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Endoscopic Assisted Electro-Cauterization to Treat an Acquired Pharyngeal Ostium Stenosis in a Horse: a Case Report

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Endoscopic Assisted Electro-Cauterization to Treat an Acquired Pharyngeal Ostium Stenosis in a Horse: a Case Report Case Report Veterinarni Medicina, 56, 2011 (7): 362–366 Endoscopic assisted electro-cauterization to treat an acquired pharyngeal ostium stenosis in a horse: a case report M. Pietra1, N. Romagnoli1, S. Valentini1, G. Spinella2, A. Spadari1 1Department of Veterinary Medical Sciences, University of Bologna, Italy 2Department of Experimental and Clinical Medicine, University of Catanzaro, Italy ABSTRACT: An 8-year-old Italian saddle-horse gelding with a history of left guttural pouch empyema was referred to the clinic. Endoscopic examination showed a stenosis of the left pharingeal ostium that was treated with an endoscopic assisted electro-cauterization. Endoscopic follow-ups were performed before discharge and at six months after stenosis removal. No recurrence was observed, confirming the patency of the pharyngeal orifice. Keywords: guttural pouches; pharingeal ostium; empyema; ostium stenosis; horse Guttural pouches are air-filled pharyngo-timpanic the mucosa (Getty, 1982). The dorsal portion is con- or auditory tube diverticula that, in the adult horse, tinuous with the pharynx through the pharyngeal have a volume varying from 300 to 600 milliliters orifices (pharyngeal ostium) of the auditory tubes. (Munoz et al., 2008). They are located in the caudal These openings are equal in size and are covered by area of the head and extend ventro-dorsally from the the medial cartilage lamina, placed dorso-laterally to pharynx to the base of the skull and oro-aborally from the rynopharynx. Exudate and biological materials the dorsal pharyngeal recess to the atlanto-occipital that may accumulate in the pouch are removed daily joint. Moreover, they appear divided by the stylohy- by a dynamic mechanism of mucociliar clearance and oid bone into two compartments: lateral and medial. through the uplift of the pouch base to the pharyngeal Each pouch is separated from the contralateral one orifice during the swallowing phase. by a median septum and, dorsally, by the rectus capi- Guttural pouches are particularly developed tis and longus capitis muscles. On the lateral side, in horses and donkeys, but are also present in the guttural pouch confines the pterigo-pharingeus, other animals like tapirs, some rhinoceros (ex- levator and tensor veli palatini muscles, stylohyoi- cept for white rhinoceros), certain bats, the South deus and occipitohyoideus muscles, the ventral belly American forest mouse and hyraxes (Getty, 1982; of the digastricus muscle, as well as the parotid and Alsafy et al., 2008). The function of the guttural mandibular salivary glands (Getty, 1982; Hardy and pouch is not yet completely understood but differ- Leveille, 2003). The guttural pouch is lined with a ent suggestions have been made, including a role pseudostratified ciliated epithelium containing gob- in equilibration across the tympanic membrane, let cells. The main arteries (internal carotid, external in inspirated air warming, as a resonance cham- carotid and maxillary arteries) and nerves (IX, X, XI ber for equine whinny, and as a device for head and XII cranial nerves, sympathetic nerves and cra- flotation (Briggs, 2000). Recently, Baptiste et al. nial cervical ganglion) are located inside each gut- (2000) suggested that the function of the guttural tural pouch, under the mucosa fold, and are easily pouches may be connected with cooling the blood visualized with an endoscope (Getty, 1982; Freeman, that supplies the brain through the internal and 1999). Moreover, retropharyngeal lymph nodes and external carotid arteries. This mechanism would the recurrent laryngeal nerve are clearly visible in provide heat exchange between the blood that flows the ventral side of the medial compartment, under through arteries located under the guttural mucosa, 362 Veterinarni Medicina, 56, 2011 (7): 362–366 Case Report and the air of the pouch that, during physical activ- The owner observed a slight decrease in weight, ity, is refreshed more quickly because of the orifice but no respiratory noises, laryngeal or pharyngeal openings (Baptiste et al., 2000). However, a more dysfunction or dysphagia. On the day of our visit, recent study by Mitchell et al. (2006) rejected this the horse showed good general condition with no latter hypothesis based on direct measurement of nasal discharge, hyperemic conjunctival and oral extra and intracranic blood temperature. To achieve mucosae and the presence, in the retromandibular this, dedicated probes were positioned in the com- region, of a fistula with thickening edges. Emission mon carotid, in the jugular vein and close to the of a purulent exudate from the fistula was also ob- hypothalamus (Mitchell et al., 2006). However, no served. Around the fistula the skin was hairless, temperature decrement between the intracranic thickening, hyperaemic and had a purulent con- and extracranic blood was observed during physical glomerate exudate. Standard preoperative blood activity or at rest (Mitchell et al., 2006). parameters