Train images of head Flashcards
diagnosis
Fig 14: A straight lateral view radiograph showing a well-delineated sinus cyst (arrow)
dorsal to tooth 209, with secondary soft tissue radiopacity in the rostral nasal cavity. There
is an abnormality of the dental structures around teeth 08 and 09, possibly displacement
or a supernumerary tooth, but this is not clear because of superimposition of the left and
right cheek teeth rows. Oblique radiographs would show this more clearly. (Picture: Marco
Mora)
treatment
Frontonasal bone flap for removal of the cyst linning
Fig 18: a) Horse showing a large exostosis of the nasofrontal suture
line. The nasolacrimal suture line is not affected and so epiphora is
not present. b) Characteristic radiographic appearance of a
frontonasal suturitis.
Fig 2: A latero 30° dorsal-lateroventral oblique radiograph
showing periapical infection of cheek tooth 107. There
are small radiolucent periapical halos around the roots
(particularly noticeable at the caudolateral root [red
arrow]) surrounded by a radiopaque zone of bony sclerosis
(green arrows)
Fig 3: A latero 20° dorsal–lateroventral oblique view radiograph showing dental sinusitis
caused by infection of tooth 209. This tooth is short, with loss of definition of individual
root structures and there is generalised soft-tissue opacity of the rostral maxillary
sinus. A drawing pin has been placed to plan a suitable trephination site for the rostral
maxillary sinus. Note there is rostrocaudal angulation present in this radiograph which is
undesirable
Fig 4: A latero 35° ventral-laterodorsal oblique view radiograph showing periapical
infection of tooth 407 in a young horse. A blunt metallic probe (arrow) has been placed into
a cutaneous draining tract which communicates with the caudal root of the tooth
Fig 6: A transverse plane CT image of a horse with primary
sinusitis. There is a fluid line within the rostral maxillary
sinus (red arrow) and also fluid filling the ventral conchal
sinus. Thickening of the sinus mucosa within adjacent
sinuses is indicated by the green arrows
Fig 5: A latero 45° ventral-laterodorsal oblique view radiograph showing periapical
infection of tooth 308, with radiopaque bone sclerosis and bony proliferation around the
roots, causing a ventrally domed appearance of the mandibular cortex underneath (arrow)
Fig 8: An open-mouthed oblique (15o) view radiograph of the maxillary cheek teeth
showing configuration of a fracture of the erupted crown of tooth 108 (arrow)
Fig 9: A latero 30° dorsal-lateroventral oblique view radiograph of a Welsh pony with
dysplastic teeth 109, 110 and 111
Fig 6: This 2-year-old trotting horse presented with a firm
mandibular swelling with overlying soft tissue swelling (arrows).
Radiography showed the presence of a mandibular cyst and
absence of the (permanent) 307 and 308 cheek teeth (Image
courtesy of Tibor Sahin-Toth).
Fig 10: A latero 20° dorsal-lateroventral oblique view radiograph showing a fluid line
(green arrows) running through the dorsal conchal and caudal maxillary sinuses
Fig 12: A latero 30° dorsal-lateroventral oblique view
radiograph showing gross thickening of the ventral
conchal bulla (arrows). There is also a fluid line within this
sinus compartment
Fig 11: A straight lateral view radiograph showing multiple fluid lines (arrows) in the right
caudal maxillary and rostral maxillary sinuses
Fig 13: A dorsoventral radiograph of the skull showing
fluid opacity within, and mild distension of, the ventral
conchal sinus (blue arrows)
Fig 14: A straight lateral view radiograph showing a well-delineated sinus cyst (arrow)
dorsal to tooth 209, with secondary soft tissue radiopacity in the rostral nasal cavity. There
is an abnormality of the dental structures around teeth 08 and 09, possibly displacement
or a supernumerary tooth, but this is not clear because of superimposition of the left and
right cheek teeth rows. Oblique radiographs would show this more clearly. (Picture: Marco
Mora)
Fig 15: A latero 30° dorsal-lateroventral oblique view radiograph showing an ethmoidal
haematoma (green arrows) within the frontal sinus, emanating from the dorsal aspect of
the ethmoturbinates (red arrow)
Is the radiographic projection in Fig a
straight lateral or a lateral oblique?
