mouth and upper resp tract 2 Flashcards
reasons for purulent nasal discharge
- Sinusitis > Primary, Secondary
- Guttural Pouch Empyema
- Lower Respiratory disease
- Others: Tumour
drainage of paranasal sinuses:
- Frontal, maxillary, dorsal & ventral conchal, & sphenopalatine
- All drainage occurs into nasal cavity via the left & right nasomaxillary openings (rostral to the nasopharynx, nasal cavity divided by nasal septum)
> into medial meatus
which teeth have roots in the rostral maxillary sinus?
which teeth have roots in the caudal maxillary sinus?
(1) Roots of 3rd & 4th cheek teeth (P4 & M1) project into the rostral maxillary sinus
(2) Roots of 5th & 6th cheek teeth (M2 & M3) project into the caudal maxillary sinus
Primary Sinus Infection
a. Etiology & Clinical Signs
(1) Upper respiratory tract infections (viral ± bacterial) > generalized mucosal inflammation > initial bilateral mucous or mucopurulent nasal discharge
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(2) After resolution of the generalized disease, sinus inflammation may remain due to poor drainage > bacterial infection > usually unilateral purulent nasal discharge
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(3) Percussion: Dull over involved sinus
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(4) If sinus exudate becomes inspissated &/or drainage obstructed > chronic increase in sinus pressure > distortion of relatively thin surrounding bone, medially (internal) & laterally (external) > decreased air flow ± facial swelling
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(5) Foul odor: No foul odor, compare with tooth root infection
(6) Oral exam: Normal, compare with tooth root infection
primary sinus infection endoscopy
(1) Purulent material originating from middle nasal meatus
(2) In chronic cases, may see distortion of nasal cavity
primary sinus infection radiographs
(1) Fluid line, if exudate has fluid consistency & sinus not filled completely
(2) Increased density with no fluid line, if sinus filled completely with inspissated exudate or proliferative tissue
(3) Inflammed tissue
Lab Work-Cytology/Culture for primary sinus infection
- Sinocenthesis-trough Steinman pin hole
- Usually Strep (more indicative of primary sinusitis)
- take from:
- Frontal sinus (1)
- Caudal maxillary (2)
- Rostral maxillary (3)
- If no rads take sample in rostral and caudal maxillary
Treatment-Primary sinusitis:
- Antibiotherapy
- Sinus flush
- Surgical debridement -chronic cases
tooth root infection connection with sinusitis
- usually secondary to what?
(1) 50% of chronic sinus infection from extension of dental disease involving P4, M1, M2 or M3 in the upper arcade
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(2) Usually secondary to:
(a) Severe periodontal disease
(b) Fractured tooth &/or surrounding bone
(c) Dental carie (cavity) > contamination of pulp cavity
(d) Impaction of developing tooth between surrounding teeth
tooth root infection and secondary sinus infection signs
- Variable signs, if any, relating to dental pain – i.e. no signs; or ± abnormal appetite, ± abnormal eating behavior, ± weight loss, etc.
<><> - Many signs similar to primary sinus infection: Unilateral nasal discharge, dull on percussion, ± facial swelling, ± decreased air flow, & endoscopy
<><> - However, the unilateral nasal discharge is usually foul-smelling, typical of anaerobes & necrotic tissue
tooth root infection with secondary sinus infection
- cytology / culture results
Purulent material from sinus, often with multiple organisms (including anaerobes) on culture
tooth root infection, secondary sinusitis oral exam findings
(1) May be normal
(2) Impacted food material
(3) Signs of gingivitis: Hyperemia, swelling, retraction, pocket formation
(4) Loose, fractured or missing tooth
(5) Use dental pick/needle to examine occlusal surface of teeth for caries
radiology results for tooth root infection with secondary sinusitis
(1) ± Similar to primary sinus infection
(2) ± Destructive &/or productive changes (decreased/increased density) associated with tooth root &/or adjacent alveolar bone
tooth root infection with secondary sinusitis treatment
(1) Usually removal of affected tooth, debridement of infected bone, & repeated lavage
(a) If the tooth is sufficiently diseased (i.e. loosened), it may be extracted via the oral cavity
(b) However, removal of cheek teeth (premolars & molars) often requires repulsion from the root side, via a trephine hole or bone flap
(c) Remember subsequent tooth wear problems & appropriate care
(2) An endodontic (root-canal) procedure may sometimes be used to save the tooth, if the disease process has not extensively involved surrounding bone or loosened the tooth
Secondary sinusitis: Neoplasia/Sinus Cyst
Treatment and prognosis?
