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Sinus: is a blind-ending tract, usually lined by granulation tissue, that leads from an epithelial surface into the surrounding tissue, often into an abscess cavity. Ulcer: is a break in the continuity of an epithelial surface. It is characterized by progressive destruction of the surface epithelium and a granulating base.
Fistula • • Is an abnormal communication between two epithelium-lined surfaces. It is not easy to be differentiated from sinus as the internal opening of a fistula may be difficult to demonstrate.
Classification: 1. Congenital fistula: • branchial fistula • trachio-esophageal fistula • arterio-venous fistula 2. Acquired fistula: This type often follows inadequate drainage of an abscess. • Perianal abscess may burst on the surface of skin and lead to a sinus. • In other cases, the abscess opens both into the anal canal and on the surface, resulting in a true fistula-in ano.
often into an abscess cavity. Complicated fistula: that has multiple tracts. colo-vesical fistula. internally connected to a hollow viscous e. entero-cutaneous fistula. Congenital sinuses: • Arise from the remnants of embryonic ducts that persist instead of being obliterated and disappearing completely during embryonic development. High-output fistula: > 500 ml output per day.e. Classification: • Congenital sinuses. According to fistula tract: Simple fistula: that has one tract. Sinuses: • Is a blind-ending tract. • Examples: • • Preauricular sinuses. usually lined by granulation tissue.e. 2 . Internal fistula i. that leads from an epithelial surface into the surrounding tissue.• • • • • • • • • According to fistula location: External fistula i. one of the openings is located in the skin e. According to fistula output: Low-output fistula: < 500 ml output per day.g.g. Umbilical sinuses. • Acquired sinuses.
Suture sinuses. Hydradenitis suppurativa. Sacral sinuses. pelvic. skeletal or thoracic sepsis. • • • • Recurrent infections. Clinical features: • Sinus may be asymptomatic. 3 . Persistent discharge. Principles of treatment: • Accurate detection of any associated deep abscess cavity or deep complex extensions. Constitutional symptoms if the sinus originates from deep-seated intra-abdominal. Coccygeal sinuses. Local pain. Post-surgical abdominal or perineal sinuses. as any sinus is prone for infection. • Examples: • • • • • • Pilonidal sinuses. • Failure to do so result in recurrence of the sinus after treatment at or near the original site. Acquired sinuses: • These are usually secondary to the presence of foreign or necrotic material (with or without associated sepsis) within the affected tissue or certain types of microbial infections. Tuberculosis.• • • Urachal sinuses. Osteomyelitis.
a "sinogram" should be performed using water soluble contrast material under image intensification (this can differentiates sinus from fistula). • More common after closure of contaminated wounds. Perineal sinus: • Can follow proctocolectomy. • • Liable for infection and abscess formation. direction and extension by gentle propping. # Post-surgical abdominal sinuses after intra-abdominal abscess or anstomotic leak. • Can be avoided by making the suture knots buried beneath the subcutaneous tissue. Crohn's disease. If necessary. and after resection of Crohn's disease.g. Generally by surgical excision or lying the sinus open with tissue biopsy to exclude malignancy and specific conditions e. • Treatment by removal of the suture. Can be secondary to a deep pelvic abscess above the levator plate. 4 .• Microbial evaluation of the sinus discharge. Definitive treatment depends on the removal or specific management of the cause. occasionally specific infections such as tuberculosis or actinomycosis may be detected. • • • Acquired sinuses: Post-surgical abdominal and perineal sinuses: # Suture sinus: • Caused by non-absorbable suture material acting as focus of infection within the wound. although most pathogens will be skin organisms and gut commensals. Evaluation of the sinus depth.
