The mystery of fungal infection in the guttural pouches

Advances in the understanding of guttural pouch physiology and novel therapeutic approaches to mycotic infections in the horse are reviewed. It is suggested that the guttural pouches may contribute to the regulation of arterial blood temperature, cooling the circulation to the brain to below body temperature. Aspergillus spp. is the major organism found in a guttural pouch affected with mycosis but it is unclear why this agent becomes aggressive. Conventional therapy aims to prevent fatal haemorrhage and to treat any neurological lesions but it is desirable to try to prevent the disease. A technique consisting of inserting a transarterial coil into the internal carotid, external carotid and maxillary arteries in normal and affected horses has been reported to be rapid, safe and effective in occluding the arteries and in inducing regression of the mycotic lesions without adjunctive medical treatment. When faced with acute and uncontrollable epistaxis in the field, the most effective means to reduce haemorrhage is probably the occlusion of both common carotid arteries. However, how such arterial occlusions can result in the successful management of guttural pouch mycosis without antifungal medication remains a mystery.     

Occlusion of the External Carotid and Maxillary Arteries in the Horse to Prevent Hemorrhage from Guttural Pouch Mycosis

Balloon-tipped catheters were used to occlude the external carotid artery and its branches in nine horses with hemorrhage caused by guttural pouch mycosis. The internal carotid artery on the affected side was occluded simultaneously in four horses and had been occluded previously in two others. In three horses, a single balloon-tipped catheter was inserted in the external carotid artery beneath the floor of the guttural pouch and its tip was advanced blindly into distal branches. In one horse, the superficial temporal artery was occluded briefly during surgery by a balloon-tipped catheter so a catheter inserted into the external carotid artery could be diverted into the maxillary artery. In the other five horses, the external carotid artery was occluded proximally and the maxillary artery was occluded immediately caudal to the alar canal by a balloon-tipped catheter inserted into the major palatine artery. Serious postoperative hemorrhage did not occur in eight horses, but one horse that had a single balloon-tipped catheter inserted into the external carotid artery had profuse hemorrhage 11 days after surgery and was euthanatized. One horse was euthanatized because of persistent dysphagia. The only complication related to use of balloon catheters was a mild incisional infection in one horse. It was concluded that the external carotid and maxillary arteries must be occluded on both sides of the eroded segment to prevent hemorrhage from normograde and retrograde flow.     

Detachable latex balloon occlusion of an internal carotid artery with an aberrant branch in a horse with guttural pouch (auditory tube diverticulum) mycosis

An aberrant branch of the internal carotid artery was detected by angiography in a horse with guttural pouch (auditory tube diverticulum) mycosis after the distal portion of the artery had been occluded by use of a detachable latex balloon. A second balloon was placed to eliminate retrograde hemorrhage from the aberrant branch. The horse recovered and returned to its previous activity. Vascular anomalies of the internal carotid artery my be more common than expected, and have resulted in fatal complications during and after surgical treatment in guttural pouch mycosis. Intraoperative identification of vascular anomalies by use of angiography may avoid these fatal complications.     

Complications of Balloon Catheterization Associated With Aberrant Cerebral Arterial Anatomy in a Horse With Guttural Pouch Mycosis

A 3-year-old Quarter Horse gelding was treated for left guttural pouch mycosis by ligation and balloon catheterization of the left internal carotid artery. Catheter advancement was shorter (10 cm) than the normally reported distance (13–15 cm), but was observed endoscopically during placement as it coursed within the internal carotid artery through the guttural pouch. The horse developed a persistently abnormal respiratory pattern after catheter placement, failed to gain consciousness, developed pulmonary edema, and died 5.5 hours postoperatively. Postmortem examination revelaed an aberrant left internal carotid arterial course with location of the embolectomy catheter at the junction of the basilar and caudal cerebellar arteries. Brainstem neuronal necrosis and alveolar and interstitial pulmonary edema were identified on histological examination. Angiography may be used to identify aberrant branching patterns. Failure to identify and occlude aberrant branches may result in fatal epistaxis and Brainstem lesions.     

