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The anatomy and diagnosis of disorders of the paranasal pressurized garden spray is useful for administering large
sinuses has been discussed in previous articles (UK Vet Vol volumes quickly and easily. Four litres twice daily is usually
9 No 8 and Vol 10 Nos 1 and 2). This final article in the sufficient for lavage of the paranasal sinuses. If the sinusitis
series discusses the treatment, prognosis and potential involves the rostral maxillary (RMS) or ventral conchal
complications of paranasal sinus disorders. sinus (VCS) in addition to the other sinuses (as determined
by radiography) then a RMS trephine or breaking down
PRIMARY SINUSITIS the ventral conchal bulla is required for efficient lavage (see
Primary sinusitis results from bacterial infection (usually UK Vet Vol 10 No 2).The prognosis for primary sinusitis is
streptococcal) of the upper respiratory tract. Treatment of excellent. Horses refractory to lavage are usually affected
primary sinusitis is initially aimed at increasing mucociliary by secondary sinus disorders, or may have inspissation of
clearance from the sinuses. Medical treatments include purulent material within a sinus compartment.
antibiotics, mucolytics, feeding the horse from the floor
and light exercise. Horses that do not respond to medical
treatment can undergo trephination of the frontal or
maxillary bone (see UK Vet Vol 10 No 2), placement of a T H E P RO G N O S I S
Foley catheter and lavage of the sinuses (Figs. 1 and 2). F O R P R I M A RY
Physiologic saline is a suitable lavage solution. If povidine SINUSITIS IS
iodine is used in the lavage fluid it needs to be very dilute EXCELLENT
(0.01% or a weak tea colour) because higher
concentrations irritate the sinus mucosa. Sterile lavage
fluids are generally not required and addition of antibiotics
to the lavage solution is usually unnecessary. An isotonic
saline solution can be made simply by adding 30 mls
(measured by volume) of sodium chloride to 4 L of tap
water. Most horses will tolerate lavage unsedated. A
UK VET - Online
Fig. 1: A 22F Foley catheter inserted into the www.ukvet.co.uk
caudal maxillary sinus for lavage of the sinuses after
sinus flap surgery has been performed.
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Treatment involves surgical removal of the pus (Fig. 3).This therapy (2-3 months) can be attempted and is occasionally
is most commonly performed through a frontonasal flap successful in early cases. Removal of the tooth is required
(see Surgical approaches to the paranasal sinuses). Creation in most cases. Three methods of tooth removal are
of a sino-nasal fistula is usually unnecessary.The prognosis available: oral extraction, cheek tooth repulsion or lateral
for cases with inspissated pus in their paranasal sinuses is buccotomy. Endodontic therapy has been attempted but is
good after surgical treatment. difficult to perform in equine cheek teeth and presently
has a high complication and failure rate.
SECONDARY SINUSITIS
Sinusitis commonly occurs secondary to periapical infection
of one of the caudal 4 maxillary cheek teeth. Bacterial
sinusitis also occurs secondary to facial fracture or necrosis of
tissue/reduced sino-nasal drainage caused by an expanding
mass within the sinuses, such as a sinus cyst, neoplasm,
osteoma, or progressive ethmoidal hematoma (PEH).
Dental sinusitis
Periapical dental infections can be primary or secondary.
The cause of primary periapical dental infections is
unclear, but vertical impaction and anachoresis (blood or
Fig. 4: Molar extractors have been applied to a
lymphatic borne bacterial infection), occlusal exposure of maxillary cheek tooth for oral extraction, and the
pulp and infundibular caries (infundibular cemental caries) periodontal ligament is being slowly broken down
have all been suggested. Most cases involve a single tooth, using small lateral movements of the extractors.
and the upper 09s (4th maxillary cheek teeth) are most
frequently involved in cases of primary dental sinusitis. Progressive Ethmoid Haematoma (PEH)
Secondary periapical dental infections may occur after The aetiology of PEHs is unknown but they are slowly
deep periodontal infection (often associated with expanding, non-neoplastic haemangiomatous masses that
diastemata or displacement of cheek teeth), dental caries or originate in the submucosa of the ethmoid labyrinth.
dental fracture with pulpar exposure. PEHs can expand into the nasal passages, paranasal sinuses,
or nasopharynx causing destruction of adjacent tissue. A
The apices of the caudal 4 maxillary cheek teeth are PEH can be ablated transendoscopically using a laser with
contained within the rostral and caudal maxillary sinuses. the horse conscious and standing, but laser therapy usually
Periapical dental disease involving these cheek teeth requires multiple treatments, and the cost of equipment
usually results in communication with the paranasal sinuses limits its availability. PEHs are most commonly treated by
and associated secondary sinusitis. Long term antibiotic transendoscopic injection of an aqueous solution of 4%
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formaldehyde into the lesion until they distend and begin Sinus cysts
to leak formaldehyde solution through their capsule The aetiology of sinus cysts is uncertain, but they are
(Fig. 5). Treatment is repeated at 3- to 4-week intervals expansive fluid-filled space-occupying lesions which are
until the lesion is eliminated or reduced in size such that lined by a layer of secretory, respiratory-type,
it is no longer accessible for injection. In rare cases pseudostratified epithelium, with plates or spicules of bone
where the PEH has penetrated the cribiform plate, also frequently present in the capsule. Sinus cysts are
injection of formaldehyde solution can result in death of usually found in the maxillary sinuses, and as they expand,
the horse. Surgical ablation is usually reserved for large can destroy the architecture of the sinuses. Treatment
PEH (Fig. 6) that have not responded to other involves surgical removal of the cyst, via a sinus osteotomy
treatments, because severe haemorrhage occurs (Fig. 7). The prognosis after surgical intervention is good.
commonly during the surgery. Haemorrhage is reduced Removal of the entire cyst is not essential for success.
when the surgery is performed in standing horses Internal distortion of the nasal cavity usually resolves once
compared to those under general anaesthesia. the cyst is successful removed.
THE MOST
COMMON
NEOPLASM OF
T H E PA R A N A S A L
SINUSES OF
HORSES IS A
Fig. 5: Transendoscopic injection of a progressive
CARCINOMA
ethmoid haematoma with 4% formaldehyde.
Neoplasia
Although rare, most neoplasms of the paranasal sinuses of
horses are malignant. The most common neoplasm of the
paranasal sinuses of horses is a carcinoma. Carcinomas tend
to be locally invasive (Fig. 8) and may metastasise, making
complete surgical removal difficult. Treatment of horses
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with neoplasia of the paranasal sinuses is usually only
palliative because the success rate of treatment is poor.
Surgical debulking alone of the tumour (Fig. 9) rarely
extends life for longer than a year. Radiotherapy is likely to
be unsuccessful if the neoplasm has invaded bone. The
usual treatment of horses affected with neoplasia of the
paranasal sinuses is euthanasia.
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