Br. J. Surg. Vol. 64 (1977) 494-495
Umbilical pilonidal sinus NICHOLAS D COLAPINTO* SUMMARY
A rare case of umbilical pilonidal sinus is reportedthe only documented case of barber's pilonidal of the umbilicus. Possible mechanisms of formation are described. It is suggested that this possibility should be considered in cuses of resistant or recurrent omphalitis. Definitive treatment consists of sinus excision with cosmetic umbilical reconstruction. Total omphalectomy is probably only justified for recurrence.
PILONIDAL sinus of the umbilicus is probably more common than is indicated by the small number of published reports. The purpose of this report is to present the successful treatment of an unusual case and to draw attention to a condition which frequently may be misdiagnosed. Case report A 29-year-old white male barber presented with a one-day history of pain in the umbilical region. There had been no previous similar episodes and no history of trauma. The patient denied abnormal manipulation of his umbilicus. His abdomen was not abnormally hirsute. Examination revealed a tender swelling just below the umbilicus, approximately 3 cm in diameter, with a surrounding area of erythema and increased warmth which involved the entire circumference of the umbilicus. The mass itself was not fluctuant. His temperature was normal and his white blood cell count was 10900. Incision and drainage were performed in the operating room, with the release of thick, yellow, purulent material, necrotic tissue and hundreds of short, clipped hairs. The hairs varied in size but all were apparently less than 1 cm long. The colours were recognizable within the spectrum of normal human hair, but ranged widely through shades of blonde, red and black. The wall of the abscess cavity appeared smooth and fibrous and the entire lesion resembled a pilonidal sinus. The cavity was cleaned and packed open and recovery was quick and complete. Six weeks later the area of incision had completely healed, but there was evidence of thin, creamy fluid in the base of his umbilicus. Close inspection revealed an abnormal orifice in the depths of the inferior umbilical wall. Through this opening a probe could he passed into a sinus tract which extended 7 cm
Fig. 2. Cyst content at high magnification. Note especially the hair end in the centre, clearly showing a chisel-like appearance. (HE. X 20.)
Fig. 3. Section of cyst wall showing a hair in cross-section sheathed by squamous epithelium (arrow). (HE. x 20.)
subcutaneously. He was readmitted for definitive treatment. The sinus tract and orifice were excised en bloc without breaching their walls. The resultant defect was closed primarily and the umbilicus cosmetically reconstructed. The patient is now well and has had n o recurrence 4 years subsequently. Pathological examination revealed that the lesion was indeed a pilonidal sinus. It was lined by fibrous tissue, chronic inflammatory cells and an occasional foreign body giant cell. There were islands of keratin present, but true epithelization had not occurred and no hair follicles were present in the lining of the cyst. The lumen contained necrotic debris and tiny hairs with sharp square-cut ends (Figs. 1 , 2 ) . Many of these hairs were sheathed in squamous epithelium (Fig. 3).
Fig. 1. Cyst content. Note the numerous short thick hairs with sharp chisel-like ends (arrow). (HE. x 20.)
* Department of Surgery, St Michael's Hospital, University of Toronto. Correspondence to: 55 Queen Street East, Suite 503, Toronto, Ontario, M5C 1R6,Canada.
Umbilical pilonidal sinus Discussion Pilonidal sinus of the umbilicus was first described by Jackson in 1854. A total of only 15 cases has been reported (Patey and Williams, 1956; Sadeghi-Nejad and Rains, 1958; Hardaway, 1959; Mayo et al., 1960; Goodall, 1961; Clery and Clery, 1963; Stoller, 1966; Thorlakson, 1966; Urquhart-Hay, 1966; Allegaert, 1967; Hassan, 1969; Eby and Jetton, 1972). The case presented here is the first reported in a barber, although the entity of barber’s pilonidal sinus occurring in the web space of the fingers is well known (Patey and Scarfe, 1948; Downing, 1952; Patey, 1969,1970,1971), and historically, Hodges (1880) stated that ‘hair cutters are continually in trouble from short hairs which penetrate the skin of their fingers and hands’. The majority of umbilical pilonidal sinuses have occurred in hirsute white males, a correlation long noted in sacrococcygeal pilonidals. In fact, three of the reported cases of umbilical pilonidal sinus have had associated lesions in the sacral area. The patient usually presents with acute