Time and rate of sinus formation in pilonidal sinus disease

Background and aims To elicit mechanisms and timing of sinus development, the role of age at onset of symptoms, symptomatic disease duration, and consecutive number of sinuses were investigated. Materials and methods Analysis of 1,962 medical records of patients admitted for primary surgical pilonidal sinus treatment. Results Sinus number ranged from 1 to 16 (median 2), with chronic pilonidal disease showing more sinuses than acute disease (mean 2.6 vs 2.1 sinuses; p < 0.0001; Kolmogorov–Smirnov). Disease duration in chronic pilonidal disease was not linked to sinus formation (p = 0.98; Spearman). In acute pilonidal disease, duration was linked to the development of six sinuses per 1,000 symptomatic disease years (p = 0.0001; Spearman). A larger sinus number correlated with earlier onset of symptoms (p = 0.009; Spearman). Conclusion Long-standing chronic disease does not produce sinus per se. As sinus does not substantially arise during the course of symptomatic disease, there must be a time before the start of symptomatic disease when the sinus originates. These findings suggest that sinus can only be acquired up to a certain age, even if occupational exposure continues.     

Anterior perineal sinus

Each year we treat several patients with an anterior perineal sinus tract. They do not conform to commonly encountered perineal problems such as pilonidal disease, epidermal cysts, hidradenitis, fistulous abscess, or inflammatory bowel disease. In an effort to improve understanding of the problem and its clinical significance, we reviewed our practice records for the period from 1968 through 1988. Fifty-six patients underwent surgery for an anterior perineal sinus tract. In 31 patients, the clinical and pathologic condition defied classical diagnostic categorization. We have termed these lesions anterior perineal sinuses. Their clinical characteristics, treatment, and pathologic assessment form the body of this report. Male predominance (87 percent) and midlife presentation (average age, 44 years) characterized this group. Local symptoms were present from several weeks to several years prior to treatment. Local anesthesia (74 percent) and limited surgery (100 percent) resulted in complete healing in all patients (average, 7 weeks). A 15 percent recurrence rate was noted. The pathologic evaluation demonstrated acute and chronic dermal and subcutaneous inflammation. The etiology of this process remains uncertain. Its predominance along the median raphe suggests a congenital midline inclusion disorder.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Cardioinhibitory carotid sinus hypersensitivity in subjects with symptomatic sinus dysfunction

Cardioinhibitory carotid sinus hypersensitivity is present in about one third of patients affected by sinus dysfunction. Aim of the study was to evaluate whether carotid sinus hypersensitivity is related to a well defined (intrinsic or extrinsic) sinus node damage. Fifty-four patients with ecg signs of sinus dysfunction underwent an electrophysiological study and carotid sinus massage. Spontaneous heart rate and corrected sinus node recovery time were measured in basal condition, after adrenergic blockade (propranolol 0.2 mg/Kg i.v.) and after autonomic blockade (propranolol 0.2 mg/Kg i.v. plus atropine 0.04 mg/Kg i.v.). The association between sinus dysfunction and cardioinhibitory carotid sinus hypersensitivity was found in 18/54 pt. (16 men, 2 women; mean age +/- 1 SD 63.6 +/- 14.5 years). The remaining 36 patients (19 men, 17 women; mean age +/- 1 SD 65.8 +/- 9.8 years), affected by sinus dysfunction alone, were used as controls. No electrophysiological differences between the two groups were found; particularly, an abnormal intrinsic heart rate (according to Jose values) or an abnormal intrinsic corrected sinus node recovery time (greater than 385 msec.) were present in 83% of the patients in both groups. Among sinus dysfunction clinical features, heart rate, presence of spontaneous syncope, sino-atrial block or sinus arrest and organic heart disease were similar in the two groups while the percentage of patients with spontaneous atrial tachyarrhythmias (bradi-tachy syndrome) was significantly smaller (11% vs 44%; p less than 0.01) in carotid sinus hypersensitivity group. In conclusion, in sinus dysfunction patients, the presence of carotid sinus hypersensitivity cannot be used as a criterion to differentiate a subgroup with peculiar clinical and electrophysiological sinus node characteristics.(ABSTRACT TRUNCATED AT 250 WORDS)     

Paranasal sinus mycoses

The incidence of paranasal sinus mycoses (fungal sinusitis) varies widely with higher frequency in Sudan, southwestern states of USA and north India, which have hot and dry climate. The disease has been described as having four types: allergic, non-invasive, invasive and fulminate. A possible fifth type: non-invasive destructive may also exist. In a prospective study of 176 cases of fungal sinusitis from our centre, on the basis of clinical, radiological, histopathologic and mycologic findings the patients could be categorized into: allergic (12), non-invasive without bone destruction (81), non-invasive destructive (16), chronic invasive (55) and fulminant (12) types. Except the fulminate variety, the disease is commonly found in young immuno-competent population of rural areas. Aspergillus spp. are the commonest etiological agents though the importance of dematiaceous fungi in allergic fungal sinusitis has been stressed. Zygomycetes are common agents in fulminate type. In our series A. flavus (80%) was the commonest isolate, followed by A.fumigatus (9.7%), Rhizopus arrhizus (6.3%) and Alternaria spp. (1.1%). Curvularia lunata, Apophysomyces elegans and Candida albicans were isolated from one patient each. Different host and environmental factors may help in lodging the causal fungi in mucosal plugs of these patients. Fungal allergy is associated with all varieties of the disease. But it is not clear what determines the invasion of mucosa. Rabbit can be used as an animal model. Histopathology and radio-imaging techniques help to distinguish different types and delineate extension of disease process. Culture helps to identify the responsible etiological agent. The presence or absence of precipitating antibody correlates well with disease progression or recovery. For effective management, non-invasive disease requires surgical debridement and sinus ventilation only. But for invasive type the need of adjuvant medical therapy is recommended to prevent recurrence and further extension. Itraconazole was found to be most useful in our study to prevent recurrence. Patients with fulminate type require radical surgery and immediate chemotherapy.     

Nonrespiratory sinus arrhythmia

We report here 2 cases of sinus arrhythmia considered to be a form of nonrespiratory sinus arrhythmia because they did not have variances in the RR interval sequence within the oscillations modulated by respiration. Because the patients had pulsus alternans similar that observed in bigeminy, and because they did not have signs or symptoms of heart failure, we believe the arrhythmias represent intrinsic alterations of the electric activity of the sinus node