pns

1. Classificatio
n
• 3 categories that represent different
stages of the clinical course
– (1) acute pilonidal abscess,
– (2) chronic pilonidal disease, and
– (3) complex or recurrent pilonidal disease.
• Ideal treatment varies according to the
clinical presentation/category of the
disease

2. Epidemiolog
y
WORLDWIDE INCIDENCE
7 per 10000 population
Gender
Predisposition
Adult M:F ( 3-4 :
1)
Children  M:F (1 : 4)
RACE

3. Epidemiolog
y AGE*
typically in the late teens to early
twenties, decreasing after age 25 and
rarely occurs after age 40
average age of presentation 21 years(male) and 19
years(female) **
*it occurs after puberty, when sex hormones are known to affect
the
pilosebaceous gland and change healthy body hair growth
**due to the fact that puberty occurs earlier in females

4. Pathophysiolo
gy
SAME AS FOR ACNE VULGARIS/HIDRADENITIS
SUPPURATIVA
• Sex hormones affect the pilosebaceous glands after onset of puberty
– Hair follicle becomes distended with keratin.
– Resulting in folliculitis, leading to edema and follicle occlusion.
– Infected follicle extends and ruptures into the subcutaneous tissue,
forming a pilonidal abscess.
• resulting in a sinus tract leading to a deep, subcutaneous cavity.
• Direction of the sinus tract is cephalad(90%),
– coincides with the directional growth of the hair follicle.
– Places the tracking follicle approximately 5-8 cm from the anus.
ACNE/FOLLICULAR OCCLUSION TETRAD = hidradenitis suppurativa, acne
conglobata, dissecting

5. Pathophysiolo
gy
– In the rarer instance that the sinus is located caudally, it is
usually found 4-5 cm from the anus.
– The laterally communicating sinus overlying the sacrum is
created as the pilonidal abscess spontaneously drains to
the skin surface.
– The original sinus tract from the natal (intergluteal) cleft
becomes an epithelialized tube.
– The laterally draining tract becomes a granulating sinus tract
opening

6. Pathophysiolo
gy
Buttock
friction
+ shearing
forces in
natal cleft
Allows shed
hair or
broken hairs
collected in
natal cleft
To DRILL
through
midline skin
1st MECHANISM

7. Pathophysiolo
gy
Infection in
relation to
hair follicle
+ suction
created by
buttocks
movement
s
Allows hair
to enter
skin
2nd MECHANISM

8. Pathophysiolo
gy
Both mentioned mechanism
Create a subcutaneous, chronically
infected, midline track (PRIMARY
SINUS)
SECONDARY TRACKS may spread
laterally from primary sinus
Emerge at skin as granulation tissue
lined discharging openings

9. Pathophysiolo
gy
• Microscopically, the sinus tract where the hair enters is lined with
stratified squamous epithelium with slight cornification (itself soft)
– Additional sinuses are frequent.
– sinus tract openings are actually an extension of the deep cavity
• Cyst/sinus cavities are lined with chronic granulation tissue and may
contain hair, epithelial debris, and young granulation tissue.
– Cutaneous appendages are not seen in the wall of cysts.
– Cellular infiltration consists of PMNs, lymphocytes, and plasma cells in
varying proportions.
– Foreign body giant cells in association with dead hairs are a frequent
finding.
• Hair enters tip first, and the barbs on the hair prevent it from
being expelled, causing the hair to become entrapped.
– Physical examination occasionally may reveal a tuft of hair emerging
from the midline opening in the natal cleft.

10. Pathophysiolo
gy
3 pieces are instrumental in this
process:
(1) the invader, hair;
(2)the force, causing hair penetration;
and
(3)the vulnerability of the skin.
This process has been well characterized by Patey and
Scarff as well as a number of other authors from the
second half of the 20th century through today

11. Pathophysiolo
gyMICROBIOLOGY
most commonly reported bacteria cultured from
pilonidal abscesses differ by author
• In one study, anaerobic cocci were present 77% of the
time; aerobic, 4%; and mixed aerobic and anaerobic,
17%.
• Other studies quote Staphylococcus aureus, an
aerobe, as being the most common bacterial
pathogen.

12. Clinical
Manifestation
• Most common presentation in the ER is a intermittent
painful (persistent, throbbing), swollen discharging
(serosanguinous/ purulent) lesion in the sacrococcygeal
region about 4-5 cm posterior to the anal orifice
– May be asymptomatic
• At times, spontaneous drainage may have occurred
prior to presentation to the clinician
• Occasionally, a history of trauma is recalled
• Patient may state that a similar lesion occurred in that area
before, for which the patient may have had a primary incision
and drainage or other definitive care prior to this
presentation.

