The equine paranasal sinuses Part 4

Justin Perkins BVetMed MS Cert ES (ST) DipECVS, MRCVS

LECTURER IN EQUINE SURGERY, ROYAL VETERINARY COLLEGE, HAWKSHEAD LANE, NORTH MYMMS, HATFIELD,
HERTFORDSHIRE. AL9 7TA
Safia Barakzai BVSc Cert ES (ST) MRCVS
LECTURER IN EQUINE SOFT TISSUE SURGERY, ROYAL (DICK) SCHOOL OF VETERINARY STUDIES, UNIVERSITY OF
EDINBURGH, EASTER BUSH, ROSLIN, MIDLOTHIAN. EH25 9RG

UK VET - VOLUME 10 No 5 JUNE 2005

The anatomy and diagnosis of disorders of the paranasal
sinuses has been discussed in previous articles (UK Vet Vol
9 No 8 and Vol 10 Nos 1 and 2). This final article in the
series discusses the treatment, prognosis and potential
complications of paranasal sinus disorders.
PRIMARY SINUSITIS
Primary sinusitis results from bacterial infection (usually
streptococcal) of the upper respiratory tract. Treatment of
primary sinusitis is initially aimed at increasing mucociliary
clearance from the sinuses. Medical treatments include
antibiotics, mucolytics, feeding the horse from the floor
and light exercise. Horses that do not respond to medical
treatment can undergo trephination of the frontal or
maxillary bone (see UK Vet Vol 10 No 2), placement of a
Foley catheter and lavage of the sinuses (Figs. 1 and 2).
Physiologic saline is a suitable lavage solution. If povidine
iodine is used in the lavage fluid it needs to be very dilute
(0.01% or a weak tea colour) because higher
concentrations irritate the sinus mucosa. Sterile lavage
fluids are generally not required and addition of antibiotics
to the lavage solution is usually unnecessary. An isotonic
saline solution can be made simply by adding 30 mls
(measured by volume) of sodium chloride to 4 L of tap
water. Most horses will tolerate lavage unsedated. A
pressurized garden spray is useful for administering large
volumes quickly and easily. Four litres twice daily is usually
sufficient for lavage of the paranasal sinuses. If the sinusitis
involves the rostral maxillary (RMS) or ventral conchal
sinus (VCS) in addition to the other sinuses (as determined
by radiography) then a RMS trephine or breaking down
the ventral conchal bulla is required for efficient lavage (see
UK Vet Vol 10 No 2).The prognosis for primary sinusitis is
excellent. Horses refractory to lavage are usually affected
by secondary sinus disorders, or may have inspissation of
purulent material within a sinus compartment.
T H E P RO G N O S I S
F O R P R I M A RY
SINUSITIS IS
EXCELLENT

Fig. 2: The sinuses of a horse being flushed

postoperatively using a large volume of very dilute
povidine iodine administered using a pressurised
garden spray.

Inspissated pus in the Ventral Conchal Sinus

Inspissated pus is a manifestation of chronic primary
sinusitis resulting in the accumulation of pus that
aggregates into a ‘cottage cheese’ consistency. It is more
common in the VCS but can be seen in any of the sinuses.

UK VET - Online
Fig. 1: A 22F Foley catheter inserted into the www.ukvet.co.uk
caudal maxillary sinus for lavage of the sinuses after
sinus flap surgery has been performed.

