- Email: [email protected]
Pilonidal disease of the abdominal wall
Pilonidal
Disease DONALD E. JANELLI,
of the Abdominal M.D.,
Journal
of Surgery,
Volume
~5, January.
1958
Williston Park, New York
obesity, poor hygiene, tender or macerated skin and repeated trauma [4]. To the growing list of unusua1 sites of origin of piIonida1 disease may be added another previousIy unreported area.
ILONIDAL cyst has been described as a hairsacrococcygea1 dermoid cyst or sinus which often opens at a postana1 dimpIe. It is usuaIIy considered to be a deveIopmenta1 defect having origin either from a remnant of the neura1 canal or from an ectodermaI incIusion resuIting from midIine maIfusion [4]. Sporadic case reports of piIonida1 sinus having origin in sites other than the sacrococcygea1 area have aroused interest as to the possibiIity of the lesion being acquired. Patey and Scarff, in 1946, reported a case of piIonida1 sinus arising in an interdigita1 cIeft of a barber [6]. Ewing reported a simiIar Iesion in a barber in 1947 [5]. In 1948, Smith reported four cases of piIonida1 cyst Iocated in the perineum anterior to the ana verge [9], and in the same year Patey and Scarff reported two additiona cases occurring in the interdigital webs of barbers [7]. In 1952, Aird reported a case occurring in the axiIIa [I], and Downing reported another case originating in a barber’s interdigital web [J]. Ten cases of interdigita1 piIonida1 disease in barbers were reported in 1953 by Currie et a1. who stated that this Iesion in this Iocation is now known to be reIativeIy common [2]. In 1956, Patey and WiIIiams described a case of piIonida1 sinus of the umbiIicus, and on the basis of a detaiIed study of the orientation of two hundred sixty hairs found in the sinus beIieved that further evidence was provided against the vaIidity of the theory that piIonida1 sinus of the nata cIeft is of congenital origin [S]. On the basis of their reported experience with four hundred forty-nine cases of piIonida1 sinus, Dwight and MaIoy suggest that the majority of these Iesions are not congenita1 but acquired in origin. The basic pathogenesis is beIieved to be penetration of skin by Ioose, stiff hair shafts. This is particuIarIy prone to occur in the presence of a skin dimpIe, hirsuties,
P containing
American
Wall
CASE REPORT R. S., a twenty-two year old white man was first seen on November 8, 1955 with the compIaint of a draining sinus in the Ieft posteroIateraI abdomina1 waI1. The patient had aIways been aware of the sinus; he had been toId by his parents that he had faIIen down a ffight of stairs at eighteen months of age “rupturing blood vesseIs” in this region necessitating incision and drainage by the family physician. Since that time a sinus had persisted. The sinus was asymptomatic, however, until six months prior to the present examination when sweIIing and drainage appeared and recurred intermittentIy. Hairs had recentIy been removed from the sinus opening by the famiIy physician. Examination was within norma limits except for the skin sinus in the Ieft posterolateral abdomina1 waI1. A probe was inserted into the sinus under IocaI anesthesia. The tract was unroofed by incision and found to contain a bundle of hairs. A wide excision of the Iesion was carried out and the wound primarily closed. Because of subsequent drainage, the sutures were removed on the fifth postoperative day and the wound was opened and packed. Secondary heaIing was compIete in sIightIy under two months’ time. The pathoIogic report foIIows: GrossIy, the specimen was a 15 mm. ovoid of skin with a centra1 opening Ieading to a previously opened tract about 20 mm. deep, which had a fibrous waI1. In the tract were severa projecting hairs. Microscopically, the tract was Iined by stratified squamous epitheiium and underneath this were some skin appendages including a few hair I42
PiIonidaI
Disease
of AbdominaI
shafts. The surrounding tissue showed a focal chronic inflammatory reaction. The diagnosis was piIonida1 sinus. A fourteen-month folIow-up showed no evidence of recurrence.
WaII SUMMARY
I. The reported sites of extra sacrococcygea1 areas of piIonida1 disease are presented. 2. A case of piIonida1 sinus in a site of origin not previousIy described is reported. 3. The accumulated evidence for piIonida1 disease being acquired is briefly summarized.
