Sinonasal Disease Flashcards
List 10 ddx for epistaxis/serosanguinous nasal discahrge
EIPH
PEH
GP mycosis
Fungal rhinitis
Sinonasal neoplasia
Trauma/skull fracture
Foreign body
Sinus cyst
Ulcerative rhinitis
Rupture of the ventral straight muscles of the head (rectus capitis ventralis and longus capitis)
Most common PEH signalment
Middle aged males
Reported age 3-20
Histo features of PEH
Capsule consisting of resp epithelium and fiborous tissue
Contains haemosiderophages
May have calcerious deposits
Tx options for PEH (3)
Trans-endoscopic intralesional 4% formalin injection (inject until the mass begins to distend), repeated q3-4 weeks until resolution
Sinus flap/trephination and mass extirpation - frontonasal bone flap has the most exposure and versatility
Nd:YAG laser ablation for lesions <5cm diameter
% of PEH with bilateral involvement
& % with involvement of the sphenopalatine sinus as determined on CT
50% bilateral
38% involvemet of SPS
Sinocentesis (/trephine) site for choncofrontal sinus
60% of the distance from midline to medial canthus and 0.5cm caudal to a line connecting the medial canthi
Sinocentesis/trephine site for caudal max
2cm rostral and 2cm ventral to the medial canthus
(ie dorsal to the facial crest and rostral to the orbit - facial crest forms the ventral border of the max sinus and dorsal border formed by a line from medial canthus to infra-orbital foramen)
Sinocentesis/trephine site for rostral max
40% of the distance from the rostral end of the facial crest to the level of the medial canthus and 1cm ventral to a line joining the infraorbital foramen and medial canthus
This is approx 3 cm dorsal to facial crest and approximately 3 cm caudal to the infraorbital foramen.
Methods of haemostasis for sinus surgery
Packing w gauze (most effective) - necessitates tracheotomy if bilateral packing required
Epinephrine soaked gauze packing
Cold physiologic saline lavage (can’t see how this doesn’t wash clotting factors away)?
Bilateral carotid artery ligation
Liquid nitrogen
Label the nerves
A- Facial nerve
B - Trigeminal nerve; maxillary branch
1: Auriculopalpaebral
2: Supraorbital (this is trigeminal)
3: Dorsal buccal
4: Ventral buccal branches of facial nn
5: Maxillary
6: Infraorbital
7: Inferior alveolar
8: Mental
In Strand et al (2019 VS) what dx criteria were used to dx alar fold collapse. What breed are over-represented for this condition?
Dx criteria - presence of continuous abnormal expiratory vibrating flutter noise, which coincided with visible inspiratory filling of the nasal diverticula throughout the exercise test and when temporarily suturing the alar folds in a dorsal position alleviated these signs
SBs are over-represented
What sx procedure was reported by Strand et al (2019 VS) to treat alar fold collapse?
Describe the main steps
Alar fold resection:
1: GA dorsal w 90° neck flexion
2. 10cm skin incision from the lateral alar caudally to the back of the nasal diverticulum
3. Rochester Carmalt forceps placed along lateral and medial margins of the AF, then AF resected with 10 bade in caudal direction removing as much tissue as poss (incl. the rostral portion of ventral concha) but leaving enough to suture edges in direct apposition
4) The nasal mucosa was sutured to the skin of the nasal diverticulum in a simple continuous pattern with 2-0 polyglactin 910, medially & laterally
5) The lateral ala of the nostril was sutured in 2 layers; the (inner) nasal diverticular skin was sutured with 2-0 polyglactin 910 in a simple continuous fashion, and the external skin was sutured with 2-0 polypropylene in a Ford interlocking pattern.
Outcomes following alar fold resection reported by Strand 2019 (VS)
20 of 25 horses had competed after surgery, and 13 of 17 of the harness racehorses had established or improved their km racing time marks
Expiratory nasopharyngeal pressures which were initially elevated, were reduced with suturing and alar fold resection to WNL.
