Pilonidal sinus and Pilonidal cyst are collectively referred to as Pilonidal disese, which is a chronic sinus or cyst in the soft tissue of sacrococcygeal cleft, and it is characterized by embedded hair. It can also be manifested as an acute abscess in the sacrococcygeal region, which forms a chronic sinus after perforation, or temporarily heals and finally penetrates, so it can recur. The cyst is accompanied by granulation tissue and fibrous hyperplasia, and often contains a tuft of hair. Although the disease can be seen after birth, it mostly occurs at the age of 2 ~ 3 after puberty, and symptoms only appear because of the increased activity of hair fat glands.

The main diagnostic signs of pilonidal sinus and pilonidal cyst are acute abscess in sacrococcygeal region or chronic sinus with secretion, with local acute inflammation. The pilonidal cavity can be seen in the midline during examination, and pilonidal sinus can be easily diagnosed by symptoms and signs.

treatment measures

a non-surgical treatment

the sacrococcygeal fossa does not need treatment, because there is only a depression in the sacrococcygeal joint, the lower part of the sacrum and the tip of the coccyx, which has no symptoms and is of no clinical importance.

In case of infection of sacrococcygeal pilonidal sinus and sacrococcygeal swelling, anti-inflammatory treatment should be performed to keep the local area clean. If abscess reappears, incision and drainage should be performed. However, the sacrococcygeal skin and subcutaneous tissue are thick and hard, and there is no obvious manifestation in the early stage. Inflammation often spreads to surrounding tissues and causes cellulitis. Deep tissue necrosis should be treated by early incision and drainage.

Sclerosing therapy is to inject corrosive drugs into the sinus to destroy the epithelium in the sinus and capsule, and close the capsule cavity and sinus. Since 196, some people have applied phenol solution injection therapy, but few people have applied it, because the pure phenol solution was used and the pain was severe, and then it was switched to 8% concentration and carried out under general anesthesia. Inject glue into the sinus to protect the surrounding skin. Hegge(1987) slowly injected 1 ~ 5ml of 8% phenol solution into sinus for about 15min. Slow injection can prevent complications, such as skin burn, fat necrosis or severe pain. This method can be repeated once every 4 ~ 6 weeks, about half of patients can be cured after only one injection, and 12% need five injections or more. 43 cases were followed up for more than one year, only 3 cases (6%) recurred. Stansby(1989) injected 8% phenol solution into the sinus under general anesthesia, kept it for 1min, and scraped the sinus for 3 times. Among 14 cases, 4 cases developed aseptic abscess and 1 case suffered from bee-infested fossa tissue inflammation, and there were no other complications. Compared with 65 cases of surgical resection, the treatment rate; Excision is 86%, phenol injection is 75%; The average follow-up was 8 months (from March to 4 years), and 1 cases of resection recurred and 12 cases of injection recurred.

second surgical treatment

surgery is the main treatment, but it is contraindicated when there is inflammation, and surgery should be performed after the inflammation subsides. There are several surgical methods as follows:

1. One-stage suture surgery removes all diseased tissues, free muscles and skin, and completely sutures the wound to make it heal in the first stage. In order to eliminate deep intergluteal fissure and its negative pressure, and reduce wound dehiscence, hematoma and abscess, Z-plasty is feasible (Figure 1). It is suitable for cysts and small non-infected sinuses on the midline, with a recurrence rate of % ~ 37%. Its advantages are short healing time, soft movement of scars formed in intergluteal fissure, and soft tissue between scars and sacrum, which can tolerate injuries.

Figure 1: Oval incision at the pilonidal sinus

Left: Oval incision at the pilonidal sinus;

middle picture: separation and displacement of full-thickness flap;

right picture: skin suture

2. Cut off the diseased tissue by partial suture. The skin on both sides of the wound is sutured to the sacral fascia, so that most of the wounds are healed in the first stage, and the middle part of the wounds are healed by granulation tissue. It is suitable for cases with many ostia and sinuses, and the effect is the same as that of primary suture, but the healing time is longer.

3. Open secondary suture after excision of wound is suitable for cases with severe infection and cases with infected wound incision and drainage after primary suture.

4. Open cut is suitable for cases where the cut is too large to be sutured and the operation recurs. The operation is simple, but the healing period is long, and the scar is extensive, with only a thin layer of epithelium sticking to the sacrum. If there is injury, the scar is easy to rupture.

5. Bag suture is used to remove the surface part of sinus wall and the upper skin, and the wound is wound with catgut or absorbable artificial suture to promote healing. Careful postoperative care can often lead to satisfactory results. It is mostly used in cases that cannot be resected or recurrent pilonidal sinus.

the results of three kinds of various treatments

Keighley(1993) analyzed the recurrence rate of seven treatments in the literature: ① only open treatment is 7% ~ 24%; ② % ~ 22% for resection and opening; ③ 7% ~ 13% for excision and bag suture; ④ resection and primary suture were 1% ~ 46%; ⑤ % ~ 1% for resection and Z-shaped plastic surgery; ⑥ 3% ~ 5% for excision and rhombic skin flap; ⑦ % ~ 5% for excision and layered skin transplantation.

