Pilonidal sinus

from Wikipedia, the free encyclopedia
Classification according to ICD-10
L05 Pilonidal cyst
L05.0 Pilonidal cyst with abscess
L05.9 Pilonidal cyst without abscess
ICD-10 online (WHO version 2019)
This article or the following section is not adequately provided with supporting documents ( e.g. individual evidence ). Information without sufficient evidence could be removed soon. Please help Wikipedia by researching the information and including good evidence.

The pilonidal sinus (from Latin pilus 'hair' and nidus 'nest') is a chronic inflammatory disease of the gluteal folds ( rima ani ). Synonyms for the disease are coccyx fistula , pilonidal cyst or sacral dermoid . It is widely believed that the disease is caused by hair penetrating the skin. Other opinions assume a congenital (congenital) malformation. Trauma (caused by falls, for example) are also discussed as a possible cause. The S3 guideline of the AWMF and its corresponding publications offer the best overview of this clinical picture.

Epidemiology

The pilonidal sinus is a disease mainly of young men in which hair can be detected in the soft tissue covering over the sacrum . The subsequent inflammatory and foreign body reaction leads to the formation of ducts with scarred duct walls, which then epithelialize secondarily - from the skin surface downwards. Once epithelialized, the fistula duct only rarely recedes. In the depths of the presacral soft tissue there is an additional cavity in 10–20%, in which there is a ball of hair - the hair nest that gives the disease its name. Corridors and hair nests maintain a chronic inflammatory response that can exacerbate acutely. The disease can only be treated surgically.

First mentioned in writing by Herbert Mayo in 1833, AW Anderson reported in his publication “Hair extracted from an ulcer” in 1847 for the first time about a hair finding in an ulcer “on the back” of a 21-year-old forest worker [Mayo 1833, Anderson 1847]. Injections of silver nitrate and mercuric chloride in the fistula brought no cure, and the incision of the pressure painful paramedian cooker did not lead to a cessation of Pussekretion - until it from the depths of the wound away a tuft of hair. The finding healed within the next three weeks. It was Hodges in 1880 who coined the concept of the hair nest - pilonidal sinus (from Latin pilus = hair; nidus = nest), and thus gave this widespread disease a name [Hodges 1880].

The estimated annual incidence in Europe and North America is 26 per 100,000 people; The incidence is highest in the Mediterranean countries, while the disease is almost unknown in Africa and Asia. Thick, straight hair encourages the formation of the pilonidal sinus, while soft, curly hair prevents it. Since men are 4 to 12 times more likely to be affected than women and the age peak is between 16 and 26 years of age, the disease is a not inconsiderable health problem even for young recruits. Due to the increased occurrence of US soldiers in World War II , the disease was also called Jeep's disease or Jeep driver's disease or Jeep rider's disease in the English-speaking world . It has now been shown that driving a car or allegedly poor hygiene are not responsible for the disease.

In hairdressers , the clinical picture can also appear between the fingers (interdigital) and is caused by cut hair that has penetrated, which is why the disease is also referred to as "inter- finger hair pocket disease" or "hairdresser's disease". Dog groomers and sheep shearers can also be affected.

In the case of Bundeswehr soldiers , the incidence increased between 1986 and 2006 from 50 / 100,000 to 260 / 100,000; a comparable increase can also be found in the civilian population. At the same time, the age of onset continues to decrease. The causes are unclear.

Opening of the fistula or "porus" (arrow)

causes

There are two theses about the cause:

Congenital pilonidal cyst

Up until the middle of the 20th century, it was wrongly assumed that the pilonidal sinus was congenital, since it can only be found in the midline. The hair nest, it was postulated, was formed during a faulty ectoderm closure over the neural tube by dispersing hair follicles into the subcutaneous tissue [Fox 1935]. A neuropore (an opening at the end of a neural tube or nerve tube) could also have been preserved, which creates a connection to the tip of the coccyx, anal edge, perineum or sacral skin [Gage 1935; Kooistra 1942]. Alternatively, an embryological vestigial gland (similar to the sebum gland located on the back of birds near the tail) is the cause [Tourneux 1887].

