ULCERS, SINUSES & FISTULAE

ULCER
• Breach or discontinuity
of an epithelium or
mucosal surface.
 Classification
Infective (a) non-specific
(b) specific – TB, gumma
CHEMICAL

PHYSICAL

Neuropathic
 Epithelioma of
hand with
typical edge 

Thrombo- Early rodent

phlebitis ulcer on the
occurring in side of the nose
varicose
veins
 Diagnosis –

• 1. History:
– age (young – infective, >40 Ca, 60 Rodent)
– sex (female – varicose, male – squamous
cell Ca)
– Race (Chinese – Varicose ulcer)
– Religion (Muslim/Jews - squamous cell
Ca)
– Occupation - prolong standing
(baker/hairdresser/surgeons/traffic police –
• 2. Mode of onset:
–acute
inflammation/trauma 
sudden
-chronic
chronic inflammation very slowly
malignant  rapid
• 3. Duration:

–very short (days) – acute infection;

–short (month) – malignant;
–long - chronic
inflammation
• 4. Progress:
–very rapid – acute inflammation,
–rapid – malignant,
–slow – chronic inflammation
• 5. Pain:
–acute inflammation, arterial
ulceration– painful (venous – not
usually very painful)
–Neuropathic – less pain
–malignant – early – usually
painless.
• 6. Fever:
infective/TB
•• 7.
8. Loss of weight: Buerger's disease,
Smoking:
malignant/TB
artherosclerosis
• Past History – TB, Syphilis, Diabetes
Mellitus, Hypertension
• Responses to Antibiotics:
(+) in infection (-) in malignancy
 PHYSICAL EXAMINATION

• General – cachexia, anaemia,weight

loss (Ca, TB)
• Local:
1. Number (single or multiple –TB)
2. Site
Rodent –lobule of ear & angle of
the mouth;
 Pigmentation & Residual varicosity,
linear healing ulcer 

Varicose – medial aspect of lower half of leg,

Arterial – tip/between toes, malleoli, heel

Arterial ulcer due to

ischaemic pressure
to the heel
Squamous cell Carcinoma
SCC – lower lip, Gumma – s/c bone ~
tibia/sternum/skull

Diabetic/Perforating/trophic – heel/ball of
the foot (head of 1st /2nd metatarsals

TB – neck, axilla, groin

Lupus – face, fingers, hands,
Chancre/soft sore – ext.genitalia
Rodent
ulcer

Hunterian
chancre

Lupus
vulgaris

Primary chancre
of upper lip with
lymphadenitis
• 3. Size (depends on duration
& rate of growth)
• 4. Shape (oval – varicose,
circular – rodent,
irregular – malignant)
• 5. Edge: (a) flat sloping ~
simple or healing ulcer,
venous ulcer (edge red,
blue, transparent zone)
 FLAT SLOPING
ULCERS OF A BURN
LESION TO LEG

• Healing granulating
ulcer with skin
islands. 
• (b) square cut or punched
out
– gumma, trophic,
diabetic
- Chronic GU/DU, leprosy
(rapid death & loss of whole
thickness of skin without much
attempt by the body to
repair the defect)
 SLOUGH IN THE BASE OF
DEEP SACRAL ULCER

• (c) undermined
– TB, amoebic, bed
sore,
carbuncle
BUTTOCK (infection affects
underneath tissue more
than epithelial surface)
• (d) raised & rolled up
– rodent/BCC

(slow growth of tissue in the edge of

ulcer, edge pale pink or white with
clumps of cluster of cells visible through
paper thin superficial coverings of
squamous cell)
• (e) raised & everted
– malignant
ulcer, epithelioma

(tissue in edge growing quickly and

spilling out of the ulcer to overlap normal
skin or mucosa)
Everted edges which to the
palpating fingers feels hard - Ca

Slightly raised edges – Rodent

Septic ulcer (commonest –

varicose ulcer) sloping edges

Undermined edges -
tuberculous

Punched out ulcer –

tertiary syphilis
 Varicos
e ulcer
confined
to the
lower
quarter
of the
leg Multiple gummatous ulcers in lower
limb
Perforating ulcer on the sole

Exuberant
granulation
tissue
around a
sinus
On rib
 Colour of the Edge
• Red  inflammation
• Pale or cyanosed  ischaemia
• Late  blue, purple, black

• Pigmentation  venous ulcer,

malignant melanoma
• Pearly edge  BCC
• Keratinization  Neuropathic
ulcer
• 6. Floor:
Haemorrhage & necrotic slough–
malignant
purulent - acute infection
washed leather- gumma
bluish unhealthy granulation tissue
TB (whitish in brownish space/
apple jelly)
solid brown or gray – dead tissue
full thickness skin death
• 7. Discharge:
On dressing gauze – serous,
sero- sanguinous,
purulent, offensive, copious, or so
slight – dries up into a scab.

