ULCERS, SINUSES & FISTULAE

ULCER

Breach or discontinuity
of an epithelium or
mucosal surface.

Classification
Infective
Traumatic
Venous

(a) non-specific
(b) specific TB, gumma
CHEMICAL
PHYSICAL

Arterial

Neoplastic

Neuropathic

Iatrogenic

Epithelioma of
hand with
typical edge

Thrombophlebitis
occurring in
varicose
veins

Early rodent
ulcer on the
side of the nose

Diagnosis

1. History:
age (young infective, >40 Ca, 60 Rodent)
sex (female varicose, male squamous
cell Ca)
Race (Chinese Varicose ulcer)
Religion (Muslim/Jews - squamous cell
Ca)
Occupation - prolong standing
(baker/hairdresser varicose veins)

2. Mode of onset:

acute
inflammation/trauma sudden
-chronic
chronic inflammation very slowly
malignant
rapid

3. Duration:

very short (days) acute infection;

short (month) malignant;
long chronic inflammation

4. Progress:

very rapid acute inflammation,

rapid malignant,
slow chronic inflammation

 5.

Pain:
acute inflammation, arterial
ulceration painful (venous not
usually very painful)
Neuropathic less pain
malignant early usually
painless.

 6.

Fever:
infective/TB
7. Loss of weight:
malignant/TB
8. Smoking:
Buerger's disease,
artherosclerosis
Past History TB, Syphilis, Diabetes
Mellitus, Hypertension
Responses to Antibiotics:
(+) in infection (-) in malignancy

PHYSICAL EXAMINATION
General

cachexia, anaemia,weight
loss (Ca, TB)

Local:

1. Number (single or multiple TB)

2. Site
Rodent lobule of ear & angle of
the mouth;

Pigmentation & Residual varicosity,

linear healing ulcer

Varicose medial aspect of lower half of leg,

Arterial tip/between toes, malleoli, heel

Arterial ulcer due to

ischaemic pressure to
the heel

SCC lower lip, Gumma s/c

bone ~ tibia/sternum/skull
Diabetic/Perforating/trophic
heel/ball of the foot (head of 1st /2nd
metatarsals
TB neck, axilla, groin
Lupus face, fingers, hands,
Chancre/soft sore ext.genitalia

 3.

Size (depends on duration

& rate of growth)
4. Shape (oval varicose,
circular rodent,
irregular malignant)
5. Edge: (a) flat sloping ~
simple or healing ulcer,
venous ulcer (edge red,
blue, transparent zone)

FLAT SLOPING
ULCERS OF A BURN
LESION TO LEG

Healing granulating
ulcer with skin
islands.

 (b)

square cut or punched

out
gumma, trophic, diabetic
- Chronic GU/DU, leprosy

(rapid death & loss of whole

thickness of skin without much
attempt by the body to repair the
defect)

SLOUGH IN THE BASE OF

DEEP SACRAL ULCER

(c) undermined
TB,

amoebic, bed
sore, carbuncle

BUTTOCK

(infection affects
underneath tissue more
than epithelial surface)

(d) raised

& rolled up
rodent/BCC

(slow growth of tissue in the edge of

ulcer, edge pale pink or white with
clumps of cluster of cells visible through
paper thin superficial coverings of
squamous cell)

(e) raised

& everted

malignant ulcer,
epithelioma
(tissue in edge growing quickly and
spilling out of the ulcer to overlap
normal skin or mucosa)

Everted edges which to the

palpating fingers feels hard - Ca
Slightly raised edges Rodent
Septic ulcer (commonest
varicose ulcer) sloping edges

Undermined edges tuberculous

Punched out ulcer
tertiary syphilis

Varicose
ulcer
confined
to the
lower
quarter of
the leg
Multiple gummatous ulcers in lower
limb
Perforating ulcer on the
sole
Exuberant
granulation
tissue
around a
sinus
OM rib

Colour of the Edge

Red inflammation
Pale or cyanosed ischaemia
Late blue, purple, black
Pigmentation venous ulcer,
malignant melanoma
Pearly edge BCC
Keratinization Neuropathic ulcer

6. Floor:

Haemorrhage & necrotic slough

malignant
purulent - acute infection
washed leather- gumma
bluish unhealthy granulation tissue
TB (whitish in brownish space/
apple jelly)
solid brown or gray dead tissue
full thickness skin death

 7.

