Chapter 47 - Guttural Pouch Flashcards

Question

What projections in radiographs?

Answer 1

DV and VD projection useful for stylohyoidbones temporohyoid joint

Answer 2

Right lateral radiographic view of skull Basilar skull fracture between the basisphenoid and basioccipital bone

Answer 3

Figure 47-4. Magnetic resonance imaging of parotid melanoma (between arrows) extending rostrally from the left guttural pouch (1). 2, Pterygoideus lateralis muscle; 3, pterygoideus medialis muscle; 4, squamous part of temporal bone; 5, masseter muscle.

Answer 4

**Normal GP lavage has :** **<5% neutrohiles** ciliated columnar epitelial cells ** ++ nonciliated cuboidal epitelial cells** **< 1% monocytes lymphocytes and eosinophils ** If **neutrop > 25% = abnormal --> probably Streptococcus equi subeso. Equi present** The method of sampling by guttural pouch lavage can affect measures of mucosal reactivity!! Ifsample collected by endoscope à much cleaner than lavage transcutaneously

Answer 5

Arabians and german warmbloods

Answer 6

After 1 month up to 1 year of age NONPAINFUL, elastic swelling in the parotid regionuIt can swell and give impression that is bilat Dyspnea + dysphagia + inhalation pneumonia + 2ary empyea You have to solve quickly as possible

Answer 7

**Needle decompression** OR **indwelling catheter (temporary)** **Chronic catherization (2-3 weeks) can be done but can cause:** **PERMANENT DEFORMITY + SCARRING** of cartilage of the pharyngeal ostium Empyema Bronchopneumonia **Indwelling transnasal Foley catheter (22-24French) for 2 to 4 weeks is effetive (study in 5/8 foals when sx is not anoption) **

Answer 8

SURGERY – 3 options: 1.**Permanent evacuating air** through the **unaffected GP** (f**enestration medium spetum**)- **Viborg triangle** or through **Whitehouse** approach. 2.T**hrough abnormal GP** opening (removal of obstructing membrane) via Modified Whitehouse approach 3.Artificially created opening into **pharynx (salpingopharyngeal fistula)** with Nd:YAG or diode laser transendoscopically

Answer 9

Figure 47-5. Method for creating a fenestration between the abnormal and normal guttural pouches in a foal with unilateral tympany. The affected guttural pouch (on the left side) is approached through an incision in the Viborg triangle, and a Chamber mare catheter in the right guttural pouch is used to elevate and expose the median septum. In the expanded view, a pair of scissors has been placed to start fenestration (broken line). (Redrawn from Milne DW, Fessler JF. Tympanitis of the guttural pouch in a foal.

Answer 10

The median septum can be fenestrated by removal of a **2-cm** 2 segment to allow egress of trapped air from the tympanitic pouch through the normal side *Use **Chambers catheter** or **scope to transilluminate** *Major disadvantage = only effective for unilateral disease - ( majority of cases). Adv = simple and effective.

Answer 11

Can be combined with removal of a small segment (1.5 × 2.5 cm) of the medial lamina of the Eustachian tube and associated mucosal fold (plica salpingopharyngea) within the guttural pouch orifice; this forms a larger opening into the pharynx

Answer 12

removal of the obstructing membrane via **Modified Whitehouse approach.** For bilateral disease, fenestration of the septum can be combined with removal of segment of medial lamina of Eustation tube & associated mucosal fold; (salpingopharyngea) Superseded by Nd:Yag/diode laser fenestration of the Ostia or septum

Answer 13

Right ostium fenestration with laser ablation of the protective cartilage flap. This can also be achieve with chronic trochaterization with Foley Catheter

Answer 14

This is also seen externally as a bilateral nasal discharge. Injury to CN’s IX and X can result in this clinical finding.