inflammation in the periumbilical region, The infected pilonidal sinus may not fluctuate, as was the case in our patient. As cellulitis may be a prominent feature, a diagnosis of omphalitis may be made and the true nature of the disease remain obscure. On pathological examination, the lesion resembles pilonidal sinus in other areas. The lining is composed of granulation tissue and does not contain hair follicles. As in the sacral region, there is no evidence of a pre-existing epithelial-lined cyst. Weale (1964) enumerates the characteristics which differentiate a barber’s pilonidal sinus from the typical postanal pilonidal. The most important of these (hair ends square-cut and sharp, hairs less than 1 cm in length and sheathed by squamous epithelium, patches of epithelial necrosis) are present in the case reported here and should be sufficient to qualify it as a true case of barber’s pilonidal, the first ever reported at the umbilicus. It is necessary to speculate as to how the hairs reached the barber’s umbilicus. Our patient informed us that it is common for barbers to find fine hairs on their bodies at the end of a working day. On direct questioning, he admitted that although he bathed daily, he specifically avoided thorough cleansing of his umbilicus due to superstitious fear induced it childhood. This would explain how a collection o hair might occur in this area. That they were not the barber’s own abdominal hairs is indicated by the microscopic evidence reported above plus the fact that the patient’s hair in this region was observed to be much longer and finer than that found in the sinus cavity. Also, the patient’s body hair was jet black in contrast to the colour of most of the hairs noted in the sinus. Conservative measures, consisting of washing out the umbilicus, extracting protruding hairs, shaving the
495
skin and frequent cleansing, have been recommended as primary treatment (Eby and Jetton, 1972), but this seems to be insufficientin either the acute or the chronic case. Omphalectomy was performed in 10 of the 15 reported cases, but this seems to be unnecessarily radical, as indicated by the success obtained in our patient without umbilical excision. Omphalectomy is probably only justified for cases of recurrence, as it is not usually acceptable to the patient when alternative good treatments exists. We recommend total excision of the sinus followed by reconstruction of the umbilicus, in cases which are not acutely infected. In patients who present with acute abscess formation, a simple incision and drainage should be performed primarily, followed by definitive excision in 6-8 weeks’ time. References ALLEGAERT w. J.
(1967) Pilonidal sinus of the umbilicus. Br. J. Clin. Pract. 21, 2 0 1 . CLERY A. P. and CLERY A. B. (1963) Pilonidal disease of the umbilicus. Br. J. Surg. 50, 666-669. DOWNING J. G . (1952) Barber’s pilonidal sinus. JAMA 1 4 8 , 1 5 0 1 . EBY c. s. and JETTON R. L. (1972) Umbilical pilonidal sinus. Arch. Dermatol. 106, 8 9 3 . GOODALL P. (1961) The aetiology and treatment of pilonidal sinus. Er. J. Surg. 4 9 , 212-218. HARDAWAY R. M. (1959) Pilonidal sinus of the umbilicus. US Armed Forces Med. J. 10,88-90. HASSAN M. s. (1969) Simultaneous occurrence of the umbilical and postanal-pilonidal cysts. S. Afr. Med. J. 43,79-80. HODGES R. M. (1880) Pilonidal sinus. Boston Med. Surg. J . 103, 485486. JACKSON J. B. s. (1854) Abscess, containing hair, on the nares. Am. J. Med. Sci. 28, 113. MAYO c. w., FRANCKOWIAK J. J. and DOCKERTY M. B. (1960) Pilonidal sinus of the umbilicus. Proc. Mayo Cfin. 35, 175-178. PATEY D. H. (1969) A reappraisal of the acquired theory of
sacrococcygeal pilonidal sinus and an assessment of its influence on surgical practice. Er. J. Surg. 56, 4 6 3 4 6 6 . PATEY D. H. (1970) The principles of treatment of sacrococcygeal pilonidal sinus. Proc. R . Soc. Med. 63, 939-940. PATEY D. H. (1971) Pilonidal sinus: a postscript (Letter to the Editor). Lancet 1, 245. PATEY D. H. and SCARFE R. w. (1958) Pilonidal sinus in a barber’s hand. Lancet 2, 13-14. PATEY D. H. and WILLIAMS E. s. (1956) Pilonidal sinus of the umbilicus. Lancet, 2, 281-282. SADEGHI-NEJAD H. and RAINS A. J. H. (1958) Pilonidal Sinus Of the umbilicus. Lancet 1, 567. STOLLER J. L. (1966) Pilonidal sinus of the umbilicus. Br. J. Clin. Pract. 20, 429. THORLAKSON R. H. (1966) Pilonidal sinus of the umbilicus. Er. J. Surg. 53, 78-78., URQUHART-HAY D. (1966) Pilonidal sinus or hair granuloma Of the umbilicus. NZ. Med. J. 65, 9 8 4 9 8 5 . WEALE F. E. (1964) A comparison of barber’s and postanal pilonidal sinuses. Br. J. Surg. 51, 513-516.