- what are more vs less common causes?
- Surgical excision
- Good prognosis for sinus cyst, guarded for neoplasia
<><> - Uncommon: Fibroma, Fibrosarcoma, osteoma, osteosarcoma, SCC
- More common: Sinus Cyst
secondary sinusitis due to trauma
- cause, dx, tx
Trauma:
- Penetrating wound, facial Fx
- Possible infection
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Radiology, Ultrasound
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Treatment
- Wound care =/- stabilization
guttural pouch anatomy and structures
a. Divided by stylohyoid bone into lateral & medial compartments
b. In walls of each pouch: Internal carotid & maxillary arteries; cranial nerves VII, IX,
X, XI, & XII; sympathetic branches to face; & retropharyngeal lymph nodes
c. Pouches open into pharynx on dorsolateral walls of pharynx at 10 & 2 o’clock
(1) This opening does not originate on the ventral floor of the pouch
(2) Therefore, poor drainage of pouch when horse standing with head up
guttural pouch emyema etiology and clinical signs
a. Usually secondary to upper respiratory tract infection (be wary of Strep equi equi)
b. Usually bilateral nasal discharge, even if only 1 pouch affected, because openings are caudal to nasal septum
c. Discharge worse when horse’s head down, due to position of pharyngeal openings
d. Other signs may include: Cranial cervical swelling (Viborg’s triangle), dysphagia, respiratory noise, & general signs of illness
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- Bilateral discharge often (even if 1 affected)
+/- Swelling
+/- Neurological sign
- dysphagia-food material at nostril
- Laryngeal hemiplegia
- Horner’s Syndrome
- Facial paralysis
guttural pouch emyema dx
- Endoscopy
a. Pus from pharyngeal opening(s) of pouch(es)
b. Can introduce scope into pouch for direct visualization - Radiology
a. Fluid line, if pus has fluid consistency & pouch not filled completely
b. If pouch filled with inspissated pus, generalized increased density & loss of pouch borders
c. Chronic disease may form concretions of pus (“chondroids”) ventrally in pouch
guttural pouch emyema tx, prognosis
- Medical treatment (common) – Similar to an abscess, encourage drainage by:
(1) Systemic antibiotics (Strep most common organism)
(2) Feed on ground, to lower horse’s head & promote drainage
(3) Lavage with saline or Ringer’s via a catheter (intermittent or indwelling) through the nostril into the pouch opening
<><><><> - Surgical drainage (uncommon)
(1) If unsuccessful medical therapy, or if inspissated pus or chondroids present
(2) Several possible surgical approaches
<><><> - Prognosis favorable, unless neurologic involvement
bloody nasal discharge - common reasons
- Guttural Pouch Mycosis
- Ethmoid hematoma
- EIPH
- Trauma
- Nasal or Sinus Tumor
Guttural Pouch Mycosis
Etiology:
- Fungal infection invading vessel wall
- May be fatal
Guttural Pouch Mycosis
Clinical Signs:
- Bilateral discharge often (even if 1 affected)
- Medial compartment more common
- May cause neurological signs
Guttural Pouch Mycosis
Dx
- Endoscopy
a. Blood from pharyngeal opening of pouch
b. Entering pouch to evaluate fungal lesion & determine which artery(s) involved will help determine appropriate treatment
> However, endoscopic procedure may cause acute hemorrhage
<><> - Radiology: Fluid line or, if pouch filled, generalized increased density
Guttural Pouch Mycosis
Treatment:
- Medical
> Local antifungal - Surgical
> Ligation of artery on both side of the lesion to avoid Circle of Willis (coil, balloon catheter)
