Sacral adipofascial turn-over flap for the excisional defect of pilonidal sinus.

The aim of pilonidal sinus surgery includes complete resection of the lesion and filling of the resultant soft-tissue defect by some means; this has a major influence on whether a lesion will occur after surgical treatment. The creation of a sacral adipofascial turn-over flap for the excisional defect has been performed in seven cases of pilonidal sinus since November of 1992. During the postoperative follow-up period, which ranged from 10 months to 7 years 11 months (mean duration, 5 years 2 months), partial dehiscence of the wound as a result of fatlysis was observed and treated conservatively in one case; however, primary healing was obtained in the other cases. No recurrence was seen in any of the seven cases. This procedure is not indicated in patients in whom wide skin resection is required because of the excessive tension associated with skin closure in such cases. However, the method is convenient, less invasive, and reliable, and therefore considered to be useful in the treatment of pilonidal sinus.     

Silicone foam sponge for pilonidal sinus: a new technique for dressing open granulating wounds.

A silicone foam sponge has been used to replace the daily packing of deep granulating wounds with moist sterile gauze. In the treatment of pilonidal sinus use of the sponge demands less nursing time and is more comfortable for the patient than the excision and open granulation technique. Patients can usually return to work soon after operation. The method has many applications in surgery, and widespread application of the technique to the management of granulating wounds could result in considerable savings to the NHS in money and skilled nursing time.     

Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis

Objective To determine the relative effects of open healing compared with primary closure for pilonidal sinus and optimal closure method (midline v off-midline).Design Systematic review and meta-analyses of randomised controlled trials.Data sources Cochrane register of controlled trials, Cochrane Wounds Group specialised trials register, Medline (1950-2007), Embase, and CINAHL bibliographic databases, without language restrictions.Data extraction Primary outcomes were time (days) to healing, surgical site infection, and recurrence rate. Secondary outcomes were time to return to work, other complications and morbidity, cost, length of hospital stay, and wound healing rate.Study selection Randomised controlled trials evaluating surgical treatment of pilonidal sinus in patients aged 14 years or more. Data were extracted independently by two reviewers and assessed for quality. Meta-analyses used fixed and random effects models, dichotomous data were reported as relative risks or Peto odds ratios and continuous data are given as mean differences; all with 95% confidence intervals.Results 18 trials (n=1573) were included. 12 trials compared open healing with primary closure. Time to healing was quicker after primary closure although data were unsuitable for aggregation. Rates of surgical site infection did not differ; recurrence was less likely to occur after open healing (relative risk 0.42, 0.26 to 0.66). 14 patients would require their wound to heal by open healing to prevent one recurrence. Six trials compared surgical closure methods (midline v off-midline). Wounds took longer to heal after midline closure than after off-midline closure (mean difference 5.4 days, 95% confidence interval 2.3 to 8.5), rate of infection was higher (relative risk 4.70, 95% confidence interval 1.93 to 11.45), and risk of recurrence higher (Peto odds ratio 4.95, 95% confidence interval 2.18 to 11.24). Nine patients would need to be treated by an off-midline procedure to prevent one surgical site infection and 11 would need to be treated to prevent one recurrence.Conclusions Wounds heal more quickly after primary closure than after open healing but at the expense of increased risk of recurrence. Benefits were clearly shown with off-midline closure compared with midline closure. Off-midline closure should become standard management for pilonidal sinus when closure is the desired surgical option.     

Application of wound dressing Molndal technique in clean and potentially contamined postoperative wounds--initial comparative study

