Br. J. Surg. Vol. 62 (1975) 407-408
Pilonidal sinus treated by phenol injection B. A. S H O R E Y * SUMMARY
The method of using phenol injections for the treatment of pilonidal sinus is described in detail. This is a simple, safe and painless method which may be used as a day case procedure. The results are discussed and compare very fauourably with the more radical forms of treatment. THEfirst reported case of a pilonidal sinus that was successfully treated was described by Anderson ( I 847). The sinus was incised and the enclosed hair removed. Since that time many papers have appeared on the aetiology and treatment of this condition. It was originally thought that the aetiology was congenital due either to remnants of neural canal becoming separated or to ectodermal inclusions (Mallory, 1892; Kooistra, 1942). However, since the papers of King (1946), showing that the hairs present in these sinuses have their roots nearest the opening, and of Patey and Scarff (1946), describing pilonidal sinus in the interdigital clefts of barbers, the acquired theory of aetiology has become generally accepted. Brearley (1955) and Raffman (1959) also contributed papers supporting the acquired theory and suggesting ways in which the hairs enter the skin. Pilonidal sinuses have now been reported in many areas of the body-perineum (Smith, 1948), umbilicus (Steck and Helwig, 1965), interdigital cleft (Currie et al., 1953), scalp (Stevens and Anderson, 1961), amputation stump (Shoesmith, 1953), axilla (Aird, 1952). It would thus seem impractical to think of this condition as congenital.
Method The method used for phenol injection is similar to that first described by Maurice and Greenwood (1964). Following general anaesthesia with endotracheal intubation, the patient is placed prone on the operating table. The table is then raised in the centre or the patient lifted on to pillows to obtain the ‘jackknife’ position. The patient, having previously been shaved from the waist to mid-thigh posteriorly, has the buttocks held apart by the use of 7.5-cm strapping, thus exposing the natal area and anal verge. At this stage further shaving may be necessary, especially deep in the natal cleft. The area is now prepared and towelled up in the normal manner. A swab or large piece of cotton wool is used to protect the anus, while the rest of the area is liberally coated with paraffin jelly (Vaseline) to protect it from the phenol. After careful probing any loose hairs are removed with forceps from the sinus and any of its side tracts. With a blunt needle which fits snugly into the sinus orifice and a 10-ml syringe, the sinus is injected with
a solution of 80 per cent phenol. No excess pressure is used for fear of the phenol being forced into the surrounding tissue lining the sinus and causing a local inflammatory reaction. It has been suggested (Stephens and Sloane, 1969) that the operator should wear glasses as protection against any splash of phenol. This problem did not arise in the present series. On commencing the injection, phenol can be seen issuing from the side canals. The phenol is left in siru for 2 minutes and then expressed by pressure. The excess is mopped away with the debris. This manceuvre is repeated two or three times; the orifice of the sinus is seen to blanch at this stage. A dressing of paraffin jelly is applied, the excess Vaseline being removed. The patient is allowed home when he has recovered from the anaesthetic.
Results In the Bristol Royal Infirmary during the period 1968-72, 253 patients with pilonidal sinus came to surgery. Various forms of treatment were undertaken as shown in Table I . Table I : METHODS OF TREATMENT OF PILONIDAL SINUSES Laying Primary Brush Phenol ouen suture techniaue iniection
No. of patients No. of failures or recurrences
179 14
42 7
9
2
23 2
Although those treated by phenol injection comprise only a small percentage of the total, it can be seen that the results compare favourably with those of other methods. Of the 23 patients so far treated, 20 were male and 3 female; their ages ranged from 18 to 59 years. The presenting symptoms were recurrent abscess formation or a persistent discharge; most of the patients had been having symptoms for over a year. Successful treatment was judged by epitheIization occurring without any discharge or pain; 21 cases were deemed a success while 2 were failures. Of the 2 failures, one was at first successful but recurrence occurred after 9 months with a further abscess. The other case proved very difficult and was resistant to any form of treatment. Phenol injections failed twice and he subsequently had 6 other operations. It was emphasized to all the patients that postoperatively the natal cleft must be kept free of hair by shaving. Personal hygiene of the area was also encouraged.
