URT surgery

Question 1

Which clinical signs may mean URT surgery is required?

Answer 1

• Dyspnoea
• URT noise
• Poor performance (primary cause for URT surgery)
• Dysphagia

Question 2

Conditions of the external nares?

Answer 2

• Atheromas
• Redundant alar folds
• Lacerations affecting nostrils

Question 3

What are atheromas?

Answer 3

Cystic structures that sit at the top of the diverticulum

Question 4

Where does the maxillary sinus open into?

Answer 4

Opens into caudal middle meatus via nasomaxillary opening

Question 5

Why should you be in the ventral meatus rather than the middle meatus to pass a tube or endoscope?

Answer 5

If you pass up the middle meatus you are close to the ethmoid turbinates and risk profuse epistaxis

Question 6

Structure of the paranasal sinuses?

Answer 6

• Sphenopalatine, frontal, caudal maxillary, rostral maxillary, dorsal conchal and ventral conchal sinuses (and ethmoidal)
• Horses have two sinus systems that don’t communicate (caudal and rostral), septum in between
• Ventral conchal and rostral maxillary form rostral compartments (completely distinct)

Question 7

Which tooth roots lie in the maxillary sinus?

Answer 7

• Tooth roots of 4th, 5th and 6th cheek teeth lie within the maxillary sinuses
• infection causes sinusitis

Question 8

Which tooth root forms the rostral wall of the rostral maxillary sinus?

Answer 8

• Roots of 3rd cheek tooth forms rostral wall of rostral maxillary sinus
• infection may cause sinusitis

Question 9

Which other structures lie within the maxillary sinuses?

Answer 9

nasolacrimal canal and infra-orbital canal

Question 10

What conditions might you see in the nasal passages?

Answer 10

• Masses
  
  • Fungal granuloma
  • Neoplasia
  • Ethmoid hematoma

Question 11

When is sinus surgery indicated?

Answer 11

• Expansive lesions in paranasal sinus e.g. sinus cyst, neoplasia, ethmoid haematoma, tooth root abscess
• Primary sinusitis
• Severe trauma of facial bones

Question 12

Why is sinus surgery indicated for primary sinusitis but often not secondary sinusitis?

Answer 12

• Secondary sinusitis will not resolve without sorting the primary disease
• With primary sinusitis flushing it out and treating the sinus should resolve it

Question 13

5 cartilages of the larynx?

Answer 13

Epiglottis, cricoid, thyroid, paired arytenoids

Question 14

What is the Rima Glottidis?

Answer 14

The aperture of the larynx which goes down into the trachea

Question 15

List conditions of the pharynx and larynx.

Answer 15

• Cleft palate
• DDSP
• Laryngeal hemiplegia
• Arytenoid chondropathy
• Subepiglottic cysts
• Epiglottic entrapment

Question 16

What are the consequences of Cleft palate?

Answer 16

Nasal reflux of milk / food material and aspiration pneumonia

Question 17

Diagnosis, treatment and prognosis of cleft palate?

Answer 17

• Diagnosed on endoscopy
• Poor prognosis - recurrent infections and poor athletic function
• Tx: surgery - poor success rate

Question 18

Surgical options for Dorsal Displacement of the Soft Palate (DDSP)?

Answer 18

• Myectomy (sternothyroid +/- sternohyoid)
• Palatal fibrosis (thermocautery or laser)
• Tie forward (prosthesis to replace thyrohyoid muscle)

Question 19

Which surgical option for DDSP has the best success rate?

Answer 19

• Tie forward – currently most popular and best success rate (80%)
• Most have 60% success rate

Question 20

What is a Myectomy?

Answer 20

Cutting through some of the muscles that insert onto the larynx

Question 21

When is arytenoidectomy indicated for laryngeal hemiplegia?

Answer 21

Generally only indicated if other techniques fail.

More commonly indicated for arytenoid chondropathy

Question 22

How is arytenoid chondritis diagnosed?

Answer 22

• Endoscopy (resting)
  
  • Size—compare to other side (tricky if bilateral)
  • Mucosa—loss of “bumps”, breaks in surface
  • Drainage, granulation tissue
• Palpation—rounded muscular process

Question 23

How is arytenoid chondritis treated medically?