Because of a possible delayed wound healing, critical colonization and infection of wounds present a problem for surgeons, particularly in patients with compromised immune system or in case where the wound is heavy contaminated or poorly perfused. Molndal technique of wound dressing has proven to be effective in prevention of infection. In our study we wanted to describe the benefits of the application of Molndal technique wound dressing compared to traditional wound dressing technique at potentially contaminated and clean postoperative wounds. We examined postoperative wound after radical excision of pilonidal sinus and after implantation of partial endoprosthesis in hip fracture. Molndal technique consisted of wound dressing with Aquacel Ag - Hydrofiber. Traditional technique was performed using gauze compresses and hypoallergic adhesives. We analyzed the results of 50 patients after radical excision of pilonidal sinus. 25 patients were treated by Molndal technique and 25 patients by the traditional technique of wound dressing. In the group treated by Molndal technique only 1 (4%) patient has revealed a wound infection, proven by positive microbiological examination and suppuration. In the traditional technique group 4 (16%) patients developed wound infection as inflammation and secretion as a sign of superficial infection. In the other group we analyzed the results of 50 patients after implantation of partial endoprosthesis after hip fracture. 20 patients were treated by Molndal technique and 30 patients by the traditional technique of wound dressing. In the group treated by Molndal technique no patient has revealed a wound infection (0%). In the traditional technique group 4 (13%) patients developed wound infection. All complication in both group were superficial incisional surgical infection (according to HPSC). There was no deep incisional surgical site infection or organ/space surgical site infection. Our results are clearly showing that Molndal technique is effective in preventing the postoperative wound infection.     

Zinc, Copper, and Selenium Tissue Levels and Their Relation to Subcutaneous Abscess, Minor Surgery, and Wound Healing in Humans

Trace element involvement in wounds left to heal by secondary intention needs clarification. We have previously reported faster healing of wounds following acute surgery compared with elective excision of pilonidal sinus disease. The effect of topical zinc on the closure of the excisional wounds was mediocre compared with placebo. In contrast, parenteral zinc, copper, and selenium combined appear effective for wound healing in humans. We have investigated zinc, copper, and selenium with respect to (a) impact of acute versus chronic pilonidal sinus and (b) regional concentrations within granulating wounds treated topically with placebo or zinc in 42 (33 males) pilonidal disease patients. Baseline serum and skin concentrations of copper correlated (r _S?=?0.351, p?=?0.033, n?=?37), but not of zinc or selenium. Patients with abscesses had elevated serum C-reactive protein (CRP) and copper levels (+29 %; p?<?0.001) compared with the elective patients consistent with the strong correlation between serum copper and CRP (r _S?=?0.715, p?<?0.0005, n?=?41). Seven days after elective surgery, serum CRP and copper levels were elevated (p?=?0.010) versus preoperative values. The copper concentration in wound edges was higher than in periwound skin (p?<?0.0005) and wound base (p?=?0.010). Selenium levels were increased in wound edge compared to wound base (p?=?0.003). Topical zinc oxide treatment doubled (p?<?0.050) zinc concentrations in the three tissue localizations without concomitant significant changes of copper or selenium levels. In conclusion, copper and selenium are mobilized to injured sites possibly to enhance host defense and early wound healing mechanisms that are complementary to the necessity of zinc for matrix metalloproteinase activity.     

Outpatient treatment of pilonidal disease.

In pilonidal disease there are recurrent painful draining intergluteal abscesses that require surgical treatment. Many types of treatment have been suggested for this condition. On the basis of our experience, as described below, we propose that pilonidal disease can be successfully treated on an outpatient basis with local anesthesia, minimal excision, marsupialization and packing.     

Pilonidal Disease—A Surgical Enigma

A retrospective review of 72 patients with pilonidal disease was conducted in order to examine current methods of treatment and establish certain guiding principles for success. The criteria for diagnosis included a pit of variable depth lined by epithelium or granulation tissue containing hair or from which hair had been extracted. A study of these patients suggested the possibility of a dual etiology for pilonidal disease, either congenital or acquired, acting singly or in combination. Management will be influenced by the surgeon''s concept of origin in each case. These 72 patients who underwent a total of 116 operations were divided into two groups: (1) unifected sinuses and cysts, (2) infected and recurring cysts. The results of various operative procedures in both these groups indicate a higher probability of success when wide excision and open healing is employed.     

Results of various operations for sacrococcygeal pilonidal disease.

A comparative evaluation of 4 operations designed to treat sacrococcygeal pilonidal disease is presented, to show the duration of treatment time and the recurrence rate. Case records of 112 patients (131 operations) were studied. The results indicate that the healing times with the excision and Z-plasty operation are clearly less than those obtained by incision with drainage and packing, excision with primary closure, or excision and lay open. The overall recurrence rate in this series was 28 percent, all occurring within 3 years of the first operation. With the exception of the Z-plasty operation, other methods required considerable outpatient treatment time and were more susceptible to recurrence. We suggest that by reconstructing the intergluteal cleft, the likely effect of the Z-plasty operation is to eliminate factors that may promote pilonidal disease in this region.     

