Chapter 43 & 44 - Nasal passages and sinuses Flashcards
1
Q
What are strong indicators of palatal dysfunction?
A
Easy and prolonged displacement of the soft palate (SP).
2
Q
How can dynamic displacement of the soft palate (DDSP) be induced during endoscopy?
A
- By transient nostrils occlusion
- inserting an endoscope into the cranial trachea, slowly withdrawing,
- flexing the head and neck.
3
Q
What is the specificity and sensitivity of observing DDSP at rest?
A
Specificity is 85%, and sensitivity is 26%.
4
Q
Apart from DDSP, what other abnormalities may be observed, as per postmortem studies in racehorses?
A
Prevalent lesions in the subepiglottic area.
5
Q
What is the gold standard for diagnosing DDSP, and why?
A
Exercising endoscopy is the gold standard because DDSP is a dynamic event occurring during exercise.
6
Q
What steps are taken during a resting endoscopic evaluation of the trachea, guttural pouch, and nasal passage?
A
Sedation, local anesthesia, and elevating the epiglottis with bronchoesophageal forceps.
7
Q
What might indicate temporohyoid osteoarthropathy during endoscopy?
A
Enlargement of the stylohyoid bone and the temporohyoid joint within the dorsal guttural pouch.
8
Q
What factors are simulated on the treadmill to induce exercise stress?
A
Head/neck flexion,
fatigue,
and incremental speed.
9
Q
What is the primary diagnostic tool for exercise intolerance and respiratory noise?
A
Treadmill.
10
Q
Why is uphill exercise considered appropriate, especially in jumping horses?
A
To simulate the conditions faced by jumping horses.
11
Q
How can septal deviation be evaluated since it’s difficult with an endoscope?
A
Check with radiographs.
12
Q
How is dynamic endoscopy categorized, and what are the major criteria for abnormal laryngeal function during exercise?
A
Categorized as A, B, C;
A is able to obtain and maintain full abduction of the arytenoid cartilages (AC) during exercise.
13
Q
What are predisposing factors for inducing dynamic displacement of the soft palate (DDSP)?
A
Headgear, head/neck flexion, and pressure on the bit.
14
Q
What cases exhibit** normal laryngeal** and pharyngeal function at rest but not during** exercise?**
A
1- Axial deviation of the aryepiglottic folds,
2- pharyngeal wall collapse,
3 - epiglottic retroversion.
15
Q
How might epiglottic hypoplasia and flaccidity contribute to predicting DDSP during exercise?
A
These conditions, along with soft palate ulceration, can help predict DDSP during exercise.
16
Q
What percentage of racehorses with respiratory noise or exercise intolerance may have a false-negative diagnosis DDSP based on resting endoscopic findings?
A. 60%
B.30%
C. 85%.
A
C. 85%.
17
Q
What is considered the gold standard for diagnosis of upper airway disease?
A
Overground endoscopy or dynamic endoscopy
18
Q
A
Ventral concha sinus and rostral maxillary sinus
19
Q
What additional diagnostic information can ultrasound provide regarding upper airway diseases?
A
It can provide structural and functional information about the location and extent of disease, corroborating endoscopic findings.
20
Q
What enhances the diagnostic value of radiography for equine skulls?
A
Large gas-filled structures such as the guttural pouch, nasal cavity, larynx, pharynx, and paranasal sinus.
21
Q
A
Middle (MM) and common (CM)nasal meatuses of the right nasal cavity in thenormal horse. The middle meatus is defined asthe space between the dorsal and ventralconchae, and the common meatus is the spacebetween the conchae and the nasal septum –note the ‘y’-shape created by the dorsal concha(DC) dorsally, the ventral concha (VC) ventrolaterallyand the nasal septum (NS) medially.The lateral part of the middle meatus is usuallytoo small to pass an endoscope into.
22
Q
What is the major criteria for diagnosing sinusitis in radiographs?
A
Identification of a fluid line, but multiple fluid lines require careful distinction of affected sinuses.
23
Q
What are some other special views mentioned for equine skull radiography?
A
Intraoral,
right to left lateral,
left to right lateral,
dorsal obliques,
lateral obliques,
and contrast studies.
24
Q
Which sinuses are more predisposed to disease due to direct communication with the nasal cavity and dental alveoli?
A
The maxillary sinuses.
25
Why the new discovery of sphenopalatine sinuses incomplete formation of sphenoidal septum is important?
This has clinical significance because communication between the left and right paranasal sinus compartments could lead to **bilateral clinical signs despite unilateral pathology**
26
What is the clinical significance of the rostral maxillary sinus and ventral conchal sinus communication?
They communicate with the middle nasal meatus via the nasomaxillary opening.
27
Which sinus is located beneath the rostral brain and optic chiasm in horses?
The sphenoid sinus.
28
Perez et al VS 2021 Where within the nasopharynx was the fenestration site located in cadavers?
**Midway** between the **vomer** and **dorsal conchal wall** - For the
palatine bone, **10–15 W continuous wave** varying from 1 to 2 cm focal distance was used to create the necessary **12–
15 mm fenestration mucosa required 460 J** and bone 1890 J
29
What are the most common clinical signs of diseases involving the external nares in horses?
Reduced airflow, nasal stertor, and facial distortion.
30
Perez et al VS 2021 The sphenopalatine sinus (SPS) lies within the sphenoidal and palatine bones on the ventral aspect of the cranium and is comprised of two compartments: the sphenoidal sinus (SS) that is caudally located,
and the palatine sinus (PS) that is rostrally located
31
Perez et al VS 2021 What condition was identified in the clinical case's sphenopalatine sinus?