Techniques used are: incision. • • • • • Hydradenitis suppurativa: • Is an abnormality of the apocrine sweat gland of the body. Congenital sinuses: Preauricular sinus: • Fairly common condition. • • • Found in the axillae. Treatment by opening and decortications of the abscess cavity. It characterized by multiple sinus tracts and openings. Characterized by recurrent abscess after puberty that resolve to leave chronic discharging sinuses. and perineum and around the nipples. Could be asymptomatic. but will be painful on blockage and infection of the sinus. Pilonidal sinus: • Usually found in the natal cleft. with a rate of up to 40% regardless the type of technique used. groins. • Thought to be caused by loose hair shafts that shade from the body and migrate to the natal cleft on walking. 5 . • Could be unilateral or by lateral. The condition is usually improves by low-dose Tetracycline. but radical surgical excision of the affected area may be required. Post-operative recurrence is common. Adequate excision is the key factor of successful treatment. excision with primary closure and excision and healing with secondary intention. forces into deep tissues by gluteal contraction.• • Need evaluation by CT and/or sonography.
• • • • Normally obliterated by the time of birth. urachal sinus will be formed. it require incision and drainage and later excision. but may present with infection and abscess formation. • • Umbilical sinus: • From the continued presence of the umbilical end of the vitelline (omphalomesentric) duct. Persistence of a fistula or sinus The reason for this will be found amongst the followings: 6 . Total surgical resection should be done. If the umbilical end of Urachus did not obliterate. in that condition.• May be asymptomatic. Causes chronic umbilical discharge. Urachal sinus: • Urachus is a fetal structure that connects the developing bladder to the umbilicus. that normally connects midgut to the yolk sac in embryo and normally obliterates completely. may get infection. Treatment by surgical excision. • • Close inspection reveals a sinus tract deep to the umbilicus. Complete excision is often difficult because the ramification of these sinuses may be in proximity to the branches of facial nerve. Excision is recommended only if recurrent infection has become a problem.
g. Necrotic slough that may obscure deep extensions and tracts.g. sequestrum. such as urine or feces.• A foreign body or necrotic tissue is present e. maintain continuous inflammation. Guinea worm that is Drancunculus medinensis). Inefficient or non-dependant drainage.g. Unrelieved obstruction of the lumen of a viscus or tube distal to the fistula. Dense fibrosis prevents contraction and healing. • • • • • • • Ulcer • Is a break in the continuity of an epithelial surface. a faecolith or even a worm (e. such as occurs in fistula-in-ano due to the normal contraction of the sphincter which also force fecal material into the internal opening. suture. Absence of rest. • 7 . Irritating discharge. Type of infection e. The walls have become lined with epithelium or endothelium (AV fistula). It is characterized by progressive destruction of the surface epithelium and a granulating base. tuberculosis or actinomycosis. The presence of malignant disease. The ulcer base may contain: • • Clean healthy granulation tissue.
Traumatic ulcers. Malignant ulcers. Physical agents.venous insufficiency.intravenous fluid extravasation. Neuropathic ulcers diabetes. Aphthous ulcers.Classification of ulcers • • • • Non-specific ulcers. Gravitational ulcers. Pressure sores (decubitus ulcers) and ischemic ulcers. Iatrogenic. leprosy.self-mutilation. tabes dorsalis. Specific ulcers. 8 ulcers-wound infection and abscess . Interference with sensation (neuropathic ulcers). Examples: • • • • • • • • • Peptic ulcer. Secondary infective drainage. Predisposing factors are: • • • Local irritation. Non-specific ulcers: May be caused by: • • • Infection of wounds. Chemical agents. Interference with circulation (ischemic ulcers). Dermatitis artifacta.
9 . • Malignant ulcers: Those ulcers which are caused by malignant neoplasm. Tuberculosis. Syphilis. Examples: • • Gastrointestinal malignant ulcers. Delayed epithelial healing in ischemic ulcer. Neuropathic ulcer is that indurated ulcer with densely fibrotic surrounding and deep base with sharply cut edges with little tendency for healing. Clinical examination should be conducted in a systematic manner and include: • Site: • 95% of rodent ulcers (basal cell carcinoma) occur in upper part of face. Clinical features: One should notice if there is any of the followings: • • • • Surrounding cellulitis of acutely inflamed ulcer.• Specific ulcers: Those ulcers which are caused by primary infection. Skin malignant ulcers. Fungal infections. • Squamous cell carcinoma is typically affecting lower lip. Chronic inflammation with adherent slough. Examples: • • • • Herpes simplex.