COMMENTS
A sufficient number of cases of pilonidal disease have now been reported in other than the sacrococcygea1 area to arouse curiosity as to the true origin of this .Iesion. The evidence presented in these cases suggests that pilonidal sinus is acquired. In the light of this evidence it is rational to postulate that most sacrococcygea1 piIonida1 disease is acquired as the anatomic features peculiar to the sacrococcygeaI area as we11as the usual physica characteristics of the patient affhcted with this Iesion are conducive to an acquired mechanism. The practica1 importance of recognizing the roIe of hair shafts in the pathogenesis of piIonida1 disease is refIected in the opinion of Dwight and MaIoy who beIieve that recurrence foIIowing piIonida1 surgery is caused by coIIection of hair in an imperfect scar [4]. Hair is the sine qua non in primary or recurrent piIonida1 disease and the surgica1 management of this Iesion shouId be based on this premise.
REFERENCES
I. AIRD, I. PilonidaI sinus of the axiIla. &it. M. J., 1: 902, 1952. 2. CURRIE, A. R., GIBSON, T. and GOODALL, A. L. InterdigitaI sinuses of barber’s hands. &it. J. Surg., 41: 278, 1953. 3. DOWNING, J. G. Barber’s piIonida1 sinus. J. A. M. A., 149: 1501, 1952. 4. DWIGHT, R. W. and MALOY, J. K. Pilonidal sinus. Experience with 449 cases. New England J. Med., 249: 926, 1953. 5. EWING, M. R. Hair bearing sinus. Lancet, I: 427, ‘947. 6. PATEY, D. H. and SCARFF, R. W. PathoIogy of postanal piIonida1 sinus. Its bearing on treatment. Lancei, 2: 484, 1946. 7. PATEY. D. H. and SCARFF. R. W. PiIonidaI sinus of a barber’s hand. With observations on postana1 piIonida1 sinus. Lancet, 2: 13, 194.8. 8. PATEY. D. H. and WILLIAMS. E. S. PiIonidaI sinus of the umbiIicus. Lancet, 27’r : 281, 1956. g. SMITH, T. E. Anterior or perinea1 piIonida1 cysts. J. A. M. A., 136: 973, 1948.
‘43
Disease DONALD E. JANELLI,
of the Abdominal M.D.,
Journal
of Surgery,
Volume
~5, January.
1958
Williston Park, New York
obesity, poor hygiene, tender or macerated skin and repeated trauma [4]. To the growing list of unusua1 sites of origin of piIonida1 disease may be added another previousIy unreported area.
ILONIDAL cyst has been described as a hairsacrococcygea1 dermoid cyst or sinus which often opens at a postana1 dimpIe. It is usuaIIy considered to be a deveIopmenta1 defect having origin either from a remnant of the neura1 canal or from an ectodermaI incIusion resuIting from midIine maIfusion [4]. Sporadic case reports of piIonida1 sinus having origin in sites other than the sacrococcygea1 area have aroused interest as to the possibiIity of the lesion being acquired. Patey and Scarff, in 1946, reported a case of piIonida1 sinus arising in an interdigita1 cIeft of a barber [6]. Ewing reported a simiIar Iesion in a barber in 1947 [5]. In 1948, Smith reported four cases of piIonida1 cyst Iocated in the perineum anterior to the ana verge [9], and in the same year Patey and Scarff reported two additiona cases occurring in the interdigital webs of barbers [7]. In 1952, Aird reported a case occurring in the axiIIa [I], and Downing reported another case originating in a barber’s interdigital web [J]. Ten cases of interdigita1 piIonida1 disease in barbers were reported in 1953 by Currie et a1. who stated that this Iesion in this Iocation is now known to be reIativeIy common [2]. In 1956, Patey and WiIIiams described a case of piIonida1 sinus of the umbiIicus, and on the basis of a detaiIed study of the orientation of two hundred sixty hairs found in the sinus beIieved that further evidence was provided against the vaIidity of the theory that piIonida1 sinus of the nata cIeft is of congenital origin [S]. On the basis of their reported experience with four hundred forty-nine cases of piIonida1 sinus, Dwight and MaIoy suggest that the majority of these Iesions are not congenita1 but acquired in origin. The basic pathogenesis is beIieved to be penetration of skin by Ioose, stiff hair shafts. This is particuIarIy prone to occur in the presence of a skin dimpIe, hirsuties,
