OLEH:
UNIVERSITAS UDAYANA
DENPASAR
2019
RINGKASAN
ii
SUMMARY
iii
KATA PENGANTAR
Puji syukur penulis panjatkan kepada Tuhan Yang Maha Esa karena atas
berkat dan rahmat-Nya lah penulis dapat menyelesaikan makalah ini tepat waktu
dengan judul “Teknik Operasi Trepanasio“. Makalah ini dibuat guna memenuhi
tugas mata kuliah Ilmu Bedah Khusus Veteriner Fakultas Kedokteran Hewan,
Universitas Udayana yang akan dijadikan sebagai landasan dalam penilaian
softskill pada proses pembelajaran.
Tidak lupa penulis ucapkan terima kasih kepada dosen pengampu mata kuliah
Ilmu Bedah Khusus Veteriner untuk segala bimbingan dan dukungannya serta
kepada segala pihak yang turut dalam membantu pembuatan makalah ini sehingga
makalah ini dapat selesai tepat pada waktunya.
Penulis menyadari bahwa makalah ini masih banyak kekurangan baik dari
segi materi, ilustrasi, contoh, maupun sistematika penulisan. Oleh karena itu,
penulis mengharapkan saran dan kritik dari para pembaca yang bersifat
membangun demi kesempurnaan dari makalah ini. Penulis berharap makalah ini
dapat bermanfaat bagi pembaca pada umumnya terutama bagi dunia kedokteran
hewan di Indonesia.
Penulis
iv
DAFTAR ISI
RINGKASAN/SUMMARY ................................................................................. ii
v
BAB V SIMPULAN DAN SARAN ................................................................... 15
LAMPIRAN ...................................................................................................... 18
vi
DAFTAR GAMBAR
Gambar 10. Penjahitan lubang trepanasi dan pemasang kateter Foley ................. 12
vii
DAFTAR LAMPIRAN
viii
BAB I
PENDAHULUAN
Tulang kepala memiliki rongga yang sempit yang hanya cukup ditempati oleh
otak dan cairan peredam otak (cairan cerebrospinal), maka dari itu bila terjadi
pembengkakan akibat cedera kepala dapat menyebabkan peningkatan tekanan
dalam rongga kepala. Jika hal ini terus dibiarkan, maka akan menekan batang otak
sehingga fungsi-fungsi vital dalam tubuh seperti fungsi pernafasan, sirkulasi dan
kesadaran akan terganggu yang dapat menyebabkan kematian.
1
1.2 Rumusan Masalah
2
BAB II
3
BAB III
TINJAUAN PUSTAKA
a
b
.
Gambar 1. Alat Trepan (a) Michele Trepan (b) Galt Trepan (Schleining, 2016).
Trepanasi dapat dilakukan menggunakan alat trepan Galt atau trepan Michele.
Keuntungan dari trepan Galt adalah menghasilkan portal akses yang lebih besar ke
daerah sinus (Schleining, 2016).
Akses ke sinus dilakukan dengan teknik trepaning, pertama dengan bor,
membuat pembukaan tengkorak kecil, kemudian diperkuat oleh gerakan rotasi
dengan trepan melingkar 20 mm. Lokasi trepanasi yang dipilih didasarkan pada
anatomi spesies dan difasilitasi oleh visualisasi tulang yang bertujuan untuk
evaluasi bilateral sinus frontal, maxilla dan palatina (Basso et al., 2016)
Trepanasi tidak hanya untuk membuka suatu rongga yang dibatasi oleh
tulang, melainkan dapat juga untuk trepanasi jaringan lemak di bawah kulit,
4
misalnya pada kulit kelopak mata bawah dengan tujuan operasi pengobatan
entropion dan ectropion (Sudisma et al., 2006).
5
BAB IV
PEMBAHASAN
Apabila yang sakit sebelah kiri maka hewan dibaringkan ke sebelah kanan
atau dibaringkan ke bagian yang sehat. Selanjutnya rambut di tempat operasi
dibersihkan, didesinfeksi dan dianestesi lokal. Bila diperlukan dapat juga
dilakukan dengan anestesi umum (Sudisma et al.,, 2006).
Untuk standing surgery pada kuda, pasien harus berada dalam kandang jepit
serta direstrain menggunakan halter. Halter harus digunakan untuk menahan
kepala agar meminimalkan pergerakan selama prosedur pembedahan. Kulit di
bagian yang akan dilakukan trepanasio dijepit bagian pinggirnya minimal 2 cm
dari bagian yang akan dilakukan teknik trepanasio. Kemudian dilakukan scrub
atau didesinfeksi menggunakan chlorhexidine diikuti dengan alkohol. Pastikan
tidak menyentuh mata karena dapat menyebabkan keratitis kimiawi yang parah.
Kemudian diberikan premedikasi kombinasi α2-agonis (romifidine atau
detomidine) ditambah butorphanol dan diberikan NSAID (seperti flunixin atau
phenylbuatzone) secara rutin (Barakzai dan Dixon, 2014). Kemudian anastesi
secara subkutan 1-2 mL larutan anastesi lokal (misalnya, 2% lidokain atau
mepivacaine) (Schleining, 2016).
6
4.2 Teknik Operasi Trepanasio
Portal sinus frontal dapat digunakan untuk memeriksa lesi pada frontal,
conchal dorsal, maksilla kaudal, dan pintu masuk ke sinus etmoidal dan
sinusopalatin. Situs untuk portal ini diposisikan 0,5 cm kaudal dari garis
antara canthi medial kiri dan kanan, dan setengah jalan antara garis tengah
dan canthus medial ipsilateral. Portal ini sangat berguna untuk kuda muda
yang gigi pipinya menempati sebagian besar sinus maksilaris. Ini juga
menyediakan akses ke rostral maxillary sinus (RMS) dan VCS jika ventral
conchal bulla difenestrasi di bawah bimbingan endoskopi.
Sinus maksilaris rostral (RMS) dan kaudal kuda muda (usia 6 tahun)
tidak boleh ditrepanasi secara rutin, karena berisiko merusak mahkota
cadangan gigi pipi. Jika trephinasi sinus maksilaris rostral harus dilakukan
pada kuda muda, panduan radiografi untuk memposisikan portal sangat
disarankan. Situs trepanasi RMS yang paling tepat pada dewasa kuda ialah
diposisikan 40% dari jarak antara ujung rostral krista facialis dan canthus
medial mata, dan 1 cm ventral dari garis yang menggabungkan foramen
infraorbital dan canthus medial. Portal sinus maksilaris kaudal (CMS)
7
merupakan lokasi yang berperan dalam sinoskopi CMS, sphenopalatine, dan
sinus conchofrontal. Situs ini diposisikan 2 cm rostral dan 2 cm ventral dari
canthus medial mata.
Gambar 3. Situs trepanasi sinus maksilaris rostral (RMS) dan sinus maksilaris
kaudal (CMS) (Barakzai dan Dixon, 2014).
Gambar 4. Situs trepanasi sinus (1) sinus maksilaris rostral (RMS), (2) sinus
maksilaris kaudal (CMS), dan (5) sinus frontalis (Tremaine dan Freeman, 2007).
8
4. Skalpel digunakan untuk membuat insisi tusukan menembus kulit dan
tulang (Woody, 2011). Sebuah sayatan linier 1,5 hingga 2,5 cm dibuat
di kulit dan periosteum di bawahnya, ukuran sayatan tergantung pada
ukuran trephine yang digunakan.
5. Melalui sayatan ini, tulang ditrepanasi menggunakan bor berdiameter
1,0 hingga 1,5 cm atau trephine Galt.
9
dibiarkan di situ, sayatan mungkin tertutup seperti semula (Woody,
2011).
Gambar 6. (a) Trepanasi sinus frontal sedang dilakukan menggunakan bor (b)
Sinoskopi sinus frontal (Barakzai dan Dixon, 2014).
10
Gambar 7. Pembuatan sayatan pada kulit dan periosteum (Tremaine dan
Freeman, 2007).
11
Gambar 9. Eksudat mengalir melalui lubang trepanasi (Tremaine dan Freeman,
2007).
4. Lipatan kulit dan periosteum digunakan untuk menutupi lubang yang ada
di os frontal. Dengan menggunakan jahitan terputus (seperti ditunjukkan
oleh tanda panah). Telah dilakukan juga trepanasi maksila
memungkinkan irigasi post-pembedahan untuk sinus maxillaris melalui
kateter Foley.
Gambar 10. Penjahitan lubang trepanasi dan pemasang kateter Foley (Tremaine
dan Freeman, 2007).
12
4.3 Perawatan Pasca Operasi Trepanasio
13
Gambar 11. Irigasi sinus pasca operasi trepanasi sinus menggunakan larutan
saline (Barakzai dan Dixon, 2014).
14
BAB V
5.1 Simpulan
5.2 Saran
15
digunakan untuk membersihkan sinus. Larutan yang mengandung sabun tidak
boleh digunakan untuk irigasi sinus.
16
DAFTAR PUSTAKA
Barakzai, S. Z., dan Padraic M. Dixon. 2014. Standing Equine Sinus Surgery.
Veterinary Clinics of North America: Equine Practice. Vol. 30(1) : 45–62.
Schleining, Jennifer A. 2016. Surgery of The Sinuses and Eyes. Veterinary Clinics
of North America : Food Animal Practice. Vol. 32 : 571-591.
Woodie, J. Brett. 2011. Diagnostic and Therapeutic Procedures for the Upper
Respiratory Tract. American Association of Equine Practitioners
Proceedings. Vol. 57 : 5-7.
17
LAMPIRAN
18
Ciência Rural, Santa Maria, v.46, n.7,Comparison
p.1262-1267, jul, 2016
between http://dx.doi.org/10.1590/0103-8478cr20141478
three techniques for videosinuscopy in cattle. 1262
ISSN 1678-4596 CLINIC AND SURGERY
I
Programa de Residência Multiprofissional em Saúde, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brasil.
II
Programa de Pós-graduação em Ciências Veterinárias, Universidade Federal do Paraná (UFPR), 80035-050, Curitiba, PR, Brasil. E-mail:
rogerioguedes@veterinario.med.br. Corresponding author.
III
Departamento de Medicina Veterinária, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brasil.
Received 10.06.14 Approved 01.15.16 Returned by the author 04.08.16
CR-2014-1478.R3 Ciência Rural, v.46, n.7, jul, 2016.
