1. A sinus is a tract connecting a cavity lined by granulation tissue to the skin surface, while a fistula is an abnormal connection between two epithelial surfaces usually lined by granulation tissue. 2. Sinuses and fistulae can be congenital, traumatic, inflammatory, or neoplastic in origin. Common causes include infections from organisms like Mycobacterium tuberculosis or Actinomyces. 3. Examination of sinuses and fistulae involves inspecting their number, size, location, openings, discharge, surrounding skin, palpating for tenderness or lumps, and using probes to determine depth and connections. Relevant medical history and investigations help determine the underlying cause.

1. SINUSES & FISTULAE
DR. NEERAJ K JAIN
DEPARTMENT OF GENERAL
SURGERY

2. SINUS & FISTULA

3. • 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.

4. Sinus Fistula
Congenital Pre-auricular Branchial, thyroglossal,
tracheo-oesophageal,
umbilical, rectovesical,
vesicovaginal
Traumatic Foreign body
implantation
a/f operation or accidential
injury, salivary, pancreatic,
biliary, faecal, urinary
Inflammatory OM, TB, Act,
Chronic
abscess
Appendicular fistula,
diverticulitis of colon
Neoplastic Degeneration/
2. infn which
was incised
Advanced Ca (Int/ext),
rectum, cervix – faecal fistula

5. SINUS JAW
SINUS FROM SEPTIC
ARTHRITIS OF THE
SHOULDER DUE TO
ACTINOMYCOSIS 

6. • 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

7. 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

8. Actinomycosis of the left side of the jaw with
multiple sinus formation.

9. 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

10. 5. Surrounding skin
Scar indicating Chr. OM or previously healed
TB.
Dermatitis with pigmentation  Chron’s /
Actinomycosis

11. 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

12. 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.

13. Mammary fistula

15. General Examination
• Depends on site and cause – particular system
• Sinus in loin - spine, ribs, kidneys
• Chronic empyema - chest
• Osteomyelitis- bone
• Around anus- PR/proctoscopy, sigmoid
scope, whole abdomen
• Multiples in perineum/scrotum lower urinary tract
• Groin sinus hip joint/spine (bursting of cold abscess)

16. Investigatons
• Examination of discharge –
marcro/physical/chemical/microscopy
• X-rays - sequestrum, opaque foreign
bodies/ sino/fistulogram

17. 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)
• Absence of rest

19. Primary Skin Lesions
• Macule – a small flat area of
altered colour or texture
• Papule – a small solid
elevation of skin less than
0.5 cm in diameter
• Nodule - >0.5 cm
• Plaque – elevated area of
skin greater than 2 cm in
diameter without
substantial depth
• Vesicle – circumscribed
elevation of skin <0.5 cm in
dia containing fluid
• Bulla - >0.5 cm
• Pustule – visible
accumulation of pus in the
skin
• Abscess - > 1cm
• Weal – elevated white
compressible evanescent
area produced by dermal
oedema

20. • Papilloma – a nipple like
mass protruding from the
skin
• Petechiae – Pin-head sized
macules of blood in the skin
• Purpura – A larger macule
or papule of blood in the
skin
• Ecchymosis – a larger
extravasation of blood into
the skin
• Haematoma – a swelling
from gross bleeding
• Burrow – a linear or
curvilinear papule, caused
by a burrowing scabies mite
• Comedo – a plug of keratin
and sebum wedged in a
dilated pilosebaceous
orifice
• Telangiectasia – visible
dilatation of small
cutaneous blood vessels

21. Secondary lesions (evolved from primary lesion
• Scale – a flake arising from
the horny layer
• Crust – look like a scale, but
is composed of dried blood
or tissue fluid
• Ulcer – an area of skin from
which the whole of
epidermis and at least the
upper part of the dermis has
been lost
• Excoriation – an ulcer or
erosion produced by
scratching
• Erosion – an area of skin
denuded by a complete or
partial loss of the epidermis
• Fissure – a slit in the skin
• Sinus – a cavity or channel
that permits the escape of
pus or fluid
• Scar – the result of healing
in which normal structures
are permanently replaced by
fibrous tissue
• Atrophy – thinning of the
skin due to diminution of
the epi/dermis, s/c fat
• Striae – a streak like, linear,
atrophic, pink, purple or
white lesion of the skin due
to changes in the connective
tissue