Apple-jelly granulations in tuberculous ulcer. Squamous cell carcinoma Inflammatory ulcer • Shape: • Rodent ulcer • usually circular. • Floor: Is what can be seen by inspection of the ulcer. Rolled edge or rampant edge cell carcinoma).• Size: Ulcer size should be related to the length of history of it. • Edge: • Shelving edge • • • • Undermined edge healing ulcer. Heaped up. it could be: • • Watery. non-specific ulcer. rapid extension. tends to extend more rapidly. tuberculous ulcer (often bluish). 10 . raised or everted edge Punched-out edge syphilitic ulcer (usually the base is covered by wash-leather slough). rodent ulcer (basal epithelioma. it could be: • • Indurated base carcinoma. varicose ulcer that may be Attached to deep structures attached to tibia. • Base: Is what can be palpated. • • • Rodent ulcer slow extension. square area or Dermatitis artifacta (self-mutilation) straight edge ulcer.
g. Herpes virus infection often causes painful ulcers. it should always be considered as a possibility. Lymph nodes: • Rodent ulcer usually no lymphatic secondaries. carcinoma. • Neuropathic ulcers tend to be painless. • Squamous cell carcinoma may results in hard or even fixed secondaries in the regional lymph nodes. Principle of management of ulcers: • Determine etiology. Pseudomanal infection (caused by • Blue-green Pseudomonus pyocyaneus).g. 11 . such changes can occur at the edge of any long standing benign ulcer irrespective of its cause. but it can be affected by secondary bacterial infection.• Discharge: • Purulent active infection. General examination: • Debility • • • Cardiac failure Anemia including sickle cell anemia Diabetes Pathological examination: • Biopsy from an ulcer can be diagnostic e. • Watery • tuberculous ulcer. Marjolin's ulcer: Eponym used to describe carcinomatous changes occurring at the edge of chronic venous ulcer. Ulcer & pain: • Viral ulcer e.
Desloughing: The aim of desloughing is adequate drainage of any hidden tracts and secondary extensions. • Basic requirements of the ideal ulcer dressing are: • • • • Maintain high humidity between wound and dressing. venous or arterial insufficiency & diabetes. non-adherent and non-allergic. Adequate drainage and desloughing (see below).g.g. Safe and acceptable to the patient (non-allergic). tuberculous ulcer. Non-adherent.• • • • • Accurate assessment of ulcer and the patient. Absorbent. absorbent. Also used in specific infection ulcers e. 12 . Treat underlying causes e. Surgery is also used in pressure sores (decubitus ulcers). inform of ulcer excision and skin graft or flap. • • • There are many agents used for softening and removing slough. removes excess exudates. • • Used in infected ulcers with surrounding cellulitis. Antibiotics treatment: • Usually not required in healthy granulating wounds. infection. Ulcer dressing: • The ideal dressing for granulation tissue should be on that is soft. anemia.g. allowing easy removal without trauma at dressing change. Most cost-effective method of removing slough is by surgical excision of any dead tissues. Identify and correct comorbid factors e. Avoid adherent dressings (see below).
but impermeable to micro-organisms. Alginates (Kastostat or Sorbsan): contains fibrous fleece that absorb fluid to form gel-like substance that promotes healing. Hydrocolloid gel (Granuflex. • • • Clean ulcer with healthy granulation tissue exudating serous discharge should be dressed twice a day at least. it form a gel when it come in contact with wound exudates & expand o fill the wound. When woven cotton or cellulose gauze dressing used • • • They can expand when absorb fluid causing discomfort. Ulcers with more copious discharge need more frequent change of dressings. 13 . Use normal saline (isotonic NaCl 0. Gauze going to be adherent to the granulation tissue. • Although the ideal dressing does not exist. these can be toxic to the granulation tissue. they are permeable for gases and water vapor. Microporous polyurethane films (Tegaderm & Lyofoam) : films used for shallow lesions. there are group of dressings provide a compromise e.9% solution) during change of dressings rather than any antiseptic solution.• • Permit gaseous exchange but impermeable to microorganisms.g. Hyrogel): this type of dressing contain polyurethane base which provide good wound protection. avulsing the superficial layer of wound on changing dressings that result in delay healing. Cost-effective. They can shed fibers at time of changing dressings that can cause delay healing.
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