Affections of Guttural Pouch and Its Surgical Management

Presented by:
Amir Sadaula
Roll No: 01
BVSc & AH, 8th Semester
Rampur Campus
IAAS, Rampur

January, 2010
The guttural pouches are diverticula of the auditory (or eustachian) tubes found in equids and
a limited number of other species. The function of the guttural pouch is unclear, although it
may have a role in regulation of cerebral blood pressure, swallowing, and hearing. It is
unlikely to have a role in brain cooling. Each guttural pouch of an adult horse has a volume
of approximately 300 mL and is divided by the stylohyoid bone into lateral and medial
compartments. Guttural pouches are paired extensions of the Eustachian tubes that connect
the pharynx to the middle ear.
Anatomical Consideration:
The medial compartment of the guttural pouch contains a number of important structures
including the internal carotid artery and
glossopharyngeal hypoglossal, and spinal
accessory nerves in addition to branches of the
vagus nerve and the cervical sympathetic trunk.
Retropharyngeal lymph nodes lie beneath the
mucosa of the ventral aspect of the medial
compartment, an important factor in the
development of guttural pouch empyema.
In the lateral compartment the external carotid
artery passes along the ventral aspect as do the
glossopharyngeal and hypoglossal nerves.
Involvement of any of the above-mentioned
structures is important in the pathogenesis and
clinical signs of guttural pