Comparison of equine paranasal sinus trephination complications and outcome following standing computed tomography, radiography and sinoscopy guided approaches for the treatment of sinusitis.

OBJECTIVE: The recent availability of standing computed tomography (CT) for equine paranasal sinus disease has enhanced diagnosis and enabled more targeted surgery compared to radiography and sinoscopy. To date, there have been no studies which have critically evaluated the benefit of preoperative CT versus radiography and sinoscopy on complications and outcome in horses undergoing sinus trephination. STUDY DESIGN: Retrospective study. ANIMALS: A total of 229 equids. METHODS: The medical records of equids (229) presented for sinusitis treated via trephination that had CT, radiography and/or sinoscopy at time of surgery between 2009 and 2022 were reviewed. Outcome and complications were evaluated for six different pre- and intraoperative imaging modalities. RESULTS: The six groups did not differ in demographics or disease category, though equids with less weight (p = .0179) and shorter disease duration (p = .0075) were more likely to have radiography and sinoscopy based surgical planning. Short-term postoperative complications occurred in 30.1% and were higher in groups using preoperative CT imaging (p = .01), with hemorrhage being the most common surgical complication. Following initial trephination surgery, 57.0% (127/223) of cases resolved and there was no difference between the imaging groups. Final resolution after follow-up medical or surgical treatment increased to 94.6% (211/223) and was not different between the imaging groups or between primary or secondary sinusitis. Additional nasal fenestrations to improve sinonasal drainage, maxillary septal bulla fenestrations and trephinations to treat nasal conchal bullae were made in the CT groups. CLINICAL SIGNIFICANCE: CT provided additional diagnostic information and enabled different surgical approaches but did not improve resolution in this study population.

Postoperative sinusitis and pneumonia following exploratory celiotomy for treatment of colic in horses.

Sinusitis and pneumonia following exploratory celiotomy in horses were studied, evaluating associations between these 2 respiratory complications and selected pre-, peri-, and post-operative variables. The incidence of sinusitis was 2.5% (8/318) and pneumonia 3.5% (11/318). These respiratory complications were associated with peri-operative reflux, longer antimicrobial treatment, and longer hospitalization.

Sinusite et pneumonie postopératoires suite á une coeliotomie exploratoire pour le traitement des coliques chez le cheval. La sinusite et la pneumonie consécutives á une coeliotomie exploratoire chez le cheval ont été étudiées, afin d'évaluer les associations entre ces deux complications respiratoires et certaines variables pré-, péri- et postopératoires. L'incidence des sinusites était de 2,5 % (8/318) et des pneumonies de 3,5 % (11/318). Ces complications respiratoires étaient associées á un reflux périopératoire, á un traitement antimicrobien plus long et á une hospitalisation plus longue.(Traduit par Dr Serge Messier).

Clinical characteristics and outcome of invasive fungal sinusitis in children with hematological malignancies.

Invasive fungal sinusitis (IFS) is a rare disease that requires careful attention and prompts management due to its high mortality among pediatric patients with hematological malignancies. This is a retrospective analysis of pediatric patients with hematological malignancies treated at Children's Cancer Hospital Egypt 57 357 (CCHE) through the period from 2008 till 2016 with proven IFS. Thirty-four patients were diagnosed with IFS. Five (15%) patients had an invasive rhino-cerebral fungal disease. Mucorales were isolated in 50% (n = 17) patients, Aspergillus in 38% (n = 13) patients, and mixed fungal in 12% (n = 4) patients. Sinuses were the only localized site in (45%). Extra-nasal spread was reported in 20 patients; Sino-pulmonary in 35% (n = 12), sino-cerebral in 15% (n = 5), and sino-orbital in 5% (n = 2) patients. Combined antifungal therapy with surgical debridement was done in 59% of patients with a better outcome when compared to those who received only medical antifungal treatment (P = .01). The overall mortality rate at week 12 was 35% (n = 12), and IFS attributable mortality was 20% (n = 7). IFS with cerebral extension carried the highest mortality rate for both 12-week all-cause (P = .04) and fungal-attributable (P = .01) mortality. Pediatric patients with hematologic malignancies are susceptible to invasive fungal sinusitis (IFS). Surgical debridement, combined with antifungal therapy, improves outcomes among those patients. IFS patients with cerebral extension had a higher risk of mortality. LAY SUMMARY: We studied the characteristics of invasive fungal sinusitis in children with hematological malignancies. Mucormycosis was the most common cause. Surgical debridement, combined with anti-fungal therapy, improves outcomes. Patients with rhino-cerebral fungal disease had a higher risk of mortality.