Answer 15

***salpingopharyngeal fistula** caudal to guttural pouch opening. - Nd:YAG or diode laser transendoscopically. Performed CAUDODORSAL to ostium (ie dorsal pharyngeal recess) Foley in the fistula for 7-10d Can be done bilaterally Risks = delayed thermal necrosis & delayed vessel rupture without warning *dorsal pharyngeal recess

Answer 16

Opening via pharynx: Salpingopharyngeal fistula in the dorsal retropharyngeal recess

Answer 17

The plica can still limit air exit

Answer 18

Computed tomographic image (transverse plane [A] and dorsal plane [B]; 2 mm standard window) of a horse head specimen following auditory tube diverticulotomy caudal to the nasopharyngeal ostium. Note communication between the nasopharynx and both left and right auditory tube diverticula (white arrows). The median septum is visible (black arrow).

Answer 19

**favourable ** (61-70%)after median septum fenestration **guarded **in presence of **aspiration pneumonia **and **dysphagia**

Answer 20

1) Gutural pouch tympany 2) Nasopharyngeal obstruction in adult 3) Gutural pouch empyema 4) Gutural pouch mycosis 5) Rupture of ventral straight muscles 6) Temporohyoid OA 7) Miscellaneous diseases 8neoplasia, parotid melanomatosis, malignant amelanotic, melanomas, fracture of stylohoid, FB, periocular penetration, cystic structures

Answer 21

**Transendoscopic electrocautery** or laser (high powered diode or neodymum:ytrium-aluminu-garnet (Nd:YAG) laser) can be used to create: a fenestration in the septum and to make a fistula into the GP through the pharyngeal recess Standing or GA Foley kt through the fistula for 7 to 10 days

Answer 22

attributed to failed egress of air from one or both guttural pouches during poll flexion possibly caused by an anatomic or functional defect in the salpingopharyngeal fold - congenital

Answer 23

1.Hyovertebrotomy 2.Viborg triangle approach 3.White house 4.Modified whitehouse approach (GA or standing) 5.Modified Garm technique

Answer 24

Figure 47-18. Surgical approaches to the guttural pouch. A, Hyovertebrotomy; B, Viborg triangle; C, modified Whitehouse; D, Whitehouse. 1, Lateral compartment of the guttural pouch, which is partly separated from the medial compartment (2) by the stylohyoid bone (3); 4, vertical ramus of the mandible; 5, wing of the atlas. (Redrawn from Freeman DE. Diagnosis and treatment of diseases of the guttural pouch: Part II.

Answer 25

‣Enters the pouch where cranial nerves & ICA are more closely grouped, ‣Dorsal so relatively poor for drainage - may need second ventral stab incision ‣TECHNIQUE - 10 cm incision 2cm cranial to & parallel to wing of the atlas through the skin and dense parotid fascia ‣The parotid gland and overlying parotido-auricularis muscle are reflected cranial to expose GP lining beneath areolar tissue ‣Palpate caudal & ventral stylohyoid & puncture GP medial to stylohyoid ‣Hyovertebrotomy can be closed or partially closed

Answer 26

‣Disadvantages: inadvertent parotid salivary gland damage (PO salivary leakage; usually transient), poor ventral drainage

Answer 27

Sternocephalicus muscle Linguofacial vein Vertical ramus of the mandible

Answer 28

Boundaries = **tendon of sternocephalicus muscle, linguofacial vein and the vertical ramus of the mandible ** ‣Can make a** vertical or horizontal incision** in this area, a**voiding parotid duct & branches of CN X **along the floor of the GP ‣Incision usually maintained open with soft rubber catheter to allow continued drainage ‣Ideal approach for foals with tympany as the expanded pouch is positioned SQ

Answer 29

GA dorsal ventral midline skin incision over the larynx ‣Dissection between sternohyoid & omohyoideus mm & along larynx to GP ‣Open the pouch medial to the stylohyoid avoiding the pharyngeal branch of vagus and cranial laryngeal nn which are close to the incision

Answer 30

**12cm skin incision **along the ventral edge of the** linguofacial vein** as per LP but extending **4-6cm cranially** **‣Expose lateral larynx **& continue** bluntly until GP is entered** Advantages: avoids incision between sternocephalicus & omohyoideus & dissection occurs through a natural fascial plane

Answer 31

Excellent access and ventral drainage for inspissated material. ‣Avoids contamination of anaesthetic equipment with Strep Equi ‣Sedation and local - 30ml 2% mepivacaine along ventral aspect of the linguofacial vein which is marked with a pen beforehand ‣(Retro)pharyngeal swelling can facilitate sx access, if not distended can insert chambers catheter into the pouch; should be palpable in the medial compartment through the floor of the pouch, to guide dissection

Answer 32

Dissection through natural fascial plane, no incision between sternohyoideus and omohyoideus muscles *direct access to the roof of GP *digital access to lateral compartment *excellent ventral drainage *simultaneous access through the septum to both guttural pouches.

