How to Perform a Minimally Invasive Sinus Flush in the Equine Patient

LAMENESS—SURGERY

How To Perform a Minimally Invasive Sinus Flush in the Equine Patient

Jose´ M. Garcı´a-Lo´ pez, VMD, Diplomate ACVS; and Fausto Bellezzo, DVM

Authors’ addresses: Tufts University, Cummings School of Veterinary Medicine, 200 Westboro Road, North Grafton, MA 01536 (Garcı´a-Lo´pez); and The Equine Center, 4850 Davenport Creek Road, San Luis Obispo, CA 93401 (Bellezzo); e-mail: [email protected]. © 2008 AAEP.

1. Introduction In addition, it can be curative in cases of primary Clinical signs of sinus disease can include nasal sinusitis as well as an adjunct to surgical interven- discharge (usually unilateral and can be malodor- tion. Historically, this procedure has been per- ous), facial deformity, and respiratory noise.1,2 formed using Steinmann pins or Trephinators. Sinusitis can be subdivided into two groups: pri- Although these are effective in creating an entrance mary and secondary. Primary sinusitis can be of into the sinus, they can cause secondary complications either bacterial or viral etiology. Secondary sinus- such as focal cellulitis and fistulation, especially when itis includes conditions such as paranasal sinus using large trephines or pins. Alternative methods cysts, tooth root abscess, trauma such as fracture of for gaining entrance into the sinus cavity have been the frontal/nasal bones, and neoplasia. An accu- developed by equine clinicians, including using a 14- or 16-gauge needle to create a lavage portal as previously rate diagnosis can be made using conventional im- reported by Schumacher and Perkins.10 The purpose aging modalities such as radiography (Fig. 1) and of this presentation is to show how to perform an nasal endoscopy. However, in certain cases, these effective sinus lavage using this minimally invasive fail to give the clinician an accurate idea regarding technique and without using specialized equipment. the extent of the lesion and the structures affected, thus necessitating further imaging modalities such 2. Materials and Methods as sinoscopy, nuclear scintigraphy, and computed Materials and equipment needed for the lavage in- tomography.1–8 clude: lidocainea or mepivicaine,b a #15 blade, sev- Lavage or flush of the sinuses has been performed eral 1- or 1.5-in, 14-gauge needles, a mallet, 1-l bags for years in the diagnosis and management pro- of Lactated Ringers Solutionc (LRS), a pressure bag, cesses of sinus disease.4,6,9 It can aid in achieving a primary IV set, a syringe (10–20 ml), triple anti- an accurate diagnosis, because it removes the dense biotic ointment, gloves, and scrub supplies (Fig. 2). fluid within the sinus and allows for a better radio- The lavage can be done through the maxillary or graphic visualization of the different sinus compart- frontal sinus portals. Landmarks for the maxillary ments. This is especially helpful in the field where sinus include the medial canthus, the facial crest, advanced diagnostic imaging might not be available. and the infra-orbital foramen (Fig. 3). Landmarks

NOTES

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Fig. 1. Lateral radiograph showing the dense ﬂuid line.

Fig. 3. Maxillary sinus landmarks. The circle indicates the for the frontal sinus include the medial canthus, the entry portal for the needle. supraorbital foramen, and midline (Fig. 4). The area can be clipped; however, this is not absolutely necessary. After the decision is made as to which portal will be used, it is scrubbed, and a small bleb with 1–2 ml of lidocaine or mepivicaine is placed subcutaneously (Fig. 5). A small stab incision (ϳ2–3 mm) is made on the skin using a #15 blade

Fig. 4. Frontal sinus landmarks. The circle indicates the entry Fig. 2. Materials needed for the sinus ﬂush. portal for the needle.

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Fig. 5. Frontal and maxillary portals scrubbed and blocked. Fig. 7. Placement of the needle against the bone.