EVALUATING THE EFFICACY OF HUMAN BRONCHIECTASISBASED ANTIBIOTIC THERAPY IN THE TREATMENT OF ORANGUTAN RESPIRATORY DISEASE SYNDROME.

Unique among apes, orangutans (Pongo spp.) develop a chronic respiratory disease called orangutan respiratory disease syndrome (ORDS). The authors define ORDS as intermittent bacterial infection and chronic inflammation of any region or combination of regions of the respiratory tract, including the sinuses, air sacs, cranial bones, airways, and lung parenchyma. Infection in any of these areas can present acutely but then becomes recurrent, chronic, progressive, and ultimately fatal. The closest model to this disease is cystic fibrosis (CF) in people. We hypothesized that use of a 4-8-wk course of combined oral antibiotics used in the treatment of bronchiectasis in CF patients would lead to prolonged symptomatic and computed tomography (CT) scan improvement in orangutans experiencing early signs of ORDS. Nine adult Bornean orangutans (Pongo pygmaeus, eight males, one female, 18-29 yr of age) diagnosed with early ORDS-like respiratory disease underwent CT scan before initiation of treatment. Each animal received a combined course of azithromycin (400 mg 3/wk, mean 7 mg/kg) and levofloxacin (500 mg PO q24h, mean 8.75 mg/kg) for a period of 4-8 wk. CT scan was repeated 6-14 mon after completion of antibiotic treatment. Pretreatment CT showed that six of nine animals had lower respiratory pathology (airway disease, pneumonia, or both). All six orangutans had concurrent sinusitis, mastoiditis, airsacculitis, or a combination of these conditions. Upper respiratory disease alone was observed in three animals. CT showed improvement or resolution in four of five sinusitis cases, improvement in one of two instances of mastoiditis, resolution in five of six instances of airsacculitis, improvement or resolution in six of six instance of lower airway disease (P = 0.03, 95% CI 0.54-1.0], and resolution in five of five cases of pneumonia. Resolution of pretreatment clinical signs was observed in all nine animals. Two developed signs not present at pretreatment. These results show that combination antibiotic therapy with azithromycin and levofloxacin provides improvement in clinical signs and CT evidence of ORDS-related pathology, resulting in symptom-free status in some animals for up to 33 mon.

Equine Sinus Surgery.

The anatomy of the equine paranasal sinuses is critical to understand to assess the extent of the disease process, the optimal surgical approach, and the ability to drain through the normal nasomaxillary pathway. By following established anatomic landmarks, direct sinus access can be used to further explore the sinus compartments, remove compromised cheek teeth, remove any purulent debris or feed contamination, and establish drainage. Many complications can be avoided or minimized by thoroughly evaluating all sinus compartments and critically assessing the ability of the sinus to drain.

Equine Imaging: Computed Tomography Interpretation.

Computed tomography (CT) has revolutionized the veterinarian's ability to image the equine skull and led to improved diagnostic accuracy and clarity for surgical planning. The increased cost for this evaluation is offset by more accurate diagnosis and targeted therapy. As novel technology is developed that allows for increased availability of equine head, the price will continue to decrease and more examinations will be performed. New skills are needed for the veterinarian to accurately interpret this modality. This article reviews the normal CT appearance of the equine skull and presents examples and key features of several common diseases.

Equine Nasal Endoscopy: Treating Bullae Disease and Sinus Disease.

