Hi Bohui

Thanks for sharing this case. Other colleagues might have additional suggestions, below are some initial thoughts: 

Given that recent assessment of the ulcer (and tunneling) has been limited to the patient's spouse's observations, a comprehensive evaluation by a wound care professional would be important. For a detailed plan reassessment, please refer to the 'Plan Reassessment' section under "Pressure Ulcers/Injuries - Treatment" 

Managing tunneling wounds effectively requires a thorough assessment and tailored treatment plan for successful healing. Main goals in treating a tunneling wound are to address underlying causes, stimulate the growth of granulation tissue and prevent premature closure of wound edges. Interventions might include:

• Draining of the cavity to promote granulation.
• Surgical opening and/or debridement of the tunnels to properly clean, manage bioburden, promote healing
• Negative pressure wound therapy (NPWT)

Ulcer and patient reassessment components include:

• Checking for adequate pressure redistribution, repositioning, transfer 
• Checking for adequate glycemic control and nutritional intake
• Checking for adequate moisture/incontinence management
• Checking for any co-factors that may be impeding healing (e.g., medications, smoking, immunosuppression, etc). See 'Ulcer healability' in "Pressure Ulcers/Injuries - Introduction and Assessment".
• Checking for soft tissue infection and/or osteomyelitis
• Reassessment of the ulcer: are there other tunnels and if so where? It can be helpful to draw this on the skin with a permanent marker in order to help track healing progress. Often tracts can be assessed clinically. Sometimes imaging tests may be necessary to understand the full extent of tunneling.
• Reviewing local wound care: 
• Debridement: Ensure adequate removal of devitalized tissue of the tunnels to manage bioburden and promote healing
• Checking if bioburden is adequately managed
• Checking if exudate level/moisture level has changed since spouse probed the wound
• And finally, considering techniques to manage tunneling : 
• Packing: After cleaning the wound, it may be necessary to fill the tunneling area with packing material. This packing should be done carefully to fill the space without causing the wound to sink inward or applying excessive pressure that might extend the wound's edges outward.
• To promote growth of granulation tissue,  consider using rope dressings according to exudate levels (e.g alginates, iodine-infused options, hydrogels, etc, with antimicrobials if indicated).
• Bolstering: Depending on the tract (e.g. if overlying tissue is soft so as to allow dead space to close, inner walls of the tunnel are properly debrided, no exudate, no infection), another technique is to bolster dead space using foam applied firmly on the overlying skin surface. Once this is done, a wound dressing is applied to keep the foam in place while the pockets of destroyed tissue close up.
• NPWT: NPWT may be utilized if needed to speed up healing
• Follow up: Regularly, at least once a week, the wound should be checked. This allows for the assessment of healing progress and adjustments to the type of dressing used, particularly if there's no improvement in the wound's condition

Hope this helps!