* Department of
Surgery, Bristol Royal Infirmary.
407
B. A. Shorey
Discussion A large number of operations have been described for the treatment of pilonidal sinuses and all have their supporters. Some of the procedures that have been described for this relatively minor condition are major undertakings, and it is not surprising that Walters and MacDonald (1958) suggested a return to simple treatment. Phenol injection is a simple procedure and offers many advantages to the patient. The length of hospitalization is minimal ; all the patients in this series were discharged on the day following operation. It would therefore be a logical step to treat all pilonidal sinuses as day cases, for there is little danger after recovery from the anaesthetic. In fact, 4 patients treated by Stephens and Sloane (1969) had phenol injections as outpatients without a general anaesthetic. Following phenol injection patients have very little discomfort and are thus able to return to a normal routine almost immediately. Other simple forms of treatment such as marsupialization are widely practised but healing is prolonged; an average of 86 days was quoted by Berkowitz (1949). This leads to discomfort, excess hospitalization, frequent dressings, prolonged medical supervision and more time off work. Primary excision and closure has many advocates (Holman, 1946; Mandel and Thomas, 1972; Casten et al., 1973), and in good hands very satisfying results are obtained, but failures occur (Rogers and Hall, 1935), hospitalization is longer and postoperative discomfort more severe than with phenol injections. The most drastic operation of rotational flaps has not been popular owing to the length of stay in hospital and postoperative pain. However, good results have been obtained (Davis and Starr, 1945). The simpler methods of treatment, such as diathermy coagulation (Jacobsen, 1959; Flannery and Kidd, 1967) and incision and brush technique (Lord and Millar, 1965), have the disadvantage that in each technique an incision is made over the sinus. This means that postoperatively the wound has to be dressed and frequent medical supervision is required. However, phenol injection (Maurice and Greenwood, 1964; Stephens and Sloane, 1968; Stewart and Bell, 1969) has several advantages. The operation is simple and the only postoperative dressing required is small, its purpose being to prevent any excess phenol being expressed on to the skin. Acknowledgement I would like to thank Mr H. K. Bourns for allowing me to study the patients under his care and for his encouragement in writing this paper. References AIRD I. (1952) Pilonidal sinus of the axilla. Br. Med. J. 1, 902-903. ANDERSON A. w. (1847) Hair extracted from an ulcer. Bost. Med. Surg. J. 36, 74. BERKOWITZ J. (1949) Sacrococcygeal pilonidal cyst. Am. J. Surg. 11,477-490, BREARLEY R . (1955) Pilonidal sinus: a new theory of origin. Br. J. Surg. 43, 62-68. 408
and AYUYAO A. (1973) A technique of radical excision of pilonidal diseasc with primary closure. Surgery 73, 109-1 14. CURRIE A. R., GIBSON T. and GOODALL A. L. (1953) Interdigital sinuses of barber’s hand. Br. J. Surg. 41, 278-286. DAVIS L. s. and STARR K. w. (1945) Infected pilonidal sinus. Surg. Gynecol. Obstet. 81, 309-319. FLANNERY B. P. and KIDD H. A. (1967) A review of pilonidal sinus lesions and a method of treatment. Postgrad. Med. J. 43, 353-358. HOLMAN E. (1946) Pilonidal sinus-treatment by primary closure. Sirrg. Gynecol. Obstet. 