1263 Basso et al.
large, and enable communication with the palatine MATERIALS AND METHODS
sinuses. They must be accessed via the hard palate,
making the surgical approach quite difficult (SISSON Eight cattle heads were used, obtained from
& GROSSMAN, 1998). commercial slaughterhouses in Curitiba and nearby
Among the pathologies of the sinuses, cities. The heads were received skinless, dehorned
an inflammatory process called sinusitis stands and partially stripped. The access to the sinuses was
out. In cattle, the leading cause of frontal sinusitis carried out by a trepanning technique, first with a
is associated with dehorning, as about 2% of drill, making a small skull opening, then amplified by
surgically dehorned animals develop this disease rotational moves with a 20mm circular trephine. The
(FIORAVANTI et al., 1999; SILVA et al., 2008). It chosen sites for trepanation were based on the species
can also be associated with respiratory infections, anatomy and facilitated by bone visualization, aiming
trepanations or fractures with frontal sinus for a bilateral evaluation of the frontal, maxillary and
exposure, cysts or nasal cancer (SMITH, 2006). palatine sinuses. The access holes for the maxillary
Surgery by unqualified surgeons, the presence of sinuses were located 3.7±0.9cm rostral to the eyeball
foreign bodies and improper postoperative therapy and 2.1±0.3cm dorsal to the facial crest (Figure 1A).
are also important etiologic factors in this species The access holes for the frontal sinuses were located
(FIORAVANTI et al., 1996). 4.9±1.6cm rostral to the nuchal ridge and 2.8±0.5cm
The diagnosis of sinusitis in cattle is lateral to the midline (Figure 2A).
based on history and clinical examination findings The equipment used for cavity inspection
(DIRKSEN et al., 1993). In several species, in addition included a flexible colonoscope with a diameter of
to a general clinical examination, some diagnostic 10mm and angles up to 180° (Karl Storz, Germany), a
methods can be used such as regional radiographs, 10mm and 0° laparoscope (Karl Storz, Germany), and
sinucentesis, surgical exploration (sinusotomy), a 4mm and 30° arthroscope (Karl Storz, Germany);
tomography and sinuscopy; the latter is performed all were coupled to a laparoscopic unit composed by
with rigid or flexible endoscopes (ALLISON, 1999; a LED monitor, a microcam and a xenon light source
EMSHOFF et al., 1999; SMITH, 2006). (Telepack®, Karl Storz, Germany). The sinuses were
Sinuscopy has been performed in humans inspected with the three endoscopes, trying to identify
(BERTRAND & ROBILLARD, 1985; PETRUSON,
2004), horses (PERKINS et al., 2009a) and dogs
(JOHNSON, 2006), due to its practicality and lower
postoperative morbidity compared to conventional
exploration techniques (SILVA et al., 2009). In
horses, sinuscopy is widely used to properly inspect
the sinuses as well to collect samples and perform
biopsies on those sites. In this procedure, the animal
can be kept sedated in the quadrupedal position; sinus
access occurs through trepanation, which allows for
the introduction of endoscopes (PERKINS et al.,
2009a; O’LEARY & DIXON, 2011). Until now, there
have been no studies regarding sinuscopy in cattle,
in terms of systematically describing the endoscopic
anatomy of the region, the access portals and the most
appropriate type of lens.
This study aimed to compare the
effectiveness of three different endoscopes in
sinuscopic evaluation of the maxillary, palatine
and frontal sinuses of cattle in a postmortem study.
The experiment also aimed to standardize the Figure 1 - Illustration of the sinuses in a bovine head in a left
minimally invasive surgical access for sinuscopy in lateral view. A: access hole to the maxillary sinus;
B: caudal and caudo-dorsomedial areas from
this species and to improve anatomical knowledge maxillary sinus; C: maxilo-palatine opening; D:
with an emphasis on the endoscopic anatomy of dental alveoli. Adapted from BUDRAS & HABEL,
those regions. 2003.
Figure 3 - Explored anatomical areas identified during the video sinuscopy in cattle. A: dental alveolus; B:
maxilo-palatine opening; C: tortuosity from frontal sinus; D: maxillary sinus, caudo-dorsomedial
portion; E: palatine sinus; F: maxillary sinus, caudal portion; G: maxillary sinus, rostral portion; H:
palatine sinus.
paranasal sinuses are associated with dehorning, (Figure 3E; Figure 3H) could not be accessed in all
and therefore good visualization of the frontal sinus heads. The most effective endoscopic access to the
would be interesting (SILVA et al., 2008). palatine sinus was achieved with the arthroscope,
The caudal area of the maxillary sinuses which attained a 93.75% viewing rate, with only
achieved excellent viewing with all endoscopes one not evaluated due a narrower maxillopalatine
used (Figure 1B; Figure 3F). The caudodorsomedial opening than the others. The other endoscopes
portion of the same area (Figure 1B; Figure 3D) had showed poor efficiency to this area, with a viewing
slightly limited inspection when the laparoscope was rate of 25% with the colonoscope and a 6.25% with
used, because it was ineffective in three of the 16 the laparoscope. The rostral region of the maxillary
views. The dental alveoli (Figure 1D; Figure 3A) sinus (Figure 3G) was inspected with 100% efficiency
and the maxillopalatine opening (Figure 1C; Figure when using the arthroscope and 87.5% efficiency
3C) were readily observed with all three endoscopes with the colonoscope; however, this viewing area
(viewing rate of 100%); however, the palatine sinus was not accessible with the laparoscope.
Table 1 - View capacity (percentage and total number of animals) of the anatomical regions from paranasal sinuses in the evaluated cattle
heads during the video-endoscopy techniques (n=16).
Viewed area Rigid optic 4mm e 30° Flexible optic 10mm e 180° Rigid optic 10mm e 0°
Frontal sinus (rostral portion) 0% (0)a 0% (0)a 0% (0)a
Frontal sinus (caudal portion) 87.5% (14)a 62.5% (10)ab 43.8% (7)b
Nuchal diverticulum 81.3% (13)a 12.5% (2)b 0% (0)b
Eyeball (caudal portion) 56.3% (9)a 25% (4)ab 0% (0)b
Maxilar sinus (rostral portion) 100% (16)a 87.5% (14)a 0% (0)b
Maxilar sinus (caudal portion) 100% (16)a 100% (16)a 100% (16)a
Maxilar sinus (caudo-dorsomedial portion) 100% (16)a 100% (16)a 81.3% (13)a
Palatine sinus 93.8% (15)a 25% (4)b 6.3% (1)b
Maxilo-palatine opening 100% (16)a 100% (16)a 100% (16)a
Dental alveoli 100% (16)a 100% (16)a 100% (16)a
ab
Values with different superscripts in the same row are statistically different according to the Kruskal-Wallis test (P<0.05), followed by the
Dunn`s multiple comparison test (P<0.05), using the software Graphpad Prism, V5.
MACHADO, T.S.L.; SILVA, L.C.L.C. Rigid and flexible endoscope Reconstructive Surgery and Hand Surgery, v.38, n.2, p.86-93,
in sinoscopy and triangulation technique in equine paranasal sinus. 2004. Available from: <http://informahealthcare.com/doi/abs/1
Ciência Rural, v.43, n.12, p.2254-2260, 2013. Available from: 0.1080/0284431031002324909>. Accessed: Mar. 25, 2014. doi:
<http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103- 10.1080/02844310310023909.
84782013001200022&lng=pt&nrm=iso&tlng=en>. Accessed: Mar.
25, 2014. doi: 10.1590/S0103-7 84782013001200022. SISSON, S.; GROSSMAN, J.D. Anatomia de los animales
domesticos. 5.ed. Barcelona: Salvat, 1998. 2v.
O´LEARY, J.M.; DIXON, P.M. A review of equine paranasal
sinusites. A etiopathogenesis, clinical signs and ancilliary SMITH, B.P. Doenças do Sistema Respiratório. In: _____.
diagnostic techniques. Equine Veterinary Education, v.23, n.3, Medicina interna de grandes animais. Barueri: Manole, 2006.
p.148-159, 2011. Available from: <http://onlinelibrary.wiley.com/ p.479-592.
doi/10.1111/j.20423292.201110.00176.x/abstract>. Accessed: Jun.
15, 2014. doi: 10.1111/j.2042-3292.2010.00176.x. SILVA, L.A.F. et al. Estudo retrospectivo sobre fatores de risco
e avaliação de quatro protocolos terapêuticos para sinusite em
PERKINS, J.D. et al. Comparison of sinoscopic techniques for um rebanho de 2491 bovinos (1998-2008). In: CONGRESSO
examining the rostral maxillary and ventral conchal sinuses of horses. BRASILEIRO DE MEDICINA VETERINÁRIA, 2008, Gramado,
Veterinary Surgery, v.38, p.607-612, 2009a. Available from: <http:// Rio Grande do Sul. Anais... Gramado: CONBRAVET, 2008.
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ract;jsessionid=379F60710F8DC5BEA35E910997B08097.f03t02>. anais/cd/resumos/R1028-10 3.pdf>. Accessed: Jun. 15, 2014.
Accessed: Mar. 25, 2014. doi: 16 10.1111/j.1532-950X.2009.00555.x.
SILVA, L.C.L.C. et al. Bilateral sinus cysts in a filly treated by
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ventral conchal sinusitis in 60 horses. Veterinary Surgery, v.38, p. Journal, v.50, p.417-420, 2009.
613-619, 2009b. Available from: <http://onlinelibrary.wiley.com/
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EC4FB8464AA7D961EB29B35177B1.f03t02>. Accessed: Mar. a flexible endoscope: diagnosis and treatment of sinus disease in the
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KEYWORDS
Horse Sinusitis Surgery Osteotomy Trephination
KEY POINTS
Trephination of the equine sinuses is a common surgical procedure in sedated standing
horses.
Standing sinus flap surgery has become increasingly popular and offers several advan-
tages over sinusotomy performed under general anesthesia, including reduced patient-
associated risks and costs and less intraoperative hemorrhage.
Other minimally invasive surgical procedures for managing equine sinusitis include
sinoscopic surgery, balloon sinuplasty, and transnasal laser sinonasal fenestration.
Regardless of the procedure used, appropriate indications for surgery, good patient se-
lection, and familiarity with regional anatomy and surgical techniques are imperative to ob-
taining good results.
Standing sinus surgery is indicated in the horse to treat primary or secondary sinusitis
(Tables 1 and 2). Sinus surgery is also performed for diagnostic reasons, such as to
facilitate sinoscopy (direct sinus endoscopy), allow endoscopic-guided biopsy, or to
collect samples of the sinus contents for bacterial or fungal culture or histology. Stand-
ing sinus surgeries can be divided into sinus trephination procedures and sinus flap
surgery (osteoplastic flaps). Before performing either procedure, one must complete
a detailed case investigation to confirm the presence of sinusitis, collect as much
information as possible regarding the likely cause of the condition, determine which
sinus compartments are involved, and establish the positioning of the most appro-
priate surgical site. Indications for sinus surgery are therefore based on the results
of clinical examination, nasal endoscopy, skull radiography, and a detailed intraoral
examination. If available, adjunctive advanced imaging techniques such as
Table 1
Indications and contraindications for sinus trephination and standing sinus flap surgery
Indications Contraindications
Sinus trephination 1. Sinoscopy 1. Bone opacity mass immediately
2. Placement of a lavage tube beneath the proposed trephine
3. Endoscopic fenestration of the site
ventral conchal bulla10,16
4. Sinoscopically guided sinus
surgery (eg, for mass biopsy,
removal of inspissated pus,
conchal bone sequestrae, small
sinus cysts, fungal plaques,
formalin injection, or removal
of small intrasinus progressive
ethmoidal hematoma)
Standing sinus 1. Primary sinusitis unresponsive to 1. Unsuitable patient tempera-
flap surgery or recurrent after conservative ment, particularly if sinonasal
management (antibiotics, sinus fenestration is likely to be
trephination, and lavage) required
2. Intrasinus mass diagnosed 2. Bone opacity intrasinus masses
preoperatively (eg, sinus cyst, detected radiographically (eg,
ethmoidal hematoma, odontogenic tumors, osteoma);
neoplasm) these are likely to require
3. Inspissated pus present within aggressive sectioning using
the sinus (diagnosed with chisels or bone saws to enable
radiography and/or sinoscopy); their removal, and this is often
cases can sometimes be not well tolerated in sedated
treated sinoscopically using horses
transendoscopic biopsy forceps 3. Extraction of cheek teeth
or wire retrieval baskets through repulsion, unless oral
4. Sinonasal fistulation, occasionally extraction has already been
indicated in cases of chronic attempted with significant
sinusitis with obstruction of the breakdown of the periodontal
nasomaxillary ostium; however, ligament; repulsion of firmly
effective removal of the primary attached teeth is not tolerated
lesion from all compartments in the standing horse and
will usually reduce mucosal should not be attempted
inflammation in these cases and
allow normal drainage within a
few days postoperatively (see
section on minimally invasive
techniques)
5. Depressed maxillary or frontal
bone fractures, which require
elevation and fixation or small
fragments that need to be
removed
Table 2
Comparisons between sinus flap surgery performed standing or under general anesthesia
disorders of the nasal cavity and guttural pouches, or lower respiratory tract infection/
inflammation, which can occasionally present as a unilateral nasal discharge.
