Postgrad Med J: first published as 10.1136/pgmj.43.499.353 on 1 May 1967. Downloaded from

Postgrad. med. J. (May 1967) 43, 353-358.

A review of pilonidal sinus lesions and a method of treatment B. P. FLANNERY H. A. KIDD F.R.C.S. F.R.C.S.E. St Helier Hospital, Carshalton, Surrey

Introduction barbers has been reported by Patey & Scarff (1946, This paper on pilonidal lesions is presented with 1948, 1955). Lesions have also been found in the the object of reviewing the disease and describing anterior (Smith, 1948), axilla and a method of treatment introduced by Jacobsen umbilicus (Aird, 1952) and also in an amputation (1959). stump (Shoesmith, 1953. From a review of umbilical A pilonidal sinus is an anomalous condition, in sinuses and fistulae (Steck & Helwig, 1965) thirty- which there may be found a nidus of epithelial and eight sinuses have been histologically identified as hair cells submerged in the cutaneous tissues of the pilonidal. intergluteal cleft. These elements under certain conditions give rise to symptoms or signs. Their Aetiology presence is indicated by a number of fine circular The cause of pilonidal sinuses has during the last pits, which are aligned vertically and are of four to five decades been in doubt. For some time, variable orifice-diameter. They are usually two or two beliefs supporting a congenital theory of origin

thiree in number, although larger numbers have were held: (a) remnants of the neural canal be- copyright. been described. They extend to the caudal end of came separated off and isolated, thus leading to a the anal cleft, superior to the posterior anal verge sinus tract; and (b) malfusion of the body halves beyond which they are not seen. They show no resulted in an ectodermal inclusion site. Supporters tendency to deviate from a strictly midline posi- of these theories demonstrated a space or canal tion. lying between the and skin, constant in The first clinical report of a pilonidal sinus is small embryos (Mallory, 1892) and variable in reputed to have been in 1847 (Dwight & Maloy, foetuses (Kooistra, 1942), which normally dis- 1953), but Hodge in 1880 is accepted as giving the appeared at birth. A skin dimple, at times deep http://pmj.bmj.com/ lesion its name 'pilonidal'. enough to be called the 'cisterna' of a sinus is said to be present in 150% of newly born infants. This Incidence dimple usually disappears soon afterwards, but There is no real age range, although sinuses are may persist into adult life in less than 30 of usually seen in adolescence and early adulthood. people. There seems, however, to be no direct Patients in the seventh decade have required treat- relationship between these developmental dimples ment for the first time, and Lewin (1965) has and sinus. Nor are other pilonidal anomalies such on September 25, 2021 by guest. Protected reported thirty-eight occurrences in children under as epithelial downgrowths and persistent neuren- the age of 1 year. Twenty-three of these infants teric canal remnants, or vestigial secondary sex were males and fifteen females. The incidence, glands such as the bird's preen gland, of any normally two male to one female, may vary by as aetiological significance. In the last 20 years, an much as 10: 1. This latter figure is, however, acquired cause has been widely accepted. This was exceptional, and is accounted for by the 1939-45 stimulated by the finding and reporting of Patey war years. Hardaway (1961) reported that during & Scarff (1946) of pilonidal sinuses in barbers' the years 1942-45, 77,657 soldiers of the United hands seen in the interdigital clefts. Also about States Army with pilonidal lesions were treated. this time King (1946) wrote that hairs must be A further 9000 were observed to have lesions important causative agents as the hairs found in which did not require treatment. sinuses had their roots nearest the sinus opening. The intergluteal cleft is not the sole site of Later Weale (1955) in a histological study of the these lesions as was once thought. Hodge in 1880 hairs in pilonidal sinuses suggested that as the roots reported that the removal of hairs from the skin of these hairs were deeply sited in the tissues, they of the feet was practised in those days. Pilonidal must be developmentally present in the sinus. He sinuises in the interdigital clefts of the hands of regards the barber's hand sinus as an implantation Postgrad Med J: first published as 10.1136/pgmj.43.499.353 on 1 May 1967. Downloaded from