• 8. Surrounding skin, state of

local tissue, blood supply,
innervation
Surrounding skin of infln – infective,
 PALPATIO
• TemperatureNdifference/tenderness - in
acute infected ulcer
• Base – induration +/-,
• Mobility of ulcer over underlying
structures –
– fixed – malignant; bleed on
touch +/-
• regional lymphatics –
enlarged -> inflammation
hard – malignant
 Systemic Examination:
• Infection – constitutional symptoms
- TB
• cachexia, anaemia, loss of weight-
- malignant
• hypertension, artherosclerosis –
- ischaemic ulcer
• Hansens’, tabes dorsalis, peripheral
numbness
- neuropathic
 Investigation
• D. Mellitus – Urine sugar/ RBS/FBS
• Infective - fbc, culture
TB - CXR, AFB, ESR
Syphilis- VDRL
• Discharge – smear, Gram stain, C&S
• Biopsy wedge/incisional biopsy
- margin of the ulcer & normal
tissue which allows
» (a) comparison with
normal tissue
» (b) known organ &
• Curling’s ulcer
– acute peptic ulcer in burn as a
reaction to stress
• Cushing’s ulcer
– acute PU in head injury, early
days following spinal cord injury
• Marjolin’s ulcer
– malignant change in a scar, ulcer,
sinus (Chr.venous ulcer, burn,
Chr.OM sinus –slow growth –
avascular, painless – scar not
have cut. nerve fibres, late lymphatic
spread – obliterated
lymphatics)
GRANULATING TISSUE

ESCHAR FOLLOWING SHIN TRAUMA

 Stages of Ulcer
Extension Transition Repair or healing

Floor Exudates &  Clean, healthy

slough granulation tissue
Base Indurated  No induration

Discharge Purulent/Blood Thinner Very ittle serous

Margin Sharp Less sharp Shelving

Edge Hyperaemic Less White (fibrous),

Blue
(epi.lining)
Red (gr.ts)
 Principles of Assessment
1. Combination of aetiologies in any one lesion,
especially diabetic foot.

2. Pain indicates invasion of nerve endings.

3. When the diagnosis relates directly to

treatment, biopsy may be necessary.
SINUSES &
FISTULAE
• SINUS ~
A tract which connects a cavity lined by
granulation tissue (usually an old abscess) with an
epithelial surface. {blind tract leading from
surface down to tissue}

• FISTULA ~
Pathological connection between 2 epithelial
surfaces usually lined by granulation tissue but
can become epithelialized.
 Sinus Fistula
Congenital Pre-auricular Branchial, thyroglossal,
tracheo-oesophageal,
umbilical, rectovesical,
vesicovaginal
Traumatic Foreign body a/f operation or accidential
injury, salivary,
implantation pancreatic, biliary, faecal,
urinary
Inflammatory OM, TB, Act, Appendicular fistula,
Chronic diverticulitis of
abscess colon
Neoplastic Degeneration/ Advanced Ca, rectum,
2. infn which cervix – faecal fistula
was incised
 SINUS JAW

SINUS FROM SEPTIC

ARTHRITIS OF THE
SHOULDER DUE TO
ACTINOMYCOSIS 
• History
Since birth - preauricular sinus;
due to Osteomyelitis(high fever + swelling + bone pain)
TB -lymph node enlargement or TB bone or joints
Perianal- h/o perianal/ischiorectal abscess (intermittent
contraction of anal sphincter prevent proper rest)
[Pain + inflammatory/blockage; Fever/redness of
surrounding skin inflammatory]

• Past history TB, Crohn’s, U.colitis, actinomycosis,

colloid Ca, operation complication

• Family history TB, Crohn’s, U.colitis

INSPECTION
• 1.Number – Single/Multiple (watering can
perineum – Crohn’s rectum/anal canal, U.Colitis – fistulae;
actinomycosis (multiple sinueses)

• 2. Site – Preauricular (failure of fusion of ear tubercles -

at root of helix or on tragus of pinna; direction – upwards
and backwards)
Branchial (2nd & 5th branchial arch) at the lower 3rd of
the neck in front of sternomastoid muscle
Pilonidal – in the middle behind, finger webs
Actinomycosis – multiple indurated sinuses in upper
part of the neck
A single sinus over the lower irregular jaw – due to
osteomyelitis OM
Actinomycosis of the left side of the jaw with
multiple sinus formation.
3. Opening of sinus
Sprouting granulation tissue - + of FB (stitch,
sequestrum, bullet)
Wide margin, thin blue undermined edge – TB
Sinus

4. Discharge
OM  plus; TB  serosanguinous;
Actinomycosis  sulphur granule Urine,
faeces, bile
5. Surrounding skin
Scar indicating Chr. OM or previously healed
TB.
Dermatitis with pigmentation  Chron’s /
Actinomycosis
 PALPATION

1. Tenderness  Inflammatory source OM

2. Wall of sinus thickening –fibrosis– chronicity

3. Mobility Sinuses resulting from OM is fixed to

bone (irregular, thickened, tender)

4. Lump  + in neighbourhood  TB adenitis

5. Examination of draining lymph nodes

Examination with a probe (with due
precaution)
• direction and depth of sinus
• presence of F/B (sequestrum),
moveable at wound depth
• fistula communicated with a hollow
viscus or not
• whether fresh discharge comes out on
withdrawal of the probe or not.
Mammary fistula
General Examination
• Depends on site and cause – particular system
• Sinus in loin - spine, ribs, kidneys
• Chronic empyema - chest
• Osteomyelitis- bone
• Around anus- PR/proctoscopy,
scope, whole abdomensigmoid
• Multiples in perineum/scrotum lower urinary tract
• Groin sinus hip joint/spine (bursting of cold abscess)
Investigatons
• Examination of discharge –
marcro/physical/chemical/microscopy
• X-rays - sequestrum, opaque
foreign bodies/ sino/fistulogram
 Failure to close
• Inadequate drainage
• Specific infection (actinomycosis, TB,
syphilis)
• Foregin body (stitch)
• Epitheliazation of cavity
• Malignant change in the cavity
• Dense fibrosis around the wall of the
tract preventing collapse
(empyema)