|Year : 2016 | Volume
| Issue : 2 | Page : 105-110
The role of phenol application in the management of pilonidal sinus disease
Satish Dalal, Nityasha Nara, Suresh Kumar Kataria, Vundavalli Sattibabu
Department of General Surgery, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences (P.G.I.M.S.), Rohtak, Haryana, India
|Date of Web Publication||30-Nov-2016|
Suresh Kumar Kataria
Department of General Surgery, Pt. B.D. Sharma Postgraduate Institute of Medical Sciences (P.G.I.M.S.), Rohtak - 124001, Haryana
Source of Support: None, Conflict of Interest: None
Background: Pilonidal sinus disease (PNSD) is common among young adults. The diagnosis of disease is more often a clinical one, based on the patient's history and physical findings. Numerous treatment options, ranging from simple excision to extensive flap procedures, currently exist. However, hospital stay, missed days of work, recurrence rates, and surgeon's familiarity with the techniques are important factors in the choice of treatment modality. The aim of present study was to study the role of phenol application in the management of PNSD.
Patients and Methods: In our study, we aimed to share the results of our patients who underwent treatment with local application of 80% phenol. After shaving from waist to mid-thigh posteriorly, 1 cc phenol was injected via sinus under local anesthesia.
Results: In this study, all the 30 outpatients were male. The average age was 23.5 years. Complete cure was obtained in 24 (80%) patients. The mean number of days required for complete healing of sinus were 47.83 days. Four patients had nonhealing of sinus and two patients developed recurrence.
Conclusion: This method of treatment is very simple and has acceptable relapse rates. It does not affect productive life of patient and does not need hospitalization. Thus, it could be considered as the first choice in the treatment of noncomplicated pilonidal sinus.
Keywords: Phenol, pilonidal sinus disease (PNSD), recurrence
|How to cite this article:|
Dalal S, Nara N, Kataria SK, Sattibabu V. The role of phenol application in the management of pilonidal sinus disease. Arch Int Surg 2016;6:105-10
| Introduction|| |
Pilonidal sinus disease (PNSD) is a common condition that affects mostly younger patients and occurs predominantly in the sacrococcygeal region. Incidence is reported as 26 per 100,000 populations. It occurs more frequently in young adults. It is observed most commonly in people aged between 15 years and 30 years, occurring after puberty when sex hormones are known to affect the pilosebaceous gland and change healthy body hair growth. The onset of pilonidal disease in people older than 40 years is rare.
In 1833, Herbert Mayo described a hair-containing sinus, but it was not until 1880 that Hodge suggested the term “pilonidal” (Latin:pilus = Hair and nidus = Nest)., By definition, a pilonidal sinus is a sinus that contains hairs, mainly in the sacrococcygeal region and is due to favoring conditions such as the existence of deep natal cleft and the presence of hair within the cleft, sweating, maceration, bacterial contamination, and penetration of hairs. In addition, certain effect exerted by movement of the buttocks encourages loose dead hairs to gain entry into the sinus. The disease was also branded as “jeep disease” during the Second World War because of high incidence among jeep drivers.
The correct treatment of pilonidal sinus is still a matter of debate and controversy. The disease is still a problem for the surgeon, a nuisance to the patient, and a financial strain on the health industry. The high recurrence rate of the disease stimulated some surgeons to device radical operations that not only remove the sinus but also remove the postnatal cleft. On the contrary, for the same reason, others adopted the nonsurgical and conservative procedures. One of these techniques is injection sclerotherapy of pilonidal sinus with phenol. It was first introduced by Maurice and Greenwood in 1964, and it was strongly advocated by Stephens and Sloane; Stewart and Bell; and Kelly and Graham Shorey.,, The aim of the present study was to study the role of phenol application in the management of PNSD.
| Patients and Methods|| |
This prospective study was conducted in the Department of General Surgery, of an apex institute in North India. It aimed to assess the efficacy and safety of local phenol application for the treatment of sacrococcygeal PNSD. Thirty patients with noncomplicated PNSD were treated with phenol sclerotherapy. Complex and recurrent PNSD cases were not included in the study. Previously operated patients were also excluded from the study. Written consent was taken from all patients for phenol instillation in the sinus. The patients were informed about the nature of the procedure and its potential advantages and shortcomings. All the patients were treated as outpatient.
After making the final diagnosis of the noncomplicated PNSD, a detailed history and clinical examination was recorded on designed pro forma. The patient having a single or two openings in the midline without evidence of severe/chronic disease were labeled as noncomplicated PNSD.
Patients were shaved from waist to mid-thigh posteriorly and they were instructed to remove hairs of the back and buttock down to mid-thigh by shaving or by using of a depilatory cream during the treatment period. The area was cleaned with povidone–iodine solution and was covered with gauze. The skin and sacrococcygeal fascia along with surrounding tissue of main sinus and its lateral tract was infiltrated with adequate amount of lignocaine with adrenaline. If the sinus opening was less than 3 mm in diameter, it was enlarged by use of mosquito clamp under local anesthesia. If at least one opening was 3 mm or more in diameter this enlargement was not required.