In fact, in rare cases, the pilonidal sinus can be visualized in utero on ultrasound [Efrat 2001; Zimmer 1996] and also be linked to regression disorders such as the so-called faun tail [Laurent 1998]. Congenital sinuses are associated with an increased incidence of congenital anomalies of the spinal cord and spinal canal [Avni 1991; Goldberg 1978]. It is also known that high phenytoin levels during pregnancy can cause pilonidal sinus formation in newborns [Yang 1978]. The ectodermal theory of the disintegrated skin appendages is supported by the fact that pilonidal sinuses only occur strictly in the midline of the posterior sweat trough - the fusion line of the dorsal raphe. Another argument in favor of a genetic predisposition is the fact that a familial accumulation of the pilonidal sinus can be observed [Akinci 1999]. Nevertheless, the inflamed pilonidal sinus that occurs in prepubertal age [Chamberlain 1974] is a rarity; if it does, it occurs 4.5 times more often in girls than in boys [Gollady 1990].

What speaks against the theory of the neuropore is that meningitis as a result of pilonidal sinus disease is rarely reported [Brook 1985; Forgrave 1951]. What speaks against the theory of the scattered ectoderm is that no additional skin appendages such as sebum glands, follicles or sweat glands can be shown in the ducts or the hair nest of the pilonidal sinus [Dahl 1992; Stelzner 1984]. Nor do the congenital theories explain why the disease occurs more frequently during puberty and why it occurs more frequently in men [Akinci 1999]; why patients with a steeper gluteal cleft [Akinci 2009] and a thicker presacral fat pad [Balik 2006] tend to develop sinuses.

Acquired pilonidal sine

The acquired pilonidal sinus is far more common than the extremely rare congenital form. There are two theories about the origin of the acquired sinus: It used to be assumed that the pilonidal sinus arises as a result of a hair formation disorder in which the keratin formed by the hair root is not built up into a hair in an orderly manner, but as a clod-shaped keratin initially the starting point of a foreign body granuloma ( the encapsulation of the material) and in a second step through infection with the normal bacteria the skin becomes a purulent inflammation (abscess) (folliculitis plug theory). However, this does not explain why a pilonidal sinus could develop in intergluteally hairless women. Today, however, there is increasing evidence that the pilonidal sinus can occur through the penetration of cut hair fragments through the intact epidermis . In this case, up to 400 short, sharp hair fragments are found in the fistula duct or the abscess cavity [Bosche 2017]. In quite a few cases, these cut hairs come from the back of the head, as forensic and statistical methods have shown [Doll 2018]. These cut hairs can be detected immediately after the haircut in the rear sweat trough up to the lumbar region. Frequent short haircuts of dry hair and shaving the neck, back and buttocks increase the number of sharp hair fragments and increase the rate of recurrence after surgery. This mechanism could also explain why pilonidal sinus - in addition to the presence of young men with a corresponding disposition to illness - is observed more frequently in the military.

Stages

Bland shape

The bland (mild) form is the weakest form. She shows no signs of inflammation. In the rima ani (gluteal fold) there are only a few small fistula openings, which are called “porus” in German and “pit” in English. Underneath there is a subcutaneous cavity (sinus) that is surrounded by granulation tissue .

Acute abscess form

The rubbing of the buttocks against each other causes hair to be impaled into the skin, especially when the hair is thick. These already act as foreign bodies per se and also form a lead structure for germs that regularly occur in large numbers in this region. If there is also profuse sweating, there is an optimal, humid and warm environment for bacteria. The consequences are severe inflammation and pus formation. Tight (apple-shaped) buttocks and overweight are considered unfavorable factors.

Chronic fistulous course

There are no acute signs of inflammation, but permanent secretion (fistula secretion) in the form of pus or wound secretion or bloody fluid. There is no itching, the underwear is smeared with pus or blood. The coccyx fistula can become inflamed to the size of a fist within a few days, causing a sharp pain.