Traumatic bilateral stylohyoid bone fracture in an Appaloosa

An Appaloosa gelding presented for a traumatic puncture wound of the head ventral to the base of his left ear, bilateral epistaxis and upper respiratory compromise. The horse did not exhibit dysphagia or cranial nerve deficits. The horse suffered bilateral oblique fractures of both stylohyoid bones due to the traumatic incident, diagnosed upon endoscopy of the guttural pouches. Treatment consisted of anti‐inflammatory medication, broad‐spectrum antibiotics, guttural pouch lavage and dietary management with soft feeds. At a one‐month follow‐up examination, endoscopic evaluation revealed a union at both stylohyoid bone fracture sites. Guttural pouch mycosis was diagnosed in the left guttural pouch on the lateral wall at the entrance of the lateral compartment. The guttural pouch mycosis was treated with a nystatin and gentamicin flush, followed by a course of oral fluconazole. At the 3‐month re‐evaluation, the guttural pouch mycosis had completely responded to treatment.     

Suspected retropharyngeal haemorrhage as a complication of guttural pouch mycosis

An 11-year-old Thoroughbred mare presented for evaluation of severe, acute bilateral epistaxis of several hours’ duration. Endoscopic evaluation revealed active haemorrhage from the right guttural pouch and significant dorsal compression of the nasopharynx. Rapid and severe retropharyngeal swelling developed, prompting placement of a temporary tracheostomy. Guttural pouch mycosis was suspected and transarterial coil embolisation of the right internal carotid, external carotid and maxillary arteries was successfully performed. It was suspected that haemorrhage from the vasculature of the guttural pouch tracked caudally into the retropharyngeal region resulting in significant swelling, pharyngeal collapse and a severely compromised airway. Clinicians should be aware of this rare complication of guttural pouch epistaxis.     

Unusual Internal Carotid Artery Branching That Prevented Arterial Occlusion With a Balloon-Tipped Catheter in a Horse

A mare with hemorrhage caused by guttural pouch mycosis was treated by insertion of a balloon-tipped catheter into the left internal carotid artery. During recovery from general anesthesia, the mare had profuse epistaxis, and was anesthetized again to determine the site of hemorrhage. The affected guttural pouch was opened to confirm that hemorrhage was from the left internal carotid artery. The mare was euthanatized, and, at necropsy, the balloon catheter was found in an aberrant branch that arose from the internal carotid artery and joined the basilar artery. The mycotic plaque was on the left internal carotid artery, distal to the origin of the aberrant branch, so that the balloon did not obstruct retrograde flow through the infected segment. Additional dissection of the internal carotid artery before insertion of a balloon catheter is recommended to identify any aberrant branches. Ligation of aberrant branches at their bifurcation with the internal carotid artery is recommended to prevent both inadvertent catheterization and retrograde flow from the cerebral arterial circle.     

Fistula between the guttural pouches and the dorsal pharyngeal recess as a sequela to guttural pouch mycosis in the horse

An unusual case of a two year old gelding with severe unilateral epistaxis due to guttural pouch mycosis is reported. The lesion had spread to involve the dorso-medial aspects of the right guttural pouch and had formed a fistula between the dorsal pharyngeal recess and both the left and right guttural pouches. The diagnosis, surgical treatment and postoperative management are described.     

