Multimodality evaluation and ultrasound-guided aspiration of a biopsy-proven inspissated clogged milk duct: a case report

Introduction

Background

It is well established in published literature that there are many benefits to breastfeeding to both infants and mothers. Breastfeeding has a positive effect on a child’s long-term IQ and executive function (1). Breastfeeding is protective against infectious diseases and infant mortality (2,3) and contributes to earlier cerebral white matter track maturation (4-7). There are also benefits unique to the mother such as reduced risk or breast changes leading to earlier detection of breast cancer (8-10).

Although evidence demonstrates the benefits of breastfeeding, many mothers find it difficult. One 2019 study quoted up to 70.3% of new mothers experience breastfeeding difficulties. A large percentage of these difficulties included pain, breast engorgement, and mastitis (11). Among problems that contribute to the abandonment of breastfeeding are clogged milk ducts.

Clogged milk ducts are a relatively common condition in lactating women secondary to poor or incomplete drainage of milk. This is especially common in women who are weaning or have an infant who is feeding irregularly (12). Patients present with a focal breast lump and associated breast pain, which can cause failure to meet breastfeeding goals and anxiety for a breastfeeding mother. Although a benign condition, a blocked duct can lead to more serious complications such as mastitis or cessation of breastfeeding if not treated promptly (13).

Studies describe a variety of treatments for blocked milk ducts including different types of gentle breast massage, electric breast pumping, cold compresses, laser therapy, physical therapy, therapeutic ultrasound, and duct decompression (14-21). The use of non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen is also recommended to help reduce associated inflammation further detailed in Mitchel et al.’s paper (1).

Rationale and knowledge gap

We present a case of an irretractable milk duct plug treated with direct aspiration of the plug. To our knowledge, this technique has not been described or published in the available literature. We also discuss the differential diagnosis of nipple abnormalities.

Objective

We present this case to educate and describe an interventional technique to consider for treating a refractory clogged milk duct with complete resolution and minimal side effects to the patient. We present this article in accordance with the CARE reporting checklist (available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-24-56/rc).

Case presentation

A 34-year-old postpartum female presented with 3 months of left breast and nipple pain radiating to the left upper outer quadrant, not relieved with topical antibiotic cream and conservative therapies. She had no relevant past medical history that would necessitate more invasive diagnostic testing. Physical exam revealed a small indentation on the nipple and a small palpable nodule of the left nipple. There was no associated erythema or discharge. Subsequent ultrasound evaluation revealed a Breast Imaging-Reporting and Data System (BI-RADS) 3 finding described as a probably benign round hyperechoic mass with a few tiny echogenic foci, smooth margins, and no associated internal vascularity (Figure 1) (22). Diagnostic mammogram with subareolar magnification views was obtained revealing a small mass within the nipple correlating with the mass visualized on ultrasound. No worrisome calcifications were noted (Figure 2). Given the history, imaging was most consistent with an inspissated clogged milk duct. Given the patient’s symptom duration, desire to lactate for another year, and severe pain with expression milk from the left breast, the patient’s multidisciplinary care team decided to perform an intervention which included ultrasound-guided percutaneous aspiration. This was discussed with the patient who desired to proceed; informed consent was obtained.

Figure 1 Left nipple and subareolar ultrasound. (A) B-mode ultrasound of the left nipple reveals a round, circumscribed, hyperechoic mass (arrow) with a few tiny echogenic foci. (B) Color Doppler ultrasound demonstrates no associated internal vascularity in the region of interest (box). Altogether, these findings signal benign inspissated clogged milk duct.

Figure 2 Left diagnostic mammogram. (A,B) CC subareolar magnification view with the nipple in profile shows a circumscribed nipple mass (arrow) corresponding to the ultrasound finding (Figure 1). Specifically, there are no associated suspicious calcifications. CC, craniocaudal.

The procedure was performed in the outpatient setting in breast imaging. The patient’s breast was prepped with chlorhexidine and sterile drapes. An approach that offered the shortest distance to the milk duct plug and that would not traverse intervening ducts was selected. The skin was prepped with chlorhexidine and sterile drapes. Following superficial administration of local anesthetic with buffered 1% lidocaine into the skin, lidocaine and saline were used to hydrodissect the clogged milk plug duct. Next, an 18-gauge needle was advanced into the milk plug. Following superficial administration of local anesthetic with buffered 1% lidocaine into the skin, fine-needle aspiration (Video 1) was performed.

