Chapter 5

(1) Discuss briefly on sinus.

(2) Discuss briefly on fistula.
(3) Discuss examination and treatments of ulcers.

1. Sinus
It is a blind tract extending from epithelial surface to surrounding tissues. It has one opening. It is lined by granulation tissue or epithelium.

Anatomical Sinuses
These are normally present in the body, e.g. frontal sinus, maxillary sinus.

Congenital Sinus
It is present since birth, e.g. preauricular sinus.

Acquired Sinus
Various causes are:
- Tubercular sinus in neck, occurs following rupture or drainage of cold abscess. Margins - undermined and
palpable mass of matted lymph nodes.
- Median mental sinus in submental triangle is due to ruptured tooth abscess.
- Pilonidal sinus is a midline sinus in natal cleft. It contains tuft of dead hair with foul smelling discharge.
- Hidradenitis suppurativa. It is abnormality of apocrine glands present in axilla and groin. It presents with recurrent abscesses
and multiple discharging sinuses.

2. Fistula
It is an abnormal tract between two epithelial surfaces. It has two openings. The tract is lined by granulation tissue or epithelium.

External Fistula
When the tract communicates a hollow viscus (e.g. intestine) to the skin, Parotid fistula, thyroglossal fistula, branchial fistula.

Internal Fistula
When the tract communicates with two hollow viscera (e.g. two intestinal lumens, two blood vessels),
tracheo-esophageal fistula, oro-maxillary fistula.

Congenital Fistula
It is present since birth. Examples are: Branchial fistula, Tracheo-esophageal fistula, Arterio-Venous fistula.

Acquired Fistula
- Fistula in ano (Anal Fistula)
- Arteriovenous fistula: Following trauma, created surgically for dialysis in renal failure.
- Parotid fistula: Following drainage of parotid abscess.

3. ULCER

An ulcer is a break in the continuity of epithelial surface (skin or mucus membrane) due to microscopic tissue destruction.
The dead tissue (slough) gets separated from the live tissue and exposes the floor of the ulcer.
(Specific Ulcer, Non-specific Ulcer).

Examination

Clinical Examination of an Ulcer History

- Duration of ulcer: Short in acute ulcer and long in chronic ulcer.
- Mode of onset
○ Following trauma: Traumatic ulcer.
○ Following sexual contact: Syphilitic ulcer, chancroid.
○ Long standing varicose veins: Varicose ulcer.
○ Over a scar: Marjolin’s ulcer.
○ Over matted lymph nodes in neck: Tubercular ulcer.
○ Over a nodule: Malignant ulcer.
- Progress: Change in size of ulcer.
- Painful or painless: Inflammatory and tubercular ulcers are painful,
malignant and syphilitic ulcers are painless.
- Nature of discharge: Pus, blood, serum.
- Constitutional symptoms: Fever, cough, anorexia, weight loss.

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Local Examination Site :
• Tubercular ulcer—in neck.
• Rodent ulcer—upper part of face.
• Arterial ulcer—tip of toes, dorsum of foot.
• Venous ulcer—above medial malleolus.
• Neuropathic ulcer—pressure points on sole.
Size : Exact dimensions.
Shape : Round, oval, irregular or serpiginous
Edge :
• Sloping—healing non-specific ulcer, venous ulcer.
• Undermined—tubercular ulcer (bluish margins).
• Raised and everted—squamous cell carcinoma.
• Rolled out—rodent ulcer.
• Punched out—syphilis.
Floor : This is the exposed surface of the ulcer
• Sloughed necrotic tissue—ulcer in stage of extension.
• Red granulation tissue —healing ulcer in stage of transition.
• Pale smooth granulation tissue—ulcer in stage of healing.
• Wash leather slough—syphilitic ulcer.
• Watery or ‘apple jelly’ granulation tissue— tubercular ulcer.
• Floor raised above the surface—malignant ulcer.
Base : It is the area on which ulcer rests.
Feel for the induration of the base;
• Mild induration felt in chronic nonspecific ulcer.
• Marked induration felt in malignant ulcer, syphilitic ulcer.
• Feel for the mobility of ulcer on underlying structures.
Benign - Mobile, Malignant - Fixed
Nature of discharge : It can be scanty or copious.
• Purulent discharge—bacterial infection.
• Watery discharge—tuberculosis.
• Bloody discharge—malignancy.
• Sulphur granules—actinomycosis.
Surrounding area:
• Inflamed and edematous—infective ulcer.
• Thick, pigmented with dilated veins—varicose ulcer.
• Palpable matted lymph nodes—tubercular ulcer.
• Pigmented halo—malignant melanoma.
Regional Examination Draining lymph nodes
• Tender and enlarged—secondary infection.
• Enlarged, hard, fixed—malignant ulcer.
• Enlarged, firm, matted—tubercular ulcer.
• Enlarged, shotty—syphilitic ulcer.
Examination for impaired circulation:
Look for weak or absent arterial pulsations with trophic changes
Look for varicose veins
General Examination For anemia, malnutrition, jaundice, diabetes.
Systemic Examination • Respiratory system—Pulmonary tuberculosis.
• CNS and spine—Neuropathic ulcer.
• CVS—Congestive heart failure, valvular defects.

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Treatment

Treatment during stage of extension • Antibiotics according to culture and sensitivity report of the pus discharge.
• Analgesics and anti-inflammatory drugs for control of pain and inflammation.
• Bed rest and limb elevation to relieve pain and edema in leg ulcers.
• General measures-
• Correction of anemia by hematinics/ blood transfusion.
• High protein diet with vitamins (vitamin C) to improve nutrition and wound healing.
• Control of diabetes
• Local (topical treatment) ;
- To remove slough and control sepsis so that healthy granulation forms and epithelialization starts.
• Eusol (Edinburgh University solution) is used for desloughing of wound.
• Solutions releasing nascent oxygen make bubbles in the wound.
(separation of slough, e.g. H2O2, Oxum solution)
• Magnesium sulphate (Sumag) ointment
(relieving local edema and cellulitis)
• Once line of demarcation appears between slough and healthy tissue, do mechanical debridement
- Regular wound dressings are toxic to fibroblasts and resistant strains of bacteria may develop.
- Other agents for dressing ulcers are:
• Hydrocolloids: It is made of polyurethane foam that expands and forms a gel in the wound.
• Alginates: These are sodium and calcium salts of algenic acid for management of bleeding wounds
• Tegaderm: thin polyurethane membrane that prevents water loss from the ulcer.
(prevents contamination of ulcer)
• Recombinant epidermal growth factor: It increases collagen production and
stimulates formation of granulation tissue.(enhances wound healing and reduces healing time)
Treatment during Stage of Transition • ulcer is having healthy granulation tissue and minimal discharge
• to promote surface epithelialization and prevent secondary wound infection
• Non-adhesive sterile dressing is done(easy removal of dressing and prevents epithelial breakdown)
• If there is formation of hypergranulation tissue (proud flesh)
• debrided surgically or by application of copper sulphate (chemical cautery)
• Small ulcers heal of their own while large ulcers need coverage with skin grafting or flaps.
Treatment of Underlying Cause • Varicose ulcer—surgery for varicose veins.
• Tubercular ulcer—antitubercular treatment.
• Malignant ulcer—wide excision.
• Diabetic ulcer—control of diabetes.

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