Umbilical pilonidal sinus NICHOLAS D COLAPINTO* SUMMARY
A rare case of umbilical pilonidal sinus is reportedthe only documented case of barber's pilonidal of the umbilicus. Possible mechanisms of formation are described. It is suggested that this possibility should be considered in cuses of resistant or recurrent omphalitis. Definitive treatment consists of sinus excision with cosmetic umbilical reconstruction. Total omphalectomy is probably only justified for recurrence.
PILONIDAL sinus of the umbilicus is probably more common than is indicated by the small number of published reports. The purpose of this report is to present the successful treatment of an unusual case and to draw attention to a condition which frequently may be misdiagnosed. Case report A 29-year-old white male barber presented with a one-day history of pain in the umbilical region. There had been no previous similar episodes and no history of trauma. The patient denied abnormal manipulation of his umbilicus. His abdomen was not abnormally hirsute. Examination revealed a tender swelling just below the umbilicus, approximately 3 cm in diameter, with a surrounding area of erythema and increased warmth which involved the entire circumference of the umbilicus. The mass itself was not fluctuant. His temperature was normal and his white blood cell count was 10900. Incision and drainage were performed in the operating room, with the release of thick, yellow, purulent material, necrotic tissue and hundreds of short, clipped hairs. The hairs varied in size but all were apparently less than 1 cm long. The colours were recognizable within the spectrum of normal human hair, but ranged widely through shades of blonde, red and black. The wall of the abscess cavity appeared smooth and fibrous and the entire lesion resembled a pilonidal sinus. The cavity was cleaned and packed open and recovery was quick and complete. Six weeks later the area of incision had completely healed, but there was evidence of thin, creamy fluid in the base of his umbilicus. Close inspection revealed an abnormal orifice in the depths of the inferior umbilical wall. Through this opening a probe could he passed into a sinus tract which extended 7 cm
Fig. 2. Cyst content at high magnification. Note especially the hair end in the centre, clearly showing a chisel-like appearance. (HE. X 20.)
Fig. 3. Section of cyst wall showing a hair in cross-section sheathed by squamous epithelium (arrow). (HE. x 20.)
subcutaneously. He was readmitted for definitive treatment. The sinus tract and orifice were excised en bloc without breaching their walls. The resultant defect was closed primarily and the umbilicus cosmetically reconstructed. The patient is now well and has had n o recurrence 4 years subsequently. Pathological examination revealed that the lesion was indeed a pilonidal sinus. It was lined by fibrous tissue, chronic inflammatory cells and an occasional foreign body giant cell. There were islands of keratin present, but true epithelization had not occurred and no hair follicles were present in the lining of the cyst. The lumen contained necrotic debris and tiny hairs with sharp square-cut ends (Figs. 1 , 2 ) . Many of these hairs were sheathed in squamous epithelium (Fig. 3).
Fig. 1. Cyst content. Note the numerous short thick hairs with sharp chisel-like ends (arrow). (HE. x 20.)
* Department of Surgery, St Michael's Hospital, University of Toronto. Correspondence to: 55 Queen Street East, Suite 503, Toronto, Ontario, M5C 1R6,Canada.
Umbilical pilonidal sinus Discussion Pilonidal sinus of the umbilicus was first described by Jackson in 1854. A total of only 15 cases has been reported (Patey and Williams, 1956; Sadeghi-Nejad and Rains, 1958; Hardaway, 1959; Mayo et al., 1960; Goodall, 1961; Clery and Clery, 1963; Stoller, 1966; Thorlakson, 1966; Urquhart-Hay, 1966; Allegaert, 1967; Hassan, 1969; Eby and Jetton, 1972). The case presented here is the first reported in a barber, although the entity of barber’s pilonidal sinus occurring in the web space of the fingers is well known (Patey and Scarfe, 1948; Downing, 1952; Patey, 1969,1970,1971), and historically, Hodges (1880) stated that ‘hair cutters are continually in trouble from short hairs which penetrate the skin of their fingers and hands’. The majority of umbilical pilonidal sinuses have occurred in hirsute white males, a correlation long noted in sacrococcygeal pilonidals. In fact, three of the reported cases of umbilical pilonidal sinus have had associated lesions in the sacral area. The patient usually presents with acute inflammation in