A diagnosis of sinusitis is confirmed by recognition of mucopurulent or purulent ma-
terial or blood emanating from the sinonasal ostium (sinus drainage angle), which is
situated at the caudal aspect of the middle meatus. Because of the narrow, compli-
cated drainage pathway of the ventral conchal sinus (VCS), swelling of the ventral
nasal concha caused by accumulation of exudate within the VCS is common, and
often causes narrowing of the common and middle meati (Fig. 1). If severe, distension
of the VCS may also narrow the ventral meatus, and occasionally can completely
occlude the ipsilateral nasal cavity and displace the nasal septum toward the contra-
lateral side. These horses will often have respiratory stridor at rest or exercise, and
careful assessment of nasal airflow may detect a reduction or absence of expired
air from the affected nostril. Remodeling of the nasal conchae is also common in hors-
es with sinusitis (Fig. 2), and should not be confused with primary nasal lesions.
All horses with suspected sinusitis should undergo careful endoscopic examination
of the middle meatus on the affected side, because some horses with sinus disease,
including more than 20% with chronic primary sinusitis, will have a fistula from the
middle meatus into their VCS (see Fig. 2; Fig. 3) and less commonly into their dorsal
conchal sinus (DCS).1 If present, a small-diameter endoscope can often be passed
through this fistula into the VCS, and occasionally inspissated material or conchal
sequestrae can be removed from this compartment, thus allowing the sinusitis to be
treated endoscopically. Additionally, some horses have pieces of necrotic ventral
conchal bone (Fig. 4) lodged in the caudal aspect of the middle meatus, often sur-
rounded by inspissated pus (which can be the cause of the persistent unilateral nasal
discharge), and this material can usually be removed transendoscopically. Horses that
have previously undergone sinus surgery with sinonasal fenestration to improve sinus
drainage will have a surgically created fistula.
48 Barakzai & Dixon
Fig. 1. Complete obstruction of the middle nasal meatus in a horse with sinusitis.
Radiography
Radiography is a well-established method of investigating sinus and dental disorders
in the horse. However, the complex 3-dimensional structure of the head means that
interpretation of radiographs in this region can be difficult in some cases. A minimum
of 3 radiographic views should be taken of horses with sinusitis: lateral, lateral oblique
(to examine individual cheek apices), and a dorsoventral view, the latter is taken spe-
cifically to establish if there is VCS involvement.2
Radiographs should be examined for the presence of abnormalities, such as
fluid lines, intrasinus soft tissue opacity, periapical dental infection, intrasinus
neoplasia, skull trauma, and distention of the VCS. Radiographs should also be
Fig. 2. Chronic destruction and remodeling of the dorsal concha in a horse with chronic
sinusitis. Note the large naturally occuring sinonasal fistula (arrows).
Standing Equine Sinus Surgery 49
Fig. 3. Naturally occurring sinonasal fistula into the VCS in a horse with chronic sinusitis.
used to determine which sinus compartments are affected. The use of digital and
computed radiography has increased in equine practice over the past few years
and has helped provide higher-quality images, increasing the sensitivity and speci-
ficity of sinus radiography.
Computed Tomography
Cross-sectional imaging methods such as CT (Figs. 5 and 6) and MRI are extremely
useful for evaluating the complex 3-dimensional structures of the equine head. The
availability of CT facilities that can image the head of standing horses is increasing
fast, making CT accessible to a larger number of horses. The advantages of CT
over conventional radiography in horses with sinusitis include accurate identification
of the sinus compartments involved, more precise identification of dental infection,3
Fig. 4. Bone sequestrum in the caudal aspect of middle meatus, causing chronic clinical
signs.
50 Barakzai & Dixon
Fig. 6. Transverse CT image of a horse with dental sinusitis. Image shows a lateral “slab”
fracture of 209 (yellow arrow), gas attenuation within the common pulp chamber, and
gas around a lateral root of this tooth (white arrow), which confirms the diagnosis of apical
infection. Disruption of the dental alveolus is also present, and soft tissue attenuating ma-
terial fills the rostral maxillary and ventral conchal sinuses. The dorsal nasal concha is also
filled with soft tissue–attenuating material and there is soft tissue swelling overlying the
maxillary bone.
Standing Equine Sinus Surgery 51
more information about the nature of sinus contents, and accurate identification
of other sinonasal abnormalities that are not visible on radiographs (eg, mucosal thick-
ening, conchal necrosis, remodeling).3–5 In almost all cases, CT scans provide
additional information that is not provided by radiography and, in the authors’ experi-
ence, this extra information influences the subsequent treatment in most cases.
Oral Examination
The importance of a thorough oral examination in cases of sinusitis cannot be empha-
sized strongly enough. At least 41% of cheek teeth with periapical infections are now
known to have occlusal pulpar exposure6; therefore, finding pulpar exposure in a sus-
pect tooth on oral examination may help greatly in definitively diagnosing dental sinus-
itis. The teeth should be examined (preferably in the sedated horse) with a full mouth
speculum in place, a strong headlamp, dental mirror or oral endoscope, and a dental
pick, which is used to probe the pulp cavities. The most obvious clinical sign to note is
packing of the pulp cavity with food material (Fig. 7). The dental pick should not
normally be able to enter the occlusal aspect of the pulp cavity, which should be filled
with secondary dentine. However, negative findings on oral examination do not
preclude the presence of apical infection, and occasionally pulpar exposure is found
in horses (particularly in older horses) without clinical signs of periapical infection.
In older horses with sinusitis, the junction of the hard palate and the maxillary cheek
teeth should be carefully inspected for the presence of red, proliferative soft tissue that
resembles granulation tissue. If present, this will usually be a squamous cell carcinoma
that may invade the nasal cavity or sinuses after neoplastic squames migrate from
their origin in the oral cavity up the periodontal spaces into the sinuses (Fig. 8). Biopsy
results of this abnormal oral tissue in combination with radiography will allow a defin-
itive diagnosis, and help avoid more-invasive sinus surgery.
PREOPERATIVE PREPARATION
Performing endoscopy and radiography should provide the clinician with a good
idea of the horse’s temperament and suitability for standing sinus surgery. Horses
should be restrained in stocks for standing sinus surgery, and heavily sedated with
Fig. 7. (A) A dental probe is used to check for pulpar exposure. This 106 has multiple
exposed pulps into which the probe tip can be passed. (B) Extracted maxillary cheek tooth
with pulpar exposure of all 5 pulp horns (red arrows). Both infundibulae (yellow arrows)
also have occlusal cemental defects, as is present in 90% of all cheek teeth.
52 Barakzai & Dixon
Fig. 8. (A) The oral cavity of a horse that presented with left-sided nasal discharge. The
large, pink soft tissue mass lying palatally and buccally to the caudal cheek teeth is a squa-
mous cell carcinoma that has invaded the overlying paranasal sinuses. (B) A transverse sec-
tion of the affected horse after euthanasia. This image shows very extensive invasion of the
sinonasal region by this aggressive oral tumor.
Fig. 9. Horse sedated and prepared for standing sinus surgery, restrained in stocks and head
resting on a dental headstand.
Standing Equine Sinus Surgery 53
nerve block7,8 can also be useful for anesthetizing the sinus and nasal mucosa. Addi-
tionally, if fenestration into the nasal cavity is anticipated, endoscopically guided
topical anesthesia of the nasal mucosa preoperatively greatly increases patient
compliance when fenestrating and packing the nasal cavity. Once any degree of
hemorrhage into the nasal cavity occurs, topically anesthetizing the nasal mucosa be-
comes very difficult.
If both nasal cavities are significantly obstructed (usually because of a unilateral
lesion that is pushing the nasal septum across to the contralateral side), placing a
nasopharyngeal tube via the contralateral nasal cavity is useful to maintain a patent
airway during surgery and in the immediate postoperative period. In cases with severe
bilateral nasal obstruction, a temporary tracheostomy tube may be required.
SURGICAL TECHNIQUES
Sinus trephination is a technique that can be easily performed by most equine prac-
titioners in the standing sedated patient. In contrast, sinus flap surgery is a procedure
that requires detailed anatomic knowledge and may be accompanied by complica-
tions such as significant intraoperative hemorrhage, damage to normal cheek teeth
alveoli or the infraorbital canal, postoperative wound infection, and recurrence of clin-
ical signs. The presence of sinus distension and mucosal inflammation frequently dis-
torts the normal sinus anatomy, making intraoperative decision making challenging.
For these reasons, sinus flap surgery should only be performed by veterinary surgeons
with training in and experience with the technique.
SINUS TREPHINATION
Trephination Sites
The frontal sinus portal is often the most useful, and can be used for examining lesions
in the frontal, dorsal conchal, caudal maxillary, and entrance to the ethmoidal and
sphenopalatine sinuses. The site for this portal is positioned 0.5 cm caudal to a line
drawn between the left and right medial canthi, and halfway between the midline
and the ipsilateral medial canthus (see Fig. 8). This portal is particularly useful in young
horses whose cheek teeth occupy much of the maxillary sinuses. It also provides
access to the rostral maxillary sinus (RMS) and VCS if the ventral conchal bulla is
fenestrated under endoscopic guidance.
The rostral and caudal maxillary sinuses of young horses (6 years of age) should
not be trephined routinely, because trephination risks damaging the reserve crowns
of the cheek teeth.9 Additionally, the long reserve crowns are located close to the
maxillary bone (the average distance from the maxilla to the lateral aspect of the cheek
teeth is 13 mm), which limits maneuverability of the endoscope within the sinus and
thus restricts visualization of the intrasinus structures. If trephination of the rostral
maxillary sinus must be performed in young horses, radiographic guidance for portal
positioning (lateral and dorsoventral views with markers in place) is strongly advised.
The caudal maxillary sinus (CMS) portal (for sinoscopy of the CMS, sphenopalatine,
and conchofrontal sinuses) is positioned 2 cm rostral and 2 cm ventral to the medial
canthus of the eye (Fig. 10).10 The most reliable RMS trephine site in mature horses is
positioned 40% of the distance between the rostral end of the facial crest and the medial
canthus of the eye, and 1 cm ventral to a line joining the infraorbital foramen and the
medial canthus (see Fig. 10).10 The trephination technique involves the following (Fig. 11):
1. The horse is sedated routinely using an a2-agonist plus butorphanol.
2. The skin at the trephination site is clipped and aseptically prepared.
54 Barakzai & Dixon
Fig. 10. (Left) Site for frontal sinus trephine portal. (Right) Sites for rostral (RMS) and caudal
(CMS) trephine portals. (From Barakzai S. Handbook of equine respiratory endoscopy. Edin-
burgh, UK: Elsevier; 2006; with permission.)
Fig. 11. (A) Frontal sinus trephination being performed with a modified drill bit (with T-bar
welded on). (B) Frontal sinoscopy being performed.
