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Satellite Article Diagnosis and Management of Guttural Pouch Mycosis P 522 EQUINE VETERINARY EDUCATION / AE / november 2007 Satellite Article Diagnosis and management of guttural pouch mycosis P. J. POLLOCK Division of Companion Animal Sciences, Faculty of Veterinary Medicine, University of Glasgow, 464 Bearsden Road, Glasgow G61 1QH, UK. Keywords: horse; guttural; pouch; mycosis; Aspergillus; epistaxis History, structure and function of the guttural Despite the risks involved in having guttural pouches, it is pouches fair to say that their presence in the equine head offers the clinician a unique view of vital anatomical structures hidden The equine guttural pouches were originally described in Lyon, from view in most mammals. The accessibility of the pouches France in 1764 by Claude Bourgelat, and since then their within the respiratory tract probably leads to increased risk to presence has been noted in a broad range of other mammals, these vital structures for the horse; nevertheless guttural from forest dwelling mice in South America to marine pouch disease is comparatively rare and, as such, large mammals, rhinoceros and bats (Turner 1850; Brandt 1863; evidence-based studies investigating disease and dysfunction Ellenberger and Baum 1943; Fraser and Purves 1960; are lacking. Hinchcliffe and Pye 1960). Conditions affecting the equine guttural pouches include There have been recent advances in the understanding of empyema, tympany and the topic of this article, mycosis. the anatomy and physiological role of these structures (Figs 1–3) (Baptiste et al. 2000); however, the function of the Guttural pouch mycosis guttural pouches remains a topic of hot debate. The current Guttural pouch mycosis itself was first described by Rivolta belief holds that the pouches act with the intracranial (1868), who named the condition Gutturomyces equi and cavernous venous sinuses to cool the arterial blood en route to concluded that from the appearance of the fungus and the the brain, protecting this sensitive and vital organ from type of lesion that the organism responsible was an thermal shock. Aspergillus sp. fungus. In the years that followed, further The 2 guttural pouches are expansions of the eustachian cases of the disease were reported by a number of authors tubes that connect the pharynx to the middle ear and are located and studies of 22 and 32 horses affected by mycosis (Cook side by side, on midline, dorsal to the pharynx, at the base of the 1966, 1968; Cook et al. 1968) described clinical signs, skull. The rostral extent of the pouches is the basisphenoid bone, treatment and outcome. Since then there has been a great ventrally the pharynx, oesophagus and retropharyngeal lymph deal of interest in this condition and many valuable nodes, caudally the atlanto-occipital joint, laterally, the parotid contributions to the literature. and mandibular salivary glands and dorsally the petrous temporal bone, tympanic bulla and auditory meatus. Clinical signs The pouches are separated by a thin membrane rostrally and by the longus capitis and rectus capitis ventralis muscles caudally. Moderate to severe epistaxis (Fig 4), not associated with The guttural pouches are accessed endoscopically through exercise, is by far the most common clinical sign and follows the pharynx via the guttural pouch ostia (also known as the fungal erosion of the wall of the internal carotid (2/3 of cases) plica salpingopharyngium). The stylohyoid bone separates artery or the external carotid and maxillary artery (or its each pouch into a large medial and smaller lateral branches). A bloody mucoid discharge is common for several compartment. A number of structures are found within the days following an acute haemorrhagic episode. Most affected equine guttural pouches including cranial nerves IX, X, XI and horses have several episodes of moderate haemorrhage prior XII (cranial nerves V, VII, VIII run in close proximity to the to a fatal bleed but this is not always the case. pouches and can be affected by guttural pouch disease) the The second most common presenting sign is dysphagia cranial cervical ganglion, cervical sympathetic trunk, internal (Fig 5), following damage to the glossopharyngeal nerve and carotid, external carotid artery (and its branches, the caudal pharyngeal branch of the vagus nerve. Affected horses are auricular artery, superficial temporal artery and maxillary dull, drool saliva and have food material present at the nares. artery) stylohyoid bone and temporohyoid joint. In severe cases aspiration pneumonia develops. Damage to EQUINE VETERINARY EDUCATION / AE / november 2007 523 other neurological structures within the pouches can lead to Horses presenting with epistaxis should be treated with pharyngeal paralysis, laryngeal hemiplegia and Horner’s extreme care. Endoscopy