the periumbilical region, The infected pilonidal sinus may not fluctuate, as was the case in our patient. As cellulitis may be a prominent feature, a diagnosis of omphalitis may be made and the true nature of the disease remain obscure. On pathological examination, the lesion resembles pilonidal sinus in other areas. The lining is composed of granulation tissue and does not contain hair follicles. As in the sacral region, there is no evidence of a pre-existing epithelial-lined cyst. Weale (1964) enumerates the characteristics which differentiate a barber’s pilonidal sinus from the typical postanal pilonidal. The most important of these (hair ends square-cut and sharp, hairs less than 1 cm in length and sheathed by squamous epithelium, patches of epithelial necrosis) are present in the case reported here and should be sufficient to qualify it as a true case of barber’s pilonidal, the first ever reported at the umbilicus. It is necessary to speculate as to how the hairs reached the barber’s umbilicus. Our patient informed us that it is common for barbers to find fine hairs on their bodies at the end of a working day. On direct questioning, he admitted that although he bathed daily, he specifically avoided thorough cleansing of his umbilicus due to superstitious fear induced it childhood. This would explain how a collection o hair might occur in this area. That they were not the barber’s own abdominal hairs is indicated by the microscopic evidence reported above plus the fact that the patient’s hair in this region was observed to be much longer and finer than that found in the sinus cavity. Also, the patient’s body hair was jet black in contrast to the colour of most of the hairs noted in the sinus. Conservative measures, consisting of washing out the umbilicus, extracting protruding hairs, shaving the
495
skin and frequent cleansing, have been recommended as primary treatment (Eby and Jetton, 1972), but this seems to be insufficientin either the acute or the chronic case. Omphalectomy was performed in 10 of the 15 reported cases, but this seems to be unnecessarily radical, as indicated by the success obtained in our patient without umbilical excision. Omphalectomy is probably only justified for cases of recurrence, as it is not usually acceptable to the patient when alternative good treatments exists. We recommend total excision of the sinus followed by reconstruction of the umbilicus, in cases which are not acutely infected. In patients who present with acute abscess formation, a simple incision and drainage should be performed primarily, followed by definitive excision in 6-8 weeks’ time. References ALLEGAERT w. J.
(1967) Pilonidal sinus of the umbilicus. Br. J. Clin. Pract. 21, 2 0 1 . CLERY A. P. and CLERY A. B. (1963) Pilonidal disease of the umbilicus. Br. J. Surg. 50, 666-669. DOWNING J. G . (1952) Barber’s pilonidal sinus. JAMA 1 4 8 , 1 5 0 1 . EBY c. s. and JETTON R. L. (1972) Umbilical pilonidal sinus. Arch. Dermatol. 106, 8 9 3 . GOODALL P. (1961) The aetiology and treatment of pilonidal sinus. Er. J. Surg. 4 9 , 212-218. HARDAWAY R. M. (1959) Pilonidal sinus of the umbilicus. US Armed Forces Med. J. 10,88-90. HASSAN M. s. (1969) Simultaneous occurrence of the umbilical and postanal-pilonidal cysts. S. Afr. Med. J. 43,79-80. HODGES R. M. (1880) Pilonidal sinus. Boston Med. Surg. J . 103, 485486. JACKSON J. B. s. (1854) Abscess, containing hair, on the nares. Am. J. Med. Sci. 28, 113. MAYO c. w., FRANCKOWIAK J. J. and DOCKERTY M. B. (1960) Pilonidal sinus of the umbilicus. Proc. Mayo Cfin. 35, 175-178. PATEY D. H. (1969) A reappraisal of the acquired theory of
sacrococcygeal pilonidal sinus and an assessment of its influence on surgical practice. Er. J. Surg. 56, 4 6 3 4 6 6 . PATEY D. H. (1970) The principles of treatment of sacrococcygeal pilonidal sinus. Proc. R . Soc. Med. 63, 939-940. PATEY D. H. (1971) Pilonidal sinus: a postscript (Letter to the Editor). Lancet 1, 245. PATEY D. H. and SCARFE R. w. (1958) Pilonidal sinus in a barber’s hand. Lancet 2, 13-14. PATEY D. H. and WILLIAMS E. s. (1956) Pilonidal sinus of the umbilicus. Lancet, 2, 281-282. SADEGHI-NEJAD H. and RAINS A. J. H. (1958) Pilonidal Sinus Of the umbilicus. Lancet 1, 567. STOLLER J. L. (1966) Pilonidal sinus of the umbilicus. Br. J. Clin. Pract. 20, 429. THORLAKSON R. H. (1966) Pilonidal sinus of the umbilicus. Er. J. Surg. 53, 78-78., URQUHART-HAY D. (1966) Pilonidal sinus or hair granuloma Of the umbilicus. NZ. Med. J. 65, 9 8 4 9 8 5 . WEALE F. E. (1964) A comparison of barber’s and postanal pilonidal sinuses. Br. J. Surg. 51, 513-516.