354 B. P. Flannery and H. A. Kidd dermoid. Patey & Scarff contested this idea, lining in eight. The hairs may be found either in and offered the explanation that the cuticular the sinus or extruding from the pit mouth. surface arrangement of hair scales was such Occasionally also a hair may be seen looped over as to drive hair, root first, into the skin. About or inverted, entering a pit mouth. They lie in the same time, Brearly (1955, 1959) intro- bundles with their axes in the line of the raphe. duced a puncture and suction theory, illustrated In colour they are usually dark or brunette, with by manometric tracings of pressure variations in a barbed feel as if the normal scale arrangement the gluteal cleft area. He displayed this, introducing had been exaggerated. Ginger hairs have also a needle connected to a capacitance manometer been described and blonde hairs are seen in into the subcutaneous tissues of the intergluteal Scandinavians. cleft. He pointed out that any force withdrawing skin laterally across the puts tension on Symptomatology the fascial bands between deep fascia and skin. Most patients complain of either a sinus dis- This is enhanced by gluteal muscle contraction. It charge or of a painful swelling. This latter may also occurs with stretching of buttock skin as resolve to reappear later on after the fashion of a induced by flexing the thighs and vibrating the so-called blind . Sinus discharge is usually lower limbs. These movements are seen in motor- secondary to a bout of infection, and may be cycle pillion riders and drummers of dance bands. accompanied by a crop of small follicular pustules. As the result of pressure variations set up by the These may also be secondary to the sinus dis- factors mentioned above, a suction effect occurs charge, but commonly are the result of irritation and hairs tend to puncture the skin and proceed and infection produced by strapping of the zinc by suction to a deeper location carrying epithelium oxide type to which some skins are sensitive. with them. Palmer (1959) offered a theory as to Cleansing with suitable agents, methylated spirit how hairs gain entry to a sinus. At puberty there is or cetavlon, etc., and avoidance of strapping heals a natural enlargement of the buttock and gluteal the condition. The discharge from a sinus fluctuates muscles. He believes that, at this time, there is a and to a degree is dependent on the quantity of copyright. lateral stretch directed away from the midline on infected epithelium contained within the tracts. each side of the raphe. As a result of these forces, Not infrequently the sinus dries up and may stay a spread or stretching of normal skin orifices healed without the need for further treatment. occurs, thereby permitting the entrance and pack- More usually it recurs, and it seems that chemo- ing of hair. therapy has no effect on the closure rates of these sinuses. More rarely patients will complain of Pathology bleeding, and this is often due to scratching. At Epithelial cells and hairs form the pilonidal other times the patient complains of discomfort http://pmj.bmj.com/ sinus. There is, however, no sure evidence of the when sitting. depth to which epithelium is present in these It is perhaps salutary to remember that pilonidal lesions. Usually granulation tissue is seen to form sinuses are found by accident in patients who have the deeper aspect of the sinus tract. In some cases had no symptoms from them, and who may have epithelium does not extend beyond 1-2 mm from been totally unaware of their presence. In such the surface. It is doubtful whether this is due to cases treatment is not justified. epithelial halt or to whether there is destruction on September 25, 2021 by guest. Protected of deeper epithelium and replacement by granula- Treatment tion tissue. It is possible that if skin pitting occurs Prophylactic. There are no measures that will from muscle stretch, then the microscopic opening with certainty prevent pilonidal formation, but the of surface pits might be compensated by an incidence of recurrent infection can be lowered by epithelial downgrowth, preceding the entry, by adherence to the following hygienic measures: (a) drilling action, of hairs. Subsequent infection of hairy patients would be wise, particularly in warm epithelium and foreign body irritation of hairs and moist conditions, to shave frequently the inter- would lead to granulation tissue production. gluteal area, perhaps every 4-5 days; (b) all hairs Kooistra (1942) took multiple sections of sinuses round sinus openings to be removed, either by and found no evidence of epithelial lining in 39% shaving or scrubbing or with epilation creams; of cases. Hair follicles are of doubtful occurrence (c) careful anal toilet; (d) soap and water, or and some think they never occur. Kooistra, how- detergent cleansing of the intergluteal area with ever, reported a 9% incidence. Palmer found hairs thorough drying; (e) in certain exceptional cir- present in 50% and squamous epithelium in 30% cumstances, the avoidance of occupational hazards, of ninety-six cases. Patey & Scarff demonstrated e.g. driving for prolonged periods; and (f) radia- hairs in ten of twenty-one cases and epithelial tion epilation, although this is of limited value. Postgrad Med J: first published as 10.1136/pgmj.43.499.353 on 1 May 1967. Downloaded from

