Infrequent Presentation of Pilonidal Sinus over the Nasal Bridge

Abstract

We report a patient with recurrent discharging sinus over the nasal bridge which was finally diagnosed as pilonidal sinus over the nasal bridge. Nasal pilonidal sinus is a rare condition that presents as a chronic and recurrent inflammation of the hair follicles and surrounding tissues of the nose, leading to the formation of abscesses and sinus tracts. The following report deals the dilemma of diagnosing and management of the patient. Though rare, nasal pilonidal sinus should be included as a differential diagnosis to aid in management as well as to improve awareness and inclusion of this condition. This report provides an overview of the clinical presentation, diagnosis and management of nasal pilonidal sinus.

Introduction

Pilonidal sinus is a common condition that occurs in the natal cleft of sacrococcygeal region, but it can also rarely manifest in other areas of the body, including the nose. The pathognomonic finding of the pilonidal sinus is the presence of loose hairs in the sinus tract or cavity [1]. Nasal pilonidal sinus is a rare condition that presents as a chronic and recurrent inflammation of the hair follicles and surrounding tissues in the nose, leading to the formation of abscesses and sinus tracts. The condition can be difficult to diagnose and manage, and it may cause significant pain, discomfort and aesthetic concerns for affected individuals. The cause of pilonidal sinus on the nose is not entirely clear, but it is believed to be due to a combination of factors, including hair follicle blockage, bacterial infection, and trauma. Treatment typically involves antibiotics, drainage of the abscess, and surgical excision of the affected tissues. Early intervention is crucial to prevent the spread of infection and further complications. The presence of this sinus on the nasal pyramid is an uncommon phenomenon and can cause confusion in diagnosis, which may result in incorrect treatment. Therefore, we present this case report to improve awareness and comprehension of this condition.

Case Report

A 15-year-old male patient presented to the ENT department with a history of a small swelling on the nasal bridge that had been present for 5 years. Initially, the swelling was neglected, but as it began to progressively increase in size, the patient sought medical attention. The patient reported a history of minor trauma to the area while playing. Over the past year, the swelling was associated with intermittent foul-smelling discharge, for which the patient had taken antibiotics intermittently. There site of sinus showed inverted skin rim, and no active discharge at the time of the visit to the OPD with no other significant findings. The patient’s overall health was good. Figure 1. Investigation with an X-ray sonogram revealed the presence of a sinus tract along a superficial plane, with no secondary extensions or blind tracts, leading to a diagnosis of pilonidal sinus.

Fig. 1.

Clinical photograph of sinus opening over the nasal dorsum

The patient was recommended to undergo surgical removal of the sinus, and the consent was obtained from the parents. The procedure was carried out under general anaesthesia, and antibiotics were administered prophylactically. Methylene blue dye was used on the table to locate and outline the sinus tract, which was subsequently excised. (See Figs. 2, 3) To repair the defect, the Rintala advancement flap technique was employed. (See Fig. 4) Non-absorbable sutures were used to close the wound. The patient was discharged the next day and returned for a follow-up appointment one week later and then 6 months later. (See Fig. 5) Histopathological examination of the tissue revealed a tract lined by stratified squamous epithelium extending into the dermis, with granulation tissue and a few hair shafts in the underlying tissue. The diagnosis of pilonidal sinus was therefore confirmed. (See Fig. 6a and b)

Fig. 2.

Complete excision of the sinus

Fig. 3.

Post excision wound

Fig. 4.

Advancement Flap

Fig. 5.

Healed scar on follow up

Fig. 6.

(a) HPE section of pilonidal sinus tract lined by stratified squamous epithelium along with loose fragmented hair shafts. 100x. (b) HPE section of pilonidal sinus tract lined by stratified squamous epithelium along with loose fragmented hair shafts. 400x

Discussion

Pilonidal sinus is a condition that is commonly found in the sacrococcygeal region, with only a few documented cases occurring elsewhere. The root cause of the condition has been a topic of debate among researchers, with some attributing it to congenital factors while others believe it to be acquired. However, current evidence supports the theory that pilonidal sinus is a primary infection caused by the penetration of hair, which triggers a foreign body reaction [2, 3]. A few cases have been reported where pilonidal sinus in present in interdigital spaces of barbers and animal handlers; very few cases have been reported to occur on the nasal pyramid [4]. The researchers arrived at the conclusion that pilonidal sinus is an acquired infective condition that progresses in two distinct phases. The initial phase involves the introduction of the infective organism into the tissue, resulting in the development of an infection that leads to sinus formation. The second phase involves the penetration of hair into the sinus, which triggers a foreign body granulomatous reaction [2]. In our particular case, the sinus developed following trauma to the nasal dorsum, likely due to a foreign body reaction that led to the formation of a sinus. It is possible that hair entered through the shaft and contributed to the development of the condition.

Pilonidal sinus is mostly encountered adolescent hirsute men, often situated in the midline, same as in our case [5]. The diagnosis of pilonidal sinus is primarily based on history and clinical examination. A confusion might arise for a case of dermoid cyst will also have the same features clinically. It is noted that dermoid cyst occurs early in life while pilonidal sinus occurs mostly during the onset of adult life. It is also noted that hair can occur in both the lesions, but a dermoid cyst extrudes white cheesy material [6] Although, histopathological examination which is the gold standard is mandatory to confirm the final diagnosis.

The primary treatment approach for the sinus involves complete excision of the affected area, followed by the use of an advancing flap operation to prevent further hair insertion. This technique is designed to promote proper healing and minimize the risk of recurrence. Notably, Karadakis introduced a widely recognized method that uses an advancement flap to repair the wound. This approach reduces the wound’s depth and minimizes hair accumulation, thus reducing the risk of mechanical irritation. Karadakis’ technique has reported an impressive recurrence rate of just 1% [7].

Conclusion

Pilonidal sinus though is a common entity, its occurrence in the head and neck region is rare. A lesion arising on the nasal dorsum is usually considered a case of a dermoid cyst but pilonidal sinus should also be included as a differential diagnosis. The histopathological examination gives a confirmatory diagnosis with squamous stratified epithelium lining the sinus along with pathognomic presence of tuft of hair.

Funding

No funding.

Declarations

Compliance with Ethical Standards

Yes.

Conflict of interest

None.

Ethical approval

Received from the Dept. of ENT, Bhagwan Mahaveer Hospital, Delhi.

Informed Consent

Patient had been explained about the surgery and probable publishing of his case and consent was given.