The nasal conchal bullae (dorsal and ventral) are separate, air-filled structures within their respective dorsal and ventral nasal conchae. Computed tomography scans have assisted with the increasing diagnosis of empyema of the nasal conchae. This condition is usually associated with dental or sinus disease. Drainage of affected bullae is considered critical for resolution of clinical signs. The ventral conchal bullae can be easily viewed with a standard 10 mm diameter flexible endoscopy via the middle nasal meatus. This approach can also be used for fenestration of the bullae, using a diode laser, equine laryngeal forceps, or bipolar vessel sealing device.

DERMATITIS AND RHINOSINUITIS CAUSED BY CURVULARIA SPECIES IN A CHINESE GORAL (NAEMORHEDUS GRISEUS).

Curvularia spp. are globally distributed saprophytic fungi, classified in the literature as dematiaceous, or darkly pigmented fungi. These fungi have been increasingly recognized as causing cutaneous, ocular, respiratory, and central nervous system infections in humans, but have been infrequently documented as pathogens in the veterinary literature. A 5-yr-old male Chinese goral (Naemorhedus griseus) presented with bilateral fungal dermatitis of the pinnae, and subsequent pyogranulomatous rhinosinusitis. Clinical signs included epistaxis, mucosanguineous nasal discharge, and dyspnea. Sequential histologic examinations of cutaneous and nasal lesions revealed pyogranulomatous inflammation with extracellular and phagocytized nonpigmented yeasts. Fungal culture and polymerase chain reaction identified Curvularia sp. The absence of pigmentation in tissue in this case suggests that pigmentation may not be a consistent histologic finding for this fungus, emphasizing the importance of molecular identification to prevent misidentification. Despite intensive interventions in this goral, the disease progressed, and was ultimately fatal.

Mycotic Rhinitis and Sinusitis in Florida Horses.

Rhinitis and sinusitis caused by fungal pathogens were studied in biopsy samples submitted from 52 horses distributed throughout subtropical and tropical regions of Florida. Methods included routine histopathology as well as polymerase chain reaction (PCR) with panfungal/panoomycete primers and DNA sequencing on extracted DNA (DNA barcoding). Granulomatous, pyogranulomatous, and fibrinopurulent lesions in nasal and sinus mucosa were associated with signs of upper airway obstruction and noise as well as nasal discharge. Morphologic and histochemical assessment of cases identified 31 cases of zygomycosis/pythiosis plus 1 mixed infection case, 16 cases of phaeohyphomycosis with 2 additional mixed infection cases, and 3 cases caused by other fungi. Morphologic evidence of Aspergillus sp. infection as a superficial copathogen was found in 2 of the mixed fungal infection cases. PCR and DNA sequencing facilitated identification of fungal pathogens in 11 of 52 cases (21%). No evidence of oomycete infection was found. Histomorphologic features of previously unrecognized forms of equine rhinitis/sinusitis were described, including those caused by Flavodon flavus, Curvularia lunata, Exserohilum rostrata, Alternaria alternata, Alternaria sp., Cladophialophora bantiana, Fusarium solani, and Toxicocladosporium irritans. PCR and DNA sequencing using panfungal and oomycete primers with DNA from formalin-fixed and paraffin-embedded specimens successfully identified the pathogen in phaeohyphomycosis (7/18 cases, 39%), zygomycosis/pythiosis (1/32 cases, 3%), and other nonpigmented fungal infections (3/3 cases, 100%). Zygomycosis and phaeohyphomycosis were the most common forms of fungal rhinitis found in Florida horses.

Surgical enlargement of the nasomaxillary aperture and transnasal conchotomy of the ventral conchal sinus: Two surgical techniques to improve sinus drainage in horses.