Straight lateral.
Can you see any radiographic changes indicative of sinusitis
and, if so, which sinus compartment(s) is/are affected?
Fluid lines in the caudal maxillary sinus and rostral maxillary sinus
(Fig a, red arrows).
In the dorsoventral view (Fig b), which sinus compartment
is highlighted? Can you see any changes indicative of
sinusitis and, if so, which compartment(s) is/are affected?
Ventral conchal sinus. Abnormal soft tissue opacity and distension
of the ventral conchal sinus (Fig b, red arrows). Increased radioopacity
in the rostral (green arrow) and caudal (blue arrow)
maxillary sinuses is also evident.
After having a thorough inspection of these three
radiographs, what do you think is the cause of this sinusitis? What treatment is indicated for this case
taking into account the changes seen?
Primary sinusitis. There is no obvious mass within the sinuses, nor
any changes to the dental apices. As long as purulent material within the sinuses is liquid and not
inspissated (can be confirmed using sinoscopy), first line treatment
would consist of antibiotic and anti-inflammatory therapy plus
trephination and lavage of all the sinus compartments via a frontal
trephine site, including fenestration of the ventral conchal bulla.
The apices of which cheek teeth lie in the rostral
maxillary sinus and caudal maxillary sinus?
08 and 09 usually lie within the rostral maxillary sinus; 10 and 11 lie
within the caudal maxillary sinus.
Should you use a higher or lower exposure when
viewing the cheek teeth as compared to the sinuses?Higher exposure for cheek teeth.
Higher exposure for cheek teeth.
What four specific radiographic signs have
been found to be most reliable for the diagnosis
of cheek tooth apical infection?
Periapical sclerosis; periapical halo; clubbing of one or two roots;
severity of clubbing.
Which radiographic views may be useful when
investigating the severity of periodontal disease?
Open-mouthed oblique views and intra-oral views.
What radiographic changes can be seen in
very long-standing dental infections affecting
the rostral 2 to 3 maxillary cheek teeth?
Periapical halo and sclerosis, cutaneous draining tracts, clubbing
of roots, cementoma formation, dystrophic mineralisation of the
nasal conchae.
FIGURE 1 | Transverse CT images of normal NCBs and of various types of NCB empyema. (A) Normal NCBs. (A–C) are at the level of the Triadan 08 maxillary cheek teeth,
FIGURE 1 | Transverse CT images of normal NCBs and of various types of NCB empyema. ( (B) Mixed hyper- and hypoattenuation within a
distended VCB, representing mineralisation and gas, respectively, within soft tissue attenuating material (arrow). There is compression and severe damage of the
ipsilateral DCB (arrowhead) (mineralised nasal conchae found on histology—disorder of 10 years clinical duration). (A–C) are at the level of the Triadan 08 maxillary cheek teeth,
FIGURE 1 | Transverse CT images of normal NCBs and of various types of NCB empyema. ( (C) Soft tissue/fluid attenuating material fills most of
VCB (arrow) and the ventral aspect of DCB (arrowhead). (A–C) are at the level of the Triadan 08 maxillary cheek teeth,
FIGURE 1 | Transverse CT images of normal NCBs and of various types of NCB empyema. (D,F) at the level of the Triadan 07s
FIGURE 1 | Transverse CT images of normal NCBs and of various types of NCB empyema. E) The
DCB is partially filled with material of mixed soft tissue and gas attenuation, reflecting inspissated purulent exudate (arrow). There is moderate damage of the ipsilateral
VCB (arrowhead) and ipsilateral sinus empyema (asterisk). (E) is level with the distal (caudal) aspect of Triadan 08s.
