Pilonidal Sinus

When a patient develops pilonidal disease it begins as a midline pore, and then progresses to a pilonidal cyst as hairs and debris collect under the skin. If this cyst becomes inflamed and starts tunneling, we now call that a pilonidal sinus. It usually shows up as a spot off to the side of the gluteal crease, similar to the one in this photo:

pilonidal sinus
Pilonidal Sinus

We call this opening off to the side a “secondary sinus opening” (the primary opening is the midline pore deep in the gluteal crease). A secondary sinus opening can appear off to one side and up above the crease as in the photo, or it can be in the midline of the crease, or it can appear below the midline opening. It can also be farther away from the midline than is seen in the photo. These tunnels take the path of least resistance, and that varies from patient to patient. If a patient has already had previous surgery, and a sinus recurs, it often appears directly within the old scar, because that is the weakest point.

pilonidal sinus
Midline secondary opening showing relationship to pits

It is also possible for the cyst to create more than one secondary sinus tract opening, as seen in this photo:

pilonidal sinus
multiple pilonidal sinus tracts

The typical symptoms of a sinus are that it intermittently becomes swollen and painful. Patients often call this a “flair up”. It then drains and feels better and may even seem to completely heal, until the cycle of pain and drainage begins again.

The treatment is to remove the secondary opening, the tunnel, the primary opening, and to flatten the gluteal cleft. Just treating the secondary sinus tract opening with surgical removal, silver nitrate, steroid injections, antiseptics, antibiotic ointment, or any kind of local wound care will not solve the problem without removing the entire sinus from the midline pit to the secondary sinus tract opening. The Cleft Lift Procedure is the best option to accomplish all these things. There are also “minimally invasive pilonidal operations” that do not flatten the cleft, but remove the pilonidal sinus. These are reasonable procedures, but do have a high failure rate due to the fact that they do not address the reason for the pilonidal disease which is the shape and depth of the gluteal cleft.

As mentioned above, topical medications and antiseptics will not solve the problem. However, because this is an intermittent process, they may seem to be helping – but that is just an illusion. In general, once a sinus forms it will not resolve without surgical treatment. Whether the symptoms are severe enough for a patient to see surgical treatment is an individual decision. If the symptoms are minimal, some patients opt to just endure it. Here is a discussion of pilonidal disease with minimal symptoms.

At the Evergreen Surgical Pilonidal Clinic we only perform the cleft-lift procedure because of it’s very high success rate.