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SUBCUTANEOUS TISSUE
Sinus and fistula
LEARNING OBJECTIVES
• Adnexal structures such as hair follicles, sebaceous and sweat glands span
both the epidermal and dermal layers and contain some keratinocytes in their
ducts.
• In injuries where epidermis is lost, re-epithelialisation occurs from these
structures as well as from the wound margins.
• Hair which grows out from a hair bulb at the base of a follicle is a shaft of
dead keratinized tissue. Strips of smooth muscle (erector pili) are inserted
into the wall of the hair follicle and lead to hair elevation in times of stress
and cold.
• Sebaceous glands are situated between hair follicles and erector pili muscle.
Sebum acts as a skin lubricant and physical protection barrier.
• Sweat glands open into pores in hair follicles eccrine and apocrine glands.
SKIN THICKNESS
• Sinus on the chin can be the result of a chronic apical abscess due to
pulp necrosis of a mandibular tooth.
• The tooth is usually asymptomatic, and a dental cause is therefore not
apparent to the patient or the unsuspecting clinician.
• Not infrequently, the patient may seek treatment from a dermatologist
or general surgeon instead of a dentist.
• Excision and repair of the fistula may be carried out with subsequent
breakdown because the dental pathology is not removed.
TREATMENT OF SINUS
CONGENITAL ACCQUIRED
• Traumatic
Following surgery – Intestinal fistulas (faecal, biliary, pancreatic).
Following instrumental delivery or difficult labour – Vesicovaginal
Rectovaginal
• Inflammatory – Intestinal actinomycoses, Tuberculosis, Crohn’s
disease’.
• Malignant – Rectovesical Fistula.
• Iatrogenic – Cimino AV fistula for hemodialysis.
EXTERNAL INTERNAL
• When the tract communicates • When the tract communicates
a hollow viscus to the skin. between two hollow viscera.
• E.g. Parotid fistula, • E.g. Tracheo-oesophageal
Thyroglossal fistula, Branchial fistula, Rectovesical, Colo-
fistula, Appendicular, vesical
Orocutaneous.
INTESTINAL FISTULAS
Inspection
• Site – parotid, thyroglossal, medial mental etc.
• Number – openings may be single or multiple. Multiple sinus openings
seen in HIV patients with Actinomycoses. Multiple fistula openings seen
in ‘Watering can’ perineum in Crohn’s disease affecting the rectum and
anal canal producing multiple anal fistula.
• Discharge – Caseous (tuberculous), Yellow sulphur granules
(Actinomycosis), thin watery (parotid), stools (fecal fistula)
• Opening – Sprouting with granulation tissue (Foreign body), Opening is
wide and margin is thin and undermined (Tuberculosis)
• Surrounding area – Erythematous (Inflammatory), Excoriated (Fecal),
Scar (Chronic osteomyelitis), Bluish (Tuberculosis).
PALPATION
Discharge
a) Purulent—bacterial infection
b) Caseous—tuberculous
c) Sulphur granules—actinomycosis
d) Mucus—branchial fistula
e) Saliva—parotid fistula
f) Feces—fecal fistula Bile—biliary, duodenal fistula
g) Bone—osteomyelitis sinus
• General Examination for diabetes. malnutrition, anaemia, tuberculosis.
• Specific examinations - Oral cavity in submental sinus, adjoining bones
in osteomyelitis, anal canal and rectum in fistula in ano.
INVESTIGATIONS
• Antibiotics
• Adequate excision
• Adequate drainage
• Adequate rest
• Treating the cause – Anti Tubercular Treatment (ATT) for
tuberculosis, removal of foreign body, sequestrectomy for
osteomyelitis.
• After excision specimen should be send for histopathological
examination (HPE)
• In OM there is H/O high fever – swelling, pain in the bone – abscess
develops – moves towards the surface - results in discharging
sinus.
• In Tuberculous sinus – previous history of lymphadenitis – cold
abscess – burst/incised – discharging sinus
• In perianal fistula – previous H/O of perianal or ischiorectal
abscess – intermittent contraction of anal sphincter – inadequate
rest to the part – non healing fistula.
FISTULAS AND SINUSES OF THE NECK
AND FACE
• Developmental – Thyroglossal duct cyst / sinus, Branchial cleft
cyst/fistula, Preauricular pits and sinuses.
• Traumatic – Accidental, Radiotherapy, Surgical
• Infective - Actinomycoses, Tuberculosis, Bone infection
(Osteomyelitis), Dental infection.
THYROGLOSSAL DUCT CYST / FISTULA
• The most common developmental cyst of the side of the neck arising
from the remnants of the 2nd branchial cleft.
• It usually appears beneath the anterior border of upper third of the
sternocledomastoid muscle.
• A sinus/fistula may appear on the side of the neck just above the
junction of the collarbone and breast bone (sternoclavicular joint),
in front of the sternocleidomastoid muscle. The fistulous tract is
lined by ciliated columnarvepithelium with a mucoid or
mucopurulent discharge.
• Treatment is by complete surgical excision of the fistulous
tract/sinus.
BRANCHIAL CLEFT CYST/ SINUS
PREAURICULAR SINUS
• Accidental
• Radiotherapy
• Surgical
INFECTIVE
• Actinomycosis
• Bone infection:
• Chronic osteomyelitis – most commonly associated with poorly
controlled diabetes mellitus or following radiotherapy to the jaw
for cancer or Paget disease of the bone.
Dental infection
• Chronic dentoalveolar abscess
• Dental implant
• Failed endodontic procedure
Malignancy
• Squamous cell carcinoma (most common)
THANK YOU