Standing Equine Sinus Surgery 55
Fig. 12. (A, B) Oscillating bone saw being used to create hinged bone flap in the maxillary bone.
56 Barakzai & Dixon
Fig. 13. (A, B) Frontal sinus osteotomy technique using a large Galt trephine. The disc of
bone is discarded. (Courtesy of G. Quinn, BVSc Cert ES, Dipl. ECVS, Hamilton, New Zealand.)
Fig. 14. Maxillary sinusotomy of chronic sinusitis case showing inspissated pus and seques-
trae of nasal bones in the CMS.
Standing Equine Sinus Surgery 57
Fig. 15. (A) Large sinus cyst and granulation tissue with mycotic infection (diagnosed on his-
topathology) being removed through a bilateral frontal flap. (B) Postoperative appearance.
nasal passage through a custom-built laser introducer rod and used to create a stoma
in the caudal, medial aspect of the turbinate overlying the dorsal conchal sinus.13 This
location in the nasal turbinates was chosen because it has the thinnest nasal mucosa,
and therefore presumably the least vascularity. Sinoscopy was then performed via the
new stoma to identify structures within the conchofrontal sinus and caudal maxillary
sinus. The procedure was performed first in cadavers and then in standing sedated
horses. In 4 of the 5 live horses, hemorrhage was reportedly minimal, and a stoma large
enough to pass an endoscope through (approximately 1 cm2) was successfully
created.13 Repeat endoscopy revealed that the stoma persisted for at least 5 weeks.
Four horses had adhesion formation between the stoma and the nasal septum. The au-
thors of this article13 recognized that a stoma in the dorsal conchal sinus may not be
optimal for sinus drainage because mucociliary clearance occurs toward the anatomic
nasomaxillary ostium and not toward the surgically created stoma. Application of the
technique in clinical cases and longer-term follow-up is necessary before final conclu-
sions of this technique’s efficacy can be made.
POSTOPERATIVE CARE
The sinus mucosa is extremely sensitive and only very dilute solutions of antiseptic, if
any, should be used to lavage the sinuses. Solutions containing soap (ie, surgical
scrubs) must not be used for sinus lavage. The primary purpose of sinus lavage is
to physically dislodge and dilute material in the sinus, rather than provide antibacterial
action. Lavage should therefore be performed 2 to 3 times daily with large volumes of
fluid (3–5 L) (Fig. 16). Options for sinus lavage solutions are shown in Table 3.
Fig. 16. Postoperative sinus lavage being performed using a large volume of nonsterile
saline.
this occurs, in most cases hemorrhage will be self-limiting. Elevating the head of the
sedated horse often helps reduce bleeding.
A degree of hemorrhage always occurs when sinus flap surgery is performed,
because the sinus mucosa is a vascular tissue. Hemorrhage will be particularly
copious if a surgical fenestration is made between the sinuses and the nasal cavity
(Fig. 17), because the nasal mucosa is highly vascular. Sinonasal fenestration is not
Table 3
Sinus lavage solutions
Fig. 17. Sinonasal fenestration using a stomach tube passed through the rostral aspect of
the VCS. Note the end of the tube coming out of the nostril. This sinonasal fenestration
technique causes minimal nasal hemorrhage, but the fistula tends to close within a month
or so after surgery.
indicated often in sinusitis cases, and the free flow of blood and lavage fluid down the
nasal cavity of horses undergoing sinusotomy will confirm this. We have experience of
using a bipolar vessel sealing device (Ligasure TM, Covidien, Dublin, Ireland) for
creating a bloodless sino-nasal fenestration in some standing surgery cases with
the instrument introduced via a naso-frontal flap, however the nasal and sinus mucosa
must be very well anaesthetised prior to instrument application. Hemorrhage associ-
ated with sinus surgery tends to be reduced in sedated standing horses compared
with anesthetized horses, because of the elevated head position of the standing horse.
Nonetheless, hemorrhage always occurs to some degree, and measures to control it
must be within easy reach during standing sinus flap surgery. These measures include
local application of pressure and packing the sinuses and nasal cavity with a long sterile
piece of cotton gauze (Fig. 18) or a sock-and-bandage pack. Use of topical adrenaline
is often not effective because of the amount of hemorrhage that quickly dilutes it and
carries it away from the area to which it was applied. Appropriate intravenous fluid ther-
apy, and facilities to collect and administer whole blood, should be available in case
they are required. The authors have had some success using chitosan-impregnated
bandages in cases in which controlling intraoperative hemorrhage was challenging.
Patient Noncompliance
Patient noncompliance is extremely rare for sinus trephination techniques, but is
observed more often during standing flap procedures, particularly during creation of
60 Barakzai & Dixon
Fig. 18. Long bandage packing passed via the maxillary flap, through a surgically created
sinonasal fistula, and out through the nostril. Note the horse had to be twitched for this
procedure.
the osteoplastic flap if chisels or a bone saw are used. Fenestration of the nasal
conchae and packing of the nasal cavity will cause resentment in most standing pa-
tients because the nasal aspect of the conchae is not only very vascular, but is well
innervated. Although sinonasal fenestration and packing are possible in the standing
sedated animal (see Fig. 18), horses with unreliable or fractious temperaments that are
anticipated to require sinonasal fenestration may be better subjected to general anes-
thesia in the first instance. When performing standing sinus flap surgery, resources
should be on-hand in case patient noncompliance results in a general anesthetic being
required to complete the procedure.
18% of cases, and a fair/poor result (mild or marked facial distortion) in 7% of cases.14
In comparison, use of a large Galt trephine to remove a disc of frontal bone has been
reported to result in excellent/very good surgical results in only 47% of cases (no
visible evidence, irregular hair growth associated with the incision site, or a very slight
concavity), a good result (mild to moderate asymmetry as a result of a slight prolifer-
ative frontonasal suture reaction or mild concavity at the surgical site) in 36%, and a
poor result (because of marked periostitis or concavity of the frontal bone) in
13%.11 Some surgeons also advocate application of a compression bandage placed
around the head in a figure-of-8 pattern postoperatively to improve the cosmetic
result; however, this has not been effective in the authors’ experience.
Recurrence of Sinusitis
Recurrence of sinusitis after trephination and lavage is usually attributable to an
ongoing underlying problem, such as failure to remove inspissated pus from some
compartment, the residual presence of an intrasinus mass, or an undetected infected
cheek tooth. The recurrence of clinical signs is an indication to refer the horse for
further diagnostics and sinus flap surgery, if appropriate.
Recurrence of clinical signs after sinus flap surgery is reported to occur in 13% to
28% of cases.11,14,15 These patients usually require some form of further investigation
and/or surgical intervention and are often good candidates for computed tomographic
examination if the cause of recurrence is not obvious.
REFERENCES
1. Dixon PM, Parkin TD, Collins N, et al. Equine paranasal sinus disease: a long-
term study of 200 cases (1997-2009): ancillary diagnostic findings and involve-
ment of the various sinus compartments. Equine Vet J 2012;44:267–71.
2. Barakzai SZ, McAllistair H. Radiography of the upper respiratory tract. In:
McGorum BJ, Robinson NE, Schumacher J, et al, editors. Equine respiratory
medicine and surgery. Edinburgh (United Kingdom): WB Saunders; 2006.
p. 151–74.
3. Henninger W, Frame EM, Willmann M, et al. CT features of alveolitis and sinusitis
in horses. Vet Radiol Ultrasound 2003;44:269–76.
4. Cissell DD, Wisner ER, Textor J, et al. Computed tomographic appearance of
equine sinonasal neoplasia. Vet Radiol Ultrasound 2012;53:245–51.
5. Textor JA, Puchalski SM, Affolter VK, et al. Results of computed tomography in
horses with ethmoid hematoma: 16 cases (1993–2005). J Am Vet Med Assoc
2012;240:1338–44.
6. Dacre I, Kempson S, Dixon PM. Pathological studies of cheek teeth apical in-
fections in the horse: 5. Aetiopathological findings in 57 apically infected maxil-
lary cheek teeth and histological and ultrastructural findings. Vet J 2008;178:
352–63.
7. Staszyk C, Bienert A, Bäumer W, et al. Simulation of local anaesthetic nerve block
of the infraorbital nerve within the pterygopalatine fossa: anatomical landmarks
defined by computed tomography. Res Vet Sci 2008;85:399–406.
8. Bardell D, Iff I, Mosing M. A cadaver study comparing two approaches to perform
a maxillary nerve block in the horse. Equine Vet J 2010;42:721–5.
9. Barakzai SZ, Knowles J, Kane-Smyth J, et al. Trephination of the equine rostral
maxillary sinus: efficacy and safety of two trephine sites. Vet Surg 2008;37:
278–82.
62 Barakzai & Dixon
10. Barakzai SZ. Sinoscopy. In: Handbook of equine respiratory endoscopy. Edin-
burgh (United Kingdom): Elsevier; 2006. p. 118–32.
11. Quinn GC, Kidd JA, Lane JG. Modified frontonasal sinus flap surgery in standing
horses: surgical findings and outcomes of 60 cases. Equine Vet J 2005;37:
138–42.
12. Bell C, Tatarniuk D, Carmalt J. Endoscope-guided balloon sinuplasty of the
equine nasomaxillary opening. Vet Surg 2009;38:791–7.
13. Morello SL, Parente EJ. Laser vaporization of the dorsal turbinate as an alterna-
tive method of accessing and evaluating the paranasal sinuses. Vet Surg 2010;
39:891–9.
14. Dixon PM, Parkin TD, Collins N, et al. Equine paranasal sinus disease: a long term
study of 200 cases (1997–2009): treatments and long-term result of treatments.
Equine Vet J 2012;44:272–6.
15. Tremaine WH, Dixon PM. A long-term study of 277 cases of equine sinonasal dis-
ease. Part 2: treatments and results of treatments. Equine Vet J 2001;33:283–9.
16. Perkins JD, Windley Z, Dixon PM, et al. Sinoscopic treatment of rostral maxillary
and ventral conchal sinusitis in 60 horses. Vet. Surg 2009;38:613–9.
S u r ge ry o f th e Si n u s es a nd
Eyes
Jennifer A. Schleining, DVM, MS
KEYWORDS
Sinusitis Sinusotomy Enucleation Ocular squamous cell carcinoma
Eye surgery
KEY POINTS
Sinus lavage for the treatment of frontal and maxillary sinusitis can be very effective and is
not difficult when the appropriate landmarks are identified.
Conditions of the eye and eyelids necessitating surgery are common.
When early intervention is performed, the outcome is generally favorable.
Temporary tarsorrhaphy can be an effective means of supporting eyelid laceration repair
and corneal preservation during periods of facial nerve paralysis.
Conditions of the head requiring surgery in cattle are not uncommon when considering
the incidence of conditions such as ocular squamous cell carcinoma and requests for
surgical dehorning. Surgery involving the eyes in cattle is relatively common, whereas
surgery of the paranasal sinuses is less common. Generally speaking, however, sur-
gery for conditions of the head tend to have a more favorable prognosis when there
is early intervention.