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 Treatment involves surgical removal of the pus (Fig. 3).This
is most commonly performed through a frontonasal flap
(see Surgical approaches to the paranasal sinuses). Creation
of a sino-nasal fistula is usually unnecessary.The prognosis
for cases with inspissated pus in their paranasal sinuses is
good after surgical treatment.
FMA
VCB
P the costs and risks of general anaesthesia. Serious
Rostral
Fig. 3: Following a left frontonasal flap in a standing
horse, the bulla of the ventral conchal sinus (VCB)
has been partially broken down, exposing
inspissated pus (P) within the ventral conchal sinus.
FMA frontal maxillary aperture.
SECONDARY SINUSITIS
Sinusitis commonly occurs secondary to periapical infection
of one of the caudal 4 maxillary cheek teeth. Bacterial
sinusitis also occurs secondary to facial fracture or necrosis of
tissue/reduced sino-nasal drainage caused by an expanding
mass within the sinuses, such as a sinus cyst, neoplasm,
osteoma, or progressive ethmoidal hematoma (PEH).
Dental sinusitis
Periapical dental infections can be primary or secondary.
The cause of primary periapical dental infections is
unclear, but vertical impaction and anachoresis (blood or
lymphatic borne bacterial infection), occlusal exposure of
pulp and infundibular caries (infundibular cemental caries)
have all been suggested. Most cases involve a single tooth,
and the upper 09s (4th maxillary cheek teeth) are most
frequently involved in cases of primary dental sinusitis.
Secondary periapical dental infections may occur after
deep periodontal infection (often associated with
diastemata or displacement of cheek teeth), dental caries or
dental fracture with pulpar exposure.
The apices of the caudal 4 maxillary cheek teeth are
contained within the rostral and caudal maxillary sinuses.
Periapical dental disease involving these cheek teeth
usually results in communication with the paranasal sinuses
and associated secondary sinusitis. Long term antibiotic
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therapy (2-3 months) can be attempted and is occasionally
successful in early cases. Removal of the tooth is required
in most cases. Three methods of tooth removal are
available: oral extraction, cheek tooth repulsion or lateral
buccotomy. Endodontic therapy has been attempted but is
difficult to perform in equine cheek teeth and presently
has a high complication and failure rate.
The authors believe that oral extraction (Fig. 4) should
always be attempted prior to repulsion as the complication
rates following oral extraction (approximately 4%) are
much less than for repulsion. Oral extraction can usually be
performed in the standing sedated horse, thus eliminating
complications of maxillary dental repulsion are common
and result in up to 60% of horses requiring further surgery.
The most common post-operative complications of cheek
tooth repulsion are sequestration of alveolar bone, damage
to a second cheek tooth, chronic sinusitis and chronic
draining tracts. Lateral buccotomy requires general
anaesthesia and access to the caudal cheek teeth can be
difficult using this technique.Additionally, there is a risk of
damaging branches of the facial nerve during this surgery.
Fig. 4: Molar extractors have been applied to a
maxillary cheek tooth for oral extraction, and the
periodontal ligament is being slowly broken down
using small lateral movements of the extractors.
Progressive Ethmoid Haematoma (PEH)
The aetiology of PEHs is unknown but they are slowly
expanding, non-neoplastic haemangiomatous masses that
originate in the submucosa of the ethmoid labyrinth.
PEHs can expand into the nasal passages, paranasal sinuses,
or nasopharynx causing destruction of adjacent tissue. A
PEH can be ablated transendoscopically using a laser with
the horse conscious and standing, but laser therapy usually
requires multiple treatments, and the cost of equipment
limits its availability. PEHs are most commonly treated by
transendoscopic injection of an aqueous solution of 4%
formaldehyde into the lesion until they distend and begin
to leak formaldehyde solution through their capsule
(Fig. 5). Treatment is repeated at 3- to 4-week intervals
until the lesion is eliminated or reduced in size such that
it is no longer accessible for injection. In rare cases
where the PEH has penetrated the cribiform plate,
injection of formaldehyde solution can result in death of
the horse. Surgical ablation is usually reserved for large
PEH (Fig. 6) that have not responded to other
treatments, because severe haemorrhage occurs
commonly during the surgery. Haemorrhage is reduced
when the surgery is performed in standing horses
compared to those under general anaesthesia.
Fig. 5: Transendoscopic injection of a progressive
ethmoid haematoma with 4% formaldehyde.
Fig. 6: A large progressive ethmoid haematoma
(arrows) within the frontal sinus, exposed via a
frontonasal flap, in a standing horse. Photograph
courtesy of Jim Schumacher.
Regardless of the method of treatment, the prognosis for
long-term complete cure is guarded. However, with
intermittent treatment, most horses with PEHs can be
managed successfully. Even when the condition appears to
have been resolved, horses should periodically be re-
examined endoscopically to determine if the lesion has
regrown.
Sinus cysts
The aetiology of sinus cysts is uncertain, but they are
expansive fluid-filled space-occupying lesions which are
lined by a layer of secretory, respiratory-type,
pseudostratified epithelium, with plates or spicules of bone
also frequently present in the capsule. Sinus cysts are
usually found in the maxillary sinuses, and as they expand,
can destroy the architecture of the sinuses. Treatment
involves surgical removal of the cyst, via a sinus osteotomy
(Fig. 7). The prognosis after surgical intervention is good.
Removal of the entire cyst is not essential for success.
Internal distortion of the nasal cavity usually resolves once
the cyst is successful removed.
THE MOST
COMMON
NEOPLASM OF
T H E PA R A N A S A L
SINUSES OF
HORSES IS A
CARCINOMA
Fig. 7: A sinus cyst being removed through a
frontonasal flap in a standing horse. The cyst
typically contains a clear, vivid yellow fluid.
Neoplasia
Although rare, most neoplasms of the paranasal sinuses of
horses are malignant. The most common neoplasm of the
paranasal sinuses of horses is a carcinoma. Carcinomas tend
to be locally invasive (Fig. 8) and may metastasise, making
complete surgical removal difficult. Treatment of horses
Fig. 8: Transverse section of the skull of a horse with
squamous cell carcinoma within the right maxillary sinuses
which has eroded the maxillary bone. These tumours
commonly originate from the squamous epithelium of the
hard palate, and are locally invasive and quite destructive.
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 with neoplasia of the paranasal sinuses is usually only
palliative because the success rate of treatment is poor.
Surgical debulking alone of the tumour (Fig. 9) rarely
extends life for longer than a year. Radiotherapy is likely to
be unsuccessful if the neoplasm has invaded bone. The
usual treatment of horses affected with neoplasia of the
paranasal sinuses is euthanasia.

Fig. 9: Surgical excision of a large adenocarcinoma within

the frontal and caudal maxillary sinuses. Clinical signs
returned within a year and the horse was euthanased.

Osteomas are not actually neoplasms but are thought to be

hamartomas that arise from the periosteum of the skull or
facial bones. They are composed of dense, but normal,
bone, and they do not undergo malignant transformation.
Osteomas may grow slowly for months and then remain
quiescent for years. They may be an incidental finding
during radiographic examination of the skull. Surgical
removal via a frontonasal flap is required if the osteoma is
large enough to produce clinical disease. Following
complete removal, osteomas do not recur.

SURGICAL APPROACHES TO THE PARANASAL SINUSES

There are two common approaches to the paranasal sinuses
in horses, a frontonasal flap or a maxillary flap. With the
exception of repulsion of maxillary cheek teeth, most sinus
surgery can be performed in standing sedated horses.
Performing paranasal sinus surgery in the standing horse
eliminates the risks of general anaesthesia, reduces the
expense and causes less haemorrhage when compared to
horses which are anaesthetised and placed in lateral
recumbency.

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