A. A benign cyst
B. A soft tissue abscess
C. An undifferentiated carcinoma
D. A vascular anomaly
C. An undifferentiated carcinoma
32
Perez et al 2021 What tool was used to ablate the mucosa and palatine bone during the procedure?
A. Bronchoesophageal forceps
B. Flexible endoscope
C. CO2 laser fiber
D. Standing CT scanner
C. CO2 laser fiber - Endoscopically guided fenestration of the rostral palatine bone
within the nasopharynx using CO2 laser in the standing horse provided good
access and visualization of the palatine portion of the SPS.
33
Diagnosis
FIGURE 1 Multiplanar reconstructed CT images ((A) sagittal, (B) transverse, and (C) dorsal views) at the level of the sphenopalatine
sinus (SPS) of the clinical case when initially presented for right intermittent epistaxis. **Note the soft tissue/fluid attenuating mass within the
right sphenopalatine sinus (asterisks).** Red arrow indicates proposed site of fenestration of right rostral palatine bone
FIGURE in Perez et al 2021 VS
34
What clinical signs may indicate laceration of the external nares?
Reduced airflow,
nasal stertor,
and facial distortion.
35
Why should sinus and neurological deficits together raise suspicion of disease?
Because disease processes in this area can result in erosion of thin bone plates separating sinuses from cranial nerves.
36
What is the new name for what was previously called sebaceous cysts in horses?
Epidermal inclusion cysts.
37
What diagnostic method is pathognomonic for epidermal inclusion cysts?
Visual inspection of homogenous, thick brown aspirated material during cytological examination of a fine-needle aspirate.
38
What is the age variation for horses with epidermal inclusion cysts?
2 to 18 years old.
39
Why should laceration of the nares not be underestimated in performance horses?
Nares represent the **point of maximal airflow resistance**, and suboptimal repair could lead to **undesirable airflow restriction during exercise.**
40
Diagnosis and name possible treatments
Epidermal inclusion cyst
- Single intralesional 10% formalin administratio (volume dependent on size of cyst)
- Surgical extirpation standing with sedation and local anest (do not rupture cyst wall).
- Extirpation inside the nasal diverticulum with sabe and evert cyst linning with Williams burr
41
Latero-45° Ventral-Lateral Oblique Projections
42
What is the suggested technique for standing surgery to remove epidermal inclusion cysts?
Incise the skin and subcutaneous tissue, remove the cyst by dissection, and take care not to rupture the cyst wall.
43
What other technique beside direct incision is mentioned for removing epidermal inclusion cysts from the nasal diverticulum?
Lancing the cyst into the nasal diverticulum through a stab incision, followed by cyst lining eversion using a burr.
44
What is the common outcome after treatment of epidermal inclusion cysts in horses?
Good, recurrence has not been reported
45
(R) Normal sinus anatomy. Yellow (Frontal) Red (Dorsalconchal) Green (Rostral Maxillary) Purple (Caudal Maxillary) Blue (Sphenopalatine)
46
Latero-30° Dorsal-Lateral Oblique Projections
47
name the projection
Dorsal-Ventral Projection
48
Diagnosis
Periapical sclerosis
There are many signs of apical infection described in the literature. 1 of the earliest signs reportedis loss of the lamina dura surrounding the tooth. Recent studies have shown this sign to be highlysensitive but very poorly specific, meaning a high degree of false positives which is not desirable in aclinical situation. The same study showed clubbing of the roots, periapical halo formation and periapicalsclerosis to be the most useful signs of periapical infection.
49
describe endoscopic image
L) Cadaver specimen showing the nasal passageways being divided by the dorsal and ventral conchae.(R) Endoscopic appearance of the middle nasal meatus
Septum on the right
50
Endoscopic images of the sinus drainage angle (L) and an inflamed endoturbinate (R). Both cases havedischarge from the sinus drainage angle.
51
Diagnosis
Endoscopic image of a sinus cyst protruding into the nasalpassageway between the dorsal and ventral conchae
52
Endoscopic image of a progressive ethmoid haematoma
53
Name the 2 structures in red and blue
Sagittal computed tomography imageshowing the outline of the dorsal conchal bulla(DCB – red) and ventral conchal bulla(VCB – blue)
The dorsal and ventral conchae are invaginated on their caudal aspects by the dorsal and ventralconchal sinuses respectively and within their more rostral aspect contain the dorsal and ventralconchal bullae. **These bullae do not communicate with the paranasal sinuses** and may become infectedin dependent of the sinuses.
54
name the teeth and sinuses
55
Endoscopic image with inspissated material trapped between the dorsal and ventral conchae
56
Name the sinus and teeth
57
Name the sinus and teeth
58
describe the projection and the bone
intraoral DV
59
What are the external nares and how are they supported in horses?
Openings into the nasal passages; supported by alar cartilages.
60
What divides the nasal cavity into equal halves?
Nasal septum and vomer bone.
61
How many major nasal conchae are there in each nasal cavity, and what are their divisions?
Two major nasal conchae; dorsal, middle, ventral, and common meatus.
62
What is the function of the dorsal conchal bulla and ventral conchal bulla?
They are air-filled structures separate from the paranasal sinus network.
63
How many pairs of sinuses make up the horse's paranasal sinus system?
Seven pairs.
64
How does the volume of the bullae correlate with head size and age in horses?
Older large-headed horses have larger bullae than younger, small-headed horses.
65
What is the term for the communication between the frontal sinus and dorsal conchal sinus?
Conchofrontal sinus.
66
What are the common clinical signs of diseases of the nares, and why should lacerations be carefully repaired?
Reduced airflow,
nasal stertor, and
facial distortion;
lacerations can cause airflow restriction during rigorous exercise.
67
Where is the sphenopalatine sinus located, and what nerves is it associated with?
