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Equine Final Year > Sinus Disease and Epistaxis > Flashcards

Sinus Disease and Epistaxis Flashcards

1
Q

What are the anatomical features of the nasal passages?

A
  • Nares: alar cartilages, blind diverticulum and nasolacrimal duct
  • Contribute to 50% total resistance of URT airflow at rest
  • Dilated at exercise by nasolabialis muscles (facial nerve (VII) paralysis)
  • Nasal passages divided by dorsal and ventral conchi on lateral aspect
  • Conchi divide the nasal passages into dorsal, ventral and middle meati
  • Common meatus medially
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2
Q

What are the paranasal sinuses?

A

•Series connected cavities
arranged one after another

•Divided into 2 separate function and discrete areas – caudal and rostral group and THEY DO NOT COMMUNICATE. So if disease of rostral sinuses, not point in lavaging the caudal ones!

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3
Q

Label

A
  • Rostral maxillary and ventral conchal sinus– red striped area
  • Black – dorsal sinus and conchae
  • Red – caudal maxillary sinus
  • Purple – sphenopalatine sinus
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4
Q

What is the relationship between the aperture the caudal and rostral PN sinuses drain?

A

Caudal and rostral group drain in different directions but out of the same aperture that is visible within the nose – doesn’t mean they connect though!

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5
Q

Label the colours

A

D. green - rostral maxillary sinus

L. green - caudal maxillary sinus

Blue - frontal sinus

Red - sphenopalatine sinus

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6
Q

What type of space is present in the ethmoidal sinus?

A

Air space

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7
Q

Label the letters of the thmoid region in this pic

A

D – nasal septum, going up horses RIGHT nostril

B – ventral conchal sinus

A – dorsal conchal sinus

C – area in between the ventral and dorsal sinus called the drainage angle or nasal maxillary aperture. This is where we will see any discharge that is coming from sinuses

F – remainder of ethmoid turbinates. Profound bleeding from here if you touch it!

E – generalised ethmoid region visible

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8
Q

Where would the scope have been put for this pic?

A

Middle meatus

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9
Q

What are the 2 discrete areas of sinus disease?

A

Primary and secondary sinusitis

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10
Q

What can cause primary sinusitis? (3) How can we treat these?

A

–Bacterial – NB consider S equi var equi

–Fungal (Aspergillus)

–Just an infectious process occurring within sinus

–Labage or appropriate therapy will help with these

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11
Q

What can cause secondary sinusitis? (2)

A

–Still have bacterial disease present but secondary to something else, something that is changing the environment in the sinus. If you don’t treat the primary disease, wont get rid of purulent sinus disease

–Usually secondary to dental disease

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12
Q

What sinus are PM2 and 3 associated with?

A

–Not usually associated with paranasal sinuses

•So if we have dental disease of these teeth, and we have pus and infection building u- - will present with facial distortion and swelling as primary clinical finding associated with disease of these teeth

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13
Q

What sinus are PM4 and M1 (part) associated with?

A

–Rostral maxillary sinus

  • So disease of these teeth – some variation
  • Sometimes disease of the first molar will cause rostral maxillary, sometimes will be caudal maxillary disease
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14
Q

What sinus are M1, 2 and 3 associated with?

A

–caudal maxillary sinus

•Variation with M1 as above

M2 and M3 will cause caudal maxillary sinus disease

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15
Q

Other than primary and secondary sinusitis, what are the 2 other things causing sinus disease?

A

Progressive ethmoidal Haematoma

Sinus Cyst

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16
Q

How can we diagnose sinus disease? (5)

A

•History

–Purulent (odorous) nasal discharge (unilateral), how long has it been present for? Any other clinical signs associate with horses dental presentation?

•Physical examination

–Percussion over sinuses to detect fluid

–Examine head carefully

•Nasal endoscopy

–Nasomaxillary drainage angle visible in middle meatus

–Most diagnosis will be based on this

•Sinoscopy

–Via portals described for trephination

–Direct sinoscopy via a trefined hole – also quite useful

•Radiography

–Confirmation of fluid within sinus using latero-lateral and dorso-ventral radiographs

–Oblique views to highlight dental pathology

–Combine with oral examination (dental endoscopy)

–Primary use is to determine fluid present with paranasal sinuses, can do different lesion orientated view to highlight specific areas without overlap of contralateral side

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17
Q

What is shown?

A

Normal radiographic anatomy

Should be air filled sinuses

On lateral radiograph, should have these cavities, nearly essentially black

Should see infraorbital canal passing through the sinuses

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18
Q

What radiographic views do we take for Nasal / paranasal disease? (4)

A
  • Lateral views
  • Dorsoventral views

–To compare L and R sinuses

•300 obliques for sinuses and tooth roots

–Highlight individual sinuses

•Lesion orientated obliques

–Looking for specific things

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19
Q

What does sinoscpy allow for and how do we do it?