Maxillary sinus atelectasis in a wild born gibbon (Hylobates moloch)

In a mixed sex sample of ten adult gibbon (Hylobates moloch) skulls, one cranium of a male with maxillary sinus atelectasis of the left side was identified. While external inspection revealed a slight drop of the left orbital floor, serial coronal computer tomography (CT) scans show characteristic changes of the left maxillary sinus and its surrounding structures. In addition to the sunken orbital floor, radiological features of the specimen include an inward bowing of the medial sinus wall, sinus opacification, and a reduction in maxillary sinus size to a slit-like cavity, which suggest a diagnosis of silent sinus syndrome. This report is the first, to our knowledge, of maxillary sinus atelectasis in a non-human primate. This finding is valuable for the understanding of the pathogenesis and etiology of maxillary sinus atelectasis. At the same time, however, paleoanthropologists and primatologists may refer to this information when dealing with the interpretation of maxillary sinus pneumatization of partially broken archaeological and fossil skulls.     

The role of anaerobic bacteria in cutaneous and soft tissue abscesses and infected cysts

This review presents the aerobic and anaerobic microbiological aspects and management of cutaneous and soft tissue abscesses, paronychia, anorectal, pilonidal, and perirectal abscesses, infected epidermal cysts, hidradenitis suppurativa, and pustular acne lesions. These infections often occur in different body sites or in areas that have been compromised or injured by foreign body, trauma, ischemia, malignancy or surgery. In addition to group A beta-hemolytic streptococci and Staphylococcus aureus, the indigenous aerobic and anaerobic cutaneous and mucous membranes local microflora usually is responsible for these generally polymicrobial infections. These infections may occasionally lead to serious potentially life-threatening local and systemic complications. The infections can progress rapidly and early recognition and proper medical and surgical management is the cornerstone of therapy.     

Homology and evolution of the orbitotemporal venous sinuses of humans.

The orbitotemporal venous sinuses accompany the intracranial branches of the stapedial artery. These sinuses are large in primitive primates and drain the extensive territories supplied by the stapedial artery as well as the brain. The orbit is drained by a wide cranio-orbital sinus which empties into the postglenoid emissary vein. Also emptying into the postglenoid vein is the petrosquamous sinus. The latter diverts cerebral blood from the transverse sinus and also drains the temporalis muscle. Emptying into both the cranio-orbital and petrosquamous sinuses are meningeal tributaries, which drain the cranial side wall and the dura mater. The relatively small sinus communicans runs in the angle between the petrosal bone and the cranial side wall. It commences at the postglenoid vein and connects the distal end of the petrosquamous sinus to the pterygoid venous plexus. In humans, the orbitotemporal sinus system is greatly modified. Its remnants persist for the most part as "middle meningeal veins." The system no longer drains the orbit, the temporal fossa, or the brain. The petrosquamous sinus becomes attenuated or obliterated along part or all of its length. The postglenoid vein vanishes. The cranio-orbital sinus is reduced in diameter and its connection to the orbit is feeble or absent. During development, the posterior end of the cranio-orbital sinus migrates inferiorly along the sinus communicans. In most individuals, this migration ceases at the foramen spinosum, site of the emissary vein of the sinus communicans. Meningeal tributaries are relatively large in humans, and drain principally into the cranio-orbital sinus or sphenoparietal sinus. The sphenoparietal sinus is an evolutionary novelty restricted to hominoids and is frequently developed in only Homo and Pongo.     

Frontal sinus fractures: guidelines to management

The appropriate management of frontal sinus fractures is controversial. Experience with 78 frontal sinus fractures over a 9-year period was reviewed, and the fractures were classified into anterior wall, anterobasilar, and frontal skull fracture extensions. The presence of a concomitant CSF leak or an air-fluid level in the sinus was a diagnostic clue of posterior wall involvement. Ablation or obliteration of the fractured frontal sinus is not necessary. Primary reconstruction of the sinus and nasofrontal duct drainage constitute the preferred treatment. "Cranialization" of a severely damaged sinus is performed by excision of the posterior wall plugging of the nasofrontal duct and reconstruction of the anterior wall. Reconstruction of the anterior wall with primary bone grafting may be necessary in selected patients.     

