Patient Presentation
A 15-year-old female came to the emergency room with a 2 day history of a bump on her back just above her buttocks that 1 day ago became extremely swollen, red and exquisitely painful.
She complained of a small amount of pus coming from the area on her underwear. She had taken some ibuprofen with no relief and was having difficulty sitting or walking because of the intense pain.
The past medical history and family history were negative.
The review of systems was negative for fever, chills, rashes, or bowel or bladder problems.
The pertinent physical exam showed a teenager in moderate distress secondary to pain. She was afebrile and her other vital signs were normal.
Midline at the top of the gluteal cleft was a 4×5 centimeter area of swelling with intense redness. There was exquisite tenderness and a fluctuant mass. A small amount of purulent discharge was expressed from a central punctum in the mass.
There were no other dermatological changes including hair whorls or color variations. The spine was non-tender in other areas. The anus was patent with no abnormalities externally. She had a normal neurological examination in the lower extremities.
The rest of her examination was normal.
The laboratory evaluation included a culture of the discharge.
The diagnosis of a pilonidal cyst with abscess formation was made. Under conscious sedation with nitrous oxide and local pain control, the fluctuant mass was incised, drained, and packed.
She had some pain relief following the procedure. The patient was placed on oral cephalexin and codeine.
Although arrangements were made to have her follow-up in the surgery clinic in 2 days, she was told to return to the emergency room or see her regular doctor if she had any fever, spreading of the swelling, or problems with bowel, bladder, her lower extremities or other neurological problems.
Discussion
The term pilonidal was coined in 1880 by Hodge. “Pilo” means hair and “nidal” means nest which describes this nest of hair.
There is a spectrum of pilonidal disease which ranges from asymptomatic hair with cysts and sinuses to large abscess in the sacrococcygeal area.
The cause is not entirely clear and initially was believed to be congenital remnants of neural crest tissue. Today, it appears that it is an acquired problem where hair/debris enters the skin and hair follicles causing an inflammatory reaction and edema. There is then occlusion of the entry portal and building up of material in the hair follicle and a foreign body reaction.
This reaction then forms multiple microabscess in the subcutaneous tissue. Trauma causes in more microabscessses with sinus tract and abscess formation.
This theory is consistent with the findings of pilonidal cyst formation in other places such as hands of barbers’ and sheepsheerers’, and that it can be a repetitive problem (up to 40% of patients).
During World War II, so many serviceman had pilonidal disease that it was called “jeep driver’s disease” as described by Dr. Louis Buie in 1944.
Only 50-70% of pilonidal cysts contain hair at surgery. It is more common in adolescent and young males. Other risk factors include hirsute people, hair in the gluteal cleft, sitting occupations, obesity, and caucasian race.
Presentation includes asymptomatic tracts noticed by the patient or health care provider, episodic or chronic minor pain or irritation, acute pain and irritation with or without drainage or abscess formation.
The most commonly cultured pathogens from abscesses differ by study and include anaerobic cocci and Staphlococcus aureus.
The differential diagnosis commonly includes:
- Congenital abnormalities
- Inclusion dermoid
- Presacral sinus or dimple
- Pyoderma gangrenosum
- Sacrococcygeal sinus
Learning Point
Treatment for pilonidal disease depends on the patient’s presentation.
Asymptomic cysts and tracts should be referred to a surgeon for evaluation and removing the debris.
Acute abscess formation requires initial incision and drainage removing all the debris and hair, and packing of the wound. Surgical followup within 1 week should be arranged.
Hygiene of the area is paramount and weekly shaving of the local area can decrease recurrance.
The type of definitive surgical therapy for recurrent disease is controversial. Treatments include marsupialization, z-plasty, and various flap procedures.
One review study of 16-35 year olds including men and women showed showed excision techniques to be evaluated as superior because they had a shorter period to return to work, but no differences in terms of wound infection or recurrance when compared to marsupialization and flap procedures.
A recent randomized-controlled trial of different excision techniques showed limited excision of the pilonidal sinus to be the best surgical option when compared to two different wide-resection techniques.
Questions for Further Discussion
1. What are the complications of pilonidal disease?
Related Cases
- Disease
- Pilonidal cyst
Tailbone Disorders
- Symptom/Presentation
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for this topic: Tailbone Disorders.
To view current news articles on this topic check Google News.
Ringelheim R, Silverberg MA. Pilonidal Cyst and Sinus. eMedicine.
Available from the Internet at http://www.emedicine.com/emerg/topic771.htm (rev. 06/06/2006, cited 8/7/2006).
Aydede H, Erhan Y, Sakarya A, Kumkumoglu Y. Comparison of three methods in surgical treatment of pilonidal disease. ANZ J Surg. 2001 Jun;71(6):362-4.
Available from the Internet at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11409022&query_hl=2&itool=pubmed_docsum (cited 8/7/2006).
Mohamed HA, Kadry I, Adly S. Comparison between three therapeutic modalities for non-complicated pilonidal sinus disease. Surgeon. 2005 Apr;3(2):73-7. Available from the Internet at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=15861940 (cited 8/7/2006).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competency performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
Date
August 21, 2006
Pediatric Education 