A

•Allows direct visualisation of sinus disease

–Mycosis, empyema, fracture

•Can pass endoscope through hole in horses head. Easy places to make these holes are at frontal sinus or caudal maxillary – almost always start at frontal, so can start looking at caudal maxillary sinus (where caudal sinuses drain), just because we can or cannot see fluid in there – DOESN’T TELL US ANYTHING ABOUT ROSTRAL SINUSES – would need additional procedures for this, might need tO break down septum to get into rostral maxillary sinus

–CAN ONLY OBSERVE CAUDAL SINUSES WITH JUST THE FRONTAL OPENING

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20
Q

What other diagnostic procedures can we do to view the sinus (less common)? (4)

A

•Radiography is limited by difficulties in interpretation

–Multiple overlying structures

–Sinoscopy can assist with diagnostic evaluation

•Computer tomography

–Advantage – quick! Takes around 30 seconds for all of horses head

–Difficulties - got to get horses into and out of the system etc.

–Horse is sedated, NOT GA. Stood on special table, done standing – so cheaper!

–More places do CT than MRI

•Magnetic resonance imaging

–Slow! To take a single plan image might take up to 30 minutes or so!

–Also needs GA

–In comparison to CT, can get good soft tissue and brain, but few places that have the capabilities to do MRI and more risky with GA and takes a long time

•Bone phase scintigraphy

–Can be useful

–Disadvantage – 2D image and technique so doesn’t tell us specifically due to the overlapping nature of the sinuses

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21
Q

Paranasal sinus cysts:

  1. Aetiology?
  2. Aged aniamls?
  3. What are they?
  4. What can they cause?
A
  1. Aetiology unknown
  2. Usually in young animals
  3. Expansive fluid filled lesions
    • Cyst like structures!
  4. Can cause facial distortion
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22
Q

What is seen on radiography with Paranasal sinus cysts?

A

•soft tissue opacity throughout sinuses +/- gas / fluid line

–Well circumscribed soft tissue opacity – can be obscured by secondary disease that occurs such as secondary sinusitis

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23
Q

How do you treat, and what is the prognosis of Paranasal sinus cysts?

A

•Surgical removal via a frontonasal flap

–Post-operative care as for sinusitis (promote drainage and antibiotics)

–Surgically remove the cystic structure! Want to remove all lining so it cannot reform and resolution of clinical signs

•Good prognosis - recurrence rare if you remove all of the cysts

24
Q

Primary Bacteria Sinusitis:

  1. What age horse?
  2. What discharge?
  3. What is enlarged?
  4. What is seen on radiographs?
A
  1. Usually younger horses
    • Opportunistic bacteria, often Strep. sp.
    • Sequel to URT infection, related to poor drainage of the sinuses. Aperture might be blocked in some way, fluid builds up and the situation doesn’t resolve and situation persists
  2. Purulent nasal discharge, not foul smelling
    • Just tend to have purulent, usually unilateral, but doesn’t smell like it does in strangles!
  3. Lymph node enlargement
  4. Radiography - gas/fluid lines, pretty much in horizontal straight line – pretty easy to make diagnosis of radiographically, but need to determine if primary sinus disease or secondary
25
Q

How do you treat Primary Bacterial Sinusitis? What is the prognosis?

A
  • Treatment to establish drainage and eliminate infection
    • Initial treatment to promote mucociliary clearance
    • Mucolytics, inhalations, feeding at floor level, exercise and antibiotics can all be used
  • Allow natural egress of fluid in the sinuses
  • Many resolve spontaneously or with treatment
  • If no response to medical therapy – will need to eliminate all infection within sinus space
    • Irrigation and drainage via trephine (or pin), allow us to lavage through sinus space
    • Frontal/maxillary flap if inspisated pus
      • Can be done standing
    • Don’t lavage the caudal if it’s the rostral sinuses and vice versa! As he keeps saying…
  • Prognosis - good
26
Q

Where is Secondary bacterial sinusitis usually seen?

A

•Usually seen in older horses:

–As most often secondary to dental disease

  • Dental fracture, periodontal disease (periapical abscessation)
  • Foul smelling discharge with mixed bacterial populations

–Because this is caused by bacteria migrating, then will cause anaerobic changes within sinus spaces and will get smelly discharge!

27
Q

What is seen on physical exam with Secondary bacterial sinusitis?