FIGURE 1 | Transverse CT images of normal NCBs and of various types of NCB empyema. (F) The VCB is distended with homogenous soft tissue/fluid attenuating material (arrow). All CT images were
reconstructed using using a bone filter (Window Level 800 HU, Window Width 2,800 HU). The right side of the patient is on the left side of the image. The transverse
images ((D,F) at the level of the Triadan 07s
FIGURE 2 | (A) Right parasagittal CT reconstruction with lines representing the locations of images (B–D). (B) Transverse CT image. (C,D) Dorsal CT reconstruction at
the level of the DCB and VCB, respectively, the rostral aspect is toward the bottom of the image. There is empyema of the VCB (arrow) with ipsilateral sinusitis of the
rostral (arrowhead) and caudal (x) paranasal sinus compartments. There is thickening of the mucosa of the rostral aspect of the right DCB (asterisk). All CT images are
displayed using a bone filter (Window Level 800 HU, Window Width 2,800 HU). The right side of the patient is on the left side of the image.
FIGURE 2 | (A) Right parasagittal CT reconstruction with lines representing the locations of images (B–D). (B) Transverse CT image. (C,D) Dorsal CT reconstruction at
the level of the DCB and VCB, respectively, the rostral aspect is toward the bottom of the image. There is empyema of the VCB (arrow) with ipsilateral sinusitis of the
rostral (arrowhead) and caudal (x) paranasal sinus compartments. There is thickening of the mucosa of the rostral aspect of the right DCB (asterisk). All CT images are
displayed using a bone filter (Window Level 800 HU, Window Width 2,800 HU). The right side of the patient is on the left side of the image.
FIGURE 3 | (A,B) Transverse CT images of two cases with moderate to severe damage of ipsilateral DCBs and VCBs (arrows) with distortion of the adjacent nasal
concha. (B–D) at the level of
the Triadan 08s and
(D) There is loss of the left VCB
(arrow) with flattening and irregular thickening of the surrounding ventral nasal concha.
(E) There is loss of the left VCB (arrow) with distortion and atrophy of the lateral
aspect of the surrounding ventral concha. The walls of the ipsilateral DCB is hyper-attenuated and has a scalloped appearance (arrowhead).
(F) There is loss of the
DCB (arrow) and distortion and thickening of the adjacent concha and loss of identifiable structure in the VCB (arrowhead). There is soft tissue/fluid attenuation filling
the left rostral maxillary sinus consistent with ipsilateral sinusitis (asterisk). All CT images are displayed using a bone filter (Window Level 800 HU, Window Width 2,800
HU). The right side of the patient is on the left side of the image. Transverse images (A,E) are at the level of the Triadan 07 maxillary cheek teeth
FIGURE 3 | (A,B) Transverse CT images of two cases with moderate to severe damage of ipsilateral DCBs and VCBs (arrows) with distortion of the adjacent nasal
concha.
C) The left DCB is not present (arrow) and there is contraction and thickening of the remaining adjacent nasal concha. (D) There is loss of the left VCB
(arrow) with flattening and irregular thickening of the surrounding ventral nasal concha.
FIGURE 7 | Transverse CT image of a horse suffering from right-sided sinus
disease showing empyema of the right RMS (asterisk). The contralateral DCB
contains soft tissue/fluid attenuating material indicative of empyema
(arrowhead). All CT images are displayed using a bone filter (Window Level
800 HU, Window Width 2,800 HU). The right side of the patient is on the left
side of the image
FIG. 1. Axial CT image at the level of M1 (109, 209) in a 4.6.year-old
standard-bred mare. The maxillary cheek teeth appear normal; the peri.
odontium and the alveola are narrow; the nasal and paranasal sinuses are
symmetrically shaped, normal air-filled, and show no thickening of the
respiratory epithelium. The nasolacrimal duct and the infraorbital canal are
in place. The maxillary bone forming the facial crest is smooth.
