A 20 years male met a road side accident 1 year ago.
He sustained multiple lacerations on right side of face that healed within two weeks time. However, a sinus persisted in area of scarring on right cheek (Fig. 5.4).
X-ray face showed no abnormality. Biopsy from the ulcer margin was done twice and revealed nonspecific changes. Sinus was explored twice under local anesthesia but recurred. Ultimately patient was hospitalized and the sinus was explored under general anesthesia. To surprise of the surgeon, a piece of wood measuring 3 × 1.5 cm was delivered through the sinus (Fig. 5.5) and the sinus healed rapidly thereafter.
Learning point: Previous history of trauma to face was ignored in this case that led to delay in diagnosis.
This case highlights the importance of history taking.
Past history of tuberculosis, trauma, drainage of an abscess (cold abscess).
Examination
Site: Specific location is often diagnostic, e.g.
• Parotid fistula
• Branchial fistula
• Thyroglossal fistula
• Tubercular sinus neck
• Median mental sinus.
Number: Openings may be single or multiple.
• Multiple sinus openings are seen in actinomycosis.
• Multiple fistula openings are seen in fistula in ano caused by tuberculosis, Crohn’s disease.
Nature of discharge:
• Thin caseous (Tubercular)
• Thin watery on face (parotid fistula)
• Thick purulent (Bacterial infection)
• Yellow sulphur granules (Actinomycosis)
• Stools (Fecal fistula).
Surrounding skin:
• Bluish discoloration—tuberculosis
• Erythematous with cellulitis—acute infection
• Pigmentation—chronic sinus.
Palpation: Look for local tenderness, induration, direction of the tract, mobility of the tract on underlying structures and nature of discharge on pressure.
Adjoining structures should be palpated, e.g.
• Matted lymph nodes felt in tubercular sinus.
• Thickened underlying bone is felt in chronic osteomyelitis (Fig. 5.6).
Examination of draining lymph nodes:
• Firm and matted in tuberculosis.
• Firm, discrete and mildly tender in chronic nonspecific infection.
• Hard and fixed in malignancy.
General Examination
For malnutrition, diabetes, anemia, tuberculosis.
Specific Examination
• Oral cavity—in submental sinus
• Adjoining bones—in osteomyelitis
• Anal canal and rectum—in fistula in ano.
Investigations
• Hemoglobin
• Urine
• TLC/DLC
• ESR—raised in chronic infections
• Blood sugar—for diabetes
• ELISA for HIV
• Examination of discharge:
Actinomycosis: Sulphur granules on gross-examination.
Bacterial infection: Gram staining, culture and sensitivity.
Tuberculosis: Z-N. staining for AFB, polymerase chain reaction (PCR) for tuberculosis.
• X-ray of the part: Osteomyelitis of underlying bone, radiopaque foreign body.
• Sinogram/fistulogram: To outline the tract to deter-mine its course and relation with adjoining organs.
• Biopsy from margin of sinus: Confirms tuberculosis, malignancy.
ULCER
An ulcer is a break in the continuity of epithelial surface (skin or mucus membrane) due to microscopic tissue destruction. The dead tissue (slough) gets separated from the live tissue and exposes the floor of the ulcer.
Classification
1. Nonspecific ulcer: Their causes are given in Box 5.2.
2. Specific ulcer: Causes are tuberculosis, actino-mycosis, syphilis.
Fig. 5.6: Non-healing sinus forehead due to osteomyelitis of vault
3. Malignant ulcer: Causes are
• Squamous cell carcinoma
• Basal cell carcinoma
• Malignant melanoma Life History of an Ulcer It has following stages:
a. Stage of extension: The ulcer is progressive and growing in size. The ulcer has:
• Sloughed floor
• Indurated base
• Purulent discharge
b. Stage of transition: The ulcer prepares for healing.
The ulcer has:
• Clear floor
• Decreased induration of base
• Serous discharge.
c. Stage of repair: The ulcer is nearly healed. The ulcer has:
• Fibrous tissue on floor
• No induration of base with healing margins
• No discharge.
Box 5.2: Nonspecific ulcer—causes
Infective ulcer: Secondary bacterial infection of wounds.
Traumatic ulcer: Due to a. Mechanical trauma
• Dental ulcer due to ill fitting dentures.
• Decubitus ulcer due to pressure sores.
b. Physical agents like burns, radiations.
c. Chemical agents like acids and alkalis.
Trophic ulcer: Due to impaired tissue nutrition that depends upon blood supply and nerve supply.
a. Arterial ulcer: Due to poor blood supply, e.g. Buerger’s disease, Atherosclerosis.
b. Venous ulcer: Due to venous stasis, e.g. varicose veins, deep vein thrombosis
c. Neurogenic ulcer: Due to sensory impairment, e.g.
diabetes, leprosy, tabes dorsalis. Also called as
‘perforating ulcer’.
Tropical ulcer: Infective leg ulcers in tropical countries.