Discharge:
On dressing gauze serous, serosanguinous, purulent, offensive,
copious, or so slight dries up into a
scab.

Surrounding skin, state of

local tissue, blood supply,
innervation
8.

ss of infln infective, scar TB

PALPATION
Temperature

difference/tenderness - in
acute infected ulcer
Base induration +/-,
Mobility of ulcer over underlying
structures
fixed malignant; bleed on touch +/ regional lymphatics
enlarged -> inflammation
hard malignant

Systemic Examination:

Infection constitutional symptoms

- TB
cachexia, anaemia, loss of weight- malignant
hypertension, artherosclerosis
- ischaemic ulcer
tabes dorsalis, peripheral
numbness
- neuropathic

Investigation
D.

Mellitus Urine sugar/ RBS/FBS

Infective - fbc, culture
TB
- CXR, AFB, ESR
Syphilis
- KT, VDRL
Discharge smear, Gram stain, C&S
Biopsy -

wedge/incisional biopsy
margin of the ulcer &
normal tissue which allows

(a) comparison with normal tissue

(b) known organ &
(c) +/- or infiltration

Curlings ulcer

Cushings ulcer

acute peptic ulcer in burn as a

reaction to stress
acute PU in head injury, early
days following spinal cord injury

Marjolins ulcer

malignant change in a scar, ulcer,

sinus (Chr.venous ulcer, burn,
Chr.OM sinus slow growth
avascular, painless scar not
have cut. nerve fibres, late lymphatic
spread obliterated lymphatics)

GRANULATING TISSUE

ESCHAR FOLLOWING SHIN TRAUMA

Principles of Assessment
1.

Combination of aetiologies in any one

lesion, especially diabetic foot.

2.

Pain indicates invasion of nerve endings.

3.

When the diagnosis relates directly to

treatment, biopsy may be necessary.

SINUS & FISTULA

SINUS ~
A tract which connects a cavity lined by
granulation tissue (usually an old abscess)
with an epithelial surface. {blind tract leading
from surface down to tissue}

FISTULA ~
Pathological connection between 2 epithelial
surfaces usually lined by granulation tissue
but can become epithelialized.

Sinus

Fistula

Congenital

Pre-auricular

Traumatic

Foreign body
implantation

Branchial, thyroglossal,
tracheo-oesophageal,
umbilical, rectovesical,
vesicovaginal
a/f operation or accidential
injury, salivary, pancreatic,
biliary, faecal, urinary

Inflammatory OM, TB, Act,

Chronic
abscess
Neoplastic

Appendicular fistula,
diverticulitis of colon

Degeneration/ Advanced Ca (Int/ext),

2. infn which
rectum, cervix faecal fistula
was incised

SINUS JAW

SINUS FROM SEPTIC

ARTHRITIS OF THE
SHOULDER DUE TO
ACTINOMYCOSIS

History
Since birth - preauricular sinus;
due to Osteomyelitis(high fever + swelling + bone
pain)
TB -lymph node enlargement or TB bone or joints
Perianal- h/o perianal/ischiorectal abscess
(intermittent contraction of anal sphincter prevent
proper rest)
[Pain + inflammatory/blockage; Fever/redness of
surrounding skin inflammatory]

TB, Crohns, U.colitis,

actinomycosis, colloid Ca, operation complication

Past history

Family history TB, Crohns, U.colitis

INSPECTION
1.Number
Single/Multiple (watering can
perineum Crohns rectum/anal canal, U.Colitis
fistulae; actinomycosis (multiple sinueses)

2. Site Preauricular (failure of fusion of ear tubercles at root of helix or on tragus of pinna; direction upwards
and backwards)
Branchial (2nd & 5th branchial arch) at the lower
3rd of the neck in front of sternomastoid muscle
Pilonidal in the middle behind, finger webs
Actinomycosis multiple indurated sinuses in
upper part of the neck
A single sinus over the lower irregular jaw due to
osteomyelitis OM

Actinomycosis of the left side of the jaw

with multiple sinus formation.