Etiology

The real cause is unknown, and there are two theories.

A congenital

inclusion in skin caused by residual medullary canal or malformation of sacrococcygeal suture. However, it is rare to find the precursor lesions of Tibetan hair disease in the shallow concave area behind the anus at the midline of the baby, but it is more common in adults.

Acquired

Sinus and cyst are granulomatous diseases caused by injury, operation, foreign body stimulation and chronic infection. Recently, it has been proved that the hair entering from the external fold is the main cause. Intergluteal fissure has negative attraction, which can make the fallen hair penetrate under the skin. Too much hair in the fissure is too long, and the top of the hair can filter and soften the skin. The hair penetrates into the skin, forming a short path, and then deepens into a sinus. When the hair root falls off into the sinus, the hair shaft can also penetrate, and the movement changes can be seen during the onset (Figure 2), but only half of the cases can find hair. This disease is more common in patients with hirsutism, excessive sebum activity, deep hip fissure and frequent hip injuries. The sacrococcygeal skin of automobile drivers is often damaged by long-term bumps, which can make sebaceous glands and debris accumulate in the capsule and cause inflammation. This disease occurs more frequently in the US Army, and it is called Jeep Disease. Common pathogens are anaerobic bacteria, staphylococcus, streptococcus and Escherichia coli. Rainsbury and Southan analyzed the static Tibetan wool disease, and found that less than half of them were single bacteria, and 58% were anaerobic bacteria. Strangely, staphylococcus is not common, and most aerobic bacteria are gram-negative bacteria.

Figure 2 Formation and natural evolution of pilonidal sinus

Right: There is a small pit in the groove, and the hair gradually penetrates;

right picture: hair penetrates a lot, and finally skin sinuses are formed due to secondary inflammation.

Clinical manifestations

Tibetan hair cysts are often asymptomatic if there is no secondary infection, only sacrococcygeal protrusion, and some feel pain and swelling in the sacrococcygeal region. Usually, the main and first symptom is an acute abscess in the sacrococcygeal region, which is characterized by acute inflammation such as redness, swelling, heat and pain. Most of them automatically break through the outflow of pus or the inflammation subsides after surgical drainage, and a few drainage openings can be completely closed, but most of them show repeated attacks or frequent running water to form sinus or fistula. < P > Irregular pores with a diameter of about 1 mm ~ 1 cm can be seen in the skin of sacrococcygeal midline during the static period of pilonidal sinus. The surrounding skin is red, swollen and hard, often scarred, and some can see hair. The probe can probe into 3 ~ 4 mm, some can probe into 1cm, and dilute and odorous liquid can be discharged during extrusion. During the acute attack, there are acute inflammatory manifestations, tenderness and redness, and more purulent secretions are discharged, and sometimes abscesses and cellulitis occur.

differential diagnosis

should be differentiated from furuncle, anal fistula and granuloma. Furuncle grows on the skin, protrudes from the skin, and the top is yellow. The carbuncle has multiple external pores with necrotic tissue inside. The external orifice of anal fistula is close to * * *, the fistula runs to * * *, there is a cord in the diagnosis, there is an internal orifice in the anal canal, and there is a history of rectal abscess. However, the running direction of the pilonidal sinus is mostly to the cranial side and rarely downward (Figure 3). Tuberculous granuloma is connected with bone. X-ray examination shows that bone is destroyed and other parts of the body have tuberculous lesions. Syphilitic granuloma has a history of syphilis, and syphilis serum is positive.

Figure 3 Direction of the pilonidal sinus

Note: 93% of the sinuses go out of the skin fossa to the cranial side; 7% can walk around * * * below.

Prognosis

It is rare for cancer to occur in the pilonidal sinus, and only 32 cases were reviewed by Phipshen(1981). The lesions were mostly well-differentiated squamous cell carcinoma. Wound changes should cause suspected canceration, such as ulcers that are easy to break, grow quickly, get out of the sedan chair and mold-like edges. Extensive resection should be the first choice. Because wounds are widely used to be treated with skin grafting or skin flap. Abdominal and femoral lymphadenopathy should be biopsied to exclude metastasis. If there is metastasis, the prognosis is not good. The literature reports that the 5-year survival rate is 51%. The recurrence rate is 5%. Metastasis of abdominal and femoral lymph nodes was found in 14% at the initial diagnosis.

Hope to adopt

Baidu fans sincerely answer for you.