Transarterial coil embolization of the internal and external carotid and maxillary arteries for prevention of hemorrhage from guttural pouch mycosis in horses

OBJECTIVES: To develop a transarterial coil embolization technique for occlusion of the internal carotid artery (ICA), external carotid artery (ECA), and maxillary arteries (MA) in normal horses and to evaluate this technique for prevention of hemorrhage in horses affected with guttural pouch mycosis. ANIMALS: Ten adult, normal horses and 4 horses with guttural pouch mycosis. METHODS: All horses had transarterial coil embolization of the rostral and caudal ICA, caudal MA, and rostral ECA. In 1 affected horse, an aberrant actively bleeding branch of the ECA was also occluded. Normal horses had a premortem angiogram, and were killed either at 1 or 2 weeks or 1, 2, or 3 months after the procedure. Specimens from the ICA, ECA and MA were evaluated by light microscopy. RESULTS: No surgical complications were observed, except 1 horse that developed laryngeal hemiplegia and 1 pilot horse that had embolization of the cerebral arterial circle. In normal horses, premortem angiography confirmed complete occlusion of all vessels, and coils were positioned as intended. All normal horses had partially maturing to mature, continuous thrombi occluding at the coils. In affected horses, no further episodes of epistaxis were observed. By day 60, all mycotic plaques had resolved without further treatment. Ophthalmic complications were not observed. CONCLUSION: Transarterial embolization provided a safe, rapid, and effective method for ICA, ECA, and MA occlusion in normal and affected horses. In affected horses, the technique was possible despite active bleeding, allowing adequate identification and occlusion of all sources of hemorrhage.     

Occlusion of the internal carotid artery by means of microcoils for preventing epistaxis caused by guttural pouch mycosis in horses.

Occlusion of the internal carotid artery by insertion of intravascular platinum microcoils for guttural pouch mycosis was experimentally evaluated in 9 healthy adult Thoroughbred horses. The internal carotid artery was ligated to its origin, and an arteriotomy was made distal to the ligature, which was then occluded by insertion of the microcoil approximately 13 cm distal to its origin. Cessation of blood flow was determined visually and by angiography at the arteriotomy site. Six horses were evaluated for complication clinically and by endoscopy after surgery. One horse was necropsied after 30 days of surgery for histological evaluation of artery thrombus formation. In the other 3 horses, the blood flow of the right internal carotid artery was monitored, before and after microcoil occlusion of the left internal carotid artery. One or 2 microcoils stopped blood flow within a few minutes. No other abnormal findings were observed clinically. Thrombus was observed in the occluded segment of 1 horse 30 days after insertion; but no abnormalities were detected. The blood flow in the right internal carotid artery increased by approximately 28-58% after occlusion of the left internal carotid artery. This microcoil vascular occlusion technique causes an effective thrombosis, and based on experimental studies and clinical application in 2 horses with epistaxis due to guttural pouch mycosis, this technique would appear to be safe and efficacious.     

Progression of mycosis of the auditory tube diverticulum (guttural pouch) after arterial occlusion in a horse with contralateral temporohyoid osteoarthropathy

CASE DESCRIPTION: A 6-year-old Appaloosa mare was examined because of inappetance, difficulty eating, and swelling and mucopurulent discharge in the right eye. CLINICAL FINDINGS: Results of a CBC and serum bio-chemical analysis revealed no important findings. Ophthalmologic examination revealed scarring and ulceration of the superficial layers of the cornea. Endoscopic examination of the upper portion of the respiratory tract and auditory tube diverticula (guttural pouches) revealed abnormal thickness of the right stylohyoid bone and a plaque suggestive of mycotic growth on the left internal carotid artery. Radiographic examination revealed right-sided otitis media. Temporohyoid osteoarthropathy in the right guttural pouch and mycosis in the left guttural pouch were diagnosed. TREATMENT AND OUTCOME: Ceratohyoidectomy of the right stylohyoid bone was performed, and the left internal carotid artery was occluded via placement of stainless steel spring embolization coils. The mare regained the ability to eat without difficulty and improved clinically for approximately 4 weeks. However, the mare returned to the medical center 53 days after surgery with left-sided Horner syndrome, atrophy of the right side of the tongue, and a 3-week history of dysphagia and weight loss. Endoscopic evaluation revealed progression of mycotic growth in the left guttural pouch. The mare was euthanatized. CLINICAL RELEVANCE: Although the mycotic lesion in the left guttural pouch was an incidental finding at the time of initial examination, the lesion progressed to cause dysphagia and Horner syndrome after occlusion of the left internal carotid artery, a treatment that is typically associated with resolution of guttural pouch mycosis. Arterial occlusion is not necessarily a reliable method of resolving guttural pouch mycosis.     