3. Opening of sinus
Sprouting granulation tissue - + of FB (stitch,
sequestrum, bullet)
Wide margin, thin blue undermined edge
TB Sinus
4. Discharge
OM pus; TB serosanguinous;
Actinomycosis sulphur granule
Urine, faeces, bile

5. Surrounding skin
Scar indicating Chr. OM or previously
healed TB.
Dermatitis with pigmentation Chrons /
Actinomycosis

PALPATION
1. Tenderness Inflammatory source OM
2. Wall of sinus thickening fibrosis chronicity

3. Mobility Sinuses resulting from OM is fixed

to bone (irregular, thickened, tender)
4. Lump + in neighbourhood TB adenitis
5. Examination of draining lymph nodes

Examination with a probe (with due

precaution)

direction and depth of sinus

presence of F/B (sequestrum),

moveable at wound depth

fistula communicated with a hollow

viscus or not

whether fresh discharge comes out on

withdrawal of the probe or not.

General Examination
Depends on site and cause particular system
Sinus in loin spine, ribs, kidneys
Chronic empyema chest
Osteomyelitisbone
Around anusPR/proctoscopy, sigmoid
scope, whole abdomen
Multiples in perineum/scrotum lower urinary tract
Groin sinus hip joint/spine (bursting of cold abscess)

Investigatons

Examination of discharge
marcro/physical/chemical/microscopy

X-rays
- sequestrum, opaque
foreign bodies/ sino/fistulogram

Failure to close
Inadequate

drainage
Specific infection (actinomycosis, TB,
syphilis)
Foregin body (stitch)
Epitheliazation of cavity
Malignant change in the cavity
Dense fibrosis around the wall of the
tract preventing collapse (empyema)
Absence of rest

Primary Skin Lesions

Macule a small flat

area of altered colour or
texture
Papule a small solid
elevation of skin less
than 0.5 cm in diameter
Nodule - >0.5 cm
Plaque elevated area of
skin greater than 2 cm in
diameter without
substantial depth

Vesicle circumscribed
elevation of skin <0.5
cm in dia containing
fluid
Bulla - >0.5 cm
Pustule visible
accumulation of pus in
the skin
Abscess - > 1cm
Weal elevated white
compressible evanescent
area produced by dermal
oedema

Papilloma a nipple like

mass protruding from the
skin
Petechiae Pin-head
sized macules of blood
in the skin
Purpura A larger
macule or papule of
blood in the skin
Ecchymosis a larger
extravasation of blood
into the skin

Haematoma a swelling
from gross bleeding
Burrow a linear or
curvilinear papule,
caused by a burrowing
scabies mite
Comedo a plug of
keratin and sebum
wedged in a dilated
pilosebaceous orifice
Telangiectasia visible
dilatation of small
cutaneous blood vessels

Secondary lesions (evolved from primary lesion

Scale a flake arising from

the horny layer
Crust look like a scale,
but is composed of dried
blood or tissue fluid
Ulcer an area of skin
from which the whole of
epidermis and at least the
upper part of the dermis
has been lost
Excoriation an ulcer or
erosion produced by
scratching
Erosion an area of skin
denuded by a complete or
partial loss of the
epidermis
Fissure a slit in the skin

Sinus a cavity or channel

that permits the escape of
pus or fluid
Scar the result of healing
in which normal structures
are permanently replaced
by fibrous tissue
Atrophy thinning of the
skin due to diminution of
the epi/dermis, s/c fat
Striae a streak like,
linear, atrophic, pink,
purple or white lesion of
the skin due to changes in
the connective tissue