were within the normal range. The incidence of guttural pouch diseases in the An x-ray exam of the retromandibular area was horse, such as empyema, tympany and mycosis, is performed in standing position and in lateral view rather low (Carmalt, 2002; Schaaf et al., 2006), and (kV 75 mAs 12). A thickening of the left guttural reports in the literature are constituted by several ar- pouch wall and imperfect lap siding of the two ticles with a small number of cases (Freeman, 2006; guttural pouches were visualized. No calcification Perkins et al., 2006; Schambourg et al., 2006) rather areas were observed within the pouch. than retrospective studies with large numbers of An endoscopic examination in the standing sta- cases (Judy et al., 1999). Inflammatory processes of tion was performed with a Pentax Eg 290-kP flex- the guttural pouch can result in empyema, which is ible endoscope (9.8 mm diameter) and a Pentax sometimes complicated by chondroids and exudate EG-1870 (6 mm diameter), with the patient under conglomerates. Moreover, chronic guttural pouch sedation with detomidine (Domosedan 0.01 mg/kg empyema may occasionally involve stenosis or com- i.v.) and butorfanol (Dolorex 0.05 mg/kg i.v.). plete closure of the pharyngeal ostium (Gehlen and The examination showed mild hyperaemia of the Ohnesorge, 2005; Perkins et al., 2006). rhynopharyngeal mucosa with a reduced dorsal We describe a chronic purulent case of guttur- pharyngeal recess. No abnormalities were visual- ocystitis with stenosis of the pharyngeal ostium ized in the larynx with the horse at rest or after treated with endoscopic assisted electro-cauteri- the “slap test”. Normal pharyngeal tube morphology zation to remove the stenotic tissue. was observed and no exudate was visualized close to the pharyngeal ostium or on the pharyngeal wall and lumen. Examination of the right guttural pouch Case description was performed, approaching through the right nos- tril. The pouch appeared within normal limits with An 8-year-old Italian saddle-horse gelding was no abnormalities. Examination of the left guttural referred to the University Clinic with a history of pouch was performed by introducing the endoscope about 45 days of monolateral left nasal discharge through the left nostril; endoscope progression was and a swelling in the left retromandibular region. possible until the cartilage portion of the left guttural One month before our visit, the referring veteri- pouch opening for approximately one centimetre; narian had submitted the horse to daily flushings after that, a ductal stenosis was visualized with the with physiological solution administered through presence of whitish lined fibrotic tissue and granu- endoscopic-assisted catheterization of the left gut- lation tissue in a transverse position (Figure 1). An tural pouch. Following poor clinical results, 15 days opening of about 2 mm was visualized in the ventral before our visit, the veterinarian performed surgical side of the stenotic area of the left guttural pouch. drainage by creating a permanent fistula approach- Following the endoscopic inspection a pharyngeal ing the guttural pouch over the Viborg’s triangle. ostium stenosis of the left auditory tube was diag- After fistulation, the owner observed a mild re- nosed. We concluded that the small opening would duction in the nasal discharge with a persistent probably permit the introduction of a 2 mm cathe- swelling on the left retromandibular region with ter under endoscopic guidance (Figure 2). Removal purulent material flowing out of the fistula. During of the stenotic tissue was recommended. this period the horse was excluded from agonistic The stenosis was removed under endoscopic activity and was put out to rest in the paddock. guidance by electro-cauterization (EXCELL 250 363 Case Report Veterinarni Medicina, 56, 2011 (7): 362–366 Figure 1. Stenosis of pharyngeal ostium Figure 2. Indirect evaluation of stenotic area with a 2 mm catheter introduced under endoscopic guidance MCDS – Alsa s.r.l., Italy) of the stenotic tissue. a catheter into the endoscope instrumental channel The horse was in the standing position under se- and contemporary rotation of a flexible endoscope dation with detomidine and butorfanol, as previ- that resulted in abduction of the fibrocartilagineal ously described. The aim of this procedure was to ostium and the introduction of the Foley catheter reconstruct the stenotic tube by plastic surgery. into the guttural pouch (Figure 4). The correct Foley When a diameter of 1 cm was achieved, approxi- positioning inside the guttural pouch and the dis- mately 2 h after the beginning of the procedure, the tension of the catheter balloon with 10 millilitres of Pentax EG-1870 endoscope was introduced into physiological solution were controlled using Pentax the left guttural pouch (Figure 3). An abundant EG-1870 endoscope visualization introduced into grayish exudate was observed in the medial portion the pouch through the fistula of Viborg’s trian- of this pouch. It was sucked out with a catheter gle. The external extremity of the Foley catheter introduced alongside the endoscope and was sub- was fixed to the lateral margin of the left nostril mitted to the laboratory for bacterial culture.
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