FIG. 2. Close-up axial CT image of the left M1 of the horse from Fig. 1.
The normal structure of a maxillary cheek tooth with hyperattenuating
enamel surrounded by slightly less opaque dentin and less opaque cementum
is visible. The normal infundibulum is filled with cementum. The
normal Pulp appears hypodense; the Pulp canal is opaque near the occlusal
surface because of dentine filling. The normal sinus lining is not visible.
FIG. 3. Close-up axial CT image of the left M1 (209) in a 10.4-year-old
warmblooded colt. There is gas within the cementless infundibulum and a
fragmented medial tooth root within an enlarged root area. The hyperattenuated
pulp indicates chronic infection. The hypoattenuated enamel folds
are suspected of being the infection pathway of the pulp. The respiratory
epithelium of the rostral maxillary sinus is severely thickened.
FIG. 4. Axial CT image at the level of MI (109, 209) in a 3.4-year-old
warmblooded colt (also compare Figs. 5, 6); There is a severe tooth root
granuloma of the left MI (209), hypoattenuation within the root area, and
fragmentation of the roots. The lesion spread into the rostra1 maxillary
sinus with excessively thickened lining and suspected inspissated material
infiltrated with gas. The nasal septum is deviated, and the opaque conchofrontal
sinus is compressed. The maxillary bone is deformed and partly
sclerotic, partly diminished; the face is swollen.
possible diagnosis
Fig 1: A 20-year-old mare a) and 16-year-old gelding b) at first presentation. The facial swelling (red ellipse) of the mare clinically seems to be more severe than the
gelding’s; however, CT revealed that the internal changes caused by both cysts were similar (Fig 2a, b). Both horses suffer from epiphora (red arrows) on the diseased side. Other causes: periosteal suturitis, progressive ethmoid haematoma, sinosnasal neoplasia, supranumeray tooth
b) CT head image of 16-year-old gelding (Fig 1b) at level
of 111. Changes include: the whole left sinuses appear to be filled with soft
tissue (white circle); distortion of the left orbit (white arrow); lacrimal and
infraorbital canal cannot be identified; left lateral maxillary bone surface appears
to be disrupted (white arrow); nasal septum slightly deviated (white arrow)
Fig 2: a) CT image of the skull of a 20-year-old mare (Fig 1a) at level of 111.
Changes include: the right sinuses appear to be filled with soft tissue (white
circle); the infraorbital and lacrimal canals cannot be identified; septum deviation
to the left side (white arrow); distortion of the orbit (white arrow); apex of 111 is
flattened (white arrow).
Fig 4: Follow-up radiographs with contrast medium of a 16-year-old Warmblood
gelding, 1 year after PSC surgery; white ellipses: contrast medium visible in the
rostral part of the channel and medial ocular angle (lacrimal puncta); white
dashed ellipse: former cyst area; contrast medium was administered through the
nasal orifice of the nasolacrimal duct and both lacrimal puncta.
Fig 5: Radiographic (45°) example for late sequelae in a 17-year-old Warmblood
mare with structural changes of cheek tooth 109 within the cyst area
FIGURE 2 Standard trephine approaches used in the study.
(A) Conchofrontal trephination to access conchofrontal sinus (CFS)
(blue) and ventral conchal sinus (lavender); (B) caudal maxillary
trephination to access caudal maxillary sinus (CMS) (yellow);
(C) rostral maxillary trephination to access rostral maxillary sinus
(RMS) (brown) and (D) nasomaxillary bone trephination to access
dorsal conchal bulla (DCB) (purple) and ventral conchal bulla
(VCB) (pink).
