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Dx: Hypoechoic Mass
As you suspected, the patient has a 1 x 2 cm hypoechoic mass noted on bedside ultrasound. You can visualize the adjacent vessels just posterior/farfield to the abscess on the bedside scan. Using the depth markers on the side of the screen, you can see that the middle of the abscess is approximately 1.5 cm deep to the mucosal surface and should be easily accessible for a needle aspiration or I&D. You map out the adjacent structures and are able to identify the patient’s carotid artery approximately 2.5 cm from the mucosal surface (arrow).
Now that you are sure that the patient has a PTA and you have been able to visualize adjacent structures that you want to avoid, you decide to proceed with a needle aspiration. You obtain a standard 20 gauge spinal needle and remove the plastic guard covering the needle. Using trauma shears, you cut off 2.0 cm of the plastic guard and slip it back over the spinal needle. Having the guard in place will help prevent inadvertent puncture of the carotid artery by limiting the length of needle accessible during the puncture. Under ultrasound guidance, you insert the spinal needle into the center of the PTA and obtain 4 cc of purulent material on aspiration.
The patient feels much better after the successful aspiration, and thanks you for your excellent service. You discharge the patient on antibiotics and pain medications and arrange for 48-hour follow-up with ENT.
How to prevent inadvertent puncture of the carotid artery:
1. Use a standard 20 gauge spinal needle
2. Remove the plastic guard covering the needle.
3. Using trauma shears, cut off 2.0 cm of the plastic guard
4. Slip the modified guard back over the spinal needle.
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