5 unraced horses pre-op didn’t race PO, but none were reportedly dt ongoing AF problems
22/25 owners/trainers were satisfied with outcome
What other dynamic URT obstruction may be assoc. with alar fold collapse in SBs (Strand 2019 VS)
iDDSP
What 2 surgical procedures were reported by Bach et al (VS 2019) for improving drainage from the paranasal sinuses
1) Endoscopy guided trans-nasal conchotomy of the ventral conchal sinus (TCVCS)
2) Surgical enlargement of the nasomaxillary apperture (SENMAP)
Briefly describe the 2 surgical procedures reported by Bach et al (VS 2019) for improving drainage from the paranasal sinuses
1) Trans-nasal conchotomy of the VCS:
a) Scope in middle meatus, VCS conchotomy site was located 10–50 mm rostral to the caudal end of the ventral concha and 15–20 mm dorsal to its ventral border
b) Using electrosurgical conchotomes, Coagulation (80W) of an area of approximately 50 × 15 mm of the caudomedial ventral conchal wall was performed with the ball-tipped conchotome
c) Blade-tipped conchotome inserted at the caudal aspect of the coagulated portion and pulled rostrally for 43-50mm
2) Surgical enlargement of the nasomaxillary aperture:
a) 30mm Galt trephine into CFS
b) A portion of the ventral lamella of the dorsal concha approximately 30–45 mm long and 30 mm wide that was located rostromedially to the frontomaxillary aperture was identified and the mucosal lining cauterised (80 W, coagulation mode) with an electro-thermal scalpel
c) The solid bony lamella was cut along the cauterised lines with a chisel and removed, exposing the underlying bulla of the maxillary septum (BMS).
d) The dorsal aspects of the BMS were cauterised & removed
e) An electrothermal bipolar tissue sealing system was used to make 2 vertical, parallel incisions of the medial wall of the ventral concha (VC) at the rostral and caudal aspects of the resection lines of the BMS & tissue between the incisions removed
Main clinical features of sinus cysts
Comment on signalment
Debated in the literature but possible biphasic age distribution of young and then >10yrs. Others report more commonly affecting older horses
Main CSs incl. nasal discharge, facial swelling, epiphora, resp noise, nasal occlusion.
Treatment of and reported outcomes for sinus cysts according to Fenner et al (2019 EVJ)
Tx with surgical resection via trephine (n=2) or sinus flap (n-35)
- 76.8% resolution of dz
- 19% recurrence rate
- Complete extirpation likely mandatory for resolution of dz
- Co-morbidities incl. dental dz destruction of the infra-orbital canal were more likely to be present in horses >10yrs; poss dt longer period of CSs before presentation in these
- Although head shaking may develop PO - tends to resolve without specific tx. Equally, those presenting w head shaking usually resolved also
What were the main findings of Giovatto and Barackzi (EVE 2019) when describing the radiographic appearance of the dorsal and ventral conchal bullae in cadaver heads?
- Dorsal and ventral nasal conchae are simple structures, comprising two delicate scrolls of thin, mucosa-covered bone; within each dorsal and ventral nasal concha lies an air-filled bulla = DCB and VCB
- The DCB was easily identified on straight lateral views in all the equine heads.
- The rostral border of the VCB was correctly identified on plain lateral radiographs in all the heads of horses aged >5 years, while the location of the caudal border is more difficult to ascertain - not visible in 60% plain rads; generally the caudal border extended further caudally than predicted on plain rads & partially superimposed on the rostral limit of RMS in 60% skulls
- The radiopacity of the mucosal fold rostral to the VCB was easily identified in all the heads in this study, ∴ this may be used as a landmark in the radiographic identification of the VCB
- Both more difficult to ID on latero30°dorsal lateroventral rads vs straight lateral, and the DV was not useful for the majority of cases, esp for the VCB
- Broadly speaking, the larger DCBs are usually located dorsal to the maxillary 07s–09s/10s, & the relatively shorter VCBs are most commonly located dorsal to the maxillary 07s–08s/09s
- Harder to visualise the caudal and ventral borders of the VCB in horses <5 dt superimposition of maxillary teeth and in ponies dt generalised incr. opacity in the nasal/maxillary region
- Needs investigating in disease
Which 4 muscles dilate the nares & what nerve innervates them
Levator nasolabialis
Caninus
Lateralis nasi
Dilator naris apicalis
Innervated by facial nerve; hence facial nerve paralysis performance limiting in horses exercising at fast work