Diabetic ulcer
Cryopathic ulcer: Due to chilblains and cold injury Mortorell’s ulcer: Hypertensive ulcer
Bazin’s ulcer (Erythrocyanoid ulcer): Calf ulcer in young girls due to fat necrosis, sometimes cause tuberculosis.
Clinical Examination of an Ulcer History
• Duration of ulcer: Short in acute ulcer and long in chronic ulcer.
• Mode of onset
Following trauma: Traumatic ulcer.
Following sexual contact: Syphilitic ulcer, chancroid.
Long standing varicose veins: Varicose ulcer.
Over a scar: Marjolin’s ulcer.
Over matted lymph nodes in neck: Tubercular ulcer.
Over a nodule: Malignant ulcer.
• Progress: Change in size of ulcer.
• Painful or painless: Inflammatory and tubercular ulcers are painful, malignant and syphilitic ulcers are painless.
• Nature of discharge: Pus, blood, serum.
• Constitutional symptoms: Fever, cough, anorexia, weight loss.
Local Examination
• Site
Tubercular ulcer—in neck.
Rodent ulcer—upper part of face.
Arterial ulcer—tip of toes, dorsum of foot.
Venous ulcer—above medial malleolus.
Neuropathic ulcer—pressure points on sole.
• Size: Exact dimensions.
• Shape: Round, oval, irregular or serpiginous (healing at one place and extending at another place).
• Edge (Fig. 5.7)
Sloping—healing non-specific ulcer, venous ulcer.
Undermined—tubercular ulcer (bluish margins).
Raised and everted—squamous cell carcinoma.
Rolled out—rodent ulcer.
Punched out—syphilis.
• Floor: This is the exposed surface of the ulcer that can be seen. It can have:
Sloughed necrotic tissue—ulcer in stage of extension.
Red granulation tissue (Fig. 5.8)—healing ulcer in stage of transition.
Pale smooth granulation tissue—ulcer in stage of healing.
Wash leather slough—syphilitic ulcer.
Watery or ‘apple jelly’ granulation tissue—
tubercular ulcer.
Floor raised above the surface—malignant ulcer.
• Base: It is the area on which ulcer rests. Move the edges of the ulcer between thumb and index finger so as to feel the underlying tissues (e.g. fascia, tendons, muscles, bone).
Feel for the induration of the base.
Mild induration felt in chronic nonspecific ulcer.
Marked induration felt in malignant ulcer, syphilitic ulcer.
Feel for the mobility of ulcer on underlying structures. Benign ulcers are usually mobile while malignant ulcers are fixed to underlying struc-tures.
If on palpation, ulcer is friable and bleeds, it is likely to be malignant. However, healthy granu-lation tissue also bleeds on palpation.
• Nature of discharge: It can be scanty or copious.
Purulent discharge—bacterial infection.
Watery discharge—tuberculosis.
Bloody discharge—malignancy.
Sulphur granules—actinomycosis.
• Surrounding area:
Inflamed and edematous—infective ulcer.
Thick, pigmented with dilated veins—varicose ulcer.
Palpable matted lymph nodes—tubercular ulcer.
Pigmented halo—malignant melanoma.
Regional Examination
• Draining lymph nodes
Tender and enlarged—secondary infection.
Enlarged, hard, fixed—malignant ulcer.
Enlarged, firm, matted—tubercular ulcer.
Enlarged, shotty—syphilitic ulcer.
• Examination for impaired circulation: Look for weak or absent arterial pulsations with trophic changes (thin limb, shiny skin, loss of hair, brittle nails).
Look for varicose veins
• Examination for neurological deficit Look for: Sensations
Motor power Reflexes General Examination
For anemia, malnutrition, jaundice, diabetes.
Systemic Examination
• Respiratory system—Pulmonary tuberculosis.
• CNS and spine—Neuropathic ulcer.
• CVS—Congestive heart failure, valvular defects.
Investigations
• Hemoglobin—to look for anemia.
• TLC/DLC—count raised in secondary infection.
• ESR—raised in chronic infection.
• PBF—to look for sickle cell anemia.
• Blood sugar—for diabetes.
• Serology for syphilis—VDRL, Kahn test.
• X-ray chest—For pulmonary tuberculosis.
Fig. 5.8: Red granulation tissue on floor of the ulcer Fig. 5.7: Ulcer—shape of the edge
• Examination of discharge:
Gram staining for bacterial infection.
ZN stain for AFB, culture and sensitivity.
PCR of discharge for tubercular infection.
• X-ray of affected part—osteomyelitis of underlying bone.
• FNAC of enlarged draining lymph nodes can show tuberculosis, malignancy.
• Ulcer biopsy :
Wedge biopsy from margin of ulcer including adjoining normal tissue as well. The biopsy is not taken from the center of the ulcer as it contains mainly necrotic material.
Excision biopsy is done in case of small ulcer and subjected to histopathological examination.