PARANASAL SINUSES
Cattle have 6 paranasal sinuses: the frontal, maxillary, palatine, lacrimal, sphenoid,
and conchal.1 Even though disease can affect any of these sinuses, practically and
clinically, only the frontal and the maxillary gain attention of the clinician. Similar to
the horse, the frontal sinus is very large. However, in cattle, the frontal sinus is sepa-
rated into multiple compartments with the caudal frontal sinus being the most expan-
sive, extending into the horn (if present) of mature animals. This extension is often
referred to as the cornual diverticulum. A second diverticulum is located behind the
orbit and is identified as the postorbital diverticulum.2 The further compartmentaliza-
tion of the caudal frontal sinus by irregular osseous and membranous partitions can
make successful treatment of purulent sinusitis a challenge due to the inability to thor-
oughly and completely lavage the sinus. The frontal sinus communicates with the
nasal passage via multiple fenestrations into the ethmoid meatuses.1 In longstanding
or chronic cases, effective lavage may be achieved only with a frontal sinus flap. Within
the maxillary sinus are contained the tooth roots of the upper premolar and molar
teeth. Hence, in immature animals, the sinus is relatively small, whereas in older cattle,
it becomes larger as the cheek teeth are extruded. The maxillary sinus communicates
with the nasal passage through the nasomaxillary opening. However, this communica-
tion lies high on the medial wall of the sinus allowing fluid to accumulate below this
opening in the rostral maxillary sinuses and palatine sinuses rather than draining out
the nasal passages.1
Fig. 1. A 5-year-old crossbred cow presented for unilateral nasal discharge and recent his-
tory of tipping the end of the horns.
Surgery of the Sinuses and Eyes 573
Fig. 2. Close up of the tip of the left horn showing communication of the horn with the
caudal frontal sinus.
Fig. 3. A rostrocaudal oblique view of the caudal frontal sinuses showing a fluid-filled left
frontal sinus. The metallic probe is placed into a draining tract communicating with the
sinus.
achieved resolution compared with only 3 in the 0.9% sodium chloride group indi-
cating povidone-iodine solution diluted to 5% resulted in a statistically better clinical
outcome than using saline alone.5 Chronic cases of sinusitis, however, usually require
more invasive approaches to the sinus, which could include trephination or osteotomy
(bone flap).
Maxillary sinusitis is uncommon and most commonly occurs secondary to an
infected or fractured tooth root. Clinical signs include facial deformation (Fig. 4),
Sinus Cyst
Cysts of the paranasal sinuses have been described in the literature. These include
maxillary sinus cyst, sinonasal cysts, and conchal cysts.6–8 Clinical signs include
mucopurulent nasal discharge, increased respiratory effort, or noise due to partial
or complete nasal obstruction, and/or facial deformity. Radiography will often iden-
tify a well-demarcated soft tissue opacity within the affected sinus with deviation of
normal structures. Computed tomography can be a very useful adjunct to radiog-
raphy when the full extent of the cyst is not able to be determined and/or to identify
multiple cysts. Additionally, endoscopy should be considered for masses that enter
the nasal passage. Treatment of sinus cysts will be predicated by the location of
the cyst, but can include removal via the nasal passage under endoscopic guid-
ance or via a maxillary or frontonasal bone flap technique. Complete removal of
the cyst lining appears to be curative in cattle. In a study of 10 cattle undergoing
surgical removal of paranasal and conchal sinus cysts, 9 returned to production
and had no recurrence.9 Not all well-demarcated soft tissue opacities in the sinuses
or nasal passages should be assumed to be sinonasal cysts, however. Neoplasia
can present very similarly and should be included in the differential list for paranasal
sinus disease (Fig. 6).
Fracture
Depression fracture of the frontal bone, nasal bone, and orbit can occur resulting
acutely in increased respiratory effort due to swelling, hemorrhagic nasal discharge
(Fig. 7), abnormal head carriage, and inappetance depending on the severity and
Fig. 5. Caudoventral radiograph of a bull with bilateral maxillary swelling diagnosed with A
lignieresii sinusitis. Note the severe bone destruction and remodeling.
576 Schleining
Fig. 6. Frontal plane computed tomography image at the level of the eyes in a 2-year-old
Angus cow with lymphosarcoma believed to have been a sinonasal cyst. Note the right
maxillary sinus is filled with fluid with a thick lining.
location of the fracture. The incidence of fracture is less than that reported in horses
likely because of differences in behavior and animal use.10 In cases of depression frac-
ture, surgical repair can be performed under general anesthesia using bone reduction
instruments or a 3.5-mm screw inserted proud into the fractured fragment to aid in
reducing the fragment back into alignment. Cerclage wire may or may not be
Fig. 7. An endoscopic image showing hemorrhage from the ethmoid meatus in a 5-year-old
Simmental bull with a frontal bone fracture.
Surgery of the Sinuses and Eyes 577
necessary to keep the fragment(s) in position. Orbital fractures can be repaired with
various orthopedic techniques including string-of-pearls plates, dynamic compres-
sion plates, or cerclage wire depending on the configuration of the fracture. Minor
closed fractures with minimal displacement may not require repair.
TREPHINATION
Preoperative Planning
Trephination can be completed using either a Galt or Michele trephine (Fig. 8). The
advantage of the Galt trephine is that it results in a larger access portal to the sinus.
The appropriate site should be chosen to best access the affected sinus (Fig. 9).
Box 1 lists the supplies needed for trephination of the paranasal sinuses.
Preparation and Patient Positioning
The patient should be restrained in a hydraulic chute or manual head catch. A halter
should be used to further restrain the head to minimize movement during the proce-
dure. The trephine site should be clipped allowing for at least 2-inch margins around
the proposed site of trephination. A rough preparation of the site should be conducted
with chlorhexidine scrub followed with alcohol. Ensure that these solutions do not con-
tact the eyes, as they will cause severe chemical keratitis. A large bleb of lidocaine
should be placed subcutaneously at the trephination site followed by a more thorough
cleansing of the site with scrub and alcohol.
Using a scalpel blade, a full-thickness circular area of skin should be removed corre-
sponding to the size of the trephine extending to the periosteum of the frontal or maxil-
lary bone. The trephine should then be used in a clockwise rotation to remove a
section of bone allowing access into the sinus. At this time, a sample of the fluid within
the sinus should be collected for culture and sensitivity. The sinus may now be lavaged
and/or investigated further using flexible endoscopy if necessary.
The trephine sites should be left open to heal by second intention. Covering the treph-
ination sites is recommended to keep debris and further contaminants from entering
Fig. 8. A Michele trephine on the left and a Galt trephine on the right.
578 Schleining
Fig. 9. The circles indicate the site(s) of trephination for each sinus, and shaded areas are the
frontal and maxillary sinuses. (From Gaughn EM, Provo-Klimek J, Ducharme NG. Surgery of
the bovine respiratory and cardiovascular systems. In: Fubini S, Ducharme N, editors. Farm
animal surgery. St Louis (MO): Saunders; 2004. p. 148; with permission.)
the sinus. A stent bandage using #2 polymerized caprolactam (Braunamid; Braun) (or
other nonabsorbable suture material) is easily made by placing 2 loose interrupted su-
tures through the skin perpendicular to the surgical site, one above and one below the
incision. A 12-inch segment of umbilical tape should be passed through each suture. A
roll of 4 4 gauze sponges or a 4-inch roll gauze can then be placed over the incision
and secured in place by the umbilical tape. The bandage may then be removed and
replaced for subsequent sinus lavage procedures or alternatively left in place until
the sinusotomy has been obscured by granulation tissue. Postoperative care
also should include the use of anti-inflammatory medications such as meloxicam
Box 1
Supplies needed for sinus trephination
(0.5–1.0 mg/kg by mouth once a day or every other day) or flunixin meglumine
(1.1–2.2 mg/kg intravenously (IV) as needed).
Using a scalpel blade, a 3-sided, rectangular incision should be made extending to the
bone and including the periosteum. The location for the incision should be as follows:
the caudal margin should be a line extending from midline to a point bisecting the su-
praorbital foramen and poll, the lateral margin should extend from the caudal margin to
the level of the center of the orbit approximately 3.5 to 4.0 cm medial to the medial
canthus of the eye taking care to avoid the supraorbital foramen, and the rostral
margin extends from midline to the rostral extent of the lateral margin. The periosteum
should be gently reflected with a blunt periosteal elevator along with the skin and sub-
cutaneous tissue. An oscillating bone saw or mallet and osteotome should then be
used to create osteotomy incisions following the margins of the skin incision. The
osteotomy incisions should be created at an approximately 45 oblique angle through
the bone (Fig. 10). The rostral and caudal incisions at midline should be notched to
facilitate “hinging” the flap axially. The flap may then be elevated and hinged.
Box 2
Supplies needed to perform an osteotomy
Fig. 10. Location for the skin and osteotomy incisions for a frontal sinus bone flap. Note the
angled notches at the axial border to facilitate flap hinging. The osteotomy angle is illus-
trated in the inset.
Depending on the chronicity of the condition and location of osseous structures within
the sinuses, an osteotome may be necessary to manually dissect attachments of the
flap to the sinus cavity. Fluid should now be collected for cytology and/or culture and
sensitivity. Copious lavage and debridement of the sinus should be undertaken paying
special attention to the postorbital diverticulum and other deep structures within the
sinus. If drainage is not well established, a fenestration into the nasal passage may
be made through the wall of the conchal sinuses using a probe, large hemostats, or
other blunt instrument. This usually results in profuse hemorrhage and packaging of
the sinus with fine-weave roll gauze should be performed. The front tail of the gauze
should be exited the fenestration and secured to the nasal fold with a simple interrup-
ted or mattress suture. A single, small tight knot should be placed at the back tail so
that when the packing is removed, the visualization of the knot confirms that the entire
packing was removed. A second option for packing the sinus includes exiting the
gauze packing out a corner of the osteotomy site after removing a corner of the
bone flap. If this option is chosen, a knot should not be used at the end of the gauze.
This method of packing, however, will result in an open incision that will require further
aftercare after the packing is removed. Following packing of the sinus cavity, the bone
flap should be replaced. It is not necessary to suture the bone flap. The periosteum
and subcutaneous tissues should be closed separately using 2 to 0 absorbable suture
material. The skin can then be closed either with stainless steel staples or nonabsorb-
able suture material.
Using a scalpel blade, a 3-sided, rectangular incision should be made extending to the
bone and including the periosteum. The location for the incision should be as follows:
the caudal margin should begin at the approximate level of the medial canthus of the
eye 4 to 5 cm distal to the orbit extending distally to the level of the facial tuberosity,
the ventral margin should begin at this point and extend rostrally 5 to 7 cm following a
line drawn from the zygomatic arch to the facial tuberosity, the rostral margin then ex-
tends from this point dorsally 5 cm parallel with the caudal margin.2 Care should be exer-
cised during the incision so as to not incise the facial vein as it courses across the
Surgery of the Sinuses and Eyes 581
maxillary sinus. The osteotomy should then proceed as described previously with the
bone flap hinged on its dorsal margin (Fig. 11). In young animals, the tooth roots will
occupy much of the sinus and care should be taken not to disrupt normal roots. If a tooth
is removed, the void should be filled with a temporary plug. The socket of the missing
tooth should be packed with either a methylmethacrylate plug or rolled gauze secured
to umbilical tape, which exits the sinusotomy site at a small removed corner. Following
tooth removal and/or sinus lavage, closure of the osteotomy site should be performed
as described previously. Methylmethacrylate plugs are left to fall out on their own,
whereas gauze plugs should be changed every 5 to 7 days until there is no longer commu-
nication between the oral cavity and the sinus. The gauze packing should be secured with
very long pieces of umbilical tape to allow the packing to be removed from the oral cavity
through the mouth, a new packing secured to the umbilical tape, and then the umbilical
tape again pulled taut from the sinusotomy site until the new packing is again secure
within the socket. The tails are tied in a bow around a second roll gauze to keep the
plug in place. An oral speculum is required for this packing change. The disadvantage
of the methylmethacrylate plug is that if it falls out prematurely, feed material may become
impacted into the sinus through the fistula requiring further intervention.
