SKIN AND

SUBCUTANEOUS TISSUE
Sinus and fistula
LEARNING OBJECTIVES

• To understand the structure and functional properties of the skin.

• To know the causes of different types of sinus and fistula .
• To be aware of the factors leading to persistence of sinus or
fistula.
• To have basic knowledge about management of sinus and fistula.
SKIN AND SUBCUTANEOUS TISSUE
EPIDERMIS

• The epidermis is composed of keratinized stratified squamous

epithelium and can be further subdivided into five layers:
• stratum basale (deepest)
• stratum spinosum
• Stratum granulosum
• stratum lucidum and
• stratum corneum (superficial)

• It accounts for 5 per cent of the total skin

DERMIS

• The dermis comprises 95 per cent of the skin and is structurally

divided into two layers:
• The superficial papillary layer composed of delicate collagen and
elastin fibres in ground substance into which a capillary and
lymphatic network ramifies.
• The deeper reticular layer composed of course branching
collagen layered parallel to the skin surface.
SKIN ADNEXIA

• 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

• Skin thickness varies with age and body area.

• It is thinner in children than in adults in any given region.
• The dermis is between 15 and 40 times thicker than the
epidermis, but starts to thin during the fourth decade as part of
the ageing process.
• The epidermis is thickest on the palms, soles, back and buttocks
and thinnest on eyelids (0.5–1 mm on sole of the foot, 0.05–0.09
mm on the eyelid).
FUNCTIONS OF THE SKIN

• Function of the skin:

• Barrier to the environment: trauma, radiation, pathogens
• Temperature and water homeostasis
• Excretion (e.g. urea, sodium chloride, potassium, water)
• Endocrine and metabolic functions
• Sensory organ for pain, pressure, movement
 SINUS

• Sinus – ‘Hollow’ or ‘Bay’ (Latin).

• A sinus is a blind-ending tract that connects a cavity lined with
granulation tissue (often an abscess cavity) with an epithelial
surface.
• There may be discharge from the opening of sinus.
• Often sprouting granulation tissue is seen over
the sinus opening.
TYPES OF SINUS

CONGENITAL ACCQUIRED ANATOMICAL

Due to persistence of Due to presence of a retained Frontal sinus
remnants of embryonic foreign body, specific chronic
infection, malignancy, Maxillary sinus
ducts which are not inadequate drainage of cavity
obliterated during
development • Tuberculous sinus
• Pilonidal sinus
• Preaurical Sinus
• Actinomycosis caused by
• Umbilical sins Actinomyces israelii
• Median Mental Sinus
• Osteomyelitis
PREAIRICULAR SINUS
PILONIDAL SINUS

• Infected pilonidal sinus presents with

• pain when sitting or standing
• Swelling or formation of cyst
• Reddened, sore skin around the area
• Pus or blood draining from the abscess, causing a foul odor
• Hair protruding from the lesion
• formation of more than one sinus tract, or holes in the skin

• Treated with antibiotics or surgery in case of repeated infections.

MEDIAN MENTAL SINUS

• 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

• Treatment of the sinus is directed at removing the underlying

cause e.g. removal of any foreign body.
• Recurrent infection is an indication for complete excision of the
sinus tract with adequate drainage and adequate rest. Biopsies
should always be taken from the wall of the sinus to exclude
malignancy or specific infection.
• Specific management of any disease condition should be done
simultaneously ATT for Tuberculosis,
FISTULA

• Fistula means "flute" or "a pipe or tube”.

• It is an abnormal communication between two epithelial surfaces
like the lumen of one viscus to another or to the body surface or
between the vessels. It has got two openings and is lined by
granulation tissue or epithelium.
 TYPES OF FISTULA

CONGENITAL ACCQUIRED

• Branchial fistula • Traumatic

• Tracheo-oesophageal fistula • Inflammatory – Parotid abscess
• Umbilical • Malignant

• Congenital AV fistula • Iatrogenic - Arteriovenous

fistula created surgically during
• Thyroglossal fistula dialysis in renal failure.
 TYPES OF FISTULA

• 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
• When the tract communicates
a hollow viscus to the skin.
• E.g. Parotid fistula,
Thyroglossal fistula, Branchial
fistula, Appendicular,
Orocutaneous.
INTERNAL
• When the tract communicates
between two hollow viscera.
• E.g. Tracheo-oesophageal
fistula, Rectovesical, Colo-
vesical
INTESTINAL FISTULAS