Pilonidal sinus lesions 355

Curative. The primary aim of treatment is to disposing of the lesion without disturbing . eradicate the lesion in the simplest and most effec- In a series of 359 cases using this technique, in the tive way. This implies minimal interference with majority of them Lawrence & Baker (1951) laid local anatomy and function. Many ways of treating open the sinus in its full length with an incision as this condition have been described, as briefly out- midline as possible. Other lateral sinuses or tracts lined below. were treated similarly. All infected chronic granu- (i) Simple incision. This is usually reserved for lation tissue and hair nests were curetted away; the acute infective swelling, on one or other side any lateral pockets were laid open and the sinus of the median raphe, and more usually superior lining curetted down to its base of scar tissue. than inferior to it. Recurrence is the rule, however, Overhanging skin edges were conservatively ex- as these lesions are not simple pyogenic . cised. These were then sutured to the lateral mar- Unless relief of pain is urgent, it is better to treat gins of the scar tissue sinus bed and to any these infections as a blind boil with local applica- epithelial islets (Shaner, 1957), which in the tions. Incision may otherwise be followed by a course of healing becomes covered over with persistently discharging sinus, unless drainage is epithelium. Overall healing time is 6 weeks. effected via a mid-line sinus opening. (vi) Rotation flaps and skin grafting are of use (ii) Simple laying open. This implies a mid-line in the cases where multiple sinuses and lateral incision, through the mouths of the pits and is tracts in recurrent cases are widely excised, leaving effective in those cases of so-called raphe cannuli- a median area too large to suture. zation where infection spreads from pit to pit. Estlander flaps were popularized by Davies & (iii) Open packing. In some instances elliptical Starr (1945), who on the concept that the median excision of the lesion is done and the resulting sacral groove is virtually avascular decried closure space is packed to encourage granulations to form. by suture after primary excision. Whilst there is These are eventually covered with epithelium, the little general use or need for this operation there healing process on average taking 86 days are circumstances where it is practical to use it. (Berkowitz, 1949). (vii) Phenol injection is a method described by copyright. (iv) Partial closure. After excision, a partial Maurice & Greenwood (1964), whose intention was primary suture of the skin and underlying tissue is primarily to inject the sinuses with phenol as a performed, but all tension should be avoided. On prelude to laying them open. However, a trial average these wounds take 50 days to heal com- series of cases with phenol injection alone was pletely (Korb, 1951). This time may be shortened undertaken. Basically- it entailed the injection of by applying split skin grafts at the time of suture phenol without pressure (which is of obvious im- or a few days afterwards if no signs of tension portance) into the main sinus tract. The surround- necrosis develop. This type of skin graft, however, ing skin is first protected with heavy layering of http://pmj.bmj.com/ does not wear well in the face of the stresses and petroleum jelly. Residual phenol is expressed from stretch to which the anatomical part is subject. the sinus tracts and swabbed away, the procedures (v) Primary excision and closure has been being repeated twice to permit of an overall advocated and condemned with equal enthusiasm. phenol-tissue contact time of 3 min. Reported results vary from 94-5% success (Old- (viii) Diathermy coagulation is the method pre- ham, 1945, 1950) to 100% failure (Rogers & Hall, sented by Jacobsen (1959) and allows the objective

1935) in recurrent cases. Brearly (1955) reiterates of destroying the lesion to be carried out with the on September 25, 2021 by guest. Protected and stresses the basic principles on which success least possible tissue sacrifice, interference with the depends: (i) the elimination of dead space which sacro-coccygeal fascia or with the intergluteal would fill with haematoma or serous collections, depression. For practical purposes, he divides the (ii) the avoidance of infection, and (iii) the prob- lesion into three categories; those with a distal lem of later hair intrusion. aperture, those with a series of pin-point openings, Adequate closure depends on the above factors, and the remainder having one or more draining and may be effected by the method of Oldham or sinuses. Recurrent sinuses are included in the latter. by the use of buried catgut figure-of-eight sutures Whilst he uses low spinal or saddle block anaes- (Rains, 1959) or by through and through occlusive thesia, and in some cases local block, our patients sutures. have been anaesthetized and intubated, lying face Analysis of the various methods of suturing in- down with chest and thighs supported on pillows. dicate variable success rates (Wenger, 1950; Kleiman, As the sinuses are usually associated with in- 1950), although since 1953 there has been a trend feriorly placed pits, one of these, or the distal away from block excision (Swinton & Contreras, aperture, is used to insert the diathermy electrode; 1952) towards limited resection and marsupializa- they may need dilation with a probe. Jacobsen tion, which has been regarded as the simplest way of uses a bipolar uterine cervical coagulator, but we Postgrad Med J: first published as 10.1136/pgmj.43.499.353 on 1 May 1967. Downloaded from

356 B. P. Flannerv and H. A. Kidd ::::....*~~~~~~~~~~~~~~~~~~......

FIG. 1. Note midline sinus orifice. copyright.