The surgical sites should be kept clean. Any sinus packing should be removed in 24 to
48 hours and sinus lavage instituted if needed at that time. Postoperative care also should
Fig. 11. Location for a maxillary bone flap. Note the nasal packing secured to the right
nares.
582 Schleining
EYES
Surgery involving the periorbital structures and eyes is relatively common in ruminants.
Conditions requiring surgery are varied and range from trauma to neoplasia to
congenital.10
Fig. 12. An extensive OSCC of the periorbital tissues in a 6-year-old Hereford cow.
Surgery of the Sinuses and Eyes 583
resolve the condition. When only the third eyelid is involved, the third eyelid may be
removed without worry of further problems.
Lymphosarcoma
Neoplasia should always be included on a differential list for an animal presenting with
exophthalmos. Lymphosarcoma is the most common neoplastic disease of the orbit in
cattle and tends to be fairly invasive.12 Digital palpation of the orbit should occur
because foreign bodies can also cause retrobulbar or orbital abscesses resulting in
clinical symptoms that may mimic lymphosarcoma. If lymphosarcoma is suspected,
a fine-needle aspirate, biopsy, serology for bovine leukosis virus, and/or palpation
of regional lymph nodes and abdominal lymph nodes via rectal palpation may assist
in arriving at a final diagnosis. Cattle with lymphosarcoma can sometimes be salvaged
long enough to birth or wean a calf, but quality of life should be taken into account
when deciding on how to progress. Exenteration of the orbital contents may prolong
the life of the animal, but in the author’s experience the tumor tends to reoccur very
rapidly and aggressively. Cattle with any outward signs of lymphosarcoma will be
severely discounted at market and the carcass condemned at slaughter.
Trauma
Lacerations of the eyelids, although not common, do occur and may require surgical
repair (Fig. 13). Depending on the location and extent of tissue trauma, this may be
best done under general anesthesia in the interest of cosmesis, functionality of the
lid, and integrity of the repair. It is important to perform a full ophthalmic examination
when presented with an eyelid laceration to rule out globe trauma, corneal ulceration
or laceration, and the presence of conjunctival foreign bodies that may have occurred
during the traumatic event. The tissues often will be edematous and may contain mu-
cous exudate. Practitioners should avoid the temptation to remove skin flaps, espe-
cially when the eyelid margins are involved in the laceration. The integrity of the
margin is very important when considering the future functionality of the lid. Without
the lid margin, entropion may occur resulting in chronic corneal irritation and ulceration
from hair, or even worse, the eye may not be properly protected or able to maintain a
tear film resulting in chronic exposure keratitis and discomfort. All efforts should be
made to repair the eyelid.
Cryotherapy
List of supplies needed to perform cryotherapy of the eyelids or nictitating membrane
(Box 3).
The patient should be restrained in a hydraulic chute with the head further restrained
with a halter or hydraulic head restraint system. Topical ophthalmic anesthetic
Fig. 13. Eyelid laceration in a yearling crossbred heifer. (Photograph courtesy of Dr Josh Ydstie.)
584 Schleining
Box 3
Supplies needed for cryotherapy
(proparacaine) should be generously applied to the eye. If the lesion is on the margin of
the eyelid, the rim of the Styrofoam cup can be removed, lubricated, and inserted be-
tween the lid and the eye serving as a barrier to the liquid nitrogen.
Using either a contact probe or an open spray tip, a double freeze thaw cycle should
be performed. The abnormal tissue should be frozen until either a thermocouple
placed in the skin deep to the mass reads 25 C or until an ice ball is observed
extending past the periphery of the mass. The second freeze cycle should occur
immediately after the mass has thawed.
An antibacterial ointment should be placed in the eye following cryosurgery. Edema
within the affected tissues will be evident within a few hours and is a normal sequela to
cryosurgery. This edema gradually subsides within the next few days without further
intervention. The eye should be relatively comfortable as cryotherapy results in death
of nerve endings at the site of cryogen application.
Hyperthermia
Box 4
Supplies needed for hyperthermia to remove eyelid masses
The patient should be restrained in a hydraulic chute with the head further restrained
with a halter or hydraulic head restraint system (Box 4). Alternatively, if a tilt table is
available, the patient can be restrained in lateral recumbency with the affected eye
up. Topical ophthalmic anesthetic (proparacaine) should be generously applied to
the eye.
An orbital retractor (Fig. 14) should be gently placed behind the eye while avoiding
the muscles of the eye (Fig. 15). The retractor will prevent the eye from moving during
the procedure. The radiofrequency probes should then be placed in contact with the
mass and the mass consequently heated to 50 C. Care should be taken not to overlap
the direction of hyperthermia application on the cornea, as this may cause corneal
perforation.
Antimicrobial ointment should be placed in the eye at the conclusion of the proce-
dure. The use of anti-inflammatory medications, such as meloxicam (0.5–1.0 mg/kg by
mouth SID – EOD) or flunixin meglumine (1.1–2.2 mg/kg IV as needed) also may be
used as indicated.
Surgery of the Sinuses and Eyes 585
Enucleation
Box 5
Supplies needed to perform enucleation
Three options exist for removal of the eye. They are enucleation, exenteration, and
evisceration. Enucleation refers to the removal of the globe only. Exenteration refers
to removal of the globe and all orbital contents including muscles, periorbital fat,
and optic nerve and vessels. Evisceration is a procedure in which only the intraocular
contents of the eye are removed, leaving the globe intact. Enucleation is by and far the
most frequent surgical procedure used in bovine practice and is described here. The
reader is directed to other texts for detailed descriptions of the other procedures.
The patient should be restrained in a hydraulic chute with the head further restrained
with a halter or hydraulic head restraint system (Box 5). Alternatively if a tilt table is
586 Schleining
Fig. 15. The bovine orbital retractor placed behind the eye to prevent eye movement during
hyperthermia.
available, the patient can be restrained in lateral recumbency with the affected eye up.
If indicated, a broad-spectrum antibiotic can be administered at this time. The orbital
area should be generously clipped and a rough scrub performed to remove surface
debris. Care should be taken so as to not get scrub or alcohol into the eye. The eyelids
and orbit should then be anesthetized (see Edmonson MA: Local, Regional, and Spinal
Anesthesia in Ruminants, in this issue). Following tight apposition of the eyelids with a
continuous suture pattern, a final surgical scrub should be performed. Another method
of eyelid apposition is with the use of towel clamps rather than suturing the lids closed.
An advantage of this technique is that the towel clamps may be used for traction of the
globe during the surgical procedure.
An elliptical incision should be made 1 to 2 cm around the periphery of the eyelid
margins. Using a combination of blunt and sharp dissection and using the orbit as a
guide, the surgeon should proceed through the orbicularis oculi muscle and periorbital
fascia while avoiding penetration of the conjunctiva. The ligaments at the medial and
lateral canthi are substantial and will require sharp transection. After transection of the
ligaments, the globe should be freely moveable. Dissection should proceed into the
orbit transecting the oblique, rectus, and retractor bulbi muscles. When all
the muscular attachments to the globe have been removed a Mixter forceps or other
vascular clamp (such as a kidney clamp or large curved Kelly forceps) should be
applied to the optic nerve and vessels at the base of the eye. The globe should then
be sharply removed and, if possible, a ligature placed around the optic pedicle using
an absorbable suture material. At this time, further debridement of the orbit can occur
if necessary. The globe can then be lavaged before closure of the subcutaneous tis-
sues with a 0 or 2 to 0 synthetic absorbable suture material capable of maintaining
Surgery of the Sinuses and Eyes 587
tension. Alternatively, if the pedicle is not able to be ligated effectively, the orbit can be
packed with roll gauze to provide hemostasis while the incision is being closed. The
gauze can then be removed just before placement of the final sutures in the subcu-
taneous layer. The lid margins should then be apposed using a continuous suture
pattern of the surgeon’s preference using #2 nonabsorbable suture (Fig. 16). If the an-
imal is anticipated to rub at the surgical site postoperatively, a stent bandage can be
placed over the surgical incision to protect the integrity of the sutures. This is accom-
plished by placing loose simple interrupted sutures with #2 nonabsorbable suture ma-
terial at the rostral and caudal borders of the orbit through which umbilical tape passes
in a “lacing” fashion. A rolled huck towel, laparotomy sponge, or rolled gauze can then
be placed over the incision and under the laces. The laces are then tightened to secure
the stent in place.
The surgical site should be monitored closely over the course of the next 3 to 5 days.
Postoperative swelling usually subsides within the first week as the hematoma within
the orbit resolves. The use of anti-inflammatory medications such as meloxicam (0.5–
1.0 mg/kg by mouth SID – EOD) or flunixin meglumine (1.1–2.2 mg/kg IV as needed)
should be considered. If present, the stent can be removed in 5 to 7 days and the
skin sutures in 14 days.
Laceration repair
Box 6
Supplies needed to repair eyelid lacerations
If the laceration is small, the patient may be restrained in a hydraulic chute with the
head further restrained with a halter or hydraulic head restraint mechanism (Box 6).
However, if the laceration is extensive or requires meticulous repair based on the loca-
tion or configuration of the laceration, general anesthesia is recommended. The lacer-
ation margins should be locally anesthetized with subcutaneous injection of lidocaine
and topical anesthetic liberally applied to the eye surface. The laceration should then
be prepped for surgery using 5% dilute povidone-iodine solution. The use of scrub for-
mulations and alcohol will result in chemical keratitis and should be avoided!
The margins of the laceration should be carefully and minimally debrided to pre-
serve as much tissue as possible. This is important for proper eyelid function after
the repair has healed. Flaps should not be removed and the tips of any flaps left
in situ even if they look like they will not survive. Full-thickness lacerations should
be repaired in 2 to 3 layers. The deep layer should include the fibrous tarsal plate,
which is very important in the repair process.10 The eyelid margins should be apposed
meticulously and carefully. There are numerous suturing techniques for this type of
588 Schleining
repair depending on the configuration of the laceration and the reader is directed to
ophthalmology texts for these specific suture patterns. The skin can be apposed in
simple interrupted or mattress suture patterns. Extensive laceration repairs may
require stenting after repair. This can occur in a number of different ways, including
temporary tarsorrhaphy. If the eye requires medicating postoperatively, a subpalpe-
bral lavage system is recommended to be placed before the tarsorrhaphy.
If the animal is amenable, the repair should be warm compressed 2 to 3 times a
day to help reduce inflammation and pain. The use of anti-inflammatory medications,
such as meloxicam (0.5–1.0 mg/kg by mouth SID – EOD) or flunixin meglumine (1.1–
2.2 mg/kg IV as needed) should be considered. If indicated, the eye should be medi-
cated through the subpalpebral lavage system with liquid medication or carefully at a
site distant from the repair with ointment. If there was extensive tissue damage, broad-
spectrum systemic antibiotics may be indicated. If a tarsorrhaphy was performed, it
should be removed in 7 to 10 days.
Tarsorrhaphy
Box 7
Supplies needed to perform a tarsorrhaphy
Lidocaine
Topical anesthetic (ie, Proparacaine)
2-0 nonabsorbable suture material
Rubber tubing (16 drops/s intravenous lines work well) cut into small pieces
Needle holders
Scissors
In cases such as described previously or when presented with an animal with facial
nerve paralysis (such as sometimes seen in listeriosis) a temporary tarsorrhaphy
can be a useful procedure to protect the laceration repair or the cornea from exposure
keratitis (Box 7).