Usually contiguous with the** palatine sinus; **
associated with the **calvarium** and **cranial nerves II, III, IV, V, and VI.**
68
What is the alternative name for epidermal inclusion cysts, and where are they located?
Atheromas; dorsolateral aspects of the nasal diverticulum.
69
What is the treatment option using a single intralesional 10% formalin administration?
Reported for treating intradermal inclusion cysts with complete resolution in all instances.
70
How is surgical extirpation of epidermal inclusion cysts performed?
Standing horse with sedation and local anesthesia; incision over the lesion, careful removal, and routine closure.
71
What is the significance of alar folds in the exercising horse, and how can flaccid folds be treated?
Source of respiratory noise; bilateral resection of the fold is the treatment.
72
What are the most common clinical signs of nasal cavity diseases?
Nasal stertor, unilateral nasal discharge, and facial distortion.
73
What surgical techniques are used for nasal septum resection?
Tracheotomy first
- - Subtotal nasal septum resection: Three-wire technique or two-wire technique;
- Near total septum resection
74
Strand et al 2019, Alar fold resection in 25 horses: clinical findings and effects on racing performance and airway mechanics (1998-2013) mentions a surgical technique, describe it
-Dorsal recumbency, 90° head flexion,nostrils toward ceiling
- Oral intubation
- 10 cm skin incision from lateral ala extending as far as possible to the caudal edge of the ala
- Insertion of forceps as guide to dissect the diverticulum
- Suturing of the diverticulum mucosa to skin ctu simple
- Suturing nasal skin
- Suturing external skin ford interlocking
Always bialteral
2-3 w box + 30 min walking and after 3-4w light work
75
What complications might occur after nasal septum resection, and what is the prognosis for restoring normal function?
Complications:
- Excessive granulation tissue,
- adhesions,
- persistent noise
- exercise intolerance;
**Prognosis is guarded** and complications are minimized with improved techniques
76
Kalmir et al 2019 in Complete resection of the alar folds in eight standing horses with a bipolar dividing and vessel-sealing device mentions a standing surgery with regional LA. What blocks were performed?
**Bilateral infraorbital nerve blocks** with **5-10 mL of mepivacai**ne and local anesthetic soaked tampons on the ventral/mucosal surface of alar fold
77
Describe the surgical procedure in Kalmir et al 2019 Complete resection of the alar folds in eight standing horses
with a bipolar dividing and vessel-sealing device
Deaver or Richardson-Kelly hand-held retractor wasplaced laterally in the false nostril to visualize the AF.
The AF was grasped and unfolded by using twoAllis tissue forceps. The fold was then resected under tensionby using a curved, small-jaw, open sealer/dividerLigaSure device (setting 2/3; LigaSure™ ). Specifically, the sealing/dividing instrument was “walked” from rostralto-caudal, staying against the external nares for the dorsalincision line. The same procedure was then repeated on theventroaxial aspect of the AF, keeping the instrument against the nasal cartilage. The entire AF, includingsome of the ventral conchal cartilage, was releasedwhen the transection lines met caudally. Two activations ofthe LigaSure device were often made caudally in the mostvascular part of the AF before the blade was fired.
78
How much time after surgery the training was achieved?
3-6 weeks after surgery
79
Kalmir 2019 Alar fold removal. What were the results of the surgery, how many % of horses reduced respiratory noise and improved performance?
100% had a reduction in respiratory noise and improved performance
75% improvement in earnings
80
The bleeding can occur due to which vessel in alar fold resection?
Superior labial artery and vein
81
what are the issues of having obstructions in the nares according to Bernoulli's principle and Venturi?
According to Bernoulli's principle and the Venturieffect, obstructions at the level of the nares will theoreticallyserve as a bottleneck to airflow and predispose to 2aryproblems in the nasopharynx.
82
What is the surgical approach to redundant alar folds according to Auer?
Lateral recumbency provides the best exposure to the alar foldif the alae of the external nares are incised.
The resection involves incising the alar fold from caudal to the alar cartilage on thelateral wall of the nasal cavity to the rostral end of the ventralconcha (Figure 44-2).
A second incision is directed caudad alongthe medial attachment of the alar fold to join the first incision.
Approximately 2 cm of the rostral end of the ventral nasal conchais removed with the alar fold.
Profuse hemorrhage may occuronce the cartilage has been incised.
A 22.5-cm curved Rochester-Carmalt forceps can be used as a guide for the incisions and tocontrol hemorrhage.
hemostasis is achieved by closure of the incisionusing a simple-continuous suture pattern with size 0 absorbablesuture material, commencing at the caudal limit
83
What should you consider before a surgery of the sinus or nostral for profuse hemorrhage?
**Collect 4-8 L of blood** before surgery in case a transfusion becomes necessary.
In addition, the **administration of large volumes of intravenous fluids during surgery** may be necessary to help alleviate hypotension.
The most effective method of controlling hemorrhage is to use a nasal tampon after surgery, such as rolled gauze.
84
What nerve blocks you perform if standing septum resection?
Maxillary and ethmoidal nerve block
85
describe septum resection under GA
tracheotomy is performed to secure the airway and to deliver the anesthetic gas
LR
The surgery for **subtotal resection** begins by making a curved incision on skin and periosteum for **19-mm trephine hole** on the **bridge of the nose** to gain access to the caudal portion of the septum.
The center for this opening is located just rostral to the frontal sinuses where the **nasal bones begin to diverge**
Periosteum is reflected.
Nasal septum is easily ID when the boneplug has been removed and the mucosa has been incised.
**Doyen intestinal forceps** or other suitable straight forceps are placed **vertically** on the nasal septum down to the floor of the nasal. The forceps acts as a stop for the guarded chisel when severing the dorsal and ventral attachments of thenasal septum, and it acts as a guide for making the caudal incision in the septum.