Diagnosis

The diagnosis is relatively easy due to the medical history and description of the symptoms. A simple examination in the coccyx is sufficient. Both complaints in the chronic stage (pain, secretion) as well as abscesses occurring as complications justify the need for therapy. Typical and diagnostic findings are small fistula openings and / or painful swellings in the gluteal fold or on the tailbone, which make sitting difficult.

therapy

Operating table with excessively large cut out skin area
Wound after removal of the pilonidal sinus

surgery

Primary wound closure with drainage

Surgical excision has so far been recognized as the only promising therapy for chronic pilonidal sinus . In the classic operation , the fistula is usually colored with methylene blue in order to excise the entire affected tissue over a large area. In order to avoid a relapse , the fistula system is stained with methylene blue and, if possible, not cut out to the periosteum of the coccyx or then scraped off, as lengthy wound healing disorders are to be expected here. The point of this radicalism has never been proven. The operation is usually performed under anesthesia , in less severe cases (small, not yet inflamed fistula system) also under local anesthesia . A hospital stay of three to four days may be necessary. However, these operations are increasingly being carried out on an outpatient basis.

If an open wound treatment (secondary wound healing) is carried out after the excision , the patient will be ill for a long time, depending on the size of the findings up to several months. The vacuum therapy is a method to speed up a secondary intent, the costs are not taken for the outpatient sector in general by state health insurance. One advantage of open wound treatment is the lower rate of recurrences compared to primary wound closure .

A faster recovery is sought by the primary closure (suturing) of the wound cavity. Due to the infectious genesis of the disease and the anatomically unfavorable position of the wound with symmetrical excision and wound closure in the midline, wound healing disorders are common; they occur in up to 40% of patients. Another problem is the high recurrence rate of up to 20% within three years.

On the basis of pathophysiological considerations and taking into account the special anatomical conditions, G. Karydakis has developed and applied an alternative surgical procedure since the late 1960s, the core element of which is the asymmetrical excision of the sinus, so that the resulting wound lies outside the midline. He thus achieved a recurrence rate of only 1%. Several variants of this surgical method through to complex flaps ( Limberg flaps ) have been developed. The main goal of all these methods is to shift the wound or scar from the midline in order to prevent wound healing disorders and recurrences. This enables faster wound healing to be achieved. Current studies show that the Karydakis flap is slightly superior to the Limberg flap method in terms of healing and patient satisfaction with comparable recurrence rates.

Minimally invasive surgical techniques

Also in the surgical technique ("pit-picking") published by Lord and Millar as early as 1964 and used by John Bascom , Eugene ( Oregon ), a basic principle is the avoidance of larger incisions in the midline. Here the starting points of the abscessing inflammation, the ingrown hair follicles ("pits"), are cut out in the middle line, the hair and granulation tissue are removed from the fistula down to the depths while protecting the surrounding tissue and, if necessary, the abscess cavity is also removed from a lateral incision. In this way, radical excision can usually be avoided, the tissue defect minimized and the healing time shortened considerably. This procedure was further developed by surgeons in Zurich and Munich. In the technique called "minimal tubular excision" or "sinusectomy", the entire fistula duct is selectively removed via the small pit-picking accesses. This combines the advantages of small wounds with the completeness of removal. The addition of pit-picking by laser ablation of the inflammatory tissue with the aid of a radially radiating glass fiber probe (comparable to the FiLaC technique for anal fistula) seems to improve the long-term healing rates of pit-picking.

prophylaxis

It has proven effective to remove the hair in the anogenital region by means of laser epilation. Normal depilation is not enough as the hair is not completely removed. Postoperatively, the area should be kept hair-free and consistently shaved.

The recommendation for postoperative hair removal through shave depilation, such as the blade shave, is controversial today. A study by the German Armed Forces came to the conclusion that patients who had consistently shaved their blades had a higher pilonidal sinus recurrence rate than patients who did not shave. According to a telephone follow-up interview, the patients who did not shave had a recurrence rate of 19.7% (77/391). Those who followed the recommendation to shave had a recurrence rate of 30.1% (34/113).

Postoperative laser hair removal is seen as a promising measure to reduce the recurrence rate. More recent meta-analyzes suggest that the recurrence rate is likely to decrease; further studies are necessary.