Answer 33

Allows access to the LATERAL compartment & can be done standing (reported in 4 experimental horses TVJ 2008- Munoz et al). ‣6cm skin incision made 4cm more rostral than the originally described Garm technique, between the ramus of the mandible and the mandibular LNs. ‣Blind digital dissection is continued to the rostroventral aspect of the lateral compartment where the mucosa can be penetrated without risk of damaging structures EXCEPT hypoglossal nerve & lingual vessels on route of dissection

Answer 34

Disadvantage: little can be achieved through this approach other than insertion of lavage tube

Answer 35

- damage to a vessel wall - necrosis à delayed rupture without warning - nerve damage

Answer 36

**Favorable **after median septum fenestration by any method. Can be done in 2 steps if is bilateral. Study foals tx by fenestration only 67% hadgood outcome(no recurrence) and in 71%treatedbyfenestration+ resectionofthemucosalflapcombineduRacing career is possible after? YES!

Answer 37

irritant drugs deep penetration of a periocular FB fracture of the stylohyoid bone deep congenital stenosis of pharyngeal orifice GP tympany pharyngeal perforation by nasogastric tube

Answer 38

++ young S. equi sub equi 2) S. equi subesp zooepidemicus 3) Corynebacterium pseudotuberculosis

Answer 39

intermitente bilat nasal discharge swelling of parotid + lymph nodes pain - extended head carriage excessive respi noise fever difficulty breathing and swallowing Neuropathy by compression dysphagia, RLN, persistente soft palate displacement

Answer 40

- endoscopic exam purulent discharge in the pharyngeal orifice of the affected side, - pharyngeal colapse -Fluid and mass in the x-ray. -Fluid aspirates or faline washings from GP for culture and sensivity- For strangles -PCR and culture

Answer 41

daily irrigation with physiologic saline 7-10d via indwelling Foley ▸DO NOT USE hydrogen peroxide/povidone iodine ▸Acetylcysteine→ not really effective▸+/- topical ABx (Pennicillin 6 gr into gelatin or bovin mammary preps) ▸Systemic AB (TMPs, Penn, Ceftiofur for 21 days)/NSAID▸+/- tracheostomy in those with URT obstruction ‣CHRONIC: Chondroids unlikely to respond to lavage alone; surgical drainage may be preferable ‣ Can attempt removal by maceration or endoscopic grabbing forceps/basket. 44% success with these methods but can be slow/protracted & costly (Judy 1999)

Answer 42

1) Via open approaches - approach incisions should be left to heal by second intention (mentioned previously) 2) Laser assisted salpingopharyngostomy or enlargement of the ostium

Answer 43

Satisfactory, neurologic signs are rare

Answer 44

NO AGE, BREED, SEX or GEOGRAPHIC predispostiion

Answer 45

Aspergillus fumigatus is the most common to be isolate

Answer 46

**moderate to severe epistaxis** fungal erosion of the ICA most cases and ECA and MA in 1/3 of cases + any branch of ECA such as caudalauricular artery; Bilateral issue (but +++ one side) **dysphagia **--> lesion of pharyngeal branches : vagus (X) (MOTOR function) + glossopharyngeal nerves (IX) --> leads to Aspiration pneumonia in severe or protracted cases Signs are ptosis, miosis enophtalmos, patchy cervical sweating and **congestion of nasalmucosa (CNM)** CNM if permanente = loss of performance due to partial airway obstruction Anormal respi noise due to: pharyngeal paresis / laryngeal hemiplegia / RLN Horner syndrom

Answer 47

Damage to the cranial cervical ganglion and postganglionic sympathetic fibers (usually temporary) causing Ptosis Equine sweat glands under alfa adrenergic input from receptor enophthalmos