The animal should be restrained in a hydraulic chute with the head further restrained
by a halter. A local injection of lidocaine should be performed subcutaneously at the
site of each suture. The eye should be liberally dosed with a topical anesthetic.
Surgery of the Sinuses and Eyes 589
The suture material should be placed through the rubber tubing. A partial-thickness
bite through the upper lid exiting along the eyelid margin should then be performed.
Next, the lower lid should be entered in the center of the eyelid margin opposite of
the exiting suture of the upper lid and exited through the skin. The suture should
then pass through a second piece of rubber tubing, the needle reversed, and the pro-
cedure repeated back through the lower lid and into the upper lid exiting near the up-
per rubber stent. The ends should then be tied together making a horizontal mattress
suture pattern with the stents. A second and, possibly third if needed, stent suture can
be placed to complete the procedure.
Postoperative care is minimal. The tarsorrhaphy sutures should be removed
when no longer needed, preferably within 2 weeks. When the sutures are not
removed in a timely fashion, large granulomas may form inhibiting normal lid function
(Fig. 17).
Fig. 17. Granuloma secondary to temporary tarsorrhaphy sutures left in place for 3 months.
Note the corneal scar and conjunctivitis from improperly placed suture.
590 Schleining
CLINICAL RESULTS
When used on appropriately sized OSCCs (demarcated lesions <50 mm), cryotherapy
using a single freeze thaw cycle was curative in 66% of the lesions. When a double
freeze thaw cycle was used, 97% of the lesions regressed completely.13 Cryotherapy
can also be used adjunctively following surgical debulking of the mass. However,
because of the inability of the cryogen to effectively freeze deeper tissues, large tu-
mors that invade deeper structures are not a candidate for cryotherapy. Hyperthermia
has also been reported to have a favorable outcome on ocular squamous cell carci-
noma.14,15 In one study of 76 OSCCs, 60 tumors regressed completely after 1 hyper-
thermia treatment and another 9 regressed completely after a second treatment for an
overall cure rate of 90.8%.15 Tumors that are invasive or larger than 50 mm do not
respond well to hyperthermia and other treatments should be considered. In a
single-center retrospective study of 53 cattle undergoing enucleation, nearly 85% of
eyes were removed consequent to OSCC. Despite nearly 20% of the cattle having sur-
gical site infection in the 3 weeks postoperatively, cattle undergoing enucleation in this
study largely were returned to production. The prognosis of the 22 cattle available for
long-term follow-up was very good with a very low recurrence rate.16
SUMMARY
Although surgery of the paranasal sinuses may not be an everyday occurrence, famil-
iarity with the anatomy can improve the veterinarian’s comfort level and case
outcome. The most common reason for sinus surgery is sinusitis secondary to previ-
ous dehorning or respiratory disease. Sinus lavage in early cases of sinusitis has a high
success rate. Surgery of the eyes are more common given the incidence of OSCC and
conditions requiring enucleation. Small lesions may be amenable to treatment with
cryotherapy or hyperthermia, whereas larger lesions may require enucleation. Enucle-
ation appears to have a good long-term outcome.
REFERENCES
1. Dyce KM, Sack WO, Wensing CJG. The head and ventral neck of the ruminants.
In: Textbook of veterinary anatomy. Philadelphia: Saunders; 2002. p. 633–6.
2. deLahunta A, Habel RE. Paranasal sinuses. In: Applied veterinary anatomy.
Philadelphia: Saunders; 1986. p. 51–3.
3. Ward J, Rebhun W. Chronic frontal sinusitis in dairy cattle: 12 cases (1978-1989).
J Am Vet Med Assoc 1992;201:326–8.
4. Gaughn EM, Provo-Klimek J, Ducharme NG. Surgery of the bovine respiratory
and cardiovascular systems. In: Fubini S, Ducharme N, editors. Farm animal sur-
gery. St Louis (MO): Saunders; 2004. p. 146–8.
5. Silva L, Neto A, Campos S, et al. Evaluation of four different treatment protocols to
sinusitis after plastic dehorning in cattle. Acta Scientiae Veterinariae 2010;38:25–30.
6. McPike Mundell L, Smith B, Hoffman R. Maxillary sinus cysts in two cattle. J Am
Vet Med Assoc 1996;209:127–9.
7. Ross M, Richardson D, Hackett R, et al. Nasal obstruction caused by cystic nasal
conchae in cattle. J Am Vet Med Assoc 1986;188:857–60.
8. Cohen N, Vacek J, Seahorn T, et al. Cystic nasal concha in a calf. J Am Vet Med
Assoc 1991;198:1035–6.
9. Schmid T, Braun U, Hagen R, et al. Clinical signs, treatment, and outcome in 15
cattle with sinonasal cysts. Vet Surg 2014;43:190–8.
Surgery of the Sinuses and Eyes 591
10. Irby N. Surgical diseases of the eye in farm animals. In: Fubini S, Ducharme N,
editors. Farm animal surgery. St Louis (MO): Saunders; 2004. p. 429–59.
11. Tsujita H, Plummer C. Bovine ocular squamous cell carcinoma. Vet Clin North Am
Food Anim Pract 2010;26:511–29.
12. Rebhun WC. Ocular manifestations of systemic diseases in cattle. Vet Clin North
Am Large Anim Pract 1984;6:623–39.
13. Farris HE, Fraunhfelder FT. Cryosurgical treatment of ocular squamous cell carci-
noma of cattle. J Am Vet Med Assoc 1976;168:213–6.
14. Grier RL, Brewer WG Jr, Paul SR, et al. Treatment of bovine and equine ocular
squamous cell carcinoma by radiofrequency hyperthermia. J Am Vet Med Assoc
1980;177:55–61.
15. Kainer RA, Stringer JM, Lueker DC. Hyperthermia for treatment of ocular squa-
mous cell tumor in cattle. J Am Vet Med Assoc 1980;176:356–60.
16. Schulz KL, Anderson DE. Bovine enucleation: a retrospective study of 53 cases
(1998-2006). Can Vet J 2010;51:611–4.
Disorders of the Paranasal Sinuses
26 Henry Tremaine and David E Freeman
6
1 RMS
VM
7 2
3
Fig. 26.3. Transverse section of the skull of an aged horse at the level
9 of the fourth cheek tooth (109, 209) showing the voluminous rostral
maxillary sinus (RMS) and the ventral nasal meatus (VM).
A C
4
6
5 5
7
2
8
1 6
11 2
3
10
9 1
3
2
1
Fig. 26.4. Approaches to the sinuses through a frontonasal bone flap (broken line in A) and maxillary
bone flap (broken line in B), and (C) expanded dorsal view of sinuses. 1 = rostral maxillary sinus;
2 = caudal maxillary sinus; 3 = ventral conchal sinus; 4 = sphenopalatine sinus; 5 = frontal sinus;
6 = ethmoidal labyrinth; 7 = frontomaxillary opening; 8 = dorsal conchal sinus (5 and 8 combine to form
the conchofrontal sinus); 9 = infraorbital canal; 10 = bony maxillary septum; 11 = caudal bulla of ventral
conchal sinus. Reproduced from Freeman 2003, with permission.
SECTION 4 : Disorders of the Upper Respiratory Tract
6 4
5
2 3
1
Fig. 26.7. A large (5-cm) diameter trephine is being used to create a large bone flap into the left frontal
sinus in this horse, enabling surgical access to the dorsal conchal, frontal and caudal maxillary sinuses. The
bone flap is discarded and the flap later closed by apposing the skin and periosteum.
Fig. 26.8. Copious quantities of purulent exudate flowing from a nasofrontal bone flap osteotomy in a
horse with chronic sinus empyema.
SECTION 4 : Disorders of the Upper Respiratory Tract
Fig. 26.9. The skin flap and periosteum are supported by a rim of
frontal bone and are apposed using interrupted sutures (arrowheads).
A maxillary trephine opening has then been made to allow post-
operative irrigation of the maxillary sinuses through a Foley catheter.
BF
Fig. 26.10. A large maxillary bone flap (BF) has been created in this Fig. 26.11. Diagram outlining the postsurgical packing of a paranasal
horse using an oscillating bone saw. This approach gives exposure to sinus to reduce hemorrhage following sinonasal fistulation.
the caudal and rostral maxillary sinuses. The ventral conchal sinus
is variably accessible dorsal to the infraorbital canal. This horse has
extensive, inflamed soft tissue swelling within its caudal maxillary
sinus.
SECTION 4 : Disorders of the Upper Respiratory Tract
diagnosis of dental involvement in sinusitis using radio- et al (1992), Aspergillus fumigatus was cultured from six,
graphy, scintigraphy or computed tomography is essential Pseudallescheria boydii from one, and Penicillium spp. from
before embarking on tooth removal. Anecdotal reports a single case. Pseudallescheria boydii, an opportunistic
suggesting that endodontic therapy of infected pulp per os, saprophyte, has also been isolated from a frontal sinus
effectively sealing the oral cavity from the sinus, will result lesion (Johnson et al 1975).
in resolution of the sinus (T. Johnson, personal commu- Aspergillus fumigatus is ubiquitous in dead vegetation
nication) have not been critically evaluated. including hay and straw. The mechanism of infection of
Infected cheek teeth may be removed via oral extraction, the nasal chambers or paranasal sinuses of horses by
repulsion or via a lateral buccotomy. The latter tech- normally saprophytic fungi is not clear, but previous
nique can be used for the rostral three maxillary cheek trauma from surgery or nasogastric tube passage may be a
teeth but not for the caudal maxillary cheek teeth. factor in some cases (Watt 1970, Greet 1981, Tremaine &
Extraction per os is associated with considerably reduced Dixon 2001b).
complications compared to repulsion, and additionally, Mycotic sinonasal infections caused by other fungal
may be accomplished in the standing horse (Tremaine organisms are common in warm humid climates. These
2004b, Dixon et al 2005). Dental extractions involving the have involved infection with Cryptococcus neoformans (Watt
maxillary cheek teeth that cannot be achieved by oral 1970, Corrier et al 1984), Coccidioides immitis (DeMartini &
extraction (e.g. badly fractured or carious cheek teeth) can Riddle 1969, Hodgkin et al 1984), Rhinosporidium seeberi
be performed under general anesthesia via a bone-flap (Myers et al 1964), Conidiobolus coronatus (Entomophthora
osteotomy or via trephine opening. Intraoperative imag- coronata) (Bridges et al 1962, Hanselka 1977, Zamos et al
ing to ensure accurate alignment of the punch with the 1996), Conidiobolus lamprauges (Humber et al 1989) and
affected tooth before repulsing the tooth is advised, to avoid Hyphomyces destruens (Hutchins & Johnston 1972). Such
iatrogenic damage to adjacent structures. mycotic granulomas are characterized by the presence of
If dental extraction is performed per os in horses with necrotic foci or “kunkers” within proliferative granulation
dental sinusitis, lavage of the affected paranasal sinuses tissue. Nasal infections by these lesions are described in
should also be performed post extraction. Intraoperative detail in Chapter 25.
radiographs should be taken after dental removal (espe- Sinus mycosis has also been reported secondary to other
cially by repulsion) to attempt to identify the possible intrasinus lesions such as progressive ethmoidal hematoma
presence of intraalveolar bone or dental fracture frag- and can also occur following sinus surgery for other dis-
ments that are likely to sequestrate. Following oral extrac- eases such as progressive ethmoidal hematoma, sinus cysts
tion the alveolus can be temporarily packed with an or following head trauma (McGorum & Dixon 1992,
antibiotic-soaked swab (Dixon et al 2005), but following Tremaine & Dixon 2001a).
repulsion a more robust alveolar packing is required, Mycotic sinus infections commonly cause a unilateral
such as an acrylic plug attached to adjacent cheek teeth, nasal discharge, which may vary from mucopurulent,
to prevent the development of an oromaxillary fistula. purulent to sanguineous, and is frequently malodorous
Unsuccessful treatment of sinusitis can be attributed to (McGorum et al 1992, Tremaine & Dixon 2001a).
oromaxillary fistula, persistent alveolar osteitis, abscesses The treatment of superficial mycotic lesions with anti-
within the overlying sinus, failure to remove all the infected mycotic drugs including nystatin (Campbell & Peyton
tooth and infected or loose alveolar bone, and failure to 1984), enilconazole or natamycin (McGorum et al 1992)
treat obligate anaerobes with appropriate antibiotics such by topical application directly or via an endoscope carries a
as metronidazole (De Moor & Verschooten 1982, Mackintosh good prognosis although recurrence is possible. Surgical
& Colles 1987). The presence of small alveolar sequestra, removal of large intrasinus fungal granulomas or plaques
which are not identifiable on postoperative radiographs, or of any underlying cause such as sequestra, cysts or pro-
are an occasional cause for persistent clinical signs of gressive ethmoidal hematoma lesions, followed by sinus
sinusitis. These apparently develop later as the result of irrigation with a topical antifungal such as natamycin or
damage to alveoli by the repulsion process. The long-term miconazole, usually results in rapid resolution of the lesions.
prognosis for both primary and dental sinusitis cases is
good (Tremaine & Dixon 2001b).