Multiple passes using a combination of hydrodissection and aspiration were made using both a 27- and 18-gauge needle resulting in complete resolution of the nipple mass. Hydrodissection of the clogged milk plug duct was performed initially with 1% lidocaine, then with sterile normal saline using a 27-gauge needle (Video 2). Next, an 18-gauge needle was advanced into the milk plug. Using this needle, the plug was aspirated (Video 3) until there was no sonographically visible remaining debris (Video 4). The aspirate was sent for cytological analysis. Pathology revealed blood and proteinaceous material concordant with the imaging diagnosis of inspissated clogged milk duct.

Following aspiration, a small dressing was applied to the area of entry and the patient was instructed not to submerge in water for 7 days. No additional postprocedural cares were needed. The patient reported immediate relief of her pain and resumed pumping from the affected breast immediately and nursing within 1–2 days of the procedure (to avoid exposing the baby to lidocaine used for local anesthesia). Two months after the procedure, she reported to her primary care provider that there was no return of breast symptoms or development of procedural complications. The patient continues to do well 16 months after the procedure and reports that she successfully completed her desired duration of nursing without recurrence of symptoms (Figure 3).

Figure 3 Patient timeline.

Ethical declarations

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Discussion

Key findings

We present a case of inspissated clogged milk duct that was not resolved with conservative therapies and eventually treated with minimally invasive ultrasound-guided percutaneous fine needle aspiration. The plug completely resolved immediately relieving the patient’s symptoms, and at 16 months follow-up, she reported there had been no recurrence of the inspissated clogged milk duct or associated symptoms.

Strengths and limitations

The major limitation of our case study is the single patient case utilizing this procedure. The major strength of our case study was the resolution of symptoms with interventional aspiration of the milk duct plug, a much less invasive option than surgical breast duct excision.

Comparison with similar research

The imaging diagnosis of an inspissated clogged milk duct was favored given the compelling clinical history; however, malignancy must always be ruled out. Differential diagnoses for a nipple abnormality include a nipple adenoma, syringomatous tumor of the nipple, squamous metaplasia of the lactiferous duct, Paget disease, post-traumatic change (such as from nipple piercings), or an ecstatic duct filled with debris or air (23,24). Therefore, appropriate evaluation of a nipple abnormality is warranted.

According to the American College of Radiology (ACR) Appropriateness Criteria, ultrasound evaluation of a palpable mass in a pregnant or lactating woman is usually appropriate and evaluation with mammography may be appropriate (25). Diagnostic mammograms that include magnification craniocaudal (CC) and mediolateral (ML) views with the nipple in profile are helpful to assess for suspicious calcifications or a subareolar mass that may have extended to the nipple. Further evaluation with ultrasound can provide additional information about the mass such as vascularity and margin characterization. The constellation of overall imaging appearance in the appropriate clinical history can help to diagnose an inspissated clogged milk duct. If there is concern for malignancy, biopsy is the next step. Cytology smears of inspissated clogged milk ducts will be pluricellular with proteinaceous debris, as was demonstrated in our case (Figure 4).

Figure 4 Ultrasound-guided aspiration of nipple mass. (A,B) A mass in keeping with an inspissated clogged milk duct was aspirated. (C) Following aspiration, the previously seen mass was no longer visualized. (D,E) Final pathology revealed proteinaceous material (D, arrows), and duct epithelium (E, arrow) in keeping with inspissated clogged milk duct.

Treatments for milk duct plugs are primarily conservative, with invasive treatments needed in cases involving infection. Conservatively, different types of breast massage, such as gently kneading the breast or pressing the areola, have proved successful (16,18). Additional conservative therapies include cold compresses, over the counter NSAIDs and acetaminophen, and electric breast pumping (17). Interventional treatments are needed when conservative treatments fail. Previously documented invasive techniques involve aspirating the ducts upstream of the blocked duct for infection control when abscess is suspected.

Explanations of findings

Pathology from the case revealed proteinaceous debris, consistent with an inspissated milk plug. Considering the clinical presentation and pathology results, it was demonstrated that the patient’s symptoms were caused by an inspissated milk plug and that her symptoms were relieved immediately following fine-needle aspiration of the plug.

Implications and actions needed

We present a case of irretractable milk duct plug treated successfully with direct aspiration of the plug under ultrasound guidance.

Conclusions

An inspissated clogged milk duct is a relatively common complication of breastfeeding that can lead to anxiety, cessation of breastfeeding, or more complicated conditions such as mastitis. Although most cases resolve with conservative therapies, irretractable cases sometimes require more invasive intervention.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-24-56/rc

Peer Review File: Available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-24-56/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tbcr.amegroups.com/article/view/10.21037/tbcr-24-56/coif). C.U.L. serves as an unpaid editorial board member of Translational Breast Cancer Research from October 2023 to September 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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