Asian Cardiovasc Thorac Ann 1998;6:149
© 1998 Asia Publishing EXchange Pte Ltd
Nonhealing Sternal Sinuses
Vijit Koshy Cherian, MS,
Arun Kumar Gupta, MD1,
Soman Rema Krishna Manohar, MCh
Dept. of Cardiovascular and Thoracic Surgery
1 Dept. of Radiology Sree Chitra Tirunal Institute for Medical Sciences and Technology Thiruvananthapuram 695011, India
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Chronic discharging sinuses after sternotomy is a distressing late complication in cardiothoracic surgery that usually responds to therapeutic measures such as removal of sternal wires or nonabsorable suture materials, curettage, or prolonged antibiotic therapy. We report a case of a young boy who suffered from chronic sternal sinuses with retrosternal extension for 5 years. Transcatheter obliteration by injection of tissue adhesive resulted in total healing.
The boy was 17 years-old when he underwent closure of a secundum atrial septal defect through a median sternotomy in 1991. Postoperatively, he had pericardial collection and wound infection that was managed by pericardial drainage, appropriate antibiotics, and secondary suturing of the wound. Six months after discharge he was found to have a large false aneurysm of the ascending aorta. He underwent successful aneurysmorrhaphy and was discharged following an uneventful recovery. Three months later, he presented with multiple discharging sinuses over the sternotomy scar. Removal of the sternal wires, curettage, and antibiotic therapy according to sensitivity over a period of 5 years proved to be futile and he was readmitted with two nonhealing sternal sinuses.
His routine hematological investigations were within normal limits. Chest radiograph showed no evidence of sternal osteomyelitis and no sternal wires in relation to the sinuses. Transthoracic and transesophageal echocardiography showed normal cardiac chambers and no sign of aortic aneurysm. A sinogram was performed with diatrizoate meglumine and diatrizoate sodium containing an iodine equivalent of 370 g•L–1 to delineate the sinuses. Both sinuses had retrosternal extensions; the upper sinus track was shorter, extending upwards by 2.5 cm and downwards by 5.5 cm (Figure 1
). Material aspirated from the sinuses was sent for routine acid-fast and fungal cultures. To obliterate the sinuses, each was injected with 1 mL of enbucrilate tissue adhesive. Following the procedure, the sinuses showed a tendency to heal. The culture grew coagulase-negative staphylococci but acid-fast bacilli and fungi were negative. The patient was given amikacin and co-trimoxazole and was discharged. After one month, both sinuses had completely healed and the antibiotics were stopped. One year later he was asymptomatic.
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Figure 1. Sinogram in (A) left anterior oblique view and (B) lateral view, showing restrosternal extension of the sinuses. The remaining sternal wire shows no communication with the sinuses.
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Unfortunately, a sinogram was not considered earlier in this patient. In view of the retrosternal extension and previous aortic aneurysm surgery, further sternotomy and exploration was considered risky. Although the same organism (Staphylococcus aureus) had been isolated previously and treated with antibiotics, the sinuses showed no tendency to heal. The injection of tissue adhesive proved successful in healing the sternal sinuses. We would like to invite commentary on this observation, which has not been described earlier to the best of our knowledge.