See also

literature

  • JU Bascom: Procedures for Pilonidal Disease. In: Rob & Smiths Operative Surgery. Surgery of the Colon, Rectum and Anus. 5th edition. Chapman & Hall, London / Glasgow / New York / Melbourne 1994
  • J. Bascom: Long-term Results of Follicle Removal. In: Dis Colon Rectum. 1983, 26, 12, pp. 800-807.
  • AM Downs, J. Palmer: Laser hair removal for recurrent pilonidal sinus disease. In: J Cosmet Laser Ther. Volume 4, 2002, p. 91.
  • A. Hegele et al .: Reconstructive surgical therapy of infected pilonidal sinus. In: surgeon. Volume 74, 2003, pp. 749-752.
  • RU Hodges: Pilonidal sinus. In: Boston Med Surg J. Volume 103, 1880, p. 485.
  • S. Matsushita et al .: A case of squamous cell carcinoma arising in a pilonidal sinus. In: The Journal of Dermatology . Volume 29, 2002, pp. 757-758.
  • IJ McCallum et al .: Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis . In: BMJ. 336, 2008, pp. 868-871.
  • K. Sondenaa et al .: Influence of failure of primary wound healing on subsequent recurrence of pilonidal sinus. Combined prospective study and randomized controlled trial. In: Eur J Surg . Volume 168, 2002, pp. 614-618.
  • M. Testini et al .: Treatment of chronic pilonidal sinus with local anesthesia: a randomized trial of closed compared with open technique. In: Colorectal Disease . Volume 3, 2001, pp. 427-430.