FIG. 3. Note rubber sheath about the needle and steam raising the orifice edge prior to escape. http://pmj.bmj.com/

have used a diathermy point which is passed into the pits and separated from the insulated handle by a small core of rubber tubing. This seals off the .V orifices. The coagulation current is operated with a foot switch and maintained for about 4-6 sec on September 25, 2021 by guest. Protected : until the tissues blow up with an effervescent bubbling around the electrode, indicating the escape of steam. Then the skin over the area is divided with the cutting current 05 cm beyond both ends to make a saucerized depression. By the agency of this heat, the sinus epithelium is des- troyed and intra- and extracellular water converted into steam which sterilizes and destroys where it goes. Cell destruction beyond the sinus and any communicating tract is limited by the insulating barrier of the coagulated epithelium. When a series of pin-point openings is the only indication of the disease, the skin is divided through these openings down to the deep fascia; the tracts are so small that the narrow diathermy instrument destroys FIG. 2. To illustrate diathermy point within sinus tract. them in its path. When sinuses are present, they Postgrad Med J: first published as 10.1136/pgmj.43.499.353 on 1 May 1967. Downloaded from

Pilonidal sinus lesions 357 are treated in the same way with the diathermy The operative methods used have been: unit and cutting instruments. For recurrent sinuses, diathermy is not used as there should be no Operation No. of cases epithelium to destroy. Probes are passed into the Diathermy 62 sinuses and then they are laid open with the scalpel Excision and primary closure 30 blade. The pre-sacral fascia is exposed in the Excision and closure with single or midline for a width of nearly a quarter of an inch double Estland flaps 6 and epithelialization retarded by rolling the skin Delayed epithelialization by skin edge edges into the subcutaneous tissues and holding it inversion 6 there with nylon sutures attached to buttons. When infection has settled, the skin edges may be freed Follow-up has been by out-patient attendance for and epithelialization encouraged. a minimum of 2 years and a maximum of 9 years As a result of the diathermy current the sinus is since operation. The overall recurrence rate has converted into a burn and it is treated as such, with been 19%. Of the sixty-two cases treated with the object of separating off the slough and pro- diathermy, six, or 9-6%, have recurred. moting a clean surface for epithelium to grow over. Summary Post-operative care is very imnportant. Whilst Pilonidal sinus is a common complaint occurring Jacobsen does his first post-operative dressing after in the young. Although mortality and morbidity the patient has left hospital, we have kept our are minimal, economic effects by reason of lost work patients for 10-14 days, until a clean granuation hours are significant. wound is well evident. Patients are encouraged to Most cases are explained on an acquired basis have daily baths and to scrub lightly the surround- of aetiology, although occasionally it is difficult to ing skin with a brush to remove hairs. At all out- exclude a developmental association. most cases are seen in the intergluteal patient attendances the healing epithelium is care- Whilst copyright. fully observed (with a glass if need be) for midline cleft other sites of origin have been mentioned. cracks wherein hairs may come to lie. The cracks The treatment by diathermy, after the method of are often associated with bridging, the epithelium Jacobsen, was employed in sixty-two cases with a growing faster than the granulation tissue beneath recurrence on a 2-9 year follow-up of six cases. can fill up the hiatus. By dividing the epithelium in The importance of post-operative care is stressed. the line of the crack, it thus falls down onto the underlying tissue preserving the depth of the sacro- References coccygeal depression. AIRD, I. (1952) Pilonidal sinus of axilla. Brit. med. J. i, 901. http://pmj.bmj.com/ ARONS, M.S., LYNCH, J.B., LEWIS, S.R. & BLOCKER, T.G. Malignant change has been recorded in cases (1965) Scar tissue carcinoma. Ann. Surg. 161, 170. of all long-standing sinuses, fistulae, scars, burns, BERKOWITZ, J. (1949) Sacrococcygeal pilonidal . Amer. ulcers and osteomyelitis (Arons et al., 1965). These J. Surg. 77, 477. authors illustrated a case of squamous carcinoma BREARLY, R. (1955) Pilonidal sinus. A new theory of origin. Brit. J. Surg. 43, 62. occurring in a 32-year-old white patient with a CLEVELAND, B.P. & GREEN, W.O. (1964) Squamous cell 7-year history of pilonidal sinus. This is excep- carcinoma arising in a pilonidal sinus. Surgery, 55, 381. DAVIES, L.S. & STARR, K. (1945) Infected pilondial sinus. tional. Cleveland and Green (1964) have reported on September 25, 2021 by guest. Protected thirteen cases found in American and overseas Surg. Gynec. Obstet. 81, 309. DWIGHT, R.W. & MALOY, J.K. (1953) Pilonidal sinus: publications. It is of interest that in all but two of experience with 449 cases. New Engi. J. Med. 249, 926. these patients the history lay between 15 and 43 HARDAWAY, R. (1961) Pilonidal cyst - mis-named, mis- years, and that the age of onset of the malignancy understood and mis-treated. J. med. Ass. Georgia, 50, 51. was between the and seventh decades. Though HODGE, A.M. (1880) Pilonidal sinus. Boston Med. Surg. J. fifth 103, 465. nearly all these thirteen subjects have had some JACOBSEN, P. (1959) : management without surgical procedure, ultimate recurrence was the excision. Amer. Acad. G.P. xix, No. 3. rule. KING, E.S. (1946) The nature of the pilonidal sinus. Aust. N. Z. J. Surg. 16, 182. Since 1953, 104 cases have been treated on our KLEIMAN, A. (1950) Pilonidal cyst: comparison of surgical surgical firm at St Helier Hospital. They have treatment. Surgery, 28, 851. fallen into the following category: KooISTRA, H.P. (1942) Pilonidal sinuses: review of literature and reports of 350 cases. Amer. J. Surg. 55, 3. KORB, J.H. (1951) Infected pilonidal : a simplified No. of cases Previously treated Primary cases method of treatment. Military Surgeon, 108, 29. 104 Once 15 80 LAWRENCE, K.B. & BAKER, W.J. (1951) The marsupialisation operation for pilonidal sinus. New Engi. J. Med. 245, 134. Twice 6 LEWIN, R.A. (1965) Pilonidal sinus in infancy. Paediatrics, Thrice 3 35, 796. Postgrad Med J: first published as 10.1136/pgmj.43.499.353 on 1 May 1967. Downloaded from