Halicephalobus gingivalis Infection
Halicephalobus gingivalis is a saprophytic nematode found in
Mycotic Sinusitis decaying humus and infection through an unknown route
Equine sinonasal diseases associated with fungal infection can involve the sinuses, central nervous system, and, to a
are rare in the horse in the UK. Greet (1981) first described lesser extent, the kidney in certain geographical regions
three cases of mycotic rhinitis in horses caused by (Pearce at al 2001). Infection of the sinuses produces a
Aspergillus fumigatus, and subsequent reports are sparse. mass of gray–yellow fibrous tissue that obliterates the
Of ten cases of sinonasal mycosis described by McGorum sinuses and their walls, loosens teeth and distorts sinus
SECTION 4 : Disorders of the Upper Respiratory Tract
architecture. Infection can be unilateral or bilateral, can sinus cysts can expand into the nasal cavity, causing
involve both the upper and lower jaws, and can spread compression of the nasal septum and bilateral nasal air-
from there to the kidneys and cerebellum (Freeman 1991a). flow obstruction.
Predominant clinical signs of H. gingivalis infection Diagnosis of sinus cysts is assisted by endoscopy, which
are facial distortion with firm swellings in the maxilla, may reveal distortion of nasal conchae. Radiographic
unilateral or bilateral nasal discharge, marked dyspnea and features of sinus cysts include the presence of a rounded,
stridor, difficulty in eating, and weight loss (Pearce et al expansive, soft tissue density lesion in the frontal or maxil-
2001). The condition can be confused with squamous cell lary sinuses. Distortion and thinning of the surrounding
carcinoma but the female rhabditiform nematodes and bones may be evident as the lesion increases in size, and
their larvae and eggs can be seen in clusters or scattered secondary distortion of adjacent dental apices within
throughout a biopsy specimen. Surgical debulking, intra- the sinuses may be present. The contents of the cysts fre-
operative lavage with ivermectin, and subsequent oral quently appear radiographically as a homogeneous soft
ivermectin was successful in one horse with a periorbital tissue density shadow. The radiodense capsule may contain
granuloma (Freeman 1991a). However, the response to spicules of mineralized tissue (Fig. 26.14) and extralesional
ivermectin is not always favorable and the prognosis fluid lines may be present if secondary sinus empyema is
appears to be poor, especially because of risk of spread to present (Tremaine & Dixon 2001a). Centesis of the lesion
other organs. via needle aspiration (e.g. using a 16-gauge needle inserted
into areas of thinned, swollen bone) or via a sinusotomy is
diagnostic, yielding a viscous, usually sterile, translucent
Sinus Cysts yellow fluid which is odorless and may contain some
Sinus cysts are expansive fluid-filled space-occupying leukocytes (Dixon 1985, Lane et al 1987, Tremaine &
lesions which develop within the sinuses (Leyland & Baker Dixon 2001a, Beard & Hardy 2003). Treatment of the
1975, Dixon 1985, Lane et al 1987) of young to old
horses. Congenital intrasinus cysts have also been reported
(Sanders-Shamis & Robertson 1987, Beard et al 1990).
Equine sinus cysts most commonly occur in the maxillary
sinuses but they can also occur in the other sinuses.
The etiology of these lesions is unclear and no breed or
sex predisposition has been identified. It has been suggested
that they are developmental in origin (Beard et al 1990),
or associated with dental tissues (Boulton 1985), but
little evidence for this theory has been found, although
one case described by Dixon (1985) was attached to dental
alveoli. A common etiology between these lesions and
ethmoid hematomas has been suggested (Lane et al 1987)
as both lesions histologically contain areas of hemorrhage
and hemosiderophages, but little factual evidence for this
association has been found (Tremaine et al 1999). Sinus
cysts are frequently associated with a nasal discharge and
facial swelling (Fig. 26.13). The nasal discharge varies from
mucoid, mucopurulent to purulent, and is thought to be
the result of sinus infection secondary to obstruction of
normal sinonasal drainage. A consistent clinical feature
caused by the expansive nature of sinus cysts is distortion
of the frontal, maxillary, and conchal bones (Lane et al
1987, Caron 1991, Freeman 1991b, Tremaine & Dixon
2001a). This may result in gross facial swelling and
exophthalmos as a result of thinning of the overlying
maxillary or frontal bones, and nasal obstruction as a
result of the expansion of the lesion within the sinuses and
conchae. Horses are affected unilaterally in almost all
cases, but expansion of a frontal sinus cyst with lysis of the
intersinus septum and expansion into the contralateral Fig. 26.13. The large swelling of the left side of this 8-year-old horse’s
frontal sinus, resulting in bilateral clinical signs, can occur rostral maxillary area (arrows) is the result of bone remodeling in
(H. Tremaine, personal observations). Large maxillary response to an expanding cyst within the maxillary sinuses.
SECTION 4 : Disorders of the Upper Respiratory Tract
Fig. 26.16. Nasofrontal sinus bone flap surgery showing an intrasinus Fig. 26.17. This pony has a rapidly expanding maxillary tumor, which
progressive ethmoidal hematoma (arrows), which was not detectable caused loosening and secondary apical infections of the adjacent
on nasal endoscopy and which is covered by inspissated pus. maxillary cheek teeth.
SECTION 4 : Disorders of the Upper Respiratory Tract
and malar bones have been described (Gibbs & Lane 1987, Barber SM, Clark EG, Fretz PB 1983 Fibroblastic tumour of the
Speirs 1992, Trotter 1993, Tremaine & Dixon 2001a). premaxilla in two horses. Journal of the American
They occur in many breeds but the incidence appears Veterinary Medical Association 182: 700–702
Beard WL, Hardy J 2003 Diagnosis of conditions of the para-
to be particularly high in thoroughbreds and thorough- nasal sinuses of the horse. Equine Veterinary Education
bred crosses (Dixon 1991). Although most are possibly 13: 265–273
traumatic in origin, including following sinonasal surgery, Beard WL, Robertson JT, Leeth B 1990 Bilateral congenital
especially after a large nasofrontal osteotomy, the exact cysts in the frontal sinus of a horse. Journal of the
etiology of such lesions remains unknown in other cases. American Veterinary Medical Association 196: 453–454
Boulton CH 1985 Equine nasal cavity and paranasal sinus
Affected horses present with bilateral, firm, non-painful disease: a review of 85 cases. Journal of Equine Veterinary
swellings, rostral to the eye, accompanied by epiphora Science 5: 268–275
in some cases. Differentiation from facial fractures and Bridges CH, Romane WM, Emmons CW 1962 Phycomycosis
sinusitis is usually possible clinically and radiologically. of horses caused by Entomophthora coronata. Journal of the
Radiographs frequently demonstrate proliferative peri- American Veterinary Medical Association 140: 673–677
Campbell ML, Peyton LC 1984 Muscle flap closure of a
osteal changes of the widened and incompletely closed frontocutaneous fistula in a horse. Veterinary Surgery
suture line. The swellings usually remodel and regress 13: 185–188
gradually without treatment, but in some cases continued Caron JP 1991 Diseases of the nasal cavity and paranasal
instability has resulted in progressive increases in the size of sinuses. In: Colahan PT, Mayhew IG, Merritt AM, Moore
these swellings. JN (editors) Equine Medicine and Surgery. American
Veterinary Publications, Goleta, CA, pp.386–397
Clarke CJ, Roeder PL, Dixon PM 1996 Nasal obstruction
Miscellaneous Sinus Disorders caused by nutritional osteodystrophia fibrosa in a group
of Ethiopian horses. Veterinary Record 139: 568–570
Frontal sinus eversion is probably a congenital defect that Corrier DE, Wison SR, Scrutchfield WL 1984 Equine crypto-
forms a hard, slow-growing protuberance over, and com- coccal rhinitis. Compendium on Continuing Education
for the Practicing Veterinarian 6: 556–558.
municating with, the frontal sinus (Martin & McIlwraith Cotchin E 1956 Neoplasms of the Domesticated Animals.
1981). The bony protuberance can be removed through a Commonwealth Agricultural Bureaux, Buckingham, UK
large elliptical incision and the resulting defect in the Cotchin E 1967 Spontaneous neoplasms of the upper respira-
frontal bone can be repaired with synthetic polypropylene tory tract in animals In: Muir CS, Shanmugaratnam K
mesh (Marlex) and skin. (editors) Cancer of the Naso-Pharynx. Medical Examina-
tion Publishing Co, Flushing, NY, pp.203–259
Osteodystrophia fibrosa or secondary nutritional hyper- Coumbe KM, Jones RD, Kenward JH 1987 Bilateral sinus
parathyroidism can develop in horses on a high phosphorus empyema in a six year-old mare. Equine Veterinary
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(Freeman 1991b). It is rare under modern management con- tural study of diseased equine cheek teeth. PhD thesis,
University of Edinburgh
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may be caused by advanced mycotic rhinitis (Tremaine & in two horses and a pony. Journal of the American
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The reserve tooth crowns of young (2- to 4-year-old) der Nasenmuscheln beim Pferd (Empyema and necrosis
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Welsh and miniature ponies and other smaller pony breeds Wochenschrift 89: 275–281
can project a considerable distance into the nasal and sinus Dixon PM 1985 Equine maxillary cysts. Equine Practice
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maxillary bones that should not be confused with injuries Dixon PM 1991 Swellings of the head region in the horse. In
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Dixon PM 1993a Nasal cavity. In: Equine Respiratory Endoscopy.
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IN-DEPTH: RESPIRATORY
The techniques that are described below can be performed by the practitioner in the field. Some
specialized equipment is necessary, but being able to perform these procedures will allow the
veterinarian to provide better care for their patient. Author’s address: Rood & Riddle Equine
Hospital, PO Box 12070, Lexington, KY 40580-2070; e-mail: bwoodie@roodandriddle.com © 2011
AAEP.
NOTES