210 Extraction, 209 Extraction via Sectioning, and Sinoscopy

This 28 year old Warmblood gelding had a greater than one-year history of left-sided malodorous nasal discharge. He had been treated with several rounds of antibiotics, and recently his 211 was extracted by another veterinarian. He was being treated with SMZs when he was referred to us. On oral exam, he had a faint malodor from his left nostril and left mandibular lymphadenopathy. There was no nasal discharge present. This horse’s 210 had a complicated crown root fracture and was also missing a mesial palatal fragment. The alveolus of the 211 that was previously extracted was 50% granulated in, but there were retained dental fragments.
​Radiographs revealed crown lucency, apical blunting, periapical sclerosis, and greater than 50% bone loss of the 209. The 210 had a crown lucency, greater than 50% bone loss, and a periapical soft tissue opacity. The 211 that was previously extracted had a retained distal tooth root and dental fragments in the alveolus. There was a soft tissue/ fluid opacity in the maxillary sinuses but no fluid lines. This horse was diagnosed with periodontal disease and periapical abscess of the 209 and 210, and left maxillary sinusitis.
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​The patient was standing sedated and regional anesthesia of the 200 cheek tooth quadrant was administered. The 209 and 210 were extracted orally. The 209 was extracted via cheek tooth sectioning. Because the 209 was worn down due to his age, there was very little crown available to secure forceps on the tooth for extraction. We were able to cut (section) this tooth into two halves with a specialized burr and extract each half individually. ​Post extraction radiographs confirmed a vacated alveoli. The alveoli were left open. This horse was administered antibiotics for another 4 weeks.
​Unfortunately, 6 weeks later this horse still had malodorous nasal discharge from the left nostril and was referred to a surgeon for sinoscopy. Under standing sedation and local anesthesia, a sinoscopy was performed of the left frontal and maxillary sinuses. Purulent material was immediately identified within the frontal sinus and caudal maxillary sinus. A copious amount of inspissated pus was evacuated from the sinus cavities. The sinuses were extensively lavaged and instilled with antibiotics, and the horse was placed back on a few weeks of antibiotics based on a culture and sensitivity test. He recovered well and the sinusitis has not returned.