358 B. P. Flannery and H. A. Kidd

MALLORY, F.B. (1892) Sacrococcygeal dimples, sinuses and ROGERS, H. & HALL, M.G. (1935) Pilonidal sinus: surgical cysts. Amer. J. med. Sci. 103, 263. treatment and pathologic structure. Arch. Surg. 31, 742. MAURICE, B.A. & GREENWOOD, R.K. (1964) A conservative SHANER, W. (1957) Treatment of pilonidal disease by treatment of pilonidal sinus. Brit. J. Surg. 51, 510. marsupialisation. Winconsin med. J. 56(6), 281. OLDHAM, J.B. (1945) Sacrococcygeal (pilonidal) sinus. SHOESMITH, J.H. (1953) Pilonidal sinus in an above knee Med. Press, 214, 248. amputation stump. Lancet, ii, 378. OLDHAM, J.B. (1950) Pilonidal sinus. Brit. Surg. Pract. 7, SMITH, T.E. (1948) Anterior or perineal pilonidal sinus. 417. J. Amer. med. Ass. 136, 973. PALMER, W.H. (1959) Pilonidal disease: a new concept of pathogenesis. Diseases of the Colon and , Vol. 2, STECK, W.D. & HELWIG, E.B. (1965) Umbilical granulomas, p. 303. Philadelphia. pilonidal disease and the urachus. Surg. Gynec. Obstet. PATEY, D.H. & SCARF, R.S. (1946) Pathology of post-anal 120, 1043. pilonidal sinus. Its bearing on treatment. Lancet, ii, 484. SWINTON, N.W. & CONTRERAS, 0. (1952) Pilonidal sinus. PATEY, D.H. & SCARF, R.S. (1948) Pilonidal sinus in barber's Proc. Roy. Soc. Med. Suppl. 107, 110. hand with observations on post-anal pilonidal sinus. TERRY, J.L., GAINSFORD, J.C. & HANNA, D.C. (1961) Lancet, ii, 13. Pilonidal sinus carcinoma. Amer. J. Surg. 102, 465. PATEY, D.H. & SCARF, R.S. (1955) The hair of the pilonidal WEALE, F.E. (1955) A comparison of barber's and post-anal sinus (Letter to the Editor). Lancet, i, 772. pilonidal sinuses. Lancet, i, 230. RAINs, A.J. (1959) Treatment of pilonidal sinus by excision WENGER, D.S. (1950) Pilonidal cysts: their origin and and primary closure. Brit. med. J. ii, 171. treatment. Amer. J. Surg. 80, 243. copyright. http://pmj.bmj.com/ on September 25, 2021 by guest. Protected