SouthWest Equine Medical and Surgical Center Raising the Standard of Equine Veterinary Healthcare in Arizona

Featured Case of the Month - "Copper"
Signalment:
11-year old Thoroughbred gelding

History:
"Copper" was brought to Southwest Equine Medical and Surgical Center due to a 2-year history of intermittent mild epistaxis (nose bleed) from his left nostril.

Physical Examination:
All of "Copper's" vital signs were within normal limits.

A typical preliminary physical examination includes evaluation of: heart rate/rhythm, respiratory rate and character, rectal temperature, presence of GI sounds throughout abdomen, intensity of digital pulses in front feet, and mucous membrane (gum) color and refill time.

"Copper's" body condition score was 5 (1 = emaciated, 5 = ideal, 9= obese).

There was evidence of dried blood on the left nare.

Diagnostics:
Upper Airway Endoscopy

"Copper" was given mild sedation and a 1-meter endoscope with a video camera on the end was used to visualize "Copper's" nasal passages and upper airway system.

A brown-grey mass was seen occupying the area of the ethmoid turbinates ( a portion of the upper airway system located approximately 25cm behind the nares in the sinus cavity of the skull).

The mass was irregularly shaped with a smooth surface.
Small hemorrhages were visible over the surface of the mass.

Skull Radiographs

Lateral (side view) and dorsoventral (head-on view) radiographs supported the presence of a large space occupying mass in the left frontal sinus.

Differential Diagnoses:
Neoplasia (cancerous mass), progressive ethmoid hematoma

Due to the characteristic shape, color, location, and clinical signs, an ethmoid hematoma was highly suspected.

Ethmoid Hematoma Definition and Etilogy:
An ethmoid hematoma is a slowly expanding angiomatous (blood vessel origin) mass that originates from the mucosa (lining) of the ethmoid turbinates.

Cause = unknown

Most affected horses are 8 years old or older.

Most common clinical sign: intermittent unilateral or bilateral bleeding from the nose.

Fatal bleeding does not usually occur.

There is a history of inspiratory or expiratory noise during exercise.

An ethmoid hematoma is a sac-like structure containing blood in various stages of organization.

The mass is considered benign but will slowly and progressively enlarge and can cause distortion of skull shape.

Treatment:
A sinus flap exploratory surgery was recommended to remove the mass so that a definitive diagnosis could be made and the epistaxis would resolve.

Surgery:
"Copper" was scheduled to undergo sinus flap exploratory surgery for removal of the mass. Pre-operative blood work was performed and revealed a mild, chronic anemia due to prolonged episodes of bleeding. Blood loss during surgery can be substantial intra-operatively (due to the large blood supply of the sinus cavities and the nature/origin of the mass) so a compatible blood donor was found before surgery in case a blood transfusion was necessary.
"Copper" was placed under general anesthesia for the procedure.

A six-inch 3-sided flap was created in the skull overlying the mass using a hand-held bone saw.
The 4th edge of the flap was created by slowly elevating the flap until a controlled fracture was created so that the mass could be completely visualized (this creates a "hinged" door in the skull over the sinus).
The mass was completely removed and the remaining capsule so the mass and blood clots were cleaned out.
Once the hematoma was completely removed, the sinus cavity was packed with brown gauze (to be removed the next day) to control post-operative bleeding.
The flap was sutured back in place by drilling holes in the edge of the flap and "tying" them back to the skull.
The underlying tissues were closed and the skin over the flap was put back together using skin staples (see picture).

Recovery:
"Copper" was started on antimicrobials and anti-inflammatories following surgery and was monitored very carefully for any indication of bleeding or other post-operative complications. He continued to have mild bleeding from the left nostril but that was to be expected a couple of days following surgery.
Four days after surgery the bleeding had completely stopped and the incision site was healing well. "Copper's" vital signs were within normal limits and he appeared comfortable with a normal appetite.
"Copper" was sent home on antimicrobials and anti-inflammatories four days following surgery with instructions to return in 2-weeks for follow-up endoscopy.

Follow-up:
"Copper" returned in 2-weeks for removal of the staples and recheck upper airway endoscopy.
The incision was dry and the skin had fully healed. "Copper" had not bled from the left nostril following surgery. Endoscopy revealed that the surgery site was healing well, but there was very mild fungal growth at the surgical site (very common environmental contaminant) so "Copper" was to return in another 2-weeks for a recheck.
Re-examination 4-weeks after surgery showed that the fungal growth had resolved and that the surgical site was healing very well and progressing as expected.

"Copper" was given the "go-ahead" for walking and trotting under saddle and was instructed to return every 3-4 months for upper airway endoscopy to ensure that the mass was not returning (5-20% recur following surgery).

Past Case Studies:
Lacy
Sam I Am
Copper