OBJECTIVE: To evaluate 2 surgical techniques for establishing and/or improving paranasal sinus drainage in cadaver heads and horses with sinusitis and evaluate the feasibility of postoperative transnasal sinus endoscopy. STUDY DESIGN: Ex vivo study (equine cadaver heads) and case series. SAMPLE POPULATION: Nine adult equine cadaver heads and 8 horses with recurrent sinusitis. METHODS: For the ex vivo study, the following procedures were performed on 9 cadaver heads: preoperative and postoperative computed tomography (heads 1-6), endoscopy-guided transnasal conchotomy of the ventral conchal sinus (TCVCS) and surgical enlargement of the nasomaxillary aperture (SENMAP) on opposite sides (heads 1-3), combined TCVCS and SENMAP on both sides (heads 4-9), evaluation of sinus drainage before and after surgery (heads 7-9), and postoperative transnasal endoscopy (heads 4-9). For the case series, 8 horses with secondary sinusitis were treated in standing position with SENMAP and/or TCVCS and postoperative transnasal endoscopy. RESULTS: Sinonasal communications were successfully created in all cadavers and affected live horses. Transnasal endoscopy of all sinuses except the middle conchal sinus was possible in heads 4-9 and in all clinical cases. Sinus drainage was improved (P = .028) by combining techniques. Blood loss in live horses ranged from 0.5-5.5 L (1.95 ± 1.5) per horse. Sinusitis resolved in all affected horses during follow-up of 3.2-25.5 months (13.5 ± 8.5). CONCLUSION: Transnasal conchotomy of the ventral conchal sinus and SENMAP consistently created large sinonasal communications, facilitating sinus endoscopy and improving sinus drainage. CLINICAL SIGNIFICANCE: Transnasal conchotomy of the ventral conchal sinus and SENMAP are viable options to treat horses with sinusitis and anatomical obstructions of the sinonasal communications.

Diagnosis and Treatment of a Swainson's Toucan (Ramphastos ambiguus swainsonii) With Rhinosinusitis.

A female Swainson's toucan (Ramphastos ambiguus swainsonii) was presented for examination with a 2-year history of mucoid nasal discharge and abnormal growth of the rhamphotheca. Nasal cytologic examination and culture results were consistent with mixed aerobic and anaerobic bacterial rhinitis. Radiographic and computed tomographic imaging demonstrated a deviated septum of the nasal diverticulum and multiple soft tissue densities in the caudal aspects of the maxillary and mandibular infraorbital diverticula of the infraorbital sinus. Results of rhinoscopy and biopsy confirmed bacterial rhinitis. Treatment included multiple nasal lavages with saline, gentamicin, and amphotericin B and systemic ciprofloxacin and tobramycin nebulizations for several weeks. Repeat radiographic imaging 4 years later showed resolution of most soft tissue opacities previously observed within the maxillary and mandibular diverticula but persistence of 3 areas of soft tissue, dense material within the maxillary sinus diverticulum. A sinus trephination procedure was performed through the maxillary bone for sinoscopy and sample collection and topical treatment. Results of aerobic bacterial cultures from the granulomas were negative. Biopsy results were consistent with keratin granulomas without bacterial or fungal infection. Two and a half years after trephination, the surgical site was fully healed with no recurrence of the nasal discharge. This is the first report, to our knowledge, of sinus trephination in a toucan and describes the advanced diagnostic and medical and surgical treatment of chronic rhinitis in this case.

TREATMENT OF MYCOTIC RHINOSINUSITIS IN A BENNETT'S WALLABY ( MACROPUS RUFOGRISEUS) USING TOPICAL VORICONAZOLE SUSPENDED IN A REVERSE THERMODYNAMIC PLURONIC GEL.

An approximately 4-yr-old female Bennett's wallaby ( Macropus rufogriseus) was evaluated for chronic left-sided facial swelling and nasal discharge. Computed tomography, endoscopy, biopsy, mycologic culture, and panfungal polymerase chain reaction were consistent with destructive mycotic rhinosinusitis. The patient's infection was treated with a long-term injectable antibiotic, oral antifungal therapy, and multiple intranasal infusions of voriconazole suspended in a reverse thermodynamic pluronic gel. This case represents the first documented case of mycotic rhinosinusitis in a macropod and underlines the importance of advanced cross-sectional imaging in the diagnosis, monitoring, and management of nasal cavity disease in zoo animals.