83, 94100. JACOBSEN P. (1959) Pilonidal disease. Management without excision. Am. Acad. Gen. Practice 19, 84-90. KING E. s. J. (1946) The nature of the pilonidal sinus. AUS.NZ J. Slirg. 16, 182-192. KOOISTRA H. P. (1942) Pilonidal sinuses, review of literature and report of 350 cases. Am. J . Surg. 55, 3-17. LORD P. H. and MILLAR D. M. (1965) Pilonidal sinus: a simple treatment. Br. J. Surg. 52, 298-300. MALLORY F. B. (1892) Sacro-coccygeal dimples, sinuses and cysts. Am. J. Med. Sci. 103, 263-277. MANDEL s. R . and THOMAS c . G. (1972) Management of pilonidal sinus by excision and primary closure. Surg. Gynecol. Obstet. 134, 448-450. MAURICE B. A. and GREENWOOD R . K. (1964) A conservative treatment of pilonidal sinus. Br. J. Surg. 51, 510-512. PATEY D. H. and SCARFF R . w . (1946) Pathology of postanal pilonidal sinus: its bearing on treatment. Lancet 2, 484-486. RAFFMAN R . A. (1959) A re-evaluation of the pathogenesis of pilonidal sinus. Ann. Sirrg. 150, 895-903. ROGERS H. and HALL H. G. (1935) Pilonidal sinussurgical treatment and pathological structure. Arch. Surg. 31, 742-766. SHOESMITH J. B. (1953) Pilonidal sinus in an aboveknee amputation stump. Lancet 2, 378-379. SMITH T. E. (1948) Anterior or perineal pilonidal cysts. JAMA 136, 973-975. STECK W. D . and HELWIG E. B. (1965) Umbilical granulomas, pilonidal disease, and the urachus. Surg. Gynecol. Obstet. 120, 1043-1057. STEPHENS F. 0.and ANDERSON w. A. (1961) Pilonidal sinus of the occipital region. Med. J. Aust. 2, 518. STEPHENS F. 0.and SLOANE D. R. (1968) Management of pilonidal sinus-modern approach. Med. J . Aust. 1, 395-396. STEPHENS F. 0.and SLOANE D. R . (1969) Conservative management of pilonidal sinus. Surg. Gynecol. Obstet. 129, 786-788. STEWART T. J. and BELL M. (1969) The treatment of pilonidal sinus by phenol injection. Ulster Med. J. 38, 167-171. WALTERS N. and MACDONALD I. B. (1958) Marsupialisation of pilonidal sinus and abscess, a report of 50 cases. Can. Med, Assoc. J . 79. 236-240. CASTEN D. F., TAN B. Y.
Pilonidal sinus treated by phenol injection B. A. S H O R E Y * SUMMARY
The method of using phenol injections for the treatment of pilonidal sinus is described in detail. This is a simple, safe and painless method which may be used as a day case procedure. The results are discussed and compare very fauourably with the more radical forms of treatment. THEfirst reported case of a pilonidal sinus that was successfully treated was described by Anderson ( I 847). The sinus was incised and the enclosed hair removed. Since that time many papers have appeared on the aetiology and treatment of this condition. It was originally thought that the aetiology was congenital due either to remnants of neural canal becoming separated or to ectodermal inclusions (Mallory, 1892; Kooistra, 1942). However, since the papers of King (1946), showing that the hairs present in these sinuses have their roots nearest the opening, and of Patey and Scarff (1946), describing pilonidal sinus in the interdigital clefts of barbers, the acquired theory of aetiology has become generally accepted. Brearley (1955) and Raffman (1959) also contributed papers supporting the acquired theory and suggesting ways in which the hairs enter the skin. Pilonidal sinuses have now been reported in many areas of the body-perineum (Smith, 1948), umbilicus (Steck and Helwig, 1965), interdigital cleft (Currie et al., 1953), scalp (Stevens and Anderson, 1961), amputation stump (Shoesmith, 1953), axilla (Aird, 1952). It would thus seem impractical to think of this condition as congenital.