**The rostral division** in the nasal septum is performed by making a curved incision with a scalpel, starting from the ventral aspect of the septum and extending in a dorsocaudal direction, leaving at **least 5 cm of the rostral septum** to supportthe alar cartilages and external nares.
A **guarded chisel** is used to incise **the dorsal and ventral** attachments of the septum caudal to the forceps.
The caudal incision is made with a narrow osteotome immediately rostral to the Doyen forceps.
The septumis subsequently grasped through the external nares with heavy **Vulsellum forceps** and removed.
86
What is the alternative technique of septum resection?
An alternative technique has been described to remove more **near total septal resection** of the **nasal septum using obstetric wires**. With this technique, the **caudal incision** is made at a** 60-degree** angle to the nasal bones in a **dorsocaudoventral** direction, allowing the **entire ventral septal attachment** to be incised up to the **rostral incision** in the** septum**. The **obstetric wire** is passed through the **ventral meatus **around the caudal aspect of the nasal **septum **and back through the opposite nasal passage to incise the ventral attachment. This is accomplished by passing the wire through the ventral nasal meatus into the nasal pharynx and **retrieving the wire** through the opposite side using a **rat-tooth forceps** passed through the biopsy channel in a flexible endoscope. Another instrument that can be used to retrieve the wire are **long flexible grasping forceps**. The caudal incision can be made at a **60-degree angle to the nasal bones using along narrow osteotome** or a **grooved cutting** instrument fashioned from a standard wide-tipped screwdriver. The tip of the screw drivers ground concave and the edges are rounded so that the cutting edge sits better on the septum, reducing trauma tothe nasal conchae.
- A less traumatic method of performing the **dorsocaudal** incision is achieved with obstetric wire using a Chamber catheter to guide the wire** around the vomer** as** far caudad **as possible. The wire is **retrieved on the side of the vomer **as done previously with the **ventral wire placement.** The catheter is used to hold the wire in position while performing the caudalcut. T
**Packing the nasal cavity** with sterile cotton roll gauze controls hemorrhage for 48-72 hours and keep tracheo tube
87
What is the origin of ethmoid hematomas?
Ethmoid hematomas originate in or around the ethmoid labyrinth or occasionally from the paranasal sinuses. Hemorrhage occurs in the **submucosa of an endoturbinate** or a sinus, causing the **mucosa to stretch and thicken**, forming the capsule of the hematoma
88
What is the prognosis for restoring normal function after septum removal?
Guarded
89
What is the gross appearance of an ethmoid hematoma?
An ethmoid hematoma has a smooth, glistening surface that may be mottled or green-tinged secondary to hemosiderin deposits.
90
How does the capsule of an ethmoid hematoma form?
**Hemorrhage occurs in the submucosa** of an endoturbinate or a sinus, causing the mucosa to stretch and thicken, forming the capsule of the hematoma.
91
What is the most consistent clinical sign of ethmoid hematomas?
The most consistent clinical sign is **mild, intermittent, unilateral epistaxis**.
92
How is a tentative diagnosis of ethmoid hematomas made?
A tentative diagnosis can be made from the history, clinical signs, and endoscopic, radiographic, and CT findings.
93
What other clinical signs may be associated with ethmoid hematomas?
Other possible clinical signs include malodorous breath, facial swelling, head shyness, and head shaking.
94
What is the most characteristic radiographic abnormality associated with ethmoid hematomas?
a smooth, discrete, rounded density in the frontal or maxillary sinus
95
What imaging modality is extremely useful in determining the number of lesions and their exact location and extension prior to surgery?
CT (Computed Tomography) has been shown to be extremely useful in determining the number of lesions and their exact location and extension prior to surgery.
96
What is the differential diagnosis for ethmoid hematomas?
The differential diagnosis includes conditions such:
as ulcerative or fungal rhinitis,
foreign body,
ethmoidal neoplasia,
mycosis
or neoplasia of the guttural pouch,
skull fracture,
neoplasia,
infection,
or cyst of the paranasal sinuses,
pulmonary abscess or neoplasm,
and infectious pleuropneumonia.
97
What is the goal of surgery for ethmoid hematomas?
The goal of surgery is the removal of the mass and destruction of its origin.
98
How is the surgical approach for ethmoid hematomas determined?
The surgical approach for removal depends on mass size and location.
<5 cm try conservative with 4% formalin or transendoscopically neodymium:yttrium aluminum garnet (Nd:YAG)
Larger lesions: bone flap techniques
99
What is the most effective method for controlling intraoperative hemorrhage during surgery for ethmoid hematomas?
**Firm packing of the sinus** or nasal cavity with sterile cotton roll gauze is the most effective method for controlling intraoperative hemorrhage.
100
What is the preferred method for removal of ethmoid hematomas if surgery is indicated?
If surgery is indicated, the preferred method is extirpation of the lesion with radical débridement.
101
What is the prognosis for ethmoid hematomas without treatment?
The prognosis is **unfavorable without treatment** because the lesion is progressive and eventually causes obstruction and dyspnea.
102
What is the approximate chance of recurrence after routine surgical removal of ethmoid hematomas?
The chance of recurrence after routine surgical removal is relatively high, approximately **43%**
103
What reported ablation techniques can be used for the treatment of progressive ethmoid hematomas in a standing, sedated horse?
Reported ablation techniques include **transendoscopic use of the Nd:YAG laser**,
**intralesional formaldehyde injection**,
and **cryotherapy**.
104
What is the recommended treatment using the Nd:YAG laser in a standing horse for ethmoid hematomas?
