subareolar abscess

Multimodality

approach to the nipple-areolar complex: a pictorial review and diagnostic algorithm. Zuska’s disease. a Photograph of a 47-year-old woman with a history of smoking who had a recurrent painful erythematous palpable subareolar mass with a small secreting ulcerous lesion. b Ultrasound shows skin thickening with a small hypoechogenic collection below the lesion (arrows), with increased peripheral color-Doppler signal (c)

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Multimodality

approach to the nipple-areolar complex: a pictorial review and diagnostic algorithm. Subareolar abscess. Photograph of a 42-year-old woman with a painful erythematous palpable areolar mass in her left breast with mild involvement of the adjacent skin (a). Synthesized 2D mammogram shows marked skin thickening of the nipple-areolar complex without other underlying findings (b). Ultrasound shows a heterogeneous hypoechogenic intradermal collection compatible with an abscess (c). Fine-needle aspiration was able to drain the collection completely (purulent material), and the patient was prescribed antibiotics and follow-up (d, e)

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Radiopaedia • CC-by-nc-sa 3.0 • de

Subareolar breast abscess are relatively uncommon and tend to occur mostly in young women.

Clinical presentation

Mastalgia, signs of inflammation, lump formation in the subareolar region and nipple discharge. In chronic cases fistula formation and nipple deformity may be seen. Some risk factors in nonlactating women include nipple piercing, smoking and diabetes.

Pathology

Squamous metaplasia of the cuboidal epithelium of the ducts leads to obstruction by keratin plugs. This leads to stasis of the secreted material which in turn leads to duct dilation. Significant dilatation further leads to rupture of the thin columnar epithelial lining and secondary bacterial invastion which leads to the formation of an abscess predominantly in the retroaerolar region.

Location

Retroareolar region or within a centimeter from the areola.

Radiographic features

Mammography

Lower sensitivity in young women with dense breast.

Ultrasound

Ultrasound is used most often for detecting abscess. As in other abscesses a fluid collection with irregular walls, contents and hypervascular walls may be seen. Ultrasound can demonstrate a fistulous track formation and may help in guiding abscess drainage.In cases with isolated fistula formation especially with fistulas located in the nipple, sonography failed to reveal any lesions.Also ultrasound probe pressure could be difficult for the patient to tolerate.

However, for patients with isolated fistulas, particularly if the fistulas were located inside the nipples and no masses were palpable, sonography failed to reveal the lesions. The round and irregular surface of the nipple appeared to be an obstacle and prevented a clear sonographic image of the focus inside the nipple and ampulla. Furthermore, pressure from the sonography probe can be too painful for patients with inflammation to tolerate.

MRI

Recent studies have suggested the role of MRI in imaging of subareolar abscess and demonstration of ducts and intraductal lesions as small as 1 mm. MRI has been proven to demonstrate more details than can ultrasound, like inverted nipples, abscess cavities, fistulas, dilated lactiferous ducts and inflammatory signs. On post contrast enhanced T1 weighted images, the fore mentioned findings were well apprecated.

Treatment and prognosis

Surgical therapy like excision of the lactiferous ducts, affected ampulla and distal diseased ducts and fistula. Reconstruction of the nipple and areola may be needed. Causes prolonged morbidity and has a tendency to recur.