Clinical relevance EquineEthmoid haematoma

Question 1

Look at this history and clinical signs. What are your differential diagnoses?

Answer 1

• Nasal trauma/FB
• Clotting abnormality
• Ethmoidal haematoma
• Fungal infection within sinuses (mycotic sinusitis)
• Sinus trauma
• Guttural pouch mycosis (less likely as would expect more blood associated with epistaxis)
• Paranasal sinus cysts
• Squamous cell carcinoma in the nasal passage
• EIPH (less likely as not bilateral)

Question 2

What tests would you want to do next on this horse?

Answer 2

Full clinical exam (£75)

Full physical exam - cardiac auscultation, lung auscultation - LRT disease and sounds. Rectal temp for pyrexia. Lameness exam. Neuro exam.

Problems found from this:

• Leaky eye on the right hand side ~ compression of lacrimal duct?
• Reduced airflow through right nostril ~ obstruction within the nasal passage?
• Dullness in maxillary sinus ~ fluid within the sinus?

Question 3

What did the next test endoscopy show?

Answer 3

• Resting endoscopy (£90)
• Resting endoscope - doing this because we want to asses nasal passage, pharynx, larynx, guttural ouch, ethmoid turbinates, meati, nasal maxillary opening.

See attached pic for what it showed.

Question 4

What did the radiograph allow us to assess?

Answer 4

Radiography (£165)

Assessment of sinuses and potential fluid within the maxillary sinus, what structures are associated/location of ethmoid haematoma

Question 5

What did mark make of the case?

Answer 5

D/d

• Clotting disorder
• Nasal FB (twig thorn)
• GP mycosis not appropriate given low grade haemorrhage (important to rule out as can be catastrophic)
• Normal HR suggest isn’t overtly hypovolemic and is coping well with blood loss if it was tachycardic may be more concerned blood loss was significant
• LNs normal so no inflammatory process
• Dullness in sinus localises it check airflow in both sinuses
• Small tarsal joint disease is irrelevant common condition in old horse
• Lack of CN abnormalities is relevant as this is common in GP disease
• Epiphora nasolacrimal duct passes through sinus on way to empty this is relevant as it has been blocked by the mass

Question 6

What did mark say about the value of lab tests?

Answer 6

Lab tests:

Very little value

Haematology unlikely to yield anything even in GP mycosis

PCV may be relevant (normally ref range 26 in TBx)

Fibrinogen would tell you about inflammation (not expected to be increased with regards to d/dx)

Clotting profile may be useful but rule out structural abnormality first

If the horse was bleeding from lungs would expect bilateral nasal lesions

Question 7

What did mark say was most useful further investigation?

Answer 7

Most useful diagnositic: endoscope at rest. Haemhorrhagic appearance of progressive ethmoid haematoma

Go into ventral meatus (u shaped appearance) in this case we want to visualise ethmoid region so want to go in middle meatus (Y shaped appearance)

No justification for exercise endoscopy

Cardiac ECG/US unhelpful

Head radiographs:

Fluid in maxillary sinus so need to evaluate it fully

This horse had no evidence of ST in maxillary sinus (what we could hear on percussion was changes in density in the nasal cavity)

Important show DV view labelled ethmoid region and ST mass. Useful to confirm unilateral and make sure other side is normal and shows you extent of mass and involvement of sinuses as can often extend to here.

Standing CT increasingly available can be done with sedation many centres now offer this. This can look at the extent of the lesion.

Question 8

What if we hadn’t found anything on endoscope?

Answer 8

• Then clotting profile would have been done. If nothing structural found then do some haematology and clotting.
• Clotting factor disorders in horse are uncommon except for DIC associated with sepsis. Von willebrands seen in arab horses (Uncommon).
• Glanzmann another uncommon clotting disease.
• Buccal mucosal bleeding time good test horses should clot within 5-7 mins horses with glanzmann take 40-50 mins to clot.

Question 9

How was this progressive ethmoid haematoma treated?

Answer 9

Horse treated with intralesional injections of formalin.

Some horses have seen neurological side effects but assumption made that the lesion has extended into cribiform plate and have therefore injected formalin straight into brain this is why CT is important to assess extent of lesion.

Can do Fronto-maxillary approach to remove masses surgically but huge amount of blood loss associated.

Prognosis: Excellent could not tell difference between either sinus.