The Nd:YAG laser is effective for lesions **less than 5 cm** in diameter when limited to the nasal fundus only. **60W of power contact technqiue** with multiple tx every 7 days
105
Describe the chemcal ablation of ethmoid hematomas
injected transendoscopically with a 4% formaldehyde solution,through a commercial polypropylene catheter with a retractable, swedged-on 23-gauge needle, polypropylene tube inserted through the biopsy channel of the endoscop
Volume depends on size of lesion and inject until the mass begins to distend and leakage
Repeat 3- to 4- week intervals
106
What complications can occur with chemical ablation of ethmoid hematomas using a 4% formaldehyde solution?
Complications may include **laminitis** and the risk of **nasal obstruction** with treatment of bilateral lesions. Erosion and **necrosis of the cribriform plate** that may have allowed the formalin to reach the brain
107
Why is transendoscopic use of cryogen for the treatment of progressive ethmoid hematomas not recommended?
It is not recommended due to potential damage to the endoscope, **lack of control of freezing depth**, and damage to surrounding tissues with this direct evaporation technique.
108
Sites for establishing drainage from the paranasal sinusesinto the nasal cavity (cross section of the skull at the level of the firstmolar 109/209). The conchofrontal sinus may be fenestrated at (A) toestablish drainage into the nasal cavity. Fenestration of the ventromedialwall of the ventral conchal sinus at (B) creates ventral drainage of theventral concha sinus into the nasal cavity. This diagram of the skull alsodemonstrates the medial and lateral edges of the frontonasal bone flap(arrows) at this level. The structures within the dashed lines have to beremoved to provide access to the dorsal conchal and maxillary sinuses,ventral conchal sinus, and the nasal passage. a, Dorsal meatus; b, frontalsinus; c, dorsal conchal sinus; d, infraorbital canal; e, rostral maxillarysinus; f, ventral conchal sinus; g, oblique septum between the rostral,and caudal compartments of the maxillary sinus.
109
What is the procedure being performed?
FIGURE 1 (A) The ventral wire (black) and caudal wire (red)
placed under endoscopic guidance. (B) One end of the caudal wire
(red) is redirected through a Chamber's catheter directed from caudal
to rostral (not shown) to pass through the trephine opening. This is
repeated through the other nostril to bring the caudal wire around the
intrapharyngeal portion of the septum and through the trephine
opening. (C) Three wires positioned to make final cuts in the septum.1
The black wire cuts the ventral attachment of the septum, the red wire
the caudal aspect, and the green wire cuts the dorsal attachment. The
dorsal wire is passed through the trephine opening through a
Chamber's catheter,1 without endoscopic guidance. A Chamber's
catheter (not shown) is passed over the caudal wire to direct the wire in
the direction of the arrow to create a 60 cut relative to the nasal bones.
110
Diagnosis
Periodontal ligament widening around an upper 07
111
Ratliff 2023 VS Intraop complications: wire broke, profuse hemorrhage and entrapment, Intraoperative complications developed in seven horses,
two of which required conversion to the oral method of wire placement. Entanglement of the ventral and caudal wires was documented, the entangled ventral wire was removed and
replaced by the intraoral technique.
112
Endoscopic view with the endoscope passed via a frontal portal into the frontal sinus (FS),and directed ventrally towards the caudal maxillary sinus (CMS). Note the well-defined fronto-maxillaryaperture (arrows). The ventral conchal bulla (VCB) can also be seen at the caudal rim of the frontomaxillaryaperture:a) Intact bulla visualized at the rostral edge of the fronto-maxillary aperture. The infra-orbital canal(IOC) can be seen within the caudal maxillary sinus.
113
Endoscope -assisted three wire tx for extensive nasal septum resection in horses
GA LR endoscopic guidance was used to place obstetric wires for the ventral and caudal incisions in the nasal septum and a trephine opening was used to place the dorsal wire. The rostral aspect of the septum was incised with a scalpel followed by incisions with the preplaced wires and the nasal passages were packed with gauze. Horses recovered with temporary tracheotomy.
114
What is the diagnosis?
Figure 25.12 Endoscopic appearance of the dorsal and
ventral conchae and the stump of the nasal septum at
10 weeks after surgery. Note the lack of reaction and
thickening along the cut edges. Despite the favorable
appearance of the surgery site, this horse had an abnormal
nasal odor that resolved shortly afterward.
115
FIGURE 2 Bronchoesophageal forceps guided by an
endoscope in the same nasal passage to grasp obstetrical wire
introduced into the contralateral nasal passage through a
Chamber's catheter.
116
FIGURE 3 Two sutures of different colors (size 2 nylon and
polypropylene) through two Chamber's catheters in the same nostril
to prevent crossing of wires. The sutures are retrieved with the biopsy
instrument so the ventral one is ventrally placed and the dorsal one
is dorsally placed in the nasal passages. The suture ends are tied to
obstetrical wires that are then drawn around the back of the septum
while maintaining correct ventral to dorsal relationships.
117
what is the diagnosis
FIGURE 4 (A) Right-sided
choanal atresia in horse 1. Note
the opening into a meatus in the
ethmoturbinates (*) dorsal to the
choanal membrane and the
profuse vascular branching on
the buccopharyngeal membrane.
(B) Same area in horse 1, 4 days
after laser opening of the
choanal atresia that would allow
wire passage.
118
FIGURE 7 Septum removed from horse 2 with diffuse and
marked thickening caused by Aspergillosis, to demonstrate the
approximately 60 cut required to remove the most caudal end of
the septum in a wide part of the nasopharynx.
FIGURE 8 Entanglement of ventral (black) and caudal (red)
wires with the caudal wire directed at 60 in a Chamber's catheter
(not shown) in the direction of the arrow. This cuts the septum
while the slack ventral wire can follow through the cut to emerge
through the trephine hole and be disentangled.
