Mammary duct ectasia, mammillary fistula and subareolar sinuses

Management of sub-areolar abscess and mammary fistula

Sub-areolar abscess is a form of chronic non-lactational mastitis often presenting in young women at the areolar margin as a recurring discharge or painful infection. Incision and drainage is inadequate and will be followed by recurrence unless the major duct leading from the abscess to the nipple is identified and laid open. Three cases are presented to illustrate this problem and its management.

Primary periareolar abscess in the nonlactating breast: risk of recurrence

The estimated probability of relapse of primary periareolar abscess of the nonlactating breast was 38 percent (95 percent confidence interval 18 to 58 percent) 8 years after simple incision and healing by granulation. Relapses were mainly fistulas in the line of incision. An attempt to identify relapses early was unsuccessful. This finding, in combination with the unsatisfactory results of simple incision and healing by granulation and the character of relapses, suggests improper initial operation and multifactorial causes. Initial incision followed by a search for a possible sinus tract and extensive excision in all patients with primary abscesses has been described and is recommended.

Mammillary fistula

Forty women presenting with mammillary fistulas over a 6 year period have been reviewed. The events preceding the fistula were incision of a periareolar breast abscess (n = 24), breast biopsy (n = 13) and spontaneous discharge of an inflammatory mass (n = 3). Only two of the women with abscesses were lactating. Two patients had granulomatous mastitis. The remaining 36 patients were all considered to have periductal mastitis/mammary duct ectasia as the cause of their fistulas. The two mammillary fistulas associated with lactation healed spontaneously. Nine patients had the fistula excised and the wound packed; this resulted in satisfactory healing in all but one patient. Twenty-one patients had excision of the fistula and primary closure, without antibiotic cover, but only ten healed without complications and six patients required further surgical procedures for a recurrent fistula. Six patients had primary excision and closure under antibiotic cover with a penicillin and metronidazole; all healed. Mammillary fistulas are complications of the periductal mastitis/duct ectasia syndrome. They should be treated by excision and primary closure under appropriate antibiotic cover or alternatively excised and left open to granulate.

Mammillary fistula

During a 6-year period 38 patients with 52 mammillary fistulae were seen. On average, 5 abscesses had preceded recognition of a fistula in the areolar region (range 1-18). In 11 cases the fistulae were immediately apparent as discharging openings but they more commonly presented as subareolar abscesses. Fistulae were treated either by laying open or by excision of the track and at mean follow-up of 25 months (range 1-75) there has been recurrent fistula formation in only one case. Mammillary fistulae should be suspected and sought in all patients presenting with abscesses adjacent to the nipple.

Periareolar abscess in the nonlactating breast

Periareolar abscesses in nonlactating women are usually accompanied by a sinus tract that communicates with the nipple. This abnormal tract represents the source of the initial invasive infection and, if left unattended, may be the nidus for recurrence. The medical records of 32 patients with periareolar abscess treated at Temple University Hospital from January 1970 through January 1980 were reviewed. Follow-up data were obtained recently for 21 patients, including 1 patient with bilateral disease. Several patients also had an inverted nipple. Nineteen patients denied recurrence after our initial treatment and two required a secondary procedure for cure. Only one patient was dissatisfied with the postoperative appearance of the surgical site. None required partial or simple mastectomy for cure, as reported elsewhere. Excision of the sinus tract and, when present, correction of the inverted nipple as herein described are necessary to prevent reinfection. Simple abscess excision or incision and drainage is usually inadequate therapy.