Answer 48

endoscopy + history + clinical signs

Answer 49

19% always check both GP

Answer 50

Amphotericin B 0.38 to 1.47 mg/kg diluted in 1L of 5% dextrose has been given intravenously IV for up 40 days to treat phycomycosys Itraconazole 5mg/kg PO every 24h Combination of itraconazole and topical enilconazole (60mL of 33.3 mg/mL solution in daily flush) itraconazole 3mg/kg twice a day in the feed is effective against Aspergillus but may require 4 months of tx

Answer 51

NO very poor efficacy

Answer 52

Itraconazole is more effective agains Aspergillus spp

Answer 53

Horses with blood loss should be treated with **polyionic fluids and blood transfusion**s if necessary, and horses with dysphagia should be fed by nasogastric tube or by esophagostomy and should receive nonsteroidal anti-inflammatory drugs to reduce neuritis

Answer 54

nephrotoxicity!!

Answer 55

Figure 47-19. Diagram of major arteries close to and underlying the mucosa of the guttural pouch (numbers) and sites of balloon-catheter occlusion (letters). 1, Common carotid artery; 2, external carotid artery; 3, internal carotid artery; 4, occipital artery; 5, linguofacial trunk; 6, maxillary artery; 7, caudal auricular artery; 8, superficial temporal artery; 9, rostral auricular artery; 10, transverse facial artery; 11, external ophthalmic artery; 12, caudal alar foramen. A, Balloon inserted in the major palatine artery and guided in retrograde fashion to be inflated immediately caudal to the caudal alar foramen; B, balloon of catheter inserted into transverse facial artery (10) at arrow and directed into the external carotid artery, where it is inflated close to the floor of the guttural pouch; C, balloon in internal carotid artery at the sigmoid flexure, dorsal to the roof of the guttural pouch. This catheter is inserted into the internal carotid artery (3) at the arrow. A, B, C, and (arrow) on internal carotid artery are also the sites for obstruction with microcoils delivered through a catheter in the common carotid artery (1) in the upper third of the neck. (Redrawn from Caron JP, Fretz PB, Bailey JV, et al. Balloon-tipped catheter arterial occlusion for prevention of hemorrhage caused by guttural pouch mycosis: 13 cases. J Am Vet Assoc. 1987;191:345; and Smith KM, Barber SM. Guttural pouch hemorrhage associated with lesions of the maxillary artery in horses.

Answer 56

**Removal of diphtheritic membrane** via **modified Whitehouse** approach → risk of hemorrage and nerve damage ** *Artery occlusion: **effect of arterial occlusion n mycotic plaque progression are unknown **- Balloon catheter occlusion** **- Detachable balloon catheter occlusion** ** - Transarterial Coil Embolisation (TACE)** ** - Transarterial embolisation with Nitinol Plug**

Answer 57

Ideally occlusion of just vessel involved If difficult assessment→ all vessels should be ligated 2/3 of cases involve Internal Carotid Artery (ICA) - External Carotid Artery (ECA) and Maxillary Artery (MA) in the reminder

Answer 58

9 cm skin incision 2cm cranial and ventral to the wing of the atla so ICA located deep & caudal to the occipitomandibular part of the digastric muscle, the parotid & mandibular salivary glands, and the guttural pouch ICA is identified on the cardiac side of the occipital artery and deep to it, & ICA is freed for 2-3 cm In some horses, both ICA and OA arise as a single trunk and can be ligated simultaneously without risk ICA BP remains similar to pre-op for 3-4d PO

Answer 59

Modified hyovertebrotomy (more ventral) 9 cm skin incision ventral to wing of atlas ICA ID and ligated proximally and distally close to the origin of the artery Arteriotomy distal to proximal ligature 6 French venous thrombectomy catheter is inserted for 13 cm (fixed at sigmoid flexure of ICA) endoscopy can help but is not required Balloon inflate (saline) and secure in position back to work once PCV normal Balloon left in place + kt is secured in the artery by tightening the preplaced ligature around it this portion of the kt is buried in the incision *NSADs + Abs Allow at least 7 days for a sufficient thrombus to form before removal If catheter removed can be identified with US and done under standing sedation. Really difficult to retract

Answer 60

Fig. 13. (A) Insertion of a balloon catheter into the left ICA so the balloon is inflated between the first and second flexures of the sigmoid bend in the artery and distal to the lesion (black with white highlights). Insert shows method of making an arteriotomy with a number 11 scalpel blade, inserting the blade halfway across the width of the artery between a ligature tied proximally and a preplaced ligature distally and cutting upward (arrow) to produce an opening sufficient to accommodate the catheter. (B) Balloon catheter secured in the artery by tightening the preplaced ligature around it and then tying the long ends to the folded redundant portion of the catheter. This portion of the catheter is then buried in the incision.