119
FIGURE 9 (A) Remnant edge of the buccopharyngeal membrane (arrow) in horse 1 and demonstrating close proximity to the
ethmoturbinate region day 105 after surgery. (B) Remnant of choanal membrane (arrow) in same horse close to its attachment to the floor of
the nasal passage, day 105 after surgery. Both images demonstrate the enlarged opening into the pharynx.
120
Surgical enlargement of the nasomaxillary aperture and transnasal conchotomy of the ventral conchal sinus: two surgical techniques to improve sinus drainge by Bach et al 2019. Mentiones the use of an endoscope which size? What are the instruments to access the VCS?
5.9 mm endoscope and conchotome
121
What were the 2 surgical trephinations site for SENMAP in the same article??
122
Kolas et al EVE 2019 described a transnasal endoscopic treatment of equine sinus disease in 14 clinical cases? where? How?
6 cases the ventral conhca was fenestrated in order to gain portal into the ventral conhca and rostral maxillary sinus
In 2 cases the dorsal concha was fenstrated to acess the caudal group of paranasal sinuses
One case required fenestration of the ventral conchal bulla due to its empyema.
Endoscopic sinonasal fistulation was performed using either trans-endoscopic diode laser fibre (4cases) or electrocautery instrument unter endoscopic control (5 cases)
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Which access has signifcantly improved the vision in Bach 2019?
Rostraly centered trephination portal on the L side
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Kolos et al VS 2019 How was the hemorrhage was controlled?
With nasal cavity tamponade for 24 h
Endoscopic and lavage and debridement performed 2-3 days
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instruments used in Kolas 2019
diode laser in working canal
middle laparoscopic electrocutery
customised rigid lavage catheter
126
Dixon et al. 2020 publishe a Longe-term study of sinoscopic tx of equine paranasal sinus disease:155 cases (2012-2019) what was the % of cases that fully responded to their initial treatment?
69.7%
127
What are the causes of issue?
BOny sequestrae and nspissated exsudate
128
what was the % of concurrent issues? In the long term what was the % of cases that improved?
37.4% concurrent disease
improvement long term 96.1%
129
Perez et al 2020 published a standing trans-nasal endoscopic guided CO2 laser fenestration of the palatine bone to acess the sphenopalatine sinus in a horse. What is the appropriate site to access?
Wihtin the nasopharynx midway between the vomer and dorsal conchal wall. The endoscopic procedure was performed as 2step process via standing sedation due to mucosal bleeding obscuring visualization.
This fenestration allowed biopsy under direct endoscopic visualization with long-handled bronchoesophageal forceps inserted via the ipsilateral middle meatus.
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Ostrowska et al. 2019 published Computed tomography characteristics of equine paranasal cysts. What is the characteristic?
Detection of a hyperattenuating cystic wall and the paranasal sinus cyst wall has mineralization
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F I G U R E 1 (A-D) Comparison of mineralisation pattern between two groups. A,B, Reformatted parasagittal plane CT image of two
horses showing varying degree and pattern of the paranasal sinus cyst wall mineralisation. A, Extensive spiculated paranasal sinus cyst
wall mineralisation (arrows) in the conchofrontal, caudal maxillary sinus and sphenoid sinuses; kernel H70a, WL 829 HU, WW 3429 HU. B,
Peripheral, focal and linear paranasal sinus cyst wall mineralisation (arrows) in the rostral maxillary sinus; WL 868 HU, WW 3932 HU, kernel
H70a. C, amorphous/swirling internal mineralisation (arrows) of the mass in the caudal maxillary sinus extending from the pituitary fossa
mass (meningioma), WL 596HU, WW 2051HU, kernel H40fa. D, internal mineralisations (arrows) in the rostral maxillary sinus progressive
ethmoid haematoma; WL 891HU, WW 4243HU, kernel H70a
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FIGURE 5 Transverse (A,B)
and coronar (C) computed
tomography images before (A) and
after (B,C) performing combined
TCVCS and SENMAP in head
8. The resected portions of the bulla
of the maxillary septum and the
medial wall of the ventral concha
are indicated with yellow dotted
lines (B). Two-tipped white arrows,
distance measured from the incised
medial conchal wall to the bony
base of the ventral conchal sinus (B).
Two-tipped red arrows, distance
measured from the rostral to the
caudal SENMAP incisions of the
ventral conchal wall (5C)
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Fig 7: Endoscopic fenestration of the ventral concha using a diode laser fibre (top) and an electrocautery instrument (bottom). Radiographs of a cadaver showing corresponding positions of the endoscope and instrument (left). Endoscopic images of the incision (right) (Cases 3 and 6). VC, ventral concha; DC, dorsal concha; NS, nasal septum; SP, soft palate.
134
Poyet in EVE 2022 published extranasal approach to access the dorsal and ventral conhcal bullae in horses. Name the landmarks
To access the dorsal and ventral conhal bullae through two rhinocenteses it was performed.
**Frontal sinus** - **40% of the distance** from the **medial canthus** of the eye to midline and** 2 cm caudal** to the rostral aspect ofthe **rostral lacrimal tubercle.**
**Caudal maxillary sinus** - mini sinusotomy was performed **1 cm** **rostral and 3 cm ventral **to the rostral aspect of the **rostral lacrimal tubercle, **with the needlei nserted perpendicular to the bone
**Rostral maxillay sinus** performed 40% of the distance from the rostral end ofthe facial crest to the level of the medial canthus and 1 cmventral to a line joining the infraorbital foramen and themedial canthus, with the needle directed slightly upward(approximately 30; Figure 2).
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What can you use as short-term haemostasis in post-operative paranasal sinus surgery?