Trans-endoscopic diode laser fenestration of equine conchae via contralateral nostril approach.

OBJECTIVE: To describe and report preliminary outcomes of a contralateral trans-nasal endoscopic laser fenestration of the conchae for endoscopic examination and treatment of paranasal sinuses in horses. STUDY DESIGN: Cadaveric experimental and prospective clinical study. ANIMALS: Normal cadaveric equine heads (n = 7) and equine patients (horses n = 7, donkey n = 1) diagnosed with sinusitis. METHODS: Ex vivo: a video-endoscope containing a diode laser fiber in the working canal was passed through the nostril and retroflexed in the nasopharynx toward the contralateral conchae. Ventral or dorsal conchae were fenestrated. Duration of surgery, laser energy, visualization quality, and feasibility of sinoscopy through the fenestrations were recorded. In vivo: sinus drainage, sinoscopy 24 hours postoperatively, stoma persistence, and clinical results after 3 months were evaluated in 8 patients. RESULTS: Fenestrations were performed in 8 dorsal conchae (6 cadavers, 2 patients), 10 ventral conchae (5 cadavers, 5 patients), and 1 dorsal conchal bulla (1 patient). Visualization was good in 6 patients and affected by bleeding in 2 patients. Drainage through the fenestrations was observed in all patients. Trans-nasal sinoscopy was possible in all cadavers and in 6 out of 8 patients. Masses inside the sinuses precluded sinoscopy in 2 patients. Stomata persisted until discharge of the patients (mean of 14 days). Clinical signs improved in 6/8 patients. CONCLUSION: The endoscopic approach reported here provides good visualization during the trans-endoscopic laser fenestration of the conchae. The fenestrations may allow a trans-nasal sinoscopic examination and treatment in selected cases of sinusitis in horses.

Treatment of chronic sinusitis in a horse with systemic and intra-sinus antimicrobials.

A 12-year-old Norwegian Fjord gelding was diagnosed with paranasal sinusitis as a post-operative complication of tooth repulsion surgery. The infection with inspissated purulent material persisted despite sinus trephination and lavage, and systemic antimicrobial therapy. Resolution occurred following infusion of a gelatin/penicillin mixture into the right rostral and caudal maxillary sinus.

Traitement de la sinusite chronique chez un cheval à l'aide d'antimicrobiens systémiques et dans les sinus. Une sinusite paranasale a été diagnostiquée chez un hongre Fjord âgé de 12 ans comme complication postopératoire d'une chirurgie pour la répulsion d'une dent. L'infection avec du matériel purulent épaissi a persisté malgré la trépanation et le lavage du sinus et une thérapie antimicrobienne systémique. La résorption s'est produite après l'infusion d'un mélange de gélatine et de pénicilline dans les sinus maxillaires rostral et caudal droits.(Traduit par Isabelle Vallières).

USE OF COMPUTED TOMOGRAPHY FOR INVESTIGATION OF RHINITIS AND SINUSITIS IN A GREATER RHEA (RHEA AMERICANA).

Sinusitis is a common finding in avian species; however, it presents unique treatment challenges in ratites. A 6-yr-old male greater rhea ( Rhea americana ) presented acutely with right infraorbital sinus swelling and chemosis. Oral antibiotics were prescribed based on bacterial culture results with incomplete resolution of clinical signs. A computed tomography scan of the skull demonstrated a mixed-density soft tissue mass with extensive destruction of the right nasal bone, hard palate, maxilla, and frontal bone. The affected tissue was surgically resected and histopathology was consistent with inspissated necrotic tissue. Aerobic culture of the mass grew a multidrug-resistant Escherichia coli and was treated with amikacin. Ten months postsurgery, no further clinical signs were observed. Advanced diagnostic imaging with computed tomography and surgical therapy facilitated complete resolution of this resistant bacterial sinusitis in a species that is not typically amenable to frequent handling and restraint.