Answer 61

Fig. 11. Surgical approaches to the guttural pouch. 1, hyovertebrotomy; 2, Viborg triangle; 3, modified Whitehouse; 4, Whitehouse. Shading is the guttural pouch.

Answer 62

No and that is why any deviations from normal anatomy are not identified (disadvantage)

Answer 63

Balloon penetrates defect in artery *Infection→remove catheter and drain * Meningitis!! →prevented by inflating balloon at least to 8 mm diameter (prevents displacement into infected segment) *Delayed prolapsed through hole *Caused by reduce pressure proximal and normal pressure distal prevented by use of rigid catheter *Failure to prevent haemorrhage → if aberrant branch present *To prevent expose at least 6 cm of artery and assess if branches present *Most important is aberrant branch that leads to caudal cerebellar artery → necrosis of brain stem. So if balloon goes more than 13 cm it is probably an aberrant branch. *Difficult distinction between occipital and ICA→ ICA usually deeper.

Answer 64

Immediate IV occlusion with prevention of retrograde flow from the circle of Willis *Equipment cheap & readily available, & fluroscopic guidance not required Disadvantage: largely unsuitable in the presence of aberrant vascular anatomy

Answer 65

Yes described in the report

Answer 66

fatal meningitis

Answer 67

MPA (major palatine art) which is the large continuation of the MA (maxillary artery) The MPA joins the contralateral MPA behind the upper row of incisior teeth to form a large arterial loop around upper jaw

Answer 68

kt tip can readily enter the SUPERFICIALTEMPORAL ARTERY rather than the MA

Answer 69

MA (maxillary artery) is performed via an arteriotomy of the MPA through the oral cavity

Answer 70

Local anesthesia was performed with 15 mL of lidocaine along the incision site, ventral to the atlas wing (Figure 1). An adhesive drape was used to prevent potential contamination during the surgery, and staples were added to improve fixation. A 10-cm skin incision was performed slightly ventral (1-2 cm) to the standard hyovertebrotomy. Surgical approach and occlusion were performed as previously reported under general anesthesia.4 The parotid fascia was incised, and the parotid gland was retracted cranially. Common carotid artery and bifurcation for ICA and occipital artery were identified deep to these structures. The ICA was dissected from other tissue, and a hook for cat ovariectomy was used to pull on the artery. At this stage, the endoscope was switched on to confirm the choice of the artery. Gentle tension on the artery induced movement of the ICA in the guttural pouch. The proximal ligature was performed before arteriotomy of the ICA; a 6F Fogarty venous thrombectomy catheter (Edwards Lifescience, Irvine California) was then inserted, and the balloon was inflated under endoscopic guidance.

Answer 71

For ECA occlusion, horses were clipped from the proximal third of the neck to the middle of the head. A halter without a cheekpiece was used, and the ear was fixed in a caudal position (Figure 1). The same skin antiseptic protocol was performed, and local anesthesia was performed with 10 mL of lidocaine in a circle fashion around the palpated pulse of the transverse facial artery (Figure 1). An adhesive drape was placed on the surgical site and secured with staples. Surgical approach and occlusion were performed as previously reported under general anesthesia.1 A 6-cm curved incision was performed, and the transverse facial artery was found immediately subcutaneously. The transverse facial artery was dissected from other tissue. At this stage, the endoscope light was switched on to confirm the choice of the artery. Gentle tension on the artery was related to movement of the ECA in the guttural pouch. The transverse facial artery was ligated distally; then, the arteriotomy was performed, a 6F or 4F Fogarty venous thrombectomy (Edwards Lifescience) catheter was inserted, and the balloon was inflated with 2 mL of saline under endoscopic guidance at the level of the stylohyoid bone.

