Role of Kshar-sutra in Pilonidal sinus

Dr. Praveen Kumar Choudhary Associate ProfessorDeptt. of Shalya Tantra, A & U Tibbia College, Delhi govt.New Delhi-110005

History of pilonidal sinus disease

Pilonidal sinus was first described by Hodges in 1880.

It is diagnosed by the finding of a characteristic epithelial track (the sinus) situated in the skin of the natal cleft.

It generally contains hair hence named pilonidal taken from the latin meaning ‘nest of hair’.

During the second world war the condition was common among jeep drivers; therefore, named as jeep driver’s disease.

What is Pilonidal sinus

Pilonidal sinus is a midline post anal sinus commonly seen in young adults usually without any communication with rectum and anal canal.

Pilus means hair, Nidus means nest, so Pilonidal sinus means Nest with hair inside, where hair is invaginated in subcutaneous tissue as a Bulbous Diverticula with branching and bifurcating from side.

Pilonidal sinus is lined by squamous epithelium and hair lies loose or embeded in the granulation tissue.

They are responsible for persistent infection and sinus fails to heal.

Contd.

Pilonidal sinus is common in the Gluteal cleft. While sitting, the buttocks move and the hair is

broken off by friction. The hair collects in gluteal cleft. The hair penetrates the soft and moist skin of this

region. May enter in the open mouth of sudoriferous gland.

It causes the pilonidal sinus. The hair tuft is present in the sinus.

Pilonidal sinus

Other sites of pilonidal sinus

Axilla Interdigital cleft of barbours. Umbilicus. Interdigital web of foot of a worker in hair

mattress factory. Sometimes on the face.

Predisposing factors

Abundance of hair (70%) Sedentary occupation (44%) Positive family history (38%) Obesity (50%) Local irritation and trauma (34%)

Hair abundance: Prime factor

Pathology

Hormones: At the onset of puberty sex hormones increases the activity of sebaceous glands of natal cleft.

Hair Friction Infection: Anaerobic infections predominates

on the aerobic infections.

Extension of Pilonidal Sinus

Pilonidal sinus extends into the subcutaneous tissue from the surface of the skin.

It ends blindly in the subcutaneous tissue and doesn’t reach to the bone.

It contains hair, infected material, debris etc. Sometimes it may extends into anus.

Clinical features

Mostly occurs in the persons having abundance of hair in the buttocks.

There is a chronic sinus about the level of first coccyx.

A tuft of hair is seen projecting from its mouth. Blood stained foul discharge from the sinus. Pain and tenderness. May have some secondary

openings on either side of the middle or a little away from the main sinus.

Sinus have ramifications and sometimes midline pits which are having hair follicles.

Complications

Recurrent infections causes pus discharge and foul smell.

Abscess formation. It is prone to recurrence after surgical

removal. Rarely malignant changes may occur.

Management

Conservative Management Operative Management

Conservative Management

Antibiotics and anti-inflammatory drugs. Maintenance of local hygiene such as

shaving, application of antiseptic lotion etc. Injection of Phenol in almond oil caused

sclerosis of the sinus track. However underlying pathology of impaction of hair remain unsolved.

Operative management

Incision and drainage. Excision (wide) and healing by secondary

intention. Excision and primary closure (recurrence

rates are high) Excision with grafting (flap plasty)

Excision of sinus track

The outline of the sinus cavity may be done.

Surrounding healthy tissue may be involved and excised.

The fibrous tissue is removed and packing of wound is done.

Contd. The picture is taken after two weeks.

Contd.

Extensive excision is carried out. It takes long time to heal.

The healing takes place with the formation of granulation tissue.

The picture is taken four weeks after the excision of the track.

Scar following surgery

The scar is extensive after healing of the wound.

The picture is taken eight weeks after the excision of the track.

Post operative wound infection

Early sign of wound infection includes increased pain and an abnormal dark ‘beefy’ red appearance to the granulation tissue which is friable, bleeds on contacts and exhibits superficial bridging.

Recurrence after surgery

Recurrence

Early Recurrence

Usually due to failure to identify one or more sinuses at incision and drainage.

Recurrence

Late recurrence Residual hair or debris. Inadequate wound care. Union of wound edges without healing from

the base.

Need For Alternative Treatment

To get rid of this troublesome disease as patient’s socio-economic status is also disturbed due to prolonged immobilisation , there is a need of alternative treatment and that is KSHAR SUTRA.

Certainly, Kshar sutra has got supremacy over other treatments.

Kshar-sutra: Treatment of choice

Kshar-sutra (Alkaline thread) therapy is ideal in the management of Pilonidal sinus.

It ensures complete healing without recurrence.

It removes hair from the tract in subsequent changing of the thread.

There is little discomfort to the patient. There is a small scar left after the

application.

Material and method: Patient selection

Patients were selected from the O.P.D. and I.P.D. of the hospital in random manner.

Exclusion: Patients of D.M. and osteomyelitis of coccyx/Sacrum. (We have not received such patients)

Routine investigations were carried out like hematological and Radiological.

Primary threading was performed under local anaesthesia. Thread was changed on weekly basis by railroad method.

Steps of threading

Since sinus has only one opening we have to make second opening at its other end.

A probe is passed in the track. Secondary opening is formed. The track is threaded with a kshar-sutra. Bandaging is performed.

Steps of Kshar-sutra therapy

Probing the sinus

Probing after incision

Steps of threading

Steps of threading contd.

Tying the thread

Contd.

Contd.

Contd.

Anal Fistula/Pilonidal sinus

Contd.

Recurrent Fistula – in –ano (Operated on 14th Feb 2008)

Cavity Local anaesthesia

Contd.

Benefits of kshar-sutra

Minimum tissue loss in comparison to the surgery.

No bleeding, no hospital stay and no need to put huge dressings.

Procedure takes not more than five minutes. Minimum discomfort. Pain is very less. No recurrence.

Results

Kshar-sutra is very good to treat sinus. It is also better in terms of patients acceptibility as well as final results.

The pain is very less during and after application. Discharge was noticed to be reduced in early

sittings. U.C.T is more or less same.

Contd.

Kshar-sutra is also very useful even in cases of multiple recurrence.

Our patients are more than satisfied with the therapy. We have been receiving many patients by mouth to

mouth publicity. It is concluded that kshar-sutra therapy is best mode

of treatment in pilonidal sinus.

Ramification: cause of reccurence in Pilonidal sinus

Ramifications in the pilonidal sinuses are comon causes of recurrence.

Such types of pilonidal sinuses should be dealt with care and all ramifications should be opened or cut with kshar sutra.

A case of recurrent pilonidal sinus after three surgeries Treated by Kshar sutra (Mr Verma from A.I.R)

Pilonidal sinus: ramifications

Summary

A complex condition that causes both discomfort and embarrassment to sufferers.

Causing Direct costs to healthcare system Causing indirect cost through absence from work. Kshar sutra is recommended for treatment in

pilonidal abscesses. Besides surgical technique, principles of wound care

including repeated depilation of the natal cleft, removal of hair, any debris from wound bed, keeping the wound edges separated using an appropriate dressing are also essential.

Thank you

All of you