (Gillies).• Nodovenous shunt.• Lymphovenous shunt using microscope.• Ileal mucosal patch (Kinmonth). Segment of ileum with• pedicle is isolated and opened to expose the mucosa;mucosa is denuded

and this mucosa is placed in the thigh as burial to communicate with lymphatics to drain into abdominal lymphatics across ileum.

• Baumeister lymphatic grafting.• Autotransplantation of free lymphatic fl ap from opposite side—done in

post-mastectomy lymphoedema (Trevidic and Cormier).

• e. Limb reduction surgeries:• Sistrunk operation: Along with excision of

lymphoedematous tissue, window cuts in deep fascia is done, so as to allow communication into normal deep lymphatics.

• Homan’s operation: Excision of lymphoedematous tissue is done after raising skin flaps. Later skin flaps

are trimmed to required size and sutured primarily. Medial and lateral sides of the limb are done at separate sittings with 6 months interval.

• Thompson’s operation: Lymphoedematous tissue is excised under the skin flaps. Epidermis and part ofthe dermis of one of the skin flaps is shaved off using

Humby’s knife. It is buried under opposite flap, deep to the deep fascia like a swiss roll (Swiss roll operation or buried dermal flap operation).

• Miller’s procedure: It is excision of subcutaneous tissues under the skin flap with deep fascia in two stages.

• First stage is done over the medial aspect of the limb;second stage done after two months over lateral aspect of the limb.

• Charle’s (1912) operation: Done in severe lymphoedema with elephantiasis. Along with excision of lymphoedematous tissue, skin grafting is done. It reduces the size and weight of the limb. Patient becomes ambulatory. Wound sepsis, graft failure, dermatitis,hyperkeratosis are the complications.

• Reduction surgeries are done for lymphoedema of scrotum, penis, labia and eyelid.• In severe type, occasionally amputation may be required.

Charle's excisional surgery. Here after excisinglymphoedematous tissue, area is covered with skin graft.

Diagram showing right side groin nodovenous shuntbetween iguinal lymph node and long saphenous vein. Left side

showing lymphovenous shunts between dilated lymphatics and longsaphenous vein. At least 4 lymphatics should be anastomosed using

7 zero/11 zero prolene—using operative microscope.

Thompson’s Swiss-roll operation. Here after removal oflymphoedematous tissue, deep fascia is opened to expose the muscle.Epidermis abraded using skin graft knife. This shaved dermis is buried

into the muscle to get communication into the deeper lymphatics.

Thank you