(Fig. 6). After this, a 14-gauge needle is introduced If another lavage is performed 24–48 h later, the into the stab incision and held firmly against the entry site for the needle can be identified by “walk- bone (Fig. 7). Using a mallet, the needle is driven ing” the needle over the bone through the old stab into the sinus (Fig. 8), taking care to avoid bending incision; this avoids the need for the mallet. the needle. If this happens, the bent needle is re- placed with a new one. After the needle is in the 3. Results and Discussion sinus, a syringe is attached to the needle to aspirate At our hospital, this minimally invasive flushing any purulent material for analysis and/or culture technique is used on a regular basis with subjec- (Fig. 9). A 1-l bag of LRS is connected to the IV set tively great results. This technique is especially and placed within the pressure bag. The pressure useful in patients during the pre- and post-operative bag is inflated as indicated by the manufacturer and period, because it minimizes soft tissue and bony connected to the needle (Fig. 10). Fluid should be trauma that can compromise the surgical field and able to flow easily and exit through either the other increase patient morbidity. The technique is very needle (if two were placed) and/or the appropriate easy to learn and is tolerated well by the patient. nostril (Fig. 11). The sinuses are lavaged thor- Horses with adequate sedation and a local bleb of oughly with the desired volume of fluids. At our anesthetic do not object to the noise and pressure hospital, this is usually between 2 and 5 l. After created by the mallet driving the needle into the the lavage has been completed, the needles are re- sinus. It is important, for obvious reasons, that the moved, and the stab is covered with triple antibiotic mallet and needle are held firmly. ointment. No sutures or bandages are necessary.

Fig. 6. Creating a small stab with a #15 blade. Fig. 8. Needle and mallet.

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Fig. 9. Aspiration of purulent ﬂuid. Fig. 11. Flow is established through the affected nostril. Note the syringe plugging the frontal portal.

Techniques that use a trephine require a large incision or bony defect. By using the less-invasive sinus during the lavage to maintain an adequate irriga- flush, we can eliminate or minimize problems such as tion of the sinus cavity through the needle. incisional complications, compromise of the bone flap In conclusion, we believe that this technique is caused by surgery, delayed healing, and fistula forma- very effective in achieving an adequate sinus lavage tion. The entry port does not need special care post- and should be considered by veterinarians both in lavage, because the defects created at the level of the hospitals and in ambulatory practices as a viable skin and bone are minimal. Disadvantages of this alternative to traditional techniques. technique include the lack of temporary catheter or tubing left in place, which might be desirable in some References and Footnotes hospitalized cases or in cases where owners need to 1. Freeman DE. Sinus disease. Vet Clin North Am [Equine continue treatment at home. Also, thicker frontal, Pract] 2003;19:209–243. incisive, zigomatic, and lacrimal bones can poten- 2. Beard WL, Hardy J. Diagnosis of conditions of the paranasal sinuses in the horse. Equine Vet Edu 2001;13:265–273. tially preclude the use of the 14-gauge needle. This 3. Woodford NS, Lane JG. Long-term retrospective study of 52 obstacle is more likely in heavier breeds such as horses with sinunasal cysts. Equine Vet J 2006;38:198–202. Warmbloods and draft horses. Another relative 4. Boulton CH. Equine nasal cavity and paranasal sinus disease: disadvantage is the need to maintain high pressures a review of 85. cases. J Equine Vet Sci 1985;5:268–275. 5. Freeman DE. Paranasal sinuses. In: Beech J, ed. Equine respiratory disorders, 1st ed. London: Lea & Febiger, 1991;275–305. 6. Lane JG. The management of sinus disorders: part 2. Equine Vet Edu 1993;5:69–73. 7. Rush B, Mair T. Diseases of the nasal cavity and paranasal sinuses. In: Equine respiratory diseases, 1st ed. Oxford, England: Blackwell Publishing, 2004;48–49. 8. Tremaine WH, Dixon PM. A long-term study of 277 cases of equine sinonasal disease. Part 1: details of horses, histor- ical, clinical and ancillary diagnostic findings. Equine Vet J 2001;33:274–282. 9. Tremaine WH, Dixon PM. A long-term study of 277 cases of equine sinunasal disease. Part 2: treatments and results of treatments. Equine Vet J 2001;33:283–289. 10. Schumacher J, Perkins J. Surgery of the paranasal sinuses performed with the horse standing. In: Orsini JA, ed. Clini- cal techniques in equine practice. Philadelphia, PA Elsevier, 2005;4(2):188–194.

aLidocaine 2%. Hospira, Inc. Lake Forest, IL 60045. bCarbocaine-V. Pharmacia & Upjohn Company. New York, NY 10017. cLactated Ringers Solution. LRS Baxter. Deerﬁeld, IL Fig. 10. Pressure bag and line connected to needles. 60015.

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