P containing
American
Wall
CASE REPORT R. S., a twenty-two year old white man was first seen on November 8, 1955 with the compIaint of a draining sinus in the Ieft posteroIateraI abdomina1 waI1. The patient had aIways been aware of the sinus; he had been toId by his parents that he had faIIen down a ffight of stairs at eighteen months of age “rupturing blood vesseIs” in this region necessitating incision and drainage by the family physician. Since that time a sinus had persisted. The sinus was asymptomatic, however, until six months prior to the present examination when sweIIing and drainage appeared and recurred intermittentIy. Hairs had recentIy been removed from the sinus opening by the famiIy physician. Examination was within norma limits except for the skin sinus in the Ieft posterolateral abdomina1 waI1. A probe was inserted into the sinus under IocaI anesthesia. The tract was unroofed by incision and found to contain a bundle of hairs. A wide excision of the Iesion was carried out and the wound primarily closed. Because of subsequent drainage, the sutures were removed on the fifth postoperative day and the wound was opened and packed. Secondary heaIing was compIete in sIightIy under two months’ time. The pathoIogic report foIIows: GrossIy, the specimen was a 15 mm. ovoid of skin with a centra1 opening Ieading to a previously opened tract about 20 mm. deep, which had a fibrous waI1. In the tract were severa projecting hairs. Microscopically, the tract was Iined by stratified squamous epitheiium and underneath this were some skin appendages including a few hair I42
PiIonidaI
Disease
of AbdominaI
shafts. The surrounding tissue showed a focal chronic inflammatory reaction. The diagnosis was piIonida1 sinus. A fourteen-month folIow-up showed no evidence of recurrence.
WaII SUMMARY
I. The reported sites of extra sacrococcygea1 areas of piIonida1 disease are presented. 2. A case of piIonida1 sinus in a site of origin not previousIy described is reported. 3. The accumulated evidence for piIonida1 disease being acquired is briefly summarized.
COMMENTS
A sufficient number of cases of pilonidal disease have now been reported in other than the sacrococcygea1 area to arouse curiosity as to the true origin of this .Iesion. The evidence presented in these cases suggests that pilonidal sinus is acquired. In the light of this evidence it is rational to postulate that most sacrococcygea1 piIonida1 disease is acquired as the anatomic features peculiar to the sacrococcygeaI area as we11as the usual physica characteristics of the patient affhcted with this Iesion are conducive to an acquired mechanism. The practica1 importance of recognizing the roIe of hair shafts in the pathogenesis of piIonida1 disease is refIected in the opinion of Dwight and MaIoy who beIieve that recurrence foIIowing piIonida1 surgery is caused by coIIection of hair in an imperfect scar [4]. Hair is the sine qua non in primary or recurrent piIonida1 disease and the surgica1 management of this Iesion shouId be based on this premise.
REFERENCES
I. AIRD, I. PilonidaI sinus of the axiIla. &it. M. J., 1: 902, 1952. 2. CURRIE, A. R., GIBSON, T. and GOODALL, A. L. InterdigitaI sinuses of barber’s hands. &it. J. Surg., 41: 278, 1953. 3. DOWNING, J. G. Barber’s piIonida1 sinus. J. A. M. A., 149: 1501, 1952. 4. DWIGHT, R. W. and MALOY, J. K. Pilonidal sinus. Experience with 449 cases. New England J. Med., 249: 926, 1953. 5. EWING, M. R. Hair bearing sinus. Lancet, I: 427, ‘947. 6. PATEY, D. H. and SCARFF, R. W. PathoIogy of postanal piIonida1 sinus. Its bearing on treatment. Lancei, 2: 484, 1946. 7. PATEY. D. H. and SCARFF. R. W. PiIonidaI sinus of a barber’s hand. With observations on postana1 piIonida1 sinus. Lancet, 2: 13, 194.8. 8. PATEY. D. H. and WILLIAMS. E. S. PiIonidaI sinus of the umbiIicus. Lancet, 27’r : 281, 1956. g. SMITH, T. E. Anterior or perinea1 piIonida1 cysts. J. A. M. A., 136: 973, 1948.
‘43