A

–Consider other systemic diseases (e.g. PPID)

–Draining tract, smell, swelling – or anything else we have bacteria in the sinus

–Important to do an oral examination and dental assessment – make sure there is no tooth root problems associated with the disease

28
Q

What imaging can we do for Secondary bacterial sinusitis? (2)

A

–Endoscopy – discharge from nasomaxillary opening

–Radiography – evaluate fluid lines and try to evaluate if there is any dental disease

–Soft tissue opacity with tooth roots can obscure the view and might not see fluid lines so easily, so often will trefine these horses, fluid out purulent accumulation and then re-radiograph once this has been resolved – will be a much clearer image

29
Q

How do we treat secondary bacterial sinusitis? (2)

A

•Treat primary disease

–Remove diseased teeth

•REMOVE CORRECT TOOTH, do not leave bits…

–Pack oro-nasal fistulae

  • Removal via oral extraction is usually preferred way, but if not possible, then can:
  • Removal via frontonasal flap (retropulsion)
  • Treat as for primary sinusitis

–irrigation and antibiotics – get rid of all accumulated purulent material that is in there.

30
Q

Other than sinusiitus what are the other conditions of the paranasal sinuses? (4)

A

–Fungal granulomas

–Ethmoidal haematomas

–Squamous cell carcinoma

–Other neoplasia is less common

31
Q

What are the different types of Mycotic sinusitis? (4)

A
  • Primary
  • Secondary

–Sequestra formation, can also occur as a result of chronic antibiotic administration, surgery, underlying debilitating disease (such as PPID)

•Destructive malodorous condition

–Will destroy normal architecture

–Tend to smell!!

•Nasal discharge

–+/- haemorrhage – can sometimes bleed, because of tissue destruction occurring as a result

32
Q

What is Mycotic sinusitis similar to in smallies?

A

Aspergillosis

33
Q

How do we diagnose Mycotic sinusitis? (2)

A

• Sinoscopy/endscopy

–Radiographs may be unremarkable

•If chronic, might see changes of the architecture that has been broken down

–So sinoscopy and endoscopy are the best ways to diagnose for us

34
Q

How do you treat (3) and what is the prognosis of Mycotic sinusitis?

A

–Eliminate underlying cause (or treat – eg PPID)

–lavage with topical antifungal agents (e.g. enilconazole)

  • Physical lavage but also accompany with topical antifungal agents
  • Prolonged treatment (4-6 weeks)
  • Good prognosis if treated adequately
35
Q

Mycotic Rhinitis:

  1. What type of discharge?
  2. What causes it?
A
  1. Malodorous purulent / sanguinous discharge
  2. Aspergillus fumigatus
  • In plants inc hay and straw.
  • Secondary to trauma?
  • Serology is unreliable.
  • Topical treatment with nystatin or natamycin (powder) or endoscopically flush out sacivities with another drug
36
Q

What can occur with Nasal Fungal Granulomas? How do you treat?

A

–Not in UK

•Cryptococus neoformans, Condiobolus coronatus

–Nasal airflow obstruction may occur

–Surgical removal + sodium iodide infusion

37
Q

What three things do we need to consider for an epistaxis diagnosis? (3)

A
  • Consider likely location based on character
    • Unilateral or bilateral
  • Consider volume
    • Beware that owners will always exagerate blood loss
    • If high volumes – indicates different disease to small trickles of blood!
  • Consider History
    • Trauma?
    • Iatrogenic? Has someone tried to pass something up the nose?
38
Q

What are the potential sources of epistaxis if it is bilateral? (2)

A

–Lungs

  • Exercise induced pulmonary haemorrhage – variable amounts – especially in competition horses!
  • Lung neoplasia – variable, usually small amounts

–Pharynx

  • Trauma, foreign body – variable, usually small amounts
  • Guttural pouch mycosis - large amounts, one of the most important things we need to consider
39
Q

What are the potential sources of epistaxis if it is unilateral? (3)

A

–Pharynx

•Guttural pouch mycosis - large amounts

–Sinus

  • Mycotic sinusitis – usually small amounts, anything traumatically breaking down tissue
  • Trauma – usually small amounts

–Nasal Cavity

  • Progressive Ethmoidal Haematoma – usually a slow trickle
  • Clotting abnormalities – usually slow and intermittent
  • Trauma
40
Q

What can be seen here?

A

Haemorrhage from nasomaxillary opening

Shows that there is bleeding emanating from in the sinus

41
Q

What can we do to identify trauma causing epistaxis?

A

•Fractures

–often associated with fracture depression,

–epistaxis, emphysema

–can lead to sequestra within sinuses

•Palpation

–Looking for areas of pain, crepitus, emphysema

–Evaluation entire head is important

  • Might be additional damage to nervous structures as well!
  • Emphysema

–occurs with communication into sinuses or other URT structures

  • Underlying structures - brain!, nerve damage
  • Physical exam, endoscopy, radiography
42
Q

What management can we do for facial trauma? (3)

A
  • Basic wound management (haemostasis, lavage and debridement)
  • Minimise secondary infection (drainage, antibiotics, removal of sequestra or foreign bodies)

–If fractures of bones, remove any smaller fragment that could cause problems, antibiotics?

