Management of Recurrent Pilonidal Sinus through Ayurveda Care and Surgery - A Case Report

AM Meghana; BJ Gopikrishna; Prasanna N. Rao; Mahesh Kumar ES

Management of Recurrent Pilonidal Sinus through Ayurveda Care and Surgery - A Case Report

Meghana A.^1*, Gopikrishna B.², N. Rao P.³, Kumar ES M.⁴

DOI:

^1* AM Meghana, Post Graduate Scholar, Department of Shalya Tantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.

² BJ Gopikrishna, Professor, Department of Shalya Tantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.

³ Prasanna N. Rao, Principal and Professor, Department of Shalya Tantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.

⁴ Mahesh Kumar ES, Associate Professor and HOD, Department of Shalya Tantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.

Introduction: Pilonidal disease refers to subcutaneous infection occurring in upper half of gluteal cleft having no communication in anal canal. In Ayurveda it can be correlated to Shalyajanya Nadivrana which is described in detail by Acharya Sushrutha. It presents as an acute abscess or chronic wound associated with pus discharge and severe discomfort. In this case report we present 20 years old female patient who reported to OPD of Shalya SDMCAH with complains of pain associated with pus discharge at natal cleft region since two weeks with a history of Z plasty surgery. Methods: Case was managed by surgical excision followed by Kshara Karma, Triphala Prakshalana and dressing with Jatyadi Taila. Internally the patient was administered with Triphala Guggulu and Gandhaka Rasayana. Discussion: Apamarga Kshara helps in removal of unhealthy granulation tissue and cellular debris by sclerosing properties thereby lowering recurrence rate. Triphala Prakshalana and wound dressing by Jathyadhi Taila fastens healing process by microcidal effect. Results: Initial complains of pain associated with pus discharge subsided within seven days, while complete healing of tract was observed within two months. Conclusion: Surgical approach in contemporary science includes excision with reconstructive flaps (z-plasty). However, recurrence rate is more and there are increased chances of developing wound infection. Hence in this case excision of sinus followed by apamarga kshara pratisarana was incorporated which showed promising results along with complete healing of tract.

Keywords: Apamarga Ksharakarma, Pilonidal sinus, Shalyajanya Nadivrana, Ayurveda

Corresponding Author	How to Cite this Article	To Browse
AM Meghana, Post Graduate Scholar, Department of Shalya Tantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India. Email:	AM Meghana, BJ Gopikrishna, Prasanna N. Rao, Mahesh Kumar ES, Management of Recurrent Pilonidal Sinus through Ayurveda Care and Surgery - A Case Report. J Ayu Int Med Sci. 2022;7(6):208-212. Available From https://jaims.in/jaims/article/view/1958

Introduction

Pilonidal sinus^[1] which is apparently minor condition can present the surgeon with major challenges. The initial pathology is of one or multiple deep midline pits in the natal cleft, which connect with a granulation tissue-lined cavity lying in subcutaneous fat along with tuft of hair. This leads to recurrent infections in the cavity, which later extends under apparently normal skin, both in natal cleft and laterally into one or both buttocks. Minor infections may settle with a course of antibiotics, While there is a need for surgical drainage in case of abscess formation, however even after surgical drainage the underlying pathology remains which leads to repeated episodes of infections.

The incidence of disease is approximately 26 per 100000 populations.^[2]

Pilonidal^[3] infections and chronic pilonidal sinuses are usually found in the midline of the sacrococcygeal region of young hirsute men. The presence of hair in the gluteal cleft seems to play a central role in the pathogenesis of this disease. This is consistent with the observation that pilonidal disease rarely occurs in those with less hair.

Other risk factors include obesity, local trauma, and sedentary lifestyle, deep natal cleft and family history.^[4]

Diagnosis is generally a clinical one, patients may present with a chronic inflammation or a sinus with persistent drainage. Acutely, there may be an abscess or multiple complex subcutaneous tracks.

In Ayurveda it can be correlated to Shalyaja Nadi Vrana. It is a condition which develops when Shalya (foreign matter such as hair, bone, dirt etc.) lodges in the body and leads to formation of sinus. It is characterized by continuous pain, and discharge which is sometimes blood mixed. Treatment for Shalyaja Nadi Vrana is explained as removal of Shalya by Chedana and Shalyamarga Shodana.