Answer 72

For **MA occlusion,** horses were clipped around the muzzle. Locoregional anesthesia was performed with **maxillary nerve block** (5 mL of lidocaine) and **mental nerve block** (5 mL of lidocaine), and local anesthetic was infiltrated at the incision site at the junction of the smooth mucosal surface with the undulating mucosa of the palate,** 3 cm caudal to the corner incisor tooth** (10 mL of lidocaine). A drape was placed into the mouth to isolate the surgical site from the tongue, and the lips were kept open by an assistant (Figure 1). No mouth gag was used during the procedure. Surgical approach and occlusion were performed as previously reported under general anesthesia. **A 5-cm incision was performed along the junction of the smooth mucosal surface with the undulating mucosa of the hard palate.** Blunt dissection was performed close to the bone surface until the major palatine artery was exposed. A hook for cat ovariectomy was used to pull the artery. Distal ligation and arteriotomy of the major palatine artery were performed, a** 4F Fogarty **venous thrombectomy catheter was inserted, and the balloon was inflated under endoscopic guidance.

Answer 73

Venous trombectomy catheter tip RIGHT smooth is for vein LEFT is for artery

Answer 74

The **ECA is ligated** after the** linguofacial trunk** or is occluded with a ballon inserted in** retrograde fashion** through the **transverse arterial artery**

Answer 75

with venous thrombectomy catheter 6 French Fogarty

Answer 76

**YEs **although ligation of the major **palatineartery** at its** rostral en**d could **prevent retrograde flow, **a combination of this procedure with ligation of the **ECA and ICA** can cause** ischemic optic neuropathy** and permanent blindness. This can be attributed to the “steal phenomenon”

Answer 77

Circle of Willis A - MPA + MA + ECA B - internal carotid artery The segment A that is occluded "steals" blood from the external opthalmic artery that creats a diversion of blood from from this artery in the direction of the arrow

Answer 78

Mainly in association with IC and there are 4 types: **1) origin of ICA and OA** from common trunk - most common 5% 2) aberrant branch of the** extra-cranial ICA** connecting with the basilar artery (4%) c) branch ramifying into surrounding tissues d) several smaller branches with connections to** ipsilateral OA** ** Bifurcation or duplication of ICA** also reported

Answer 79

Aberrant ICA branches and lack of oclusion

Answer 80

Standard approach (hyovertebrotomy) to ICA & 3cm segment close to origin is isolated between ligatures Balloon delivery system = Tuohy-Borst adapter (rotating Y adapter), attached to 8Fr non-tapered thin walled guiding catheter 2Fr 135cm balloon carrier microcatheter placed through the adapter & guiding catheter 19g arterial access needle is inserted into the ICA between the ligatures, and a 0.9-mm guide wire is placed through the needle into the artery Needle withdrawn & 8-French introducer advanced over the wire for 4 cm The balloon delivery system is inserted through the flexible diaphragm of the introducer sheath & advanced 13 cm into the ICA or until resistance is met. Carrier microcatheter advanced 5-10 mm within the guiding catheter while the guiding catheter is retractedBalloon inflated with 0.5 mL of radiopaque solution, & position confirmed with LM rad Balloon detached by gentle traction on the microcatheter & all proximal ligatures are secured. Catheters removed, should be no retrograde flow

Answer 81

8 cm skin incision between proximal & middle 1/3 of the neck just above jugular Separate brachiocephalicus & omohyoideus bluntly & elevate carotid sheath (CCA, vagosympathetic trunk, RLN) by finger dissection Carotid sheath bluntly separated over 5-8 cm w Mosquitos CCA elevated with Penrose & punctured with angiographic needle 6Fr introducer system inserted & position confirmed with angiography 6Fr single end hole nylon catheter (not PVC) is advanced rostrad into the CCA to the level of the ICA under fluoroscopic guidance Angiography (injection of 3-5ml 1:2 iohexol and hep saline) essential during advancement to ID the path of each vessel Cerebral (distal) ICA is embolised first Typically use 5-8mm coils for distal ICA - select coil 20% larger than arterial diameter is very important Coil should not be place in necrotic segment of vessel Embolise cardiac side of ICA midway between the 1st embolisation site and origin of CCA 8-12 mm Kt is withdrawn and procedure repeat for ECA/MA if necessary For MA embolised distal to STA and proximal to infraorbital, buccal and inferior alveolar arteries Coils 8-12 mm ECA performed on the proximal (cardiac) side of the origin of the caudal auricular artery and idstal to origin of linguofacial trunk coils 10-15mm The CCA puncture site is closed with 5-0 silk in a cruciate pattern and muscle layers and skin