• Surgical procedures to treat cancer, inflammatory bowel disease

(IBD), peptic ulcer disease
• IBD - Crohn disease and ulcerative colitis
• Diverticular disease
• Radiation
• Malignancy - Gynecologic, Pancreatic, Rectal.
• Appendicitis
• Perforation of duodenal ulcers.
• Abdominal trauma - Such as gunshot wounds, stabbing (sharp
trauma), or motor vehicle accident (blunt trauma).
• Aortic aneurysm, infected aortic graft, or previous abdominal aortic
surgery.
CAUSES OF PERSISTENCE OF SINUS OR
FISTULA
• A foreign body or necrotic tissue underneath, e.g. suture, sequestrum.
• Insufficient or non-dependent drainage.
• Persistent obstruction in the lumen, e.g. in fecal fistula, biliary fistulas
(distal obstruction).
• Lack of rest to the affected part.
• Epithelization or fibrosis of tracts prevents contraction and healing.
• Specific infections: Tuberculosis, actinomycosis, HIV.
• Presence of malignant disease.
• Radiotherapy, chemotherapy
• Malnutrition
CHIEF COMPLAINTS

• Recurrent/ persistent discharge.

• Pain.
• Constitutional symptoms if any deep seated origin.
• Specific symptoms like passage of urine or passage of foul
smelling discharge or gas per vagina.
PAST HISTORY

Few diseases are prone to develop sinus/fistula later in life :

• Tuberculosis
• Crohn’s disease
• Ulcerative colitis
• Actinomycosis
• Carcinoma
• Any operation performed
• Difficult/Instrumental labour
CLINICAL EXAMINATION

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

• Temperature and tenderness – Sinus from Osteomyelitis (OM) will be

tender.
• Discharge: after application of pressure over the surrounding area
• Induration: present in chronic fistulae/sinus as in actinomycosis, OM .
In TB Sinus induration is absent.
• Adjoining structures - Matted lymph nodes felt in tubercular sinus.
Thickened underlying bone is felt in chronic osteomyelitis .
• Fixity – Sinuses from OM are fixed to the bone which becomes irregular,
thickened and tender.
• Examination of draining lymph nodes - Firm and matted in
tuberculosis; firm, discrete and mildly tender in chronic nonspecific
infection; hard and fixed in malignancy.
DISCHARGE

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

• Complete haemogram - Hb, TLC, DLC, ESR.

• Discharge for C/S , Acid Fast Bacilli (AFB) for tuberculosis,
cytology for suspected malignancy, Gram staining for bacterial
infection.
• X-RAY of the part to rule out OM, foreign body.
• X-RAY KUB and USG abdomen
• MRI
• BIOPSY from edge of sinus
• CT Sinusogram
 FISTULOGRAPHY/ SINUSOGRAPHY:

• For knowing the exact extent/origin of sinus (or)fistula.

• • Water soluble or ultrafluid lipoidal iodine dye is used.
TREATMENT

• 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 in the neck.

• The embryonic mesoderm which ultimately develops into the
thyroid gland descends from the foramen caecum of the tongue to
the normal pre tracheal site of the gland and forms the
thyroglossal duct which gets obliterated later on. Persistence of
parts of Thyroglossal duct or the islands of thyroid tissue along the
path of descent can give rise to the cyst.
THYROGLOSSAL DUCT CYST / FISTULA

• Usually presents in the first decade of life as a midline, smooth,

soft, cystic swelling along the line of thyroid descent. The
commonest position is sub hyoid followed by suprahyoid , at the
level of thyroid cartilage and least commonly at the level of cricoid
cartilage.
• Moves upwards when the patient protrudes the tongue (unlike
thyroid swellings) because it is attached to the thyroglossal tract
which attaches to the foramen caecum of the tongue. It also
moves up with swallowing (like thyroid swellings).
• Investigations include Ultrasonography to confirm cyst and Radio
isotope scanning and estimation of Thyroid Stimulating Hormone
(TSH) to exclude ectopic thyroid. Fine Needle Aspiration Biopsy is
done to confirm the diagnosis.
THYROGLOSSAL DUCT CYST / FISTULA

• Differential diagnoses include dermoid cyst, branchial cyst, sub

hyoid bursitis, pretracheal lymph node, solitary nodule of thyroid-
isthmus, collar-stud abscess, ectopic thyroid, lipoma and
sebaceous cysts.
• Complications include secondary infection, malignant
transformation (Papillary carcinoma), formation of fistula due to
recurrent infection or inadequate excision and drainage.
• Surgical excision of Thyroglossal cyst, part of the body of hyoid
bone, entire thyroglossal tract upto foramen cecum in the tongue
(Sistrunk's operation) is the treatment of choice.
THYROGLOSSAL DUCT CYST / FISTULA
BRANCHIAL CLEFT CYST/ SINUS

• 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

• Preauricular pits and sinuses – these are common, affecting 1% of

the population, particularly Asians and blacks. 25% are bilateral in
front of both ears. The sinus opening (pit) is usually located just in
front of the upper part of the ear where the cartilage of the ear
rim (helix) meets the facial skin. They are asymptomatic unless
infected (uncommon), when they become red, sore and may
discharge pus.
TRAUMATIC

• 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