Pilonidal Cyst/Abscess
Incision and Drainage (I&D)
Madalina Pitu
UT Health Science Center at Houston
Diagnostic Tests and Procedure
N6551 Fall 2021
Pilonidal cysts- A pain in the butt
What is ?
- Pilonidal cysts are caused by ingrown hair and skin debris. These abnormal pockets can become infected and form an abscess causing extreme discomfort or pain.
- Located over the tailbone or close to the anus in the gluteal folds
- Treated with incision and drainage
- Occurs in Males > females.
- Younger > older.
- Obesity
- Prolonged sitting
- The problem may reoccur.
Risk factors
Cyst vs. Abscess
Usually caused by: Staphylococcus aureus
Streptococcus species
Diagnosis
Cyst that is painful
Swelling
Redness
Drainage
Foul smell
Fever
When?
When would you perform a pilonidal I&D?
1.
Collection of pus causing pain that has not been relieved by use of antibiotics or non-invasive methods
Indications
2.
Small abscess that enlarged, or large abscess
Need to eliminate discomfort and promote healing
3.
Contraindications
1.
Debilitating disease or
Immunocompromised
Contraindications
2.
Excessively large or deep abscesses
3.
Multiple reoccurring pilonidal abscesses may indicate need for surgical removal
Beware
Things to be mindful of
Complications
- Pain – during and after procedure
- Bleeding
- Reoccurrence of abscess
- Septic thrombophlebitis
- Formation of fistula
- Necrotizing fasciitis
- Damage to nerves and vessels
- Scarring
Informed consents are required!
Must have
Equipment
Equipment
- Antiseptic skin cleaner ex: hibiclens
- Topical anesthetic
- Lidocaine – 1% or 2%, with or without epi
- 3-10mL syringe
- 27-30 gauge, ½ inch needle
- Sterile 4x4 gauze
- No.11 scalpel
- Steril drape
- Sterile gloves
- Curved hemostats – sterile
- Iodoform gauze
- Scissors – sterile
- Culture swap
- Position patient so abscess is easily accessible- prone or left lateral
- Set up your sterile field
- Clean the abscess and surrounding skin with antiseptic cleaner – 3 inch diameter
- Drape the abscess with sterile drape
Prep
Incision and Drainage how-to
I&D
- Put on sterile gloves
- Anesthetize the perimeter around the abscess with lidocaine. Do not inject lidocaine into the abscess.
- Use your scalpel to make a deep and long incision to allow drainage of the pus and prevent premature closure. Manually express pus from abscess
- Obtain culture by swabbing deep in the wound
- Probe sinus tract with cotton tipped applicator- if deep refer to surgeon
- If sinus tract is superficial, less than 5mm, perform elliptical excision for pilonidal sinus
- Explore the wound, remove hair and breakdown any septa or sacs with curved hemostat
- Pack with iodoform gauze, leave a little protruding from wound
- Dress with sterile gauze
Medications and Follow up
After Care
- Antibiotics not necessary
- Pain management
- Tylenol #3 Q4-6 hours for the first 24 hours, then ibuprofen
- Return to office in 2 days to remove packing if indicated
- Wound care
- Offloading
- Keeping site clean
- Sitz baths
- Observe for signs of infection
- Pus continues after 5 days
- Redness, swelling, pain increases, fevers
Documentation and Billing
- Patient name and medical record number, Name of provider performing procedure, date/time, Hx, HPI, ROS, diagnosis, plan.
- Rational for ordering procedure
- Risk factors
- Procedural note:
- Anesthetic used
- Identify the I&D anatomical spot
- Identify if abscess or cyst
- Identify if simple or complicated
CPT vs ICD codes
- CPT is the treatment being given
- ICD is the diagnosis or problem needing treatment
Using the correct code
- Identify the I&D anatomical spot
- Pilonidal!!
- Identify if abscess or cyst
- Abscess has pus
- Cyst is removed with the epithelial lining
- Identify if simple or complicated
- Simple if drained and left open
- Complicated with tube, drain, or packing was needed
Using the correct code
Why is this important??
10061 vs 10081= $ 31.69
- if you do 20 a month, you’re losing $7,605.60 a year
10060 vs. 10081= $154.40
- if you do 20 a month, you’re losing $37,056 a year