Outcome of treatment in 35 cases of guttural pouch mycosis

This paper describes the outcome of treatment of 30 cases of guttural pouch mycosis by ligation of the internal carotid artery on the cardiac side of the lesion and lavage of the affected pouch with natamycin. Twenty-three horses recovered fully following this treatment while laryngeal hemiplegia persisted in one case and slight dysphagia caused by pharyngeal hemiplegia in another. The remaining five horses died or were destroyed. Five horses with guttural pouch mycosis, which had shown no epistaxis but had pharyngeal hemiplegia, were treated by topical natamycin alone. Only two of these survived, of which one remained slightly dysphagic. Ligation of the internal carotid artery of the cardiac side of the lesion is an effective means of reducing the chance of fatal epistaxis in cases of guttural pouch mycosis. Some cases of pharyngeal hemiplegia can make a complete recovery although it may take 12 to 18 months.     

Successful treatment of hyperkalaemic periodic paralysis in a horse during isoflurane anaesthesia

HistoryA 3-year-old, 400 kg, gelding Quarter Horse was presented for investigation of epistaxis.Physical examinationThe horse was bright, alert and responsive with rectal temperature, heart rate and respiration rate within normal limits.ManagementDuring a second general anaesthetic for surgical treatment of guttural pouch mycosis by balloon-tipped catheter occlusion of the right major palatine artery and ligation of the right external carotid artery, signs consistent with hyperkalaemic periodic paralysis (HYPP) were exhibited. These included concurrent hyperkalaemia, hypercapnoea, sinus tachycardia, and muscle fasciculations in the presence of normothermia. Stress associated with an acute haemorrhage pre-operatively, and intra-operative hypercapnoea may have precipitated the episode. There were no signs of HYPP during a general anaesthetic, 1 week earlier, when an initial attempt at surgical treatment of guttural pouch mycosis was performed. Treatment consisted of fluid therapy and administration of calcium gluconate (0.1–0.2 mg kg^?1 minute^?1), dextrose 5% (5 mL kg^?1 hour^?1) and insulin (0.05 IU kg^?1). Treatment resulted in the resolution of clinical signs and an uneventful recovery.Follow-upThe diagnosis of HYPP was confirmed by DNA analysis post-operatively.ConclusionsClinical cases of intra-operative HYPP can present despite a previous history of uneventful general anaesthesia. Rapid diagnosis and treatment can result in the successful management of HYPP. This report documents an unusual presentation of HYPP, a disease that remains present in the Quarter Horse population.     

Ischemic optic neuropathy and blindness after arterial occlusion for treatment of guttural pouch mycosis in two horses

Ischemic optic neuropathy accompanied by blindness was induced in 2 horses after surgical occlusion of the external and internal carotid and greater palatine arteries, performed as part of the management of guttural pouch mycosis. The blindness was acute and unilateral and may have been caused by ischemic retinal damage. Vascular occlusion is a recommended procedure for treatment of guttural pouch mycosis. Retinal damage and blindness are a possible complication if all possible sources of hemorrhage are occluded.     

Guttural pouch leiomyosarcoma causing nasopharyngeal compression in a pony

A 14‐year‐old Connemara cross gelding presented with abnormal respiratory noise and exercise intolerance. Upper airway endoscopy, ultrasonography, radiography and computed tomography revealed a large mass within the left guttural pouch causing marked left dorsal nasopharyngeal collapse and displacement and compression of the right guttural pouch. The horse was subjected to euthanasia and a post‐mortem examination confirmed the above findings. Histological and immunohistochemical examinations of the mass confirmed a diagnosis of guttural pouch leiomyosarcoma, a lesion previously unreported at this site.     

Immune-mediated hemolytic anemia associated with trimethoprim-sulphamethoxazole administration in a horse.