Answer 82

Figure 47-20. Lateral contrast fistulography of a horse with a draining tract in the throatlatch of approximately 1 year’s duration; the draining tract communicated with a balloon-tipped catheter placed 4 years previously.

Answer 83

Figure 47-24. Fluoroscopic image obtained during coil embolization showing location of the distal and proximal coils within the internal carotid artery (white arrows), the contrast material with complete occlusion of the artery (white arrowhead), and the angiography catheter within the internal carotid artery (black arrow).

Answer 84

Nitinol vascular plug is a nickel-titanium wire mesh that expands into a dumbell configuration and both ends are marked with radiopaque platinum marker bands

Answer 85

Coil too small - can migrate, too large - will elongate rather than assuming coiled position

Answer 86

- superior technique comparing to ballon because it uses fluoroscopic guidance - less invasive (all arteries accessed through a single incision in CCA) - no need of removal of implant - allows precise occlusion and not associated with blindeness for ECA occlusion

Answer 87

- Requires fluoroscopy - radiation-shielding apparel and equipement - inventory of coils and insertion catheters

Answer 88

- avoid GA and complicaitons specially in hor with hemorrhagic shock or anemia - decreases total time for the procedure - reduces the cost of the procedure

Answer 89

Warm the material to body temperature and inject slowly

Answer 90

‣approx. 50% of those with haemorrhage die. Risk can be abolished/considerablyreduced with arterial occlusion. ‣ Neurologicsigns can persist long beyond disappearance of the mycotic lesion or can bepermanent. RLN is typically permanentbut resolution has been reported ‣Dysphagia may be permanent or improveover 6-18months ‣Hornerssyndrome & CN VII signs improve in 50% of affected horses ‣TACE - 93% success rate - 2/27 hadepistaxis after occlusion (Leville2001) ‣TACE - 31 horses; 84% survival & 71%RTF (Lepage et al. 2005), making this the preferred treatment17% fatal haemorrhagewith CCA ligation alone

Answer 91

Mepivacaine local 60 mL with 5 mL of 10% phenylephrine through biopsy channel ‣980 nm Diode laser at 18W used in contact fashion used to cut through the mucosaof the dorsal pharyngeal recess directly into the GP pouch, creating stoma of 1.5 x 1.5cm ‣In cases, applied laser energy directly to fungal plaques in non-contactfashion ‣All had additional medical management: dex & Bute or flunixin in all (1 hadthroat spray instead of systemic dex), 4 had systemic itraconazole, 1 ofthese had topical miconazole, another not on systemic tx had topical voriconazole (ie 5 had some form of antifungal meds)

Answer 92

Longus capitus + rectus capitus ventralis Trauma falling backward fx basiphenoid/ basioccipital junction

Answer 93

Epistaxis and BOTH are affected

Answer 94

Rest for 4-6 weeks to limit head and neck movement AB for 2ary infection and prognosis is good without neurological signs If severe neuro signs and subdural involvement euthanasiaRupture of the ventral straight muscles

Answer 95

Guttural pouch disease, paranasal sinus disease, nasal cavity disease, and lower airway disease—e.g., exercise-inducedpulmonary hemorrhage (EIPH)

Answer 96

Severe THO of the left side

Answer 97

temporal bone tympanohyoid cartilage stylohyoid bone

Answer 98

Endoscopic examination of the RIGHT gutural pouch reveals the presenc of a suspected lesion located on the ROOF of the MEDIAL compartment obscuring the INTERNAL CAROTID ARTERY