Web links

Commons : Pilonidal Sinus  - Collection of images, videos and audio files

Individual evidence

  1. ↑ I. Iesalnieks, A. Ommer, S. Petersen, D. Doll, A. Herold: German national guideline on the management of pilonidal disease . In: Langenbeck's Archives of Surgery . tape 401 , no. 5 , 2016, ISSN  1435-2443 , p. 599-609 , doi : 10.1007 / s00423-016-1463-7 ( springer.com [accessed August 13, 2019]).
  2. ↑ A. Ommer, E. Berg, C. Breitkopf, D. Bussen, D. Doll: S3 guideline: Sinus pilonidalis: AWMF registration number: 081-009 . In: coloproctology . tape 36 , no. 4 , 2014, ISSN  0174-2442 , p. 272–322 , doi : 10.1007 / s00053-014-0467-4 ( springer.com [accessed August 13, 2019]).
  3. ↑ HD Dahl, MH Henrich: [Light and scanning electron microscopy study of the pathogenesis of pilonidal sinus and anal fistula] . In: Langenbeck's archive for surgery . tape 377 , no. 2 , 1992, ISSN  0023-8236 , pp. 118-124 , PMID 1583981 .
  4. ^ Friederike Bosche, Markus M. Luedi, Dominic van der Zypen, Philipp Moersdorf, Bjoern Krapohl: The Hair in the Sinus: Sharp-Ended Rootless Head Hair Fragments can be found in Large Amounts in Pilonidal Sinus Nests . In: World Journal of Surgery . tape 42 , no. 2 , February 2018, ISSN  1432-2323 , p. 567-573 , doi : 10.1007 / s00268-017-4093-5 , PMID 28639004 .
  5. ^ R. Favre, P. Delacroix: [APROPOS OF 1,110 CASES OF PILONIDAL DISEASE OF COCCY-PERINEAL LOCALIZATION] . In: Memoires. Academie De Chirurgie (France) . tape 90 , June 17, 1964, ISSN  0368-8291 , p. 669-676 , PMID 14179186 .
  6. ↑ Doll, D., Luedi, MM, Wieferich, K., van der Zypen, D., Maak, M., Glanemann, M .: Stop insulting the patient: neither incidence nor recurrence in pilonidal sinus disease is linked to personal hygiene . (No longer available online.) Pilonidal Sinus Journal, archived from the original on February 16, 2017 ; accessed on March 7, 2018 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.pilonidal.com.au
  7. ^ Theo Evers, Dietrich Doll, Edouard Matevossian, Sebastian Noe, Konrad Neumann: [Trends in incidence and long-term recurrence rate of pilonidal sinus disease and analysis of associated influencing factors] . In: Zhonghua Wai Ke Za Zhi [Chinese Journal of Surgery] . tape 49 , no. 9 , September 1, 2011, ISSN  0529-5815 , p. 799-803 , PMID 22177433 .
  8. ↑ Doll, D. Wilhelm, D. Ommer, A. Albers, K. Mordhorst, H. Iesalnieks, I. Vassiliu, P. Luedi, MM: Immediate cut hair translocation to the intergluteal fold in the hairdressers shop - another link to pilonidal sinus disease . Ed .: Pilonidal Sinus Journal. tape 5 , no. 1 . Pilonidal Sinus Journal, 2018, p. 23-32 .
  9. ↑ Sven Petersen, Kai Wietelmann, Theo Evers, Norbert Hüser, Edouard Matevossian: Long-Term Effects of Postoperative Razor epilation in pilonidal sinus disease: . In: Diseases of the Colon & Rectum . tape 52 , no. 1 , 2009, ISSN  0012-3706 , p. 131-134 , doi : 10.1007 / DCR.0b013e3181972505 ( ovid.com [accessed August 13, 2019]).
  10. ↑ Ömer Faruk Akıncı, Mikda: Incidence and Aetiological Factors in Pilonidal Sinus Among Turkish Soldiers . In: The European Journal of Surgery . tape 165 , no. 4 , April 19, 1999, ISSN  1102-4151 , p. 339–342 , doi : 10.1080 / 110241599750006875 ( tandf.co.uk [accessed August 13, 2019]).
  11. ↑ Igors Iesalnieks, Andreas Ommer: The management of pilonidal sinus . In: Deutsches Aerzteblatt Online . January 7, 2019, ISSN  1866-0452 , doi : 10.3238 / arztebl.2019.0012 ( aerzteblatt.de [accessed June 10, 2019]).
  12. ↑ Karydakis OP on coccyx fistula.info; accessed November 1, 2013.
  13. ↑ pilonidal sinus - The modified Karydakis operation . ( Memento of the original from November 3, 2013 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF; 67 kB) accessed November 1, 2013. @1@ 2Template: Webachiv / IABot / www.pilonidal.org
  14. ↑ Short and long-term results of the Karydakis flap versus the Limberg flap for treating pilonidal sinus disease: a prospective randomized study. In: The American Journal of Surgery . 202 (5), Nov 2011, pp. 568-573. PMID 21788003 .
  15. ↑ Comparison of short-term results between the modified Karydakis flap and the modified Limberg flap in the management of pilonidal sinus disease: a randomized controlled study. In: Dis Colon Rectum . 56 (4), Apr 2013, pp. 491-498. PMID 23478617 .
  16. ↑ Lord, Peter and Millar, Douglas: Pilonidal Sinus. A simple treatment. In: Brit J Surg . tape 52 , no. 4 . London 1964.
  17. ↑ Pit-Picking-OP by J. Bascom on Steissbeinfistel.info; accessed November 1, 2013.
  18. ↑ European Pilonidal Center Dr. Bernhard Hofer - microsurgery. (No longer available online.) In: pilonidalcenter.eu. Archived from the original on September 22, 2016 ; accessed on September 22, 2016 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / pilonidalcenter.eu
  19. ↑ DANIEL DINDO, DANIEL STEINEMANN AND DIETER HAHNLOSER: New developments in proctology. (PDF) (No longer available online.) Archived from the original on September 22, 2016 ; accessed on September 22, 2016 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.notes-chirurgie.ch
  20. ↑ S. Petersen, K. Wietelmann, T. Evers, N. Hüser, E. Matevossian, D. Doll: Long-term effects of postoperative razor epilation in pilonidal sinus disease. January 2009.
  21. ^ AA Pronk, L. Eppink, N. Smakman, EJB Furnee: The effect of hair removal after surgery for sacrococcygeal pilonidal sinus disease: a systematic review of the literature . In: Techniques in Coloproctology . tape 22 , no. 1 , November 28, 2017, ISSN  1123-6337 , p. 7-14 , doi : 10.1007 / s10151-017-1722-9 .
  22. ↑ A. Ommer, D. Doll, A. Herold, S. Petersen, B. Strittmatter, I. Iesalnieks: S3 guideline - Sinus pilonidalis . 2014.