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SINUS AND FISTULA

SINUS AND FISTULA. Dr. Varun. S Dept. of Surgery SKHMC. DEFINITION. SINUS: Blind track lined by granulation tissue leading from epithelial surface down into the tissues. Latin: Hollow (or) a bay. C A US E S. CONGENITAL Preauricular sinus. ACQUIRED

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SINUS AND FISTULA

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  1. SINUS ANDFISTULA Dr. Varun. S Dept. of Surgery SKHMC

  2. DEFINITION • SINUS: • Blind track lined by granulation tissue leading from epithelial surface down into thetissues. • Latin: Hollow (or) abay

  3. CAUSES CONGENITAL Preauricularsinus ACQUIRED TB sinus Pilonidalsinus Median mental sinus Actinomycosis

  4. FISTULA: • ABNORMALcommunication between lumen of one viscus and lumen of another (INTERNALFISTULA) • (or) • between lumen of one hollow viscus to the exterior (EXTERNALFISTULA) • (or) • between any twovessels

  5. Latin : flute (or) a pipe (or) atube .

  6. CAUSES • CONGENITAL • Branchialfistula • Tracheo-esophageal • Umbilical • Congenital AVfistula • Thyroglossalfistula ACQUIRED Traumatic Inflammatory Malignancy Iatrogenic

  7. ACQUIRED • TRAUMATIC: • following surgery : eg., intestinalfistulas • (faecal,biliary,pancreatic) • following instrumental delivery (or) difficult labour • e.g., vesicovaginal,rectovaginal, ureterovaginalfistula

  8. Intestinal actinomycosis,TB II. INFLAMMATORY: III.MALIGNANCY: when growth of one organ penetrates into the nearbyorgan. e.g., Rectovesical fistula in carcinomarectum IV.IATROGENIC: Cimino fistula- AVF forhemodialysis ECK fistula- to treat esophageal varices in portalHTN

  9. FISTULA • EXTERNAL • Orocutaneous • Enterocutaneous • Appendicular • Thyroglossal • Branchial • INTERNAL • Tracheo-esophageal • Colovesical • Rectovesical • AVF • Cholecystoduodenal

  10. .

  11. Causesforpersistenceofsinus(or)fistula • Presence of a foreign body. e.g., suturematerial • Presence of necrotic tissue underneath. e.g.,sequestrum • Insufficient (or) non-dependent drainage. e.g., TBsinus • Distal obstruction. e.g., faecal (or) biliaryfistula • Persistent drainage likeurine/faeces/CSF • Lack ofrest • [contd.]

  12. Epithelialisation (or) endothelisation of the track. e.g.,AVF • Malignancy. • Densefibrosis • Irradiation • Malnutrition • Specific causes. e.g., TB,actinomycosis • Ischemia • Drugs. e.g.,steroids • Interference by thepatient

  13. PATHOPHYSIOLOGY CONGENITAL: Arise from remnants of embryonic ducts that persist instead of being obliterated and disappearing completely during embryonic development. e.g., pre-auricular sinus, branchial fistula, TOF, congenitalAVF.

  14. ACQUIRED: Usually secondary to presence of foreign body, necrotic tissue in affected area (or) microbial infection (or) following inadequate drainage of abscess. e.g., perianal abscess when bursts spontaneously into skin forming a sinus and when bursts into both skin and anal canal forming afistula.

  15. CLINICALFEATURES • Usually asymptomatic but when infected manifest as- • Recurrent/ persistentdischarge. • Pain. • Constitutional symptoms if any deep seated origin.

  16. CLINICALEXAMINATION INSPECTION: 1. Location:usually gives diagnosis in most of thecases. pre-auricular- root of helix of ear. median mental- symphysis menti. TB-neck. SINUS: FISTULA: branchial- sternomastoid ant border. parotid- parotidregion thyroglossal- midline of neck belowhyoid.

  17. 2.Number:usually single but multiple seen in HIV patients (or)actinomycosis. • Opening: • sprouting with granulation tissue-foreignbody. • flushing with skin-TB • Surrounding area: erythematous- inflammatory bluish-TB • excoriated-faecal • pigmented- chronicsinus/fistulae.

  18. Discharge: • White thin caseous, cheesy like- TBsinus • Faecal- faecalfistula • Yellow sulphur granules-actinomycosis • Bony granules-osteomyelitis • Yellow purulent- staph.infections • Thin mucous like- brachialfistula • Saliva- parotidfistula

  19. Palpation: Temperature andtenderness: Discharge: after application of pressure over the surrounding area. Induration: present in chronic fistulae/sinus as in actinomycosis,OM TB Sinus indurationabsent. Fixity: Palpation at deeper plane: lymph nodes-TB Thickening of bone underneath-OM

  20. INVESTIGATIONS • CBP- Hb, TLC, DLC,ESR. • Discharge for C/S , AFB, cytology, Gramstaining. • X-RAY of the part to rule out OM, foreignbody. • X-RAY KUB and USG abdomen in cases of lumbar fistula to rule out staghorncalculi. • MRI • BIOPSY from edge ofsinus • CTSinusogram

  21. FISTULOGRAPHY/SINUSOGRAPHY: • For knowing the exact extent/origin of sinus (or)fistula. • Water soluble or ultrafluid lipoidal iodine dye is used. • Lipoidal iodine is poppy seed oil containing 40% iodine.