Method The method used for phenol injection is similar to that first described by Maurice and Greenwood (1964). Following general anaesthesia with endotracheal intubation, the patient is placed prone on the operating table. The table is then raised in the centre or the patient lifted on to pillows to obtain the ‘jackknife’ position. The patient, having previously been shaved from the waist to mid-thigh posteriorly, has the buttocks held apart by the use of 7.5-cm strapping, thus exposing the natal area and anal verge. At this stage further shaving may be necessary, especially deep in the natal cleft. The area is now prepared and towelled up in the normal manner. A swab or large piece of cotton wool is used to protect the anus, while the rest of the area is liberally coated with paraffin jelly (Vaseline) to protect it from the phenol. After careful probing any loose hairs are removed with forceps from the sinus and any of its side tracts. With a blunt needle which fits snugly into the sinus orifice and a 10-ml syringe, the sinus is injected with
a solution of 80 per cent phenol. No excess pressure is used for fear of the phenol being forced into the surrounding tissue lining the sinus and causing a local inflammatory reaction. It has been suggested (Stephens and Sloane, 1969) that the operator should wear glasses as protection against any splash of phenol. This problem did not arise in the present series. On commencing the injection, phenol can be seen issuing from the side canals. The phenol is left in siru for 2 minutes and then expressed by pressure. The excess is mopped away with the debris. This manceuvre is repeated two or three times; the orifice of the sinus is seen to blanch at this stage. A dressing of paraffin jelly is applied, the excess Vaseline being removed. The patient is allowed home when he has recovered from the anaesthetic.
Results In the Bristol Royal Infirmary during the period 1968-72, 253 patients with pilonidal sinus came to surgery. Various forms of treatment were undertaken as shown in Table I . Table I : METHODS OF TREATMENT OF PILONIDAL SINUSES Laying Primary Brush Phenol ouen suture techniaue iniection
No. of patients No. of failures or recurrences
179 14
42 7
9
2
23 2
Although those treated by phenol injection comprise only a small percentage of the total, it can be seen that the results compare favourably with those of other methods. Of the 23 patients so far treated, 20 were male and 3 female; their ages ranged from 18 to 59 years. The presenting symptoms were recurrent abscess formation or a persistent discharge; most of the patients had been having symptoms for over a year. Successful treatment was judged by epitheIization occurring without any discharge or pain; 21 cases were deemed a success while 2 were failures. Of the 2 failures, one was at first successful but recurrence occurred after 9 months with a further abscess. The other case proved very difficult and was resistant to any form of treatment. Phenol injections failed twice and he subsequently had 6 other operations. It was emphasized to all the patients that postoperatively the natal cleft must be kept free of hair by shaving. Personal hygiene of the area was also encouraged.
* Department of
Surgery, Bristol Royal Infirmary.
407
B. A. Shorey
Discussion A large number of operations have been described for the treatment of pilonidal sinuses and all have their supporters. Some of the procedures that have been described for this relatively minor condition are major undertakings, and it is not surprising that Walters and MacDonald (1958) suggested a return to simple treatment. Phenol injection is a simple procedure and offers many advantages to the patient. The length of hospitalization is minimal ; all the patients in this series were discharged on the day following operation. It would therefore be a logical step to treat all pilonidal sinuses as day cases, for there is little danger after recovery from the anaesthetic. In fact, 4 patients treated by Stephens and Sloane (1969) had phenol injections as outpatients without a general anaesthetic. Following phenol injection patients have very little discomfort and are thus able to return to a normal routine almost immediately. Other simple forms of treatment such as marsupialization are widely practised but healing is prolonged; an average