Model of the haemodynamic reactions to intermittent coronary sinus occlusion

Coronary sinus pressure data have been obtained from anaesthetized dogs during pressure controlled intermittent coronary sinus occlusion. It is the main aim of this paper to provide a mathematical procedure for modelling the typical time course of sinus pressure after temporary obstruction of the sinus. The model is produced by fitting a parameterized function to the systolic and diastolic pressures in order to represent mathematically the shape of the curves. The parameters characterize the rise in coronary sinus pressure following occlusion, and are used to calculate ‘derived quantities’ which mimic the physician's visual assessment of trace recordings and their clinical implications in certain forms of coronary sinus pressure reaction. This procedure should be thought of as a kind of pattern recognition which reflects the changing state of the myocardium. The mathematical results are shown to bear a close resemblance to the clinical effects of coronary sinus occlusion.     

Prostate development requires Sonic hedgehog expressed by the urogenital sinus epithelium

The prostate gland develops from the urogenital sinus by a testosterone-dependent process of ductal morphogenesis. Sonic hedgehog (Shh) is expressed in the urogenital sinus epithelium and the time course of expression coincides with the formation of the main prostatic ducts. Expression is most abundant in the lumen of the urogenital sinus and in the contiguous proximal duct segments. The initial upregulation of Shh expression in the male urogenital sinus depends on the presence of testosterone. The function of Shh was examined in the male urogenital sinus which was transplanted under the renal capsule of an adult male host mouse. Blockade of Shh function by a neutralizing antibody interferes with Shh signaling and abrogates growth and ductal morphogenesis in the transplanted tissue. These observations show that testosterone-dependent Shh expression in the urogenital sinus is necessary for the initiation of prostate development.     

Cardiac Iodine-123-Meta-Iodo-Benzylguanidine Uptake in Carotid Sinus Hypersensitivity

Background

Carotid sinus syndrome is the association of carotid sinus hypersensitivity with syncope, unexplained falls and drop attacks in generally older people. We evaluated cardiac sympathetic innervation in this disorder in individuals with carotid sinus syndrome, asymptomatic carotid sinus hypersensitivity and controls without carotid sinus hypersensitivity.

Methods

Consecutive patients diagnosed with carotid sinus syndrome at a specialist falls and syncope unit were recruited. Asymptomatic carotid sinus hypersensitivity and non-carotid sinus hypersensitivity control participants recruited from a community-dwelling cohort. Cardiac sympathetic innervation was determined using Iodine-123-metaiodobenzylguanidine (123-I-MIBG) scanning. Heart to mediastinal uptake ratio (H:M) were determined for early and late uptake on planar scintigraphy at 20 minutes and 3 hours following intravenous injection of 123-I-MIBG.

Results

Forty-two subjects: carotid sinus syndrome (n = 21), asymptomatic carotid sinus hypersensitivity (n = 12) and no carotid sinus hypersensitivity (n = 9) were included. Compared to the non- carotid sinus hypersensitivity control group, the carotid sinus syndrome group had significantly higher early H:M (estimated mean difference, B = 0.40; 95% confidence interval, CI = 0.13 to 0.67, p = 0.005) and late H:M (B = 0.32; 95%CI = 0.03 to 0.62, p = 0.032). There was, however, no significant difference in early H:M (p = 0.326) or late H:M (p = 0.351) between the asymptomatic carotid sinus hypersensitivity group and non- carotid sinus hypersensitivity controls.

Conclusions

Cardiac sympathetic neuronal activity is increased relative to age-matched controls in individuals with carotid sinus syndrome but not those with asymptomatic carotid sinus hypersensitivity. Blood pressure and heart rate measurements alone may therefore represent an over simplification in the assessment for carotid sinus syndrome and the relative increase in cardiac sympathetic innervation provides additional clues to understanding the mechanisms behind the symptomatic presentation of carotid sinus hypersensitivity.     

