Treatment of lymphadenitis and lymphedema depends on the underlying cause. For lymphadenitis, expectant management is used for smaller nodes, while antimicrobial therapy is used for larger or infected nodes. Chemotherapy and radiation are used for malignancy. Tuberculous lymphadenitis is treated with a combination of antitubercular drugs for 6-9 months, along with aspiration or incision and drainage of abscesses. Treatment of lymphedema includes conservative measures like compression, exercise and skin care, as well as surgical options like excisional procedures and bypass operations to improve lymphatic drainage.

1. Treatment of lymphadenitis
Rishi kashyap
JSSMC

2. 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.

3. • 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.

4. 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.

5. 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.)

6. • 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.

7. • 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.

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

9. 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.

10. 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.

11. • 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.

12. 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.

13. • c. Combined: Both excision + creation of
communication between superfi cial and deep
lymphatics.
Sistrunk operation
Thompson’s operation.
Kondolean’s operation..

14. • 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).

15. • 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.

16. • 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.

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

18. Diagram showing right side groin nodovenous shunt
between iguinal lymph node and long saphenous vein. Left side
showing lymphovenous shunts between dilated lymphatics and long
saphenous vein. At least 4 lymphatics should be anastomosed using
7 zero/11 zero prolene—using operative microscope.

19. Thompson’s Swiss-roll operation. Here after removal of
lymphoedematous 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.

20. Thank you