Answer 99

10.8 yold ‣head shaking, bitting issues, ear rubbing, abnormal headcarriage, facial hyperasthesia, compulsive circling to one side ‣Facial & vestibulocochlear nervesigns evident in many ‣neuro signs incl ataxia, head tilt (pollTOWARDS affected side), spontaneous nystagmus (slow phase TOWARD affected side)

Answer 100

middle/inner ear infection of hematogenous origin (?) but also the crib biters are 8x more affected and QH over represented so degenerative cause could be also present

Answer 101

‣CS may be abolished w 2% lidocaineplaced in ear canals (Bras 2014) ‣GP ENDOSCOPY most reliable.‣May be bilateral (upto 22%) ‣CT superior to rads; will also detectsubclinical bilateral disease ‣Scintigraphy Brainstem auditory evoked responses BAER;

Answer 102

Medical - NSAIDs/ABs. Tympanocentesis is technically demanding but may guide AB tx (S. Aureus) Prognosis is 35% accordingly to Espinosa EVJ 2017 so SX has better outcomes

Answer 103

1) Ceratohyoidectomy 2) Partial stylohyoiectomy (PSHO) CERATO because the other has risk of hypoglossar nerve damage and dysphagia

Answer 104

In this surgery a portion of stylohyoid is removed but this can cause laceration of lingual artery, hypoglossal neuropathy, transient dysphagia, stylohyoid bone regrowth, p permanent problems with prehension when performed bilaterally

Answer 105

10 cm incison in the skin medial to the linguofacial vein on the affected side (Fig 47-15) and centered to the basihyoid bone 2 cm from the midline where the incision cresses the basihyoid bone Fibers of the sternohyoid muscle are separeted bluntly until the basihyoid bone is exposed Rostral to the basihyoid bone the geniohyoid muscle is separated to expose the ceratohyoid bone and lateral to it the hypoglossal nerve (XII) The ceratohyoid-basihoid synovial joint is ID and disarticulated with cartilage scissors

Answer 106

Hypoglossal nerve Lingual branches of the mandibular Glossopharyngeal nerves

Answer 107

1.Certohyoideus muscle 2.Hyoideus transversus muscle 3.Genioglossus muscles

Answer 108

shear mouth 2ary to THO osteoarthropathy

Answer 109

89% improved with ceratohyoidectomy (Maher 2008) ‣87% improved 1yr post PSHO ‣Oliver 2015 - 80% RTF post ceratohyoidectomy, although mild facial nerve paralysis(21.4%) or head tilt (42.8%) persisted (not performance limiting). Px for resolution ofataxia following ceratohyoidectomy was good

Answer 110

▸Skin incision**: 10cm long from 2cm caudalto the basihyoid running rostrally**, midway between midline & mandible ▸Bluntly separate **sternohyoid &omohyoid mm **to expose **basihyoid&** its **articulation with ceratohyoid.** ▸Separate** myelohyoid **from **genioglossus rostrally** ▸Care re** hypoglossal nn & lingual aa **on lateral side of ceratohyoid; dissectionshould remain on its medialaspect ** ▸Transect articulation w basihyoid** w Mayos ▸Ceratohyoid mm digitally **separated from caudal ceratohyoid, **then transect articulation with stylohyoid bone &remove Close front & back of skin incision (USP 1 monofilament nylon);middle open to drain

Answer 111

Surgery by Racine et all 2021

Answer 112

Standing sx **3-5 cm incision **after **25 mL of mepi centered along the basihyoid-ceratohyoid joint **medial to the **linguofacial vein** Blunt dissection through** sternohyoideus musculature** and underlying **basihoid** Rostrally geniohyoideus muscle was separated digitally from the ceratohyoid bone by **digital manipulation** to expose the **basihoyioi-ceratohyoid joint **that was transected with scissors. Incision was left open to heal by second intention No complications in all horses

Answer 113

Surgery by Hall AVAMA 2021 standing

Answer 114

Yes 41% of the horses with THO had temporal bone fracture

Answer 115

9 days to 6 months

Answer 116

No association between SPS sizes and BW or breed Significant association of SPS with height and age

Answer 117

Rupture of the ventral straight muscles

Answer 118

Rupture of the ventral straight muscles