Following determination of the direction of the sinus, the hairs were removed with the use of same clamp. If the sinus abscess had been drained previously, the drainage (sinus) opening required no enlargement to remove the hair. The sinus tract was curetted with biopsy curette. After removal of the hair and curetting, a swab or large piece of cotton was used to protect the anus while rest of the area was liberally coated with povidone–iodine ointment or Vaseline. Eighty percent phenol was injected into the main sinus with the aid of 5 mL disposable syringe to fill the sinus tract with snugly fitted nozzle of the syringe with plastic or metallic cannula into the opening of the sinus and protecting the surrounding skin [Figure 1]. The phenol instillation was performed slowly using minimum pressure to avoid phenol being forced into the tissue surrounding the sinus and causing a local inflammatory reaction [Figure 2]. The phenol was left in situ for approximately 1 min and was then expressed by pressure. The excess phenol was mopped along with debris removed from the sinus. The procedure was finished after dressing the wound with a gauze piece.
|Figure 1: Showing protection of surrounding skin during the injection of phenol|
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|Figure 2: Showing instillation of phenol in the sinus tract with the help of plastic cannula|
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Whole procedure was performed in the patient in prone position. The patients were able to return to daily activities immediately after the procedure and had their first follow-up after 1 week. If the patient's wound had no leakage, no further procedure was required. If leakage was observed from the wound, same method described above was repeated at third and sixth weeks after the initial procedure. Closure of all the orifices was accepted as complete cure [Figure 3]. Nonrecurrence of the same sinus and nonappearance of a new sinus during follow-up periods was considered as successful treatment. Those who were cured were recommended to return for a follow-up consultation after 3 months. No patient was treated with more than three local applications of phenol in the study. If the patient developed discharge even after three applications, it was taken as recurrence or failure of treatment. Antibiotics were not used for any patient in the study. Tablet Diclofenac potassium, 50 mg twice a day, was given to all patients for 1 week for analgesia.
All patients were followed up initially at first week and then at the third week and finally at sixth week. Same follow-up was repeated at first week, third week, and sixth week in patients after second or third injection of phenol if it was required in a particular patient. The outcome was assessed in terms of following parameters:
- Pain after injection—mild, moderate, and severe.
- Time taken for obliteration of sinus tract and healing.
- Total no. of phenol injections given.
- Complications —such as abscess formation, cellulitis, skin necrosis, discharge, and appearance of a new opening.
All patients were reassessed after 3 months for evidence of recurrence of the PNSD after completion of treatment.
The total duration of study including follow-up period was one and a half years and we used to get 30 patients of pilonidal sinus in 1 year.
Thirty patients with noncomplicated PNSD were treated with phenol sclerotherapy. Complex and recurrent PNSD cases were not included in the study. Previously operated patients were also excluded from the study.
| Results|| |
Thirty patients with uncomplicated PNSD were included in this study. The following observations were made from the study. In our study, the youngest patient was of 15 years and the oldest patient was of 45 years. The mean age was 23.5 years suggesting that the pilonidal disease is more common in the first half of third decade. Majority of the affected patients (86.66%) were young hirsute male students. Body mass index (BMI) of every patient was calculated by standard formula, and all patients were divided into four groups as per [Table 1]. Around 53% of the patients belonged to the moderately overweight category. All patients had complaints of discharge from their sinuses. Majority (80%) of them had swelling at the site of complaint while around 50% of these patients had pain as the presenting complaint. Fever was an uncommon presentation and was present in only 3.33% of patients. Forty percent of the patients had duration of symptoms less than 6 months, and 60% patients had symptoms for more than 6 months duration.
More than 50% of the patients had purulent discharge from their sinus openings suggesting bacterial infection in the sinus. Good hygiene was observed in 96.66% patients while status of hygiene was poor in 3.33% of patients. Depth of natal cleft was assessed by subjective clinical examination. Out of all the patients, 53.33% patients were having deep natal cleft, and it was shallow in 47.66%. Majority of the patients (53.33%) had two sinus openings in the midline. Majority of the patients in our study had 1-25 hairs extruding from the sinus mouth (96.66%) and hair inside the sinus (83.33%). Very few patients had more than 50 hairs inside the sinus. Most of the patients (70%) required two phenol applications for complete relief from the symptoms of the disease. Twenty percent of the patients were given three injections. Ten percent required only one phenol application for complete cure [Table 2]. The mean number of days required for complete healing of sinus was 47.83 days. The healing of sinuses ranged from a minimum of 21 days to a maximum of 74 days [Table 3]. Majority of the sinuses healed between 4 weeks and 8 weeks after the first instillation of phenol including those who were injected phenol at 6 weeks [Table 4].
