You are in: eMedicine Specialties > Emergency Medicine > INFECTIOUS DISEASES Pilonidal Cyst and SinusArticle Last Updated: Jun 6, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 9
  Author: Robert Ringelheim, MD, Attending Physician, Memorial Regional Hospital Robert Ringelheim is a member of the following medical societies: Society for Academic Emergency Medicine Coauthor(s): Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn; Norma Jean Johnson-Villanueva, MD, Consulting Staff, Department of Emergency Medicine, Englewood Hospital Editors: Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Senior Vice President, Chief Medical Officer, Medical Director, Attending Physician in Department of Emergency Medicine, Saint Barnabas Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jeter (Jay) Pritchard Taylor III, MD, Compliance Officer, Attending Physician Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Richland Memorial Hospital, University of South Carolina; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Pamela L Dyne, MD, Associate Professor, Program Director, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine Author and Editor Disclosure Synonyms and related keywords: hair-containing sinus, hair-containing abscess, Jeep rider's disease, pilonidal disease, acute pilonidal abscess, chronic pilonidal abscess, Staphylococcus aureus, Bacteroides species INTRODUCTIONSection 2 of 9
  BackgroundIn 1833, Herbert Mayo described a cyst that contained hair just below the coccyx. Hodge in 1880 coined the name "pilonidal" from the Latin words pilus, which means hair, and nidus, which means nest. Pilonidal disease consists of a spectrum of entities ranging from asymptomatic hair containing cysts and sinuses to a large abscess in the sacrococcygeal area. The controversies surrounding the origin of pilonidal disease first came to light during World War II. From 1941-1944, 78,924 soldiers were treated for pilonidal disease. The disease was the leading cause of nontraumatic sick days taken by United States soldiers. Most soldiers had recovery times of approximately 100 days. PathophysiologyThe medical literature regarding the etiology of the pilonidal cyst has shifted. Initially, these cysts were believed to be congenital in nature. One of the more prevalent congenital theories believed that patients with pilonidal disease have persistent remnants of the caudal segment of the neural canal. This caudal segment formed multiple small cysts that remained in contact with the skin surface. As the cyst increased in size, they eventually ruptured, resulting in the formation of sinuses tracts. The congenital theory has been called into question for multiple reasons. Most notable was multiple case reports describing pilonidal cyst formation in jeep drivers in World War II. So many serviceman were affected with pilonidal disease that it was renamed "jeep disease." These findings led to the belief that pilonidal cysts can be acquired by excessive repetitive trauma to the sacrococcygeal region. Although rare, pilonidal cysts have also been reported in other parts of the body that are exposed to repetitive trauma such as barber's and sheepherder's hands. The male predominance of pilonidal cyst, the presentation in the adolescent period of life, and the recurrence after adequate surgical drainage further encouraged the rejection of the congenital theory. These points lead the way for the modern day acceptance of the acquired theory of pilonidal cysts. The acquired theory postulates that pilonidal disease is a result of hair and cellular debris finding a portal of entry into the skin and hair follicles. The entering hair causes an inflammatory reaction and edema. The edema causes occlusion of the skin opening increasing the hair follicle size. This results in a build up in pressure in the hair follicle that eventually spreads its purulent material into the subcutaneous tissue causing a foreign body reaction. This reaction forms multiple microabscesses that eventually migrate further into the subcutaneous tissue. A vacuum force caused by the tauting of skin when the patient bends over is believed to aid in the hair migration. These microabscesses eventually result in the creation of more sinus tracts and abscesses. Karydakis later described the role of hair in the formation of pilonidal disease and divided it into 3 phases: phase 1, the invader, a free hair is available to invade into a portal of entry into the skin; phase 2, the force that causes theinsertion; and phase 3, the vulnerability of the skin to the insertion of hair at the depth of the natal cleft. At surgery, only 50-75% of all pilonidal cysts actually contain hair. FrequencyUnited StatesPilonidal disease affects approximately 26 per 100,000 people. InternationalIn England in 2000-2001, a total of 11,534 admissions were recorded for pilonidal disease. The mean hospital stay was 4.3 days. SexPilonidal disease in the general population has a male preponderance. It occurs in the ratio of 3 or 4:1. In children, however, the ratio is the opposite occurring in 4 females for each male it afflicts. AgePilonidal disease commonly affects adults in the second to third decade of life. Pilonidal cysts are extremely uncommon after age 40 years, and the incidence usually decreases by age 25 years. The average age of presentation is 21 years for men and 19 years for women. CLINICALSection 3 of 9
HistoryPilonidal disease has 3 major types of presentations.
PhysicalThe physical findings in pilonidal disease are dependent on the stage of disease at presentation. In the early stages, the patient can notice a sinus tract or pit in the sacrococcygeal region. This can progress to midline edema or abscess formation. As with any abscess, physical examination findings include tenderness to palpation, fluctuance, warmth, purulent discharge, and induration or cellulitis. Fever and other systemic signs of infection are uncommon. Causes
DIFFERENTIALSSection 4 of 9
Anal Fistulas and Fissures Hidradenitis Suppurativa Perirectal Abscess Syphilis Tuberculosis
|