One of the method used is Chedana of Nadi Vrana and application of Pratisaraneeya Kshara.

Case Study

Chief complaints: A 20 years old female, from Hassan, Karnataka came to SDM College of

Ayurveda & Hospital presented with complains of pain and pus discharge in the natal cleft region since 2 weeks.

History of present illness: Patient was apparently healthy 2 months back, and then she noticed swelling on gluteal natal cleft associated with pain and pus discharge. She had history of repeated boils or abscess or slight seropurulent foul discharge in the natal cleft region. For the above complaints she consulted a surgeon and underwent Z Plasty surgery for the same. From past 2 weeks, patient complains of pain and pus discharge in the natal cleft region. For further management she consulted Shalya OPD and got admitted for the same.

History of past illness: No H/O Diabetes, hypertension, thyroid disorder or any other medical disease.

Treatment history

H/O Z - plasty

Personal history

Appetite - Altered

Bowel - Regular

Micturition - Regular

Sleep - Adequate

Examination of the Patient

General examination

General appearance: Fair

Nutritional status: Obese

Consciousness: Conscious

Pallor: Present

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Oedema: Absent

Lymphadenopathy: Absent

Vitals

BP :110/80 mm of Hg

Temperature: Afebrile, 98.2°F

Pulse: 88bpm

Respiratory Rate: 16 cycles/min

Local examination: Inspection on prone position - Surgical scar mark of z plasty, single pit with serous discharge in mid sacrococcygeal region behind anus and one secondary sinus opening extend to just right lateral to midline was present. On pressure with finger purulent discharge was escaped from opening.

Perianal area was normal.

Digital rectal examination - normal anal verge with normotonic anal sphincter.

Proctoscopy - nothing abnormality was detected

Investigations

Hb: 10.5 gm%

TC: 13,900 cells/cmm

DC: N-84, L-33, M-2, E-5

ESR: 78mm 1^st hour

RBS: 100.9 mg/dl

Serum Creatinine: 0.9 mg/dl

Lipid Profile: WNL

Final diagnosis

Pilonidal Sinus / Shalyaja Nadi Vrana

Intervention: Complete excision of sinus tract with adjoining tissue was done after laboratory and pre anesthetic evaluation. Prateesaraniya Apamarga Kshara Karma^[13] (application of chemical cautery) followed by Vranaropana with Jatyadi Taila was done. Apamarga Kshara (Alkaline preparation made by Achyranthes aspera) was used. Orally Vranashodhana drugs like Triphala Guggulu and Gandhak Rasayana were given.

Preoperative procedure: Written surgical consent was taken from legal guardian. Patient was kept nil by mouth for 4 hours prior to surgery. Surgical part preparation was done. Injection tetanus toxoid 0.5 ml was given in intramuscular in right upper limb deltoid muscle. Injection lignocaine 0.2 ml intradermal was given for pre anesthetic skin sensitivity test purpose.

Intraoperative procedure: Patient was given prone position under aseptic precaution. Painting and draping was done over natal cleft and gluteal

region. A small gauze piece was placed in the lower part of the cleft to prevent the spread of the septic materials to anal region. Natal cleft was retracted laterally to expose the opening in the mid sacral line, where primary sinus was identified,

Local anesthesia was given. Next the probe was passed through the secondary opening, which was located 2 cm above and right laterally to the primary opening in the mid spinal line.

An elliptical incision was made in the natal cleft, which includes sinus tract and its branches & 2 cm adjoining healthy tissues. Incision was deepened to cut the deeper tissues. It reaches up to the presacral fascia, which covers the sacrococcygeal region.

Now incised edges was held with Allice forceps and traction was applied firmly. Deep dissection was carried out with the scissor and scalpel to separate the tissue from deep fascia. The dissected tissue was removed and hemostasis was achieved by diathermy. Complete excision of sinus tract with adjoining tissues was done.

Prateesaraneya Apamarga Kshara (high potency alkali) was applied over the wound for 1 minute. Within a minute wound surface becomes cauterized and turns blackish. Then the wound was irrigated with Nimbu Swarasa or lime juice water to remove additional Kshara, which prevent further damage of the tissue.