Endotracheal tube that can be inserted through the dorsomedial wall of the ventral conhca into the nasal cavity and provide haemostasis by pneumatic tamponade
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note there are a Dorsal concha that has a rostral division which is the dorsal conchal bulla and a caudal the dorsal conchal sinus
The ventral conchal has a division as well with the rostral portion being the ventral conchal bulla and the caudal the ventral conchal sinus
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1 Nasal bone
2 Conchofrontal sinus
3 Rostral maxillary sinus
4 Levator labii superioris m.
5 Common nasal meatus
6 Ventral conchal sinus
7 Infraorbital a., v., and n.
8 Septum between rostral and caudal maxillary sinuses (maxillary bulla)
9 Caudal maxillary sinus
10 Facial crest
11 Nasal submucosa venous plexus
12 Palantine process of the maxilla and
palatine a.
13 Mesiolingual (mesiopalatal) root of tooth
210 (left superior second molar)
14 Transverse facial v.
15 Deep facial v.
16 Masseter m.
17 Lingual mucosa
18 Intrinsic muscles of the tongue
19 Tooth 310 (left inferior second molar)
20 Buccinator m. (molar part)
21 Genioglossus m.
22 Geniohyoideus m.
23 Inferior alveolar n. in mandibular canal
24 Buccal v.
25 Facial v.
26 Facial a.
27 Digastricus m. (rostral belly)
28 Buccinator m. (buccal part)
29 Nasolacrimal duct
30 Mylohyoideus m.
31 Hyoglossus m.
32 Styloglossus m.
33 Vomer
34 Sublingual a. and v.
35 Parotid duct
138
1 Dorsal nasal meatus
2 Dorsal conchal bulla
3 Common nasal meatus
4 Ventral conchal bulla
5 Nasolacrimal duct
6 Infraorbital n.
7 Levator labii superioris m.
8 Rostral maxillary sinus
9 Nasal septum
10 Ventral nasal meatus
11 Facial crest
12 Tooth 209 (left superior first molar)
13 Tooth 309 (left inferior first molar)
(exposed crown)
14 Tooth 308 (left inferior fourth premolar)
(reserve crown)
15 Facial v.
16 Lingual a. and v.
17 Genioglossus m.
18 Hyoglossal m.
19 Body of maxilla
20 Buccinator m. (molar part)
21 Buccinator m. (buccal part)
22 Infraorbital a. and v.
23 Digastricus m. (rostral belly)
24 Sublingual a. and v.
25 Inferior labial a.
26 Geniohyoideus m.
27 Mylohyoideus m.
28 Cutaneous facial m.
29 Zygomaticus m.
139
primary clinical features of paranasal sinus
unilateral nasal discharge, facial swelling, and decreased nasal airflow. Also externally draining tracts, malodorous breath, ocular discharge, and stertor.
140
How do you diagnose paranasal sinus disease?
history, clinical signs, and physical examination (percussion of sinus)
Radiogarphy can reveal dental disease in the premolar and maxillary sinus
Sinocentesis
Sinoscopy
141
Opacification of both maxillary and frontal sinus occur in dental disease?
No, rare! both= primary sinusitis
maxillary only = dental disease or primary sinusitis
142
Describe the procedure for sinocentesis
both compartments of the maxillary sinus should be sampled. Assepsia and local 2% lido infiltration
Skin subcut and periosteum reflected for hole drilling and indwelling plastic catheter is inserted
If no sample is obtained, 20 to 30 mL of warm saline should be infused before subsequent aspiration, or the sinus may be lavaged with 0.5 L of saline and the nasal discharge examined for evidence of purulent exudate
143
Sinoscopy can be performed through 2 paranasal sinus name them (because maxillary septal bulla might not be visible in one of them
Portals 15-mm Galt trephine through
1) conchoforntal sinus
2) caudal maxillary sinus
144
Inserting the endoscope through the frontal bone via a large trephine opening or a frontonasal bone flap provides direct access to the ____________ and ________ sinus and indirect access to the ventral conchal and rostral maxillary sinus by fenestrating the maxillary septal bulla
Inserting the endoscope through the frontal bone via a large trephine opening or a frontonasal bone flap provides direct access to the conchofrontal and caudal maxillary sinus and indirect access to the ventral conchal and rostral maxillary sinus by fenestrating the maxillary septal bulla. If the bulla cannot be viewed through the portal in the frontal bone, a second portal is recommended into the caudal maxillary sinus
145
Name the instrument for maxillary septal bulla fenestration
arthroscopic Ferris Smith
146
Name the instrument for maxillary septal bulla fenestration
Matthew aural (crocodile) forceps
147
What size is the endoscope for sinuscopy and what size is the trephanation hole?
12 mm flexible videoendoscope
15-mm Galt trephine
148
Describe the conchofrontal sinus trephanation. Be specific
60% of the distance from the midline to the medial canthus and 0.5 cm caudal to the medial canthus
149
Describe the caudal maxillary sinus trephanation. Be specific
caudal maxillary sinus—2 cm rostral and 2 cm ventral to the medial canthus; and
150
Describe the rostral maxillary sinus trephanation. Be specific
rostral maxillary sinus—40% of the distance from the rostral end of the facial crest to the level of the medial canthus and 1 cm ventral to a line joining the infraorbital foramen and the medial canthus.
151
Primary sinusitis treatment
Lavage with 28-French Foley catheter, or by using a sterile 13-mm nasogastric tube through a trephine opening in the conchofrontal sinus.
152
Primary sinusitis lavage should be done with
28 French Foley cathter The exudate is most efficiently removed by flushing the sinuses with a mild salt solution consisting of 35 g of salt per 4 L of water using a sterile nasogastric tube and stomach pump.