•Cosmetic repair of facial fractures

–Especially if over sinuses

–Can wire larger pieces of bone together etc.

43
Q

What causes Iatrogenic epistaxis? (1)

How can we stop it? (2)

A
  • Usually a result of passing stomach tube into middle meatus, need to go in the VENTRAL MEATUS!
  • Will stop with time, be patient
  • Hold head up to reduce BP
44
Q

What do we avoid in iatrogenic epistaxis?

A

•Avoid drugs to lower Blood pressure (eg ACP)

–A little bit controversial

–Might help in terms of reducing BP but if large volumes of blood loss, a bit contraindicated for lowering and already lowering BP

45
Q

What do you get with Guttural pouch mycosis?

A

•Get diptheritic fungal plaque overlying blood vessels – as these cause tissue trauma and necrosis, erodes into BV and initially causes low levels of epistaxis

–Usually affects internal carotid (medial compartment)

may be external or maxillary artery (lateral compartment)

46
Q

What causes bilateral GP mycosis?

A

–Aspergillus sp.

–Just because mycotic lesion in one GP, always evaluate the other pouch! Typically one or the other but can rarely be both – but always check!

47
Q

What are the clinical signs of GP mycosis? (2)

A

–Epistaxis

• usually 1-3 mild episodes before fatal exsanguination

–Neurological dysfunction – mycotic plague is causing tissue destruction, and internal carotid artery is close to 9, 10 and 12 CNs, so will also see:

•facial nerve, laryngeal or pharyngeal paralysis, vagal signs

–Rarely extension to other regions

–cranium, middle ear, atlanto-occipital joint

–CNS Signs

48
Q

How do you diagnose GP mycosis? (2)

A

•Endoscopy

–haemorrhage from guttural pouch ostia

  • mycotic plaques, neuro lesions – DO NOT ENTER GUTTURAL POUCH – but no other way of making diagnosis? So do need to go in!! But probably something that is best managed at a referral hospital – let someone else take the risk of going into the GP!!!
  • Radiography
49
Q

What do you do if you get a GP mycosis? (2)

A

–Emergency due to potential for fatal haemorrhage –REFERAL

–(Temporary cut down and occlusion of carotid can be used as in severe haemorrhage)

•Can occlude and ligate this… wont stop horse was from dying necessarily, as due to the circle of willis – can get retrograde bleeding – need to occlude the blood vessel on BOTH sides of the mycotic lesion

Note: Topical treatment alone (without surgery) carries high risk of haemorrhage

50
Q

How is GP myscosis treated? (2)

A

•Optimal treatment - surgical

–Ligation and balloon occlusion of affected artery

–Retrograde flow occurs therefore balloon occlusion recommended

•Ligation of external and internal carotid can cause blindness

–Need to be careful about doing this!

51
Q

How can we assess acute blood loss? (3)

A

–Loss of RBC, WBC, Protein & Volume

•No change in PCV or TP in first 4 hours – just removed blood in entirety, so PCV will be the same! As horse responds to this acute blood loss, will get changes occurring as followed:

–Splenic contraction in response to hypoxia

•Increase in PCV

–As body responds, get fluid recruited from Extracellular fluid

•Decline in TP – possible decline in PCV 4-6h

Cause initial reduction in TP, but as horse starts taking in water, recruitment of ECF, get decrease in PCV as well

52
Q

How long does it take for a PCV change?

A

12-24 hours

53
Q

How do we assess regenerative anaemia? (3)

A

–Immature red blood cells released into circulation

  • Reticulocytes
  • Larger than mature cells

–Increase in mean cell size (MCV)

–Decrease in mean corpuscular Hb concentration (MCHC)

54
Q

What is seen in non regenerative anaemia? (5)

A
  • Reduction in PCV and Hb and RBCs
  • With no change in MCV, MCHC
55
Q

Why is it hard to determine anaemia cause in horses?

A

Horse s- do not release immature RBC

56
Q

How do you differentiate regenerative anaemia?

A

•Bone marrow aspirate / biopsy to determine regenerative/non-regenerative anaemia

–Determination of MYELOID cells

–Determination of ERYTHROID cells

–Normal M:E 0.5 – 1.5 :1

–Regenerative anaemia <0.5:1

–Jam shidi needle = hollow needle, 12G, firm with hollow trocar down the middle, drive this up into centre of sternum, attach syringe and take a sample of fluid

Equine Final Year (102 decks)

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