After complete hemostasis the wound was packed tightly with ribbon gauze soaked in Jatyadi Taila.

Post operative procedure

Post operative care is aimed to achieved pain management and wound care with prevention of recurrence

Fig. 1: Case of pilonidal sinus with post-operative Z plasty scar mark

Fig. 2: Probing from primary sinus

Fig. 3: Excised pilonidal sinus – tuft of hair visualized

Fig. 4: Application of Pratisaraneeya Apamarga Kshara over surgical wound site

Fig. 5: Post OP Day 5

Fig. 6: Post OP Day 10

Fig. 7: Post OP Day 20

Complete Healed Wound

Follow Up and Outcome: Patient was called for follow up every week after discharge. By 6 weeks post-operative wound was completely healed by leaving a minimal scar tissue. Follow up study reveals complete cure without any complications without recurrence even after 1 month.

Discussion

Pilonidal sinus is a challenging condition wherein surgeons mainly face difficulties like wound healing and post-operative recurrence. Excision of complete sinus tract with adjoining tissue and removal of tuft of hair results in terminating the ongoing acute inflammatory process.

Kshara^[8] being alkaline in nature causes fat saponification and alkaline proteinates which result in liquefaction necrosis when applied over tissue. It also extracts considerable water from cells due to hygroscopic nature causing cell death and tissue damage.

So, by virtue of its caustic action it destroys and removes unhealthy tissues and promotes healing. Any residual granulation tissues left during excision may cause recurrence are destroyed by Kshara^[9] application and probably decrease the chances of recurrence.

Apamarga Kshara^[10] helps to remove unhealthy granulation tissue & cellular debris by sclerosing property where recurrence rate is low.

In post-operative Vranashodhan having anti-inflammatory and microbicidal properties like Triphala Guggulu containing Emblica officinalis, Terminalia chebula, Terminalia bellerica, Piper longum, and Commiphora mukul was helpful.

Once the granulation tissue formation takes place, Vranaropana drug like Jatyadi Taila are used for wound dressing to minimize the wound infection and accelerate wound healing by reducing microbial load.

Conclusion

Hence, complete excision of sinus tract without primary suturing and application of Pratisaraneeya Apamarga Kshara with wound care by Jatyadi Taila with systemic Vranashodhan drugs are found to be having promising efficacy for the treatment of pilonidal sinus.

It can be a better alternative to all current standard procedures. It has very less or no adverse effects. It is found to be very cost effective. It can also be done on OPD basis. A study on larger sample size is required to comment about the exact rate of recurrence.

Reference

1. Bailey & Love’s, Short practice of surgery, 26th edition, Part 11 abdominal, chapter 69, The small and large intestine, 2013; 1174.

2. Manipal manual of surgery, fourth edition, 2014; 820.

3. Sabiston Text book of surgery, First south Asia edition, Volume II, Elsevier publication, section X, chapter 46 Acute gastrointestinal haemorrhage, 2017; 1408.

4. SRB’s Manual of Surgery, 5th edition, 22 chapter, Large intestine, 2017; 909.

5. Farquharson’s text book of operative general surgery, international student edition, 10th edition, CRS press, 2015: 456.

6. A manual of clinical surgery by Dr S. Das 12th edition, 2016: 98.

7. B D Chaurasia’s human anatomy, volume 2, CBS publishers, seventh edition, 2016: 402.

8. A manual on fistula in ano and ksharsutra therapy by Dr M Sahu, first edition, 2015: 118

9. Charaka samhita, By Dr Brahmananda Tripathy, Chaukhamba surbharati prakashan, Varanasi,: chapter 9, verse 8, 2013: 139.

10. Charaka samhita, By Dr Brahmananda Tripathy, Chaukhamba surbharati prakashan, Varanasi,: chapter 11, verse 32-33, 2013: 230.

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2022-05-30	2022-05-31	2022-06-07	2022-06-14	2022-06-21
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
Nil	Nil	Yes	19%

Case Report

Pilonidal sinus

Journal of Ayurveda and Integrated Medical Sciences