Answer 23

• Antimicrobial
• Anti-inflammatories (systemic and local)
• Often improves significantly

Question 24

How is arytenoid chondritis treated surgically?

Answer 24

• Local excision (via endoscope or laryngotomy)
• Arytenoidectomy—failure of medical management
• Permanent tracheostomy— esp if bilateral

Question 25

How is intralaryngeal granulation tissue treated?

Answer 25

* Excision—endoscopic, laryngotomy * W/ concurrent chondritis * Excision can make worse * May require arytenoidectomy * W/ abscessation * Curettage via laryngotomy

Question 26

What is the prognosis with all surgical treatments of the pharynx and larynx?

Answer 26

Poor for full athletic function

Question 27

How are subepiglottic cysts (congenital or acquired) or granulomas treated?

Answer 27

* surgical excision through laryngotomy * oral removal using Nd:YAG laser or snare wire * Good prognosis

Question 28

How are subepiglottic cysts diagnosed?

Answer 28

* URT endoscopy (may not see) * Oral examination * Radiographs

Question 29

Clinical signs of epiglottic entrapment?

Answer 29

* Poor performance? * Respiratory noise (most common clinical sign) * +/- cough * +/- nasal discharge

Question 30

Diagnosis of epiglottic entrapment?

Answer 30

* Endoscopy * Lose scalloped border and vascular pattern on dorsal aspect of epiglottis * +/- mucosal ulceration * Intermittent entrapment may require exercising endoscopy

Question 31

Epiglottic entrapment options?

Answer 31

1. Resection of aryepiglottic folds 2. Axial division per os 3. Axial division per nasum 4. Transendoscopic laser division * 3 and 4 no requirement for anaesthesia

Question 32

What is contained in the medial compartment of the gutteral pouch?

Answer 32

internal carotid, cranial sympathetic nerves, cranial cervical ganglion, and cranial nerves IX (glossopharyngeal), X (vagus)and XII (hypoglossal).

Question 33

What is contained in the lateral compartment of the gutteral pouch?

Answer 33

external carotid, maxillary artery and cranial nerve VII (facial nerve on the outside of the lateral compartment ).

Question 34

Which compartment of the gutteral pouch is more likely to be affected by mycotic lesions?

Answer 34

Most mycotic lesions affect the medial compartment.

Question 35

Which compartment of the gutteral pouch is more likely to be affected by injury and trauma?

Answer 35

Lateral compartment

Question 36

List conditions of the gutteral pouch.

Answer 36

* Guttural pouch tympany * Guttural pouch empyema * Other masses * Stylohoid fractures * Guttural pouch mycosis

Question 37

Why can gutteral pouch mycosis be so serious?

Answer 37

* The fungus will erode through the soft tissues * Eventually erodes through the carotid which haemorrhages and the horse will bleed out * If you see a horse with epistaxis should always investigate for this one

Question 38

How is gutteral pouch mycosis treated?

Answer 38

* Ligation (can safely occlude one of the carotids) * Balloon catheter * Transarterial coil embolization

Question 39

Difference between tracheotomy and tracheostomy?

Answer 39

* TRACHEOTOMY (temporary) * TRACHEOSTOMY (permanent)

Question 40

Describe process of placing a tracheotomy.

Answer 40

* Cranial/mid third of neck - midline dissection to trachea * Incision made between and parallel to cartilage rings * Tracheotomy tube placed and secured with sutures or bandage * Aftercare - basic wound management and removing excess discharge

Question 41

Complications and considerations of a tracheostomy?

Answer 41

* Wound care and aftercare is significant (advise owner) * Potential complications include pulmonary infection and drowning * With both techniques there is considerable discharge, and the owner should be advised of the cosmetic appearance beforehand

Question 42

How are tracheal conditions diagnosed?

Answer 42

Endoscopy, radiographs, fluoroscopy, ultrasound

Question 43

What treatments are available for tracheal conditions?

Answer 43

* Intraluminal granulation tissue—laser * Extraluminal compression * Remove/treat compressing structure * May need to reconstruct ring * Collapse * Intra and extra-luminal stenting has been reported * Success poor