F I G U R E 1 (A-D) Comparison of mineralisation pattern between two groups. A,B, Reformatted parasagittal plane CT image of two
horses showing varying degree and pattern of the paranasal sinus cyst wall mineralisation. A, Extensive spiculated paranasal sinus cyst
wall mineralisation (arrows) in the conchofrontal, caudal maxillary sinus and sphenoid sinuses; kernel H70a, WL 829 HU, WW 3429 HU. B,
Peripheral, focal and linear paranasal sinus cyst wall mineralisation (arrows) in the rostral maxillary sinus; WL 868 HU, WW 3932 HU, kernel
H70a
C, amorphous/swirling internal mineralisation (arrows) of the mass in the caudal maxillary sinus extending from the pituitary fossa
mass (meningioma), WL 596HU, WW 2051HU, kernel H40fa. D, internal mineralisations (arrows) in the rostral maxillary sinus progressive
ethmoid haematoma; WL 891HU, WW 4243HU, kernel H70a
F I G U R E 4 A, Transverse plane image
in a horse with a left maxillary paranasal
sinus cyst showing a grossly malformed
tooth 209, interpreted as compound
odontoma; WL 1040 HU, WW 4185 HU,
kernel H70a. B, Transverse plane image
obtained rostrally to the area presented
in A, showing a denticle displaced beyond
the dental arcade (white arrow); WL 1040
HU, WW 4185 HU, kernel H70a. C, Part of
the mass focally extending from the cyst
wall lined by palisading epithelium with
cytoplasmic clearing at the basilar pole
consistent with odontogenic epithelium
(arrow) (Haematoxylin and Eosin stain,
100×). D, Part of the mass extending from
the cyst wall showing mineralised dentin
(black arrow) lined by odontoblast-like
cells (Haematoxylin and Eosin stain, 100×)
F I G U R E 5 Computed tomography images of dental lesions in a
horse with a paranasal sinus cyst. A, Transverse plane image showing
buccal fracture of tooth 109 and gas in the pulp cavity (white
arrow), clubbing of the buccal root (white arrowhead) and periapical
deposition of cementum (black asterisk); WL1077 HU, WW 3518 HU,
kernel H70a. B, Reformatted sagittal plane image of the same region
as (A) showing a mineralised cystic wall (white arrow) seen instead
of normal maxilla and a periapical deposition of cementum (black
asterisk); WL 1008 HU, WW 3107 HU, kernel H70a
F I G U R E 6 (A,B) Images showing the internal gas within the
lumen of the paranasal sinus cyst of the same horse, WL 80 HU,
WW 351 HU, kernel B40fa. A, Gas-fluid line in the cyst occupying
caudal maxillary sinus. Note the subtle hyperattenuation of the
periphery of the paranasal sinus cyst — presumed cystic wall (black
arrows). B, Gas bubbles seen within the caudal maxillary sinus
extending through the trepination site (white arrow)
name the procedure
Dorsolateral (right) to ventrolateral (left) dacrocystorhinogram with antegrade and retrograde iohexol contrast.
describe the image findings
FIGURE 1 Foal 1. A, Dorsolateral (right) to ventrolateral (left) dacrocystorhinogram with antegrade and retrograde iohexol contrast.
The nasolacrimal duct was patent within the rostral third (arrowhead), but contrast pooling in the caudal maxillary sinus provided evidence
of traumatic disruption of the canal and duct (arrow). B, Transverse computed tomographic image at the level of the erupting first molar.
The circle denotes guidewire placement through the inferior punctum of the nasolacrimal duct with incongruity of the osseous portion of
the duct (arrows) on the affected side
description of the first left image
FIGURE 3 Foal 2. A, Transverse CT image at the level of the fourth premolar. A large fragment was displaced axially and ventrally
(arrow). The circles indicate the infraorbital canal, which is displaced axially on the right. B, Transverse CT image through center of the
orbit. C, Three-dimensional reconstruction of fractures. The facial bones involved in the fracture are labeled: f, frontal; n, nasal; m,
maxillary; l, lacrimal; z, zygomatic. The blue shaded fragment was retained in saline soaked gauze prior to fracture fixation. The red shaded
fragment had periosteal attachments on its caudal border and was able to be elevated but maintained in situ. CT, computed tomography
what is going on?