  22. TREATMENT • BASICPRINCIPLES: • Antibiotics • Adequaterest • Adequateexcision • Adequatedrainage.

  23. After excision specimenSHOULDbe sent for HPE. • Treating the cause. e.g., ATT for TBsinus. • removal of any foreign body. sequestrectomy forOM.

  24. TUBERCULAR SINUS OFNECK Causative organism: mostlyM.tuberculosis but also M.bovis Site and mode ofinfection: lymph nodes in anterior triangle fromtonsils. lymph nodes in posterior triangle fromadenoids. supraclavicular nodes from apex of thelung.

  25. Clinicalstages:

  26. Stage oflymphadentis: non-tender,discrete,mobile,firm lymphnodes Stage ofperidenitis: due to involvement ofcapsule. non-tender,MATTED,mobile together,firm pathognomic ofTB

  27. Stage of coldabscess: due to caseatingnecrosis. non-tender, cystic, fluctuant swelling not adherent to overlyingskin. Sternocleidomastoid contraction test- present deep to deepfascia trans illuminationnegative

  28. TREATMENT: • Zig-zagaspiration by wide bore needle in non- dependent area to avoid a persistentsinus. • Instillation of 1g streptomycin +/- INH in solution with closure of woundwithoutplacing adrain. • ATT • NOTE:I&D not done-persistent TBsinus.

  29. Stage of collar studabscess: • cold abscess ruptures through deep fascia forming an another swelling in sub-cutaneous plane. • Fluctuant, adherent toskin. • Treated like a coldabscess.

  30. Collar studabscess

  31. Stage ofsinus: • collar stud abscess bursts out leading to a persistent dischargingsinus. • Can be multiple, wide opening, undermined edges,non-mobile. • Bluish discoloration around theedges. • NOINDURATION.

  32. INVESTIGATIONS • Hematocrit,ESR ,S.albumin ,S.globulin • FNAC of lymph nodes and smear for AFB and C/S • Open node biopsy of lymphnodes. • Edge biopsy of sinus-granuloma. • mantouxtest • Chest Xray • Sputum forAFB

  33. Sometimes, USG neck to detect coldabscess. • Hypoechoeic lesions with internal echoes S/O debriswithin. • Guided aspiration of coldabscess.

  34. TREATMENT • ATT • Excision of sinus tract with excision of diseased lymphnodes.

  35. FISTULA-IN-ANO Chronic abnormal communication usually lined to some degree by granulation tissue, which runs outwards from anorectal lumen (internal opening) to skin of perineum or the buttocks (external opening)

  36. AETIOPATHOGENESIS • Cryptoglandular (90%cases) • Non cryptoglandular (10% cases) TB • Diabetesmellitus • Crohn’s disease Carcinomarectum Trauma • Lymphogranuloma venereum Radiotherapy • Immunocompromised patients (HIVetc.,)

  37. CRYPTOGLANDULAR HYPOTHESIS

  38. CLASSIFICATION • PARK’SCLASSIFICATION: • (relation of primary tract to externalsphincter) • Inter sphincteric(45%) • Trans sphincteric(40%) • Suprasphincteric • Extrasphincteric

  39. STANDARDCLASSIFICATION • Subcutaneous • Submucous • Lowanal • Highanal • Pelvirectal

  40. Canbe • low level fistula- open into anal canalbelow • the internalring. • highlevelfistula- at/ above the internalring. • Canbe • Simple- without any extensions Complex- withextensions • Canbe • single • multiple- TB, ulcerative colitis, crohn’s, HIV,LGV

  41. CLINICALPRESENTATION • Intermittentdischarge • (sero-purulent/bloody) • Pain • (which increases until temporary relief occurs when pusdischarges) • Pruritusani • Previous h/o anal gland infection

  42. CLINICALASSESMENT • HISTORY:full medical history incl. obstetric,anal, gastrointestinal, surgical,continence • DRE: area of induration, fibrous tract and internal opening may be felt (“button-hole” defectin • Carectum) • PROCTOSIGMOIDOSCOPY: • To evaluate rectal mucosa for any underlying diseaseprocess.

  43. GOODSALL’SRULE • If external opening in anterior half of anus, fistula usually runsdirectlyinto analcanal. • If external opening in posterior half of anus, fistula usuallycurvesmidline of the anal canal posteriorly.

  44. IMAGING • Fistulography • Endoanalultrasound • MRI

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