SINUSITIS, BRONCHIECTASIS, AND FLATUS IN A SUMATRAN ORANGUTAN (PONGO ABELII): COULD THIS BE CYSTIC FIBROSIS?

A 31-yr-old male Sumatran orangutan (Pongo abelii) presented with 14 yr of chronic purulent nasal drainage and cough with intermittent exacerbation of symptoms requiring systemic antibiotic treatment. He was diagnosed with a cystic fibrosis (CF)-like condition. Evaluation consisted of bronchoscopy with bronchoalveolar lavage, culture, and computed tomography scanning of the sinuses and chest. Although the presence of low fecal elastase activity increased the suspicion for a diagnosis of CF, pilocarpine iontophoresis with sweat collection and analysis ("sweat testing") was inconclusive. Medical management included twice-daily nebulization with bronchodilators and alternating month inhaled antibiotics, pancreatic enzyme replacement therapy, and simethicone as needed. Sinopulmonary and gastrointestinal symptoms improved substantially with treatment. Several years later, the animal died acutely of colonic volvulus. Necropsy and histopathology confirmed CF-like lung disease with chronic air sacculitis.

Sinusitis associated with nasogastric intubation in 3 horses.

Sinusitis has not been reported as a complication of long-term nasogastric intubation in horses. We describe 3 horses that developed nosocomial sinusitis following abdominal surgery with associated perioperative nasogastric intubation. Sinusitis was suspected by the presence of malodorous discharge and confirmed by percussion, upper airway endoscopy, radiographs (n = 3), and bacterial culture (n = 1).

Sinusite associée à l'intubation naso-gastrique chez 3 chevaux. La sinusite n'a a pas été signalée comme une complication de l'intubation naso-gastrique à long terme chez les chevaux. Nous décrivons 3 chevaux qui ont développé une sinusite nosocomiale après une chirurgie abdominale utilisant une intubation naso-gastrique péri-opératoire connexe. La sinusite a été suspectée en observant la présence d'un écoulement malodorant et confirmée par percussion, endoscopie des voies respiratoires supérieures, radiographies (n = 3) et culture bactérienne (n = 1).(Traduit par Isabelle Vallières).

Standing equine sinus surgery.

Trephination of the equine sinuses is a common surgical procedure in sedated standing horses. Standing sinus flap surgery has become increasingly popular in equine referral hospitals and offers several advantages over sinusotomy performed under general anesthesia, including reduced patient-associated risks and costs; less intraoperative hemorrhage, allowing better visualization of the operative site; and allows surgeons to take their time. Other minimally invasive surgical procedures include sinoscopic surgery, balloon sinuplasty, and transnasal laser sinonasal fenestration. Despite the procedure used, appropriate indications for surgery, good patient selection, and familiarity with regional anatomy and surgical techniques are imperative for good results.

Nasal adenocarcinoma and secondary chronic sinusitis in a hyacinth macaw (Anodorhynchus hyacinthinus).

An adult male hyacinth macaw (Anodorhynchus hyacinthinus) that presented for acute onset nasal discharge and dyspnea had purulent discharge from the right naris and serosanguineous discharge from the left naris on physical examination. Results of a complete blood count revealed severe leukocytosis with a mature heterophilia. Computed tomography scans showed a large amount of soft-tissue attenuating material within the infraorbital sinus and associated diverticula. Aerobic culture results of the nasal discharge showed a mixed population of Staphylococcus intermedius and Pasteurella species, including Pasteurella pneumotropica; all isolated bacteria were susceptible to enrofloxacin. Clinical signs did not resolve over the course of 9 weeks of antibiotic treatment. The macaw died after cardiopulmonary arrest while hospitalized. At necropsy, a 2 x 2 x 3-cm firm, tan, friable, space-occupying mass surrounded by a thick exudate was present in the left preorbital diverticulum of the infraorbital sinus. The cranioventral one-third of the trachea contained a 4 x 0.5-cm white-yellow plaque. On histologic examination, the sinus mass was diagnosed as a nasal adenocarcinoma, and the tracheal plaque was caused by fungal infection, most likely with an Aspergillus species.