A 10-year-old, thoroughbred gelding was administered sulphonamide drugs during surgical treatment of guttural pouch mycosis. The horse became anemic and a diagnosis of immune-mediated hemolytic anemia was made after other causes of anemia had been ruled out. The anemia resolved after the drugs were withdrawn.     

Treatment of guttural pouch mycosis

Seventeen cases of guttural pouch mycosis (including two bilaterally affected cases) were diagnosed in a three year period. The presenting signs were, in order of frequency, epistaxis at rest, nasal catarrh, pharyngeal paralysis, ipsilateral laryngeal hemiplegia, swelling of the submandibular/parotid region, extension of the head and neck and dyspnoea. Ligation of the origin of the internal carotid and occipital arteries was attempted in 10 of the cases exhibiting epistaxis. Bilateral ligation was performed on one animal with an untoward sequelae. Where surgery was successfully completed further haemorrhage was prevented in eight out of nine affected pouches (89 per cent). Medical treatment involving local administration of various antifungal preparations via a specially designed catheter and/or the oral administration of benzimidazole drugs was successful in eliminating the mycotic plaque in most cases. Cases which presented with pharyngeal paralysis were all fatal.     

Surgical site infection after occlusion of the internal carotid artery with a thrombectomy catheter: Five cases

Although rare, guttural pouch mycosis is a potentially life-threatening disease in the horse. The disease is most commonly treated surgically. One surgical option is occlusion of the internal carotid artery with a combination of ligation and use of a balloon tipped venous thrombectomy catheter. Complications of such treatment are rarely reported. This case series of five individuals describes the appearance, diagnosis and management of medium (>2 weeks) and long-term (>10 years) complications (including abscess formation, draining sinuses and wound dehiscence) of internal carotid artery occlusion with a venous thrombectomy catheter and management of these surgical site infections. The clinical presentations included swelling and/or discharging tracts in the parotid region. In one horse, an osseous reaction of the basisphenoid bone and penetration of the contralateral guttural pouch by the implant were identified by computed tomography. In all five horses, the surgical site infections were successfully resolved following removal of the venous thrombectomy catheter.     

Carotid and cerebral angiography in the horse

Carotid and cerebral angiography has been found to be a relatively simple technique to carry out in the horse. At most it involves a cutdown approach to the carotid artery, followed by catheterisation of the artery and selective catheterisation, if necessary, of one of its three branches. The technique can be carried out with standard equipment normally available within equine hospital facilities. The authors have employed angiography as a routine aid to diagnosis over the past nine years, without encountering any serious complications or adverse reactions. Carotid angiography has been especially valuable in the investigation of horses with guttural pouch mycosis. The technique has permitted the presence of aneurysms to be detected in many cases and significant vascular abnormalities in four cases. This information is valuable for the surgical treatment of horses with guttural pouch mycosis by ligation of the appropriate artery. Other indications for the use of carotid angiography include the investigation of ethmoidal haematoma, idiopathic Horner's syndrome, neoplasia of the head, venous aneurysms and arterial aneurysms in sites not associated with the guttural pouch. There are fewer occasions for the use of cerebral angiography in the horse, but it is indicated as an aid to the differential diagnosis of some abnormalities of the central nervous system.     

Guttural pouch empyema secondary to a periocular foreign body

This report describes a 3‐year‐old gelding presenting with signs of injury to its left eye following an accident in which the horse crashed into a hedge. The first treatment attempted to treat infections in the eye and respiratory tract due to secretions identified in the trachea. The horse did not improve and further clinical and radiographic evaluations detected a guttural pouch empyema. Surgical drainage was performed and antimicrobial treatment continued. However, the horse presented with severe epistaxis and euthanasia was elected due to suspected arterial rupture. At necropsy, a round and stiff branch plant was found creating a fistula from the left orbit to the left guttural pouch. Another branch was found inside the pouch, confirming the origin of the persistent infection and severity of the tissue lesion.