of the pharynx will often syndrome (Greet 1987). Affected horses may present with demonstrate blood draining from one of the guttural pouch abnormal respiratory noise in the case of damage to the ostia (Fig 6), and if surgical facilities are not close at hand, no recurrent laryngeal nerve, and miosis, ptosis, enophthalmos attempt should be made to enter the guttural pouch itself as and patchy sweating following damage to the cranial cervical the endoscope may dislodge a clot, potentially leading to a ganglion. fatal haemorrhage. In a number of horses, mucopurulent nasal discharge is In horses displaying clinical signs of dysphagia, the nasal the only obvious abnormality. passages and pharynx may contain food material (Fig 7) and the Other less commonly associated clinical signs include facial dorsal wall (roof) of the pharynx is often collapsed. Permanent nerve paralysis, paralysis of the tongue, abnormal head displacement of the soft palate may also be a feature. carriage, head-shaking, sweating, colic, exposure keratitis and If endoscopy of the affected pouch is performed, the corneal ulceration, blindness and parotid pain following mycotic lesion usually appears as a yellow/brown/white and palpation at the base of the ear. Infection of the middle ear, black diphtheritic plaque, although the colour and appearance osteitis of the stylohyoid and petrous temporal bones and can be variable, on the roof of the affected pouch (Figs 8a–c). infection (Dixon and Rowlands 1981) or arthropathy of the If there has been haemorrhage it is often difficult to identify any atlanto-occipital joint (Walmsley 1988) have also been structures within the pouch and identification of the damaged reported as possible sequelae to guttural pouch mycosis. vessel can be challenging. In some cases identification of haemorrhage within either the medial or lateral compartment Aetiology may aid in identification of the damaged vessel. Other endoscopic findings include fistulas between the A number of bacterial and fungal organisms are normal pharynx and the pouches or between the pouches themselves inhabitants of the equine guttural pouches. Guttural pouch and in rare cases adhesions (Fig 9) within the pouches. mycosis is caused by many species of fungi (Lepage 1997; Ludwig et al. 2005), although Aspergillus spp. are implicated Treatment in the vast majority of cases. The mechanism of why this fungus, a normal inhabitant of the equine upper airway and If left untreated guttural pouch mycosis may result in a fatal environment, should become a pathogen in animals that are haemorrhage or irreversible neurological signs. Treatment of not debilitated or immunosuppressed is not understood. guttural pouch mycosis has historically been divided into Obtaining positive cultures of early mycotic lesions is difficult medical and surgical options, or in some cases, a combination and this is complicated by the fact that most horses are not of both. The goal of therapy is aimed at occlusion of the sampled until they have clinical signs, by which time the lesion damaged artery and/or elimination of the fungal plaque using is at an advanced stage. Unfortunately the presence of serum topical antifungal agents. It is postulated that occlusion of the antibodies to Aspergillus spp. detected by ELISA cannot affected artery leads to elimination of the fungus through differentiate between healthy horses and those affected by removal of nutrients in the blood substrate on which the the disease. fungus is maintained (Lane 1989). However, cases of Considerable debate exists as to why the fungus seems to spontaneous regression of fungal plaques and fungal plaques confine itself to specific anatomical areas. The presence of in atypical locations that do not involve blood vessels concomitant disease, such as guttural pouch empyema, low (Freeman 1999) may suggest that this hypothesis is too oxygen tension, low light levels, variations in temperature and simplistic a view of what is probably a complex, dynamic humidity have all been suggested although they lack credible process (Baptiste 2004). evidence. The presence of an aneurysm on the affected artery Therefore, choice of treatment modality may be affected has also been proposed as a factor (Colles and Cook 1983); by the area occupied by the fungus, economic factors or however, angiographic studies suggest that only a small personal preference of the clinician involved. proportion of cases have such vascular changes. Erratic larval A variety of agents have been used in the medical migration (Owen 1974) and prolonged treatment with treatment of mycotic lesions including systemic thiabendazole, antimicrobials and corticosteroids (Guillot et al. 1996) have topical nystatin (Caron et al. 1987), natamycin (Greet 1987), also been suggested as possible causes
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