13. Clinical
Presentation
• Given most patients are young and healthy, other
comorbidities are not common, and review of
systems is often negative, including fever and
chills.
• There is no known preponderance of this
disease in smokers or alcohol or drug abusers.
• Although usually found near the
coccyx/natal (intergluteal) cleft
/sacrococcygeal region
– Condition can also affect the umbilicus, web spaces of
hand, armpit or genital region (though rarer)

14. Clinical
Presentation
• Usually, the patient is afebrile and
nontoxic(minimum constitutional symptoms)
• Local examination may show a relatively unremarkable
sinus tract in the sacrococcygeal region
– Primary sinus having 1 or more openings
• All strictly in the midline, with tuft of hairs seen in opening of sinus
• Between level of sacrococcygeal joint and tip of coccyx
• or may have secondary lateral openings superior to the midline pit.
• Usually at ER presentation, the patient has typical findings of
an abscess, including redness, warmth, local tenderness, and
fluctuance with or without induration.

16. Differential
Diagnosis
• Anal Fistulas and
Fissures
• Hidradenitis
Suppurativa
• Perirectal Abscess
• Syphilis
• Tuberculosis
• Osteomyelitis of
Coccyx

17. Worku
p
• No specific laboratory studies or tests are
needed to diagnose pilonidal disease and its
sequelae or differentiate it from other disease
entities
– It is a clinical diagnosis best elicited by history and
physical examination findings.

18. Treatmen
t
• Conservative treatment
– INDICATION: patients whose
symptoms are relatively minor( and
without abscess)
• natural history of condition is usually one of
regression
– Cleaning out the tracks and removal of all
hair, with regular shaving of area and
strict hygiene

19. Treatmen
t
• Pilonidal Abscess(acute exacerbation)
– Conservative
• Rest, baths, local antiseptic dressings and
broad- spectrum antibiotics
– Surgery
• Incision and drainage
– Small longitudinal incision made over the abscess and
off the
midline
– Through curettage of granulation tissue and hair
– May or may not be associated with complete resolution

20. Treatmen
t
• Chronic Pilonidal Disease
– Lack of overall superiority of 1 method over others
– Factors affecting choice of method
• Time spent off work
• Perceived recurrence rates
• Surgeon preference
– Goals of the ideal procedure should be
• Reliable wound healing
• Low risk of recurrence
• Short period of hospitalization
• minimal inconvenience to the patient(low morbidity)
• few wound-management problems.
• Resumption to normal daily activities as quickly as
possible.

21. Treatmen
t
• POSITION: Jack Knife*(Kraske position) (prone with buttocks elevated)
• Anesthesia: General or Local
• OPTIONS
– Laying open & curetting of all tracks(demonstrated by methylene
blue) +/- marsupialisation
– Excision of all tracks with
• OPEN METHOD: wound left open-secondary intention healing over 3-4 weeks (Least
recurrence)
• CLOSED METHOD:
– primary closure(+/- retention suturing)
– closure by some other means designed to avoid a midline wound
» Z-plasty,
» Karydakis procedure
• semilateral incision and lateralised suturing of wound away from
midline
*Jackknifing means the folding of an articulated vehicle (such as one towing a
trailer) such

23. – Bascom’s
procedure
• Incision(s) 2-4 mm sized lateral to midline to gain
access to sinus cavity
• Pus drained, hairs removed with only
minima/NO excision of sinus/cavity wall
• Most effective for primary pilonidal sinuses

24. Treatmen
t
POSTOPERATIVE CARE
• Daily pack/dressing change after warm shower/sitz bath
• elimination of hair (ingrown, local or other) from the wound
every
1-3 weeks
– as effective in preventing recurrence as a secondary
surgical procedure
FOLLOW UP
• After 1-2 weeks
– examine the wound for healing,
– assess for potential recurrence,
– arrange for definitive care of the sacrococcygeal region if
necessary

25. Treatmen
t
RECURRENT PILONIDAL SINUS
ETIOLOGY
• Part of sinus complex overlooked at primary operation
• New hairs enter the skin or the scar
• Persistence of a midline wound caused by shearing forces and
scarring
TREATMENT
– Revisional surgery including extensive resection/re-excision
followed by wound closure and obliteration of natal cleft either by
• (Limberg-single/double Rhomboid) myocutaneous rotational buttock flap
• V-Y gluteal advancement flap

27. Treatmen
t
CONTRAINDICATION
• Although no specific contraindications exist
for the treatment of pilonidal disease,
consider the patient's overall situation and
well-being
– weigh the complexity of the proposed
surgical procedure against the patient's
individual comorbidities and long-term
prognosis.

28. Complication
s
• Recurrence of the abscess
– most common complication(40-50 %)
• Wound infection
– Leading to sacral osteomyelitis, necrotising
fascitis and
rarely meningitis
• SCC in chronic pilonidal disease
– Exceedingly rare
– requires en bloc surgical resection and
appropriate oncologic care with local radiation
and possibly chemotherapy

29. Prognosi
s
• Excellent long-term prognosis
• Mortality is practically NIL
– unless SCC develops,
– though abscess recurrence is
common