Cannulation of the middle cardiac vein during MICS

Coronary sinus cannulation for retrograde cardioplegia administration during cardiac surgery is common practice. Several of the cannulas that are placed by the cardiac surgeon on open procedures are now placed by the cardiac anesthesiologist during minimally invasive cardiac surgery, including the coronary sinus catheter. The understanding of the cardiac venous anatomy is very important during coronary sinus catheter placement. We present a case where a percutaneously placed coronary sinus catheter was inadvertently placed into the middle cardiac vein but detected with the use of fluoroscopy.     

Morphology, constraints, and scaling of frontal sinuses in the hartebeest, Alcelaphus buselaphus (Mammalia: Artiodactyla, Bovidae)

The frontal sinuses of bovid mammals display a great deal of diversity, which has been attributed to both phylogenetic and functional influences. In-depth study of the hartebeest (Alcelaphus buselaphus), a large African antelope, reveals a number of previously undescribed details of frontal sinus morphology. In A. buselaphus, the frontal sinuses conform closely to the shape of the frontal bone, filling nearly the entire element. However, the horncores are never extensively pneumatized, contrasting with the condition seen in many other bovids. This evidence is inconsistent with the hypothesis that sinuses are opportunistic pneumatizing agents, suggesting that phylogenetic factors also play a role in determining sinus size. Both cranial sutures and neurovasculature appear to constrain the growth of sinuses in part. In turn, the sinus also affects the growth of the parietal; apparently this element is not truly pneumatized by the sinus in most cases, but the bone's shape changes under the influence of the sinus. Furthermore, the sinuses present relatively few struts when compared with the sinuses of some other bovids, such as Ovis. By adapting methods previously developed for measuring structural parameters of trabecular bone, it is possible to quantify certain aspects of sinus morphology. These include the number of bony struts within the sinus, the spacing of these struts, and the size of individual cavities within the sinus. Some differences in the number of struts are evident between subspecies. Similarly, significant differences occur in the relative number of struts between male and female A. buselaphus, which may be related to behavior. The volume of the sinus is strongly correlated with the size of the frontal, but less so with overall cranial size. This finding illustrates the importance of choosing variables carefully when comparing sinus sizes and growth between species.     

Isolation of residual sinus node during catheter ablation for the treatment of inappropriate sinus tachycardia

Inappropriate sinus tachycardia is an unusual arrhythmia that is difficult to treat. To date, catheter ablation has concentrated on modifying the sinus node to attain rate control. We describe a patient where sinoatrial block was created by radiofrequency ablation for the treatment of inappropriate sinus tachycardia.     

An allometric study of the frontal sinus in Gorilla, Pan and Pongo

There is considerable speculation about the role and significance of the paranasal sinuses in the Hominoidea, and this study aims to present new data about an old problem from cephalograms of dried crania. Measurements of frontal sinus volumes were determined for Gorilla gorilla gorilla; G. gorilla beringei and Pan troglodytes. By adopting an allometric approach it was determined that the frontal sinus volume of Gorilla is relatively smaller than that of Pan, and that the frontal sinus of G. g. gorilla is relatively smaller than that of G. g. beringei. Frontal sinus volume scales in a positive allometric fashion relative to skull length. Since the slope is steeper for Pan, frontal sinus volume is increasing at a faster rate than in Gorilla. Sexual dimorphism in frontal sinus volume is present. Thirty crania of Pongo were investigated for evidence of pneumatization of the frontal bone. In no case was secondary invasion of the frontal bone by the maxillary antrum observed. In Gorilla, the nasal cavity volume scales isometrically with skull length. The scaling relationships discussed do not support any 'functional' role of the frontal sinus associated with nasal function but suggest a 'structural' role associated with craniofacial architecture.     

RECURRENT PILONIDAL CYST AND SINUS—A Plan of Preoperative Preparation,Operation and Postoperative Care

Evaluation ten years following radical excision and primary closure of recurrent pilonidal cysts led to the conclusion that the method of preoperative and postoperative care and the surgical technique employed gave satisfactory results. In 50 patients operated upon, the duration of symptoms varied from ten days to six years. Primary healing was achieved in all but one case in which there was slight skin overlapping. Thirty-three of the 50 patients were located for appraisal at the end of ten years. Three had had recurrences.The procedure involved eradication of acute infection preoperatively, wide, en bloc radical excision, with primary closure reattaching flaps centrally to the presacral fascia, and drainage of the depths of the wound.