Treatment
Treatment during stage of extension:
• Antibiotics according to culture and sensitivity report of the pus discharge.
• Analgesics and anti-inflammatory drugs for control of pain and inflammation.
• Bed rest and limb elevation to relieve pain and edema in leg ulcers.
• General measures like:
Correction of anemia by hematinics/ blood transfusion.
High protein diet with vitamins (vitamin C) to improve nutrition and wound healing.
Control of diabetes (if present).
• Local (topical treatment): It is done with regular antiseptic dressings. The aim is to remove slough and control sepsis so that healthy granulation forms and epithelialization starts. Various methods are:
Eusol (Edinburgh University solution) is used for desloughing of wound. It contains boric acid and bleaching power.
Solutions releasing nascent oxygen make bubbles in the wound and help in separation of slough, e.g. H2O2, Oxum solution.
Magnesium sulphate (Sumag) ointment is hygro-scopic in nature and applied on area surrounding the ulcer. It helps in relieving local edema and cellulitis.
Once line of demarcation appears between slough and healthy tissue, mechanical debride-ment should be done in multiple sittings.
Regular wound dressings are done using anti-septic solution or local antibiotics. However, these should be used only till the infection becomes clear. Their excess use can interfere with normal healing because they are toxic to fibroblasts and resistant strains of bacteria may develop.
Steps of dressing are:
a. Wound cleaning with sterile and warm saline solution.
b. Application of local antiseptic, e.g. Povidone iodine, chlorhexidine, mupirocin etc.
c. Covering the ulcer with sterile gauge pieces.
d. Putting cotton pads to absorb the discharge.
e. Applying bandage.
The dressing is changed once or twice a day depending upon soakage due to discharge.
The features of an ideal dressing are given in Box 5.3.
Other agents used for dressing of ulcers are:
i. Hydrocolloids: It is made of polyurethane foam that expands and forms a gel in the wound. It promotes angiogenesis and wound healing.
ii. Alginates: These are sodium and calcium salts of algenic acid. These are hemostatic and useful in management of bleeding wounds. They absorb liquids and swell to form gel, hence, useful in heavy exuding wounds.
iii. Tegaderm: It is thin polyurethane membrane that prevents water loss from the ulcer. It prevents contamination of ulcer from the environment.
Epithelial regeneration occurs rapidly and it prevents epithelial breakdown due to friction or exposure. It is useful in treating non-oozing wounds.
iv. Recombinant epidermal growth factor: It increases collagen production and stimulates formation of granulation tissue. Thus, it enhances wound healing and reduces healing time. It is useful in dressing of clean wounds.
Box 5.3: Ideal dressing
• Removes exudates and toxins
• Maintains high humidity in the wound
• Porous (permits gaseous exchange with atmosphere)
• Non-allergic
• Non-irritant
• Non-toxic
• Easy to remove (without causing trauma)
• Cost effective
Arterial Ulcer (Fig. 5.10)
• It is due to inadequate skin perfusion due to peripheral arterial disease.
• Common causes are atherosclerosis, Buerger’s disease, diabetes.
• Commonly seen in parts prone to trauma (anterior and lateral side of leg, toes, heel, dorsum and sole of foot).
• Hallmark of arterial ulcer is rest pain.
• Ulcers are irregular, punched out and deep (involving deep fascia, tendon or even bone).
• The affected limb shows gangrenous patches and trophic changes (See Chapter 18: Gangrene and Diseases of Arterial System).
• The limb feels cold and peripheral pulses are diminished or absent.
• Investigations helpful in diagnosis are: Doppler pressures, duplex ultrasonography and arterio-graphy.
Venous Ulcer (Fig. 5.11)
• It is typically situated on medial side of lower half of the leg above medial malleolus.
• It is vertically oval in shape, sloping edges and never penetrates deep fascia.
• It is painless.
• Surrounding skin shows varicose veins, pigmentation and eczema (Lipodermatosclerosis).
(Details of venous ulcer are given in chapter 19:
Diseases of Venous System).
Fig. 5.10: Arterial ulcer Treatment during Stage of Transition
• At this stage, ulcer is having healthy granulation tissue and minimal discharge.
• Aim is to promote surface epithelialization and to prevent secondary wound infection.
• Non-adhesive sterile dressing is done on alternate days or even twice a week using vaseline gauze. It helps in easy removal of dressing and prevents epithelial breakdown during change of dressing.
• If there is formation of hypergranulation tissue (proud flesh), it is debrided surgically or by applica-tion of copper sulphate (chemical cautery).
• Small ulcers heal of their own while large ulcers need coverage with skin grafting or flaps.
Treatment of Underlying Cause
• Varicose ulcer—surgery for varicose veins.
• Tubercular ulcer—antitubercular treatment.
• Malignant ulcer—wide excision.
• Diabetic ulcer—control of diabetes.
CLINICAL FEATURES OF VARIOUS ULCERS