153
Flushing the rostral maxillary and ventral conchal sinus can be done with which flusing tip?
Yankauer suction tip to a sterile 13-mm nasogastric tube
154
Secondary sinusitis causes
dental disease,
facial fractures,
granulomatous lesions
neoplasms
155
Empyema of the dorsal and ventral conchal bulla has been recently, what is most common the dorsal or ventral?
ventral conchal bulla
156
Paranasal sinus cyst clinical signs
The most common clinical features are dyspnea, facial swelling, and nasal discharge
157
Paranasal sinus cyst is most common in young or adult?
usually seen in horses ranging in age from nursing foals to young adults, but it is also seen in adult horses
158
Paranasal sinus cyst surgical management consists of removing the cyst lining by which bone flap?
Exposure of the sinus is best provided by a frontonasal or a modified frontonasal bone flap
159
The cysts are typically filled with a
yellow, viscous fluid unless they become secondarily infected.
160
Paranasal cyst prognosis
A long-term retrospective study reported excellent results
161
Most common neoplasia in paranasal sinus and prognosis?
squamous cell carcinoma
prognosis is generally unfavorable unless the neoplasm is a well-capsulated, solid, noninvasive tumor, because the majority are malignant
162
Describe the anatomical boundaries from maxllary sinus flap
The **rostral margin** is a line drawn from the rostral end of the facial crest to the infraorbital foramen;
**the dorsal margin** is a line from the **infraorbital foramen** to the **medial canthus of the eye**,
**caudal margin** is a line (**parallel to the rostral margin**) from the **medial canthus of the eye** to the **caudal aspect of the facial crest**, and the **ventral margin** is the facial crest.
163
frontonasal bone flap anatomical bounderies
**caudal margin** is a **perpendicular line from the dorsal midline** to a point **midway** between the **supraorbital foramen** and the **medial canthus of the eye**,
the **lateral margin** begins at the **caudal margin 2 to 2.5 cm medial** to the **medial canthus** of the eye and **extends** to a point approximately **two-thirds the distance** from the **medial canthus of the eye to the infraorbital foramen**, and the **rostral margin** is a **perpendicular line** from the **dorsal midline** to the rostral extension of the lateral margin. The estimated course of the nasolacrimal duct is a line from the medial canthus of the eye to the nasoincisive notch. In some horses, the rostral portion of the lateral margin has to be angled toward the midline to avoid the duct
164
once boundaries of bone flap are determined the periosteum is reflected how many mm?
5mm from the osteotomy site
165
In maxillary bone flap you have to severe also what?
As the bone flap is being elevated for the maxillary approach, the septum between the compartments should be severed using a long, thin osteotome. The fracture can be controlled by steady, even pressure, and the bone flap completely elevated to expose the area.
166
Before closure of bone flap what should you do?
Before closure, an indwelling lavage system is usually placed through the adjacent bone or a corner of the flap and secured to the skin to facilitate daily lavage.
167
How do you close the bone flap?
Closure is initiated by pressing the bone flap into its original position and by closing the periosteum with 2-0 absorbable suture using a simple-continuous pattern. The subcutaneous tissue and skin are closed in routine manner. The skin incision usually heals rapidly with minimal scarring.
168
How do you creat a surgical opening into nasal cavity if the nasomaxillary aperture is not functional?
Identifying such a site in the conchofrontal sinus (Figure 44-9) can be aided by passing a mare urinary catheter caudad in the middle meatus and feeling the catheter tip through the thin conchal portion of the sinus. The conchal wall is perforated using a curved forceps. The catheter is passed through the opening to aid in the placement of a Seton drain threaded through the nasal cavity from the sinus. Other txc is transnasal laser vaporization
169
Figure 44-8. Diagram of the skull demonstrating the site for thefrontonasal bone flap technique for exposing the caudal aspect of thenasal cavity, dorsal conchal sinus, and frontal sinus (a). The long dashedline (b) from the medial canthus to the incisive notch depicts the approximatecourse of the nasal lacrimal duct. (For a description of the marginsof the frontonasal bone flap, see “Surgical Approaches to the ParanasalSinuses.”)
170
Figure 44-7. Diagram of the skull demonstrating the site for the boneflap technique for exposing the maxillary sinus. The boundaries outlinedby bold dashed lines provide maximal exposure of the maxillary sinuswhile protecting the nasolacrimal duct and infraorbital canal. The longdashed line from the medial canthus to the incisive notch depictsthe approximate course of the nasolacrimal duct. (For a description ofthe margins of the maxillary bone flap, see “Surgical Approaches to theParanasal Sinuses.”)
171
The communication between rostral maxillary sinus and nasal cavity is dorsal over the infraorbital canal in _________(young/old) horse and ventral in ____________(young/old) horse. This way you are acessing the __________ sinus
The site for establishing communication between the rostral maxillary sinus and the nasal cavity is located dorsally over the infraorbital canal in young horses and ventral to the canal in older horses. Ventral conchal sinus with nasal cavity
172
Ways to access the ventral conchal sinus
The medial or ventromedial wall of the sinus can be fenestrated to create an opening into the nasal passage if the nasomaxillary opening is not functional (dorsal to IF canal in young and ventral in old horses)
or removal of inspissated exudate from the ventral conchal sinus can also be achieved in the standing horse via a 19- or 25-mm trephine opening **conchofrontal sinus** after removal of **maxillary septal bulla**
exudate is removed by inserting a **bent, Yankauer suction tip** attached to a sterile, 13-mm (outside diameter) nasogastric tube into the ventral conchal sinus and flushing with a mild salt solution (35 g of salt per 4 L of water) using a sterile stomach pump.
173
which vessel you have to be careful in the maxillary bone flap?
angularis oculi vein
