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PILONIDAL SINUS

Dr.K.Prathapan www.medshortnotes.com

Usually occur in the natal cleft Lined by granulation tissue rather than epithelium

subcutaneous sinus containing hair


Mid line openings - either single or multiple overlying coccyx sometimes -umbilicus,Finger webs, Axilla Occupational disease : Drivers( in buttocks) ,Hair dressers (Finger webs/ Interdigital cleft)
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Male> Female mostly affect hairy men. common/Usually age group: 20 - 30 years of age after age of 40 it is rare. commonest site - Interbuttock sacral region Recurrence are very common

organisms involved - staph.aures and bacteriodes species (skin and perineal bacteria)
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Primary sinus - occurs in the mid-line.

Secondary sinus - occurs laterally(paramedian)


Hair follicles have never been demonstrated in the wall of the sinus. But Only hairs have found. Congenital theory is no longer considered. It is an acquired entity. The diagnosis is made by inspection of the area and identification of the epithelialized, follicle opening. A deep area of induration can most often be palpated.
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Risks:
obeisty and overweight Prolonged sitting (buttock friction causing increased sweating) Coarse, curly or crinkly hair Family predisposition Poor hygiene Repeated local injury People with hidradenitis suppurativa, acne conglobata and dissection cellulitis.
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Clinical Features
Intermittent/recurrent pain (Majority of the cases) Tender Swelling/Lump ( pus collection) If at just above the coccyx in the midline - Primary If on either sides of the midline - Secondary sinus When infected Fever Discharge + (Majority of the cases) either sero-sanguinous or purulent (Mostly). Tuft of hairs may be seen in the opening of the sinus Recurrent infection, abscess formation which bursts open forming recurrent sinus with pain,discharge and discomfort. Presentation may be either ACUTE EXACERBATION or CHRONIC.
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Complications
Chronic can cause occasionally Sacral osteomyelitis, Nectrozing fasciitis and rarely meningitis.
It is not an life threading disease, but It can be a morbid disease due to its high recurrence rate.

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Rx:
1. Conservative Mx Majority of patients receive conservative mx alone --> simple cleaning of tract and shaving A pilonidal cyst that does not cause any problems require No treatment. The patient should keep the area clean and free of hair by shaving or using a hair removal agent every 2-3 weeks.
2. If infected -Incision and Discharge 3. If recurrent -> Sx
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Most often, pilonidal disease can be managed surgically in the ambulatory setting. Although, medical therapy with phenol has been used before attempting surgery. Phenol is injected into the site, which sterilizes the sinus tract and removes embedded hair. Its use in the U.S. is limited, because of the toxicity of phenol. Surgically, a pilonidal abscess is treated as any type of abscess. Incision, drainage, and curettage of the abscess cavity is the primary management goal.
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The patient should then be instructed to cleanse the wound daily or take warm, Sitz baths.
Good personal hygiene and close hair shaving. Most wounds heal within 1 month, although the meticulous cleansing process should be done for at least 3 months.
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Sx
Jack Knife-prone position methylene blue injection to identify all of the tracts. There are many operations for pilonidal sinus, indicating that none are 100% effective. mid line incision should be avoided.
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Excision and healing by secondary intention Excision and primary closure is done under G/A OR L/A.

Marsupialisation - takes long weeks to heal.


Lord's procedures Phenol injections Excision with skin grafting - high recurrence rate Excision with Z plasty - good reusult

Excision with Z multiple plasty


Skin flap procedures/ Karydakis excision via a semilaterl incision and lateralised suturing of the wound away from the midline - good result and Very Less recurrent rate V-Y gluteal advancement flap Bascom Technique of excision via lateral approach - good method
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Why this condition has got high recurrence rate?


Improper removal
Overlooking of existing diverticulum Entry of new tuft of hairs Breakage of scar

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THANK YOU

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