of 86 days was quoted by Berkowitz (1949). This leads to discomfort, excess hospitalization, frequent dressings, prolonged medical supervision and more time off work. Primary excision and closure has many advocates (Holman, 1946; Mandel and Thomas, 1972; Casten et al., 1973), and in good hands very satisfying results are obtained, but failures occur (Rogers and Hall, 1935), hospitalization is longer and postoperative discomfort more severe than with phenol injections. The most drastic operation of rotational flaps has not been popular owing to the length of stay in hospital and postoperative pain. However, good results have been obtained (Davis and Starr, 1945). The simpler methods of treatment, such as diathermy coagulation (Jacobsen, 1959; Flannery and Kidd, 1967) and incision and brush technique (Lord and Millar, 1965), have the disadvantage that in each technique an incision is made over the sinus. This means that postoperatively the wound has to be dressed and frequent medical supervision is required. However, phenol injection (Maurice and Greenwood, 1964; Stephens and Sloane, 1968; Stewart and Bell, 1969) has several advantages. The operation is simple and the only postoperative dressing required is small, its purpose being to prevent any excess phenol being expressed on to the skin. Acknowledgement I would like to thank Mr H. K. Bourns for allowing me to study the patients under his care and for his encouragement in writing this paper. References AIRD I. (1952) Pilonidal sinus of the axilla. Br. Med. J. 1, 902-903. ANDERSON A. w. (1847) Hair extracted from an ulcer. Bost. Med. Surg. J. 36, 74. BERKOWITZ J. (1949) Sacrococcygeal pilonidal cyst. Am. J. Surg. 11,477-490, BREARLEY R . (1955) Pilonidal sinus: a new theory of origin. Br. J. Surg. 43, 62-68. 408
and AYUYAO A. (1973) A technique of radical excision of pilonidal diseasc with primary closure. Surgery 73, 109-1 14. CURRIE A. R., GIBSON T. and GOODALL A. L. (1953) Interdigital sinuses of barber’s hand. Br. J. Surg. 41, 278-286. DAVIS L. s. and STARR K. w. (1945) Infected pilonidal sinus. Surg. Gynecol. Obstet. 81, 309-319. FLANNERY B. P. and KIDD H. A. (1967) A review of pilonidal sinus lesions and a method of treatment. Postgrad. Med. J. 43, 353-358. HOLMAN E. (1946) Pilonidal sinus-treatment by primary closure. Sirrg. Gynecol. Obstet. 83, 94100. JACOBSEN P. (1959) Pilonidal disease. Management without excision. Am. Acad. Gen. Practice 19, 84-90. KING E. s. J. (1946) The nature of the pilonidal sinus. AUS.NZ J. Slirg. 16, 182-192. KOOISTRA H. P. (1942) Pilonidal sinuses, review of literature and report of 350 cases. Am. J . Surg. 55, 3-17. LORD P. H. and MILLAR D. M. (1965) Pilonidal sinus: a simple treatment. Br. J. Surg. 52, 298-300. MALLORY F. B. (1892) Sacro-coccygeal dimples, sinuses and cysts. Am. J. Med. Sci. 103, 263-277. MANDEL s. R . and THOMAS c . G. (1972) Management of pilonidal sinus by excision and primary closure. Surg. Gynecol. Obstet. 134, 448-450. MAURICE B. A. and GREENWOOD R . K. (1964) A conservative treatment of pilonidal sinus. Br. J. Surg. 51, 510-512. PATEY D. H. and SCARFF R . w . (1946) Pathology of postanal pilonidal sinus: its bearing on treatment. Lancet 2, 484-486. RAFFMAN R . A. (1959) A re-evaluation of the pathogenesis of pilonidal sinus. Ann. Sirrg. 150, 895-903. ROGERS H. and HALL H. G. (1935) Pilonidal sinussurgical treatment and pathological structure. Arch. Surg. 31, 742-766. SHOESMITH J. B. (1953) Pilonidal sinus in an aboveknee amputation stump. Lancet 2, 378-379. SMITH T. E. (1948) Anterior or perineal pilonidal cysts. JAMA 136, 973-975. STECK W. D . and HELWIG E. B. (1965) Umbilical granulomas, pilonidal disease, and the urachus. Surg. Gynecol. Obstet. 120, 1043-1057. STEPHENS F. 0.and ANDERSON w. A. (1961) Pilonidal sinus of the occipital region. Med. J. Aust. 2, 518. STEPHENS F. 0.and SLOANE D. R. (1968) Management of pilonidal sinus-modern approach. Med. J . Aust. 1, 395-396. STEPHENS F. 0.and SLOANE D. R . (1969) Conservative management of pilonidal sinus. Surg. Gynecol. Obstet. 129, 786-788. STEWART T. J. and BELL M. (1969) The treatment of pilonidal sinus by phenol injection. Ulster Med. J. 38, 167-171. WALTERS N. and MACDONALD I. B. (1958) Marsupialisation of pilonidal sinus and abscess, a report of 50 cases. Can. Med, Assoc. J . 79. 236-240. CASTEN D. F., TAN B. Y.