Local pain was the most common early symptom after the phenol application in 10 patients followed by skin burn or necrosis in seven patients. Complications of abscess formation and appearance of new sinus opening occurred in five patients each. There was nonhealing of sinus in four patients and in two patients recurrence of the sinus opening was observed. These patients (6) were counted as treatment failures and underwent surgical intervention for further treatment [Table 5].
| Discussion|| |
Pilonidal sinus is generally accepted to be an acquired condition that bears high postoperative morbidity and patient discomfort. Though known from centuries, effective treatment of PNSD is still a major problem in the medical world. Pilonidal sinus affects mostly the population in second and third decades. The condition is rare in people under 15 years, that rises sharply to peak in people from 16 years to 20 years of age and declines after age of 25 years.,
In our study, the mean age was 23.5 years and all of them were male. Main reason why it is widely seen among males could be that male population has more hair follicles than females and the less referral of women to health centers due to sociocultural barriers. Besides, as sex hormone activity levels are higher in young population, it could be the reason why it is usually seen in younger people.
In our study, mean BMI was 26.03 ± 3.95 and most of the patients (53.33%) were moderately obese. So as per literature and also as per our study, obesity is a risk factor for the development of PNSD. The role of obesity as a causative factor and its effect on effectiveness of some treatment modalities has been discussed in the literature. There was no particular occupation associated with PNSD. Occupation requiring long sitting is described as primary risk factor for PNSD. Men are thought to be at higher risk because of their more hirsute nature. Other associations with pilonidal disease are obesity (37%), sedentary occupation (44%), and local irritation or trauma (34%). The increased risk of PNSD in the students was higher due to more sitting hours in a day. The majority of the classical articles about PNSD indicate a relation between long sitting time and this disease.
Most surgical methods usually involve a lengthy hospital stay and considerable time off work. Numbers of surgical techniques have been tried including excision, excision with primary closure, and Z-plasty. Goodall and Verbeck have reported a hospital stay of 18 days and 15 days, respectively, for excision with primary closure, while Notaras and Goodall have reported a mean hospital stay of 17 day and 18 days, respectively, for excision without closure. Although these method can be very effective, they are more painful and require repeated uncomfortable dressings. The technique of open excision that resulted in high incidence of cure was associated with a very prolonged healing time, an average of 86 days was reported by Berkowitz and an average of 10 weeks was reported by Notaras. The radical procedure with Z-plasty or Rhomboid flap with least recurrence risk are too lengthy surgeries for such a minor disease. Bose and Candy reported 20% of necrosis of corners of the Z-flap, 14.3 days average hospital stay and 5.5 weeks average absence from work. The complication rates in surgical procedures has remained high and are mainly hemorrhage, hematoma, infections, fluid collection, flap necrosis, wound dehiscence, delayed healing, and poor cosmesis. For these young patients, who are otherwise healthy, active, these wounds cause considerable social and economical disabilities. Spinal anesthesia an invasive procedure, it has its own complications, such as headaches and urinary retention, and it is more costly than local anesthesia, additionally it requires patient monitoring after the procedure.
In surgical treatment of PNSD, different relapse rates are reported according to the surgical procedure. These relapse rates are stated as follows: 5-19% in cystotomy, 6-17% in Bascom operation, 16-22% in primary excision and closure, 1-7% in Karydakis operation, 0-5% in Limberg flaps.
The phenol is an aromatic alcohol that exhibits weak acidic properties, also has corrosive and poisonous properties. It is also called carbolic acid. It sterilizes the sinus tract by intense inflammatory response and remove embedded hair after normal saline wash., Phenol after injecting into the sinus tract acts as sclerosing agent and leads to healing of the sinus tract. The method was first proposed by Morris and Greenwood as an alternative to extensive procedures. The efficacy of phenol has been demonstrated in some studies but overall results are mixed after giving one or two injections in a gap of 1 month. Successful healing rates have been reported in more than 70% cases in different studies., In our study, 30 cases of noncomplicated pilonidal sinus were treated with 80% phenol on outpatient basis and a cure rate of 80% was obtained. So out of 30 patients, the sinuses of 24 patients healed with phenol in our study. Out of these 24 patients, 3 patients required one injection and 21 patients required 2 injections for complete healing of sinus. Six patients were given three injections, four of them did not respond to phenol therapy and another two developed recurrence after a few weeks. So in our study, 2 out of 30 patients had a recurrence and the recurrence rate of around 7%. While four patients did not respond to phenol therapy and were labeled as a treatment failures. These six patients were counted as treatment failure and underwent surgical intervention for further treatment. The mean numbers of days required for complete healing of sinus were 47.83 days. Surgical treatment need long period including preoperative preparation period, postoperative hospital stay, and long recovery period after discharge; however, phenol-applied patients can be sent home after a 15-min procedure. In addition, operative stress and postoperative cosmetic problems are also an extra psychological burden on the patients. Injection of phenol is a simple procedure that can be done under local anesthesia as an outpatient procedure.
| Conclusion|| |
Pilonidal sinus is considered as an acquired disease mainly involving the young and adult males in their productive life. Though numbers of procedures are available, no method is ideal for the treatment of all cases of PNSD. The goal of this treatment is to minimize the morbidity of treatment and to limit the recurrence to the barest minimum. The treatment of PNSD with phenol, which is simple, inexpensive, done on OPD basis, leads to rapid return to normal daily activity and has got acceptable recurrence rates, so it can be considered as a first-line treatment for simple cases of PNSD while surgical methods are reserved for complex and recurrent cases.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]