Fig 1: Size 24 endotracheal tube in Case 1 exiting the right nostril and secured in place with elastic tape 24 h post-surgery. placement of an endotracheal
tube (ETT) with an air-inflated cuff within surgically created sinonasal windows as a technique of post-operative haemostasis. A frontonasal bone flap and a sinonasal window were performed routinely in three standing horses with paranasal sinus disease
Figure 1. Chronic draining tract at the ventromedial aspect of the left
mandible.
diagnosis
Figure 2. Open pulp horns were identified on the occlusal surface
over pulp horns 1 (A) and 3 (B) of the left mandibular first molar (309).
Figure 3. Open-mouth right ventral to left dorsal lateral oblique view
(Rt45V-LeDO) of the left mandibular cheek teeth. A radiopaque
probed was inserted in the draining mandibular fistula to confirm
communication with tooth 309. Radiographic changes present in
tooth 309: periodontal ligament widening and osteosclerosis along the
mesial reserve crown root and the mesial aspect of the distal dilacerated
root. Radiolucent area present within the pulp horns and pulp
chamber of the reserve crown just coronal to the furcation and was
associated with a mesial bulge of the reserve crown. Periapical alveolar
bone lysis present along the mesial root tip.
what could be the surgical options?
- Oral tooth extraction but in miniatures migth be difficult specially in mandibular
- Partial coronectomy and tooth extraction but it failed as you can see in image
- Lateral alveolar ostectomy (case report Journal of veterinary dentistery) as in cows (be careful with facial artery, vein nerve, parotid duct
what is being performed VS 2016
Conclusion: This report describes a simple technique for canaliculosinostomy into
the caudal maxillary sinus and long-term outcome in 4 of 5 horses, all of which had
resolution of epiphora.
diagnosis
F I G U R E 2 Left, Horse with a localised rostral maxillary swelling (arrow) caused by a 209 apical infection and dental sinusitis. Middle,
transverse computed tomography (CT) image showing gross maxillary bone osteitis and soft tissue swelling (arrow), distension of the
rostral maxillary sinus (RMS) (star) and empyema of the ventral conchal sinus. Right, slightly more caudal CT image showing similar features
including infraorbital canal osteitis and enlargement. The RMS (star) and dorsal conchal sinus (DCS) contain inspissated exudate [Colour
diangnosis and tx
Mycotic sinusitis of the caudal maxillary sinus (a) treated with topical application of clotrimazole (can be enilconazole) under sinoscopic control (with a catheter through the channel of the endoscope) (b). in EVE Pujol suspected primary mycotic rhinitis and paranasal sinusitis in seven horses
na,e tje bone window in this CT
Fig 1: Transverse computed tomographic images at the level of the second maxillary cheek teeth (07s) (a,b) using bone (a) and soft tissue (b) windows.
horse with parotid carcinoma, describe the lesions
Fig 11: Comparison of transverse T2-weighted (T2W) (a) and T1-weighted (T1W) (b) magnetic resonance and bone (c) and soft tissue
(d) windows computed tomographic (c,d) images of a grey horse. There is a parotid carcinoma that caused severe lysis of the
temporal bone (arrowheads), bone destruction is better evaluated with CT, however soft tissue involvement is better seen with MRI.
Multiple melanomas (arrows) are also identified; they are hypointense on T2W and hyperintense on T1W magnetic resonance images
and show high attenuation values on computed tomography images.
Fig 12: Transverse T1-weighted post-contrast magnetic
resonance (a) and computed tomographic (b) images at the
level of the internal acoustic meatus (asterisks) of two different
horses with otitis externa (white arrows) and media (arrowheads).
The right facial nerve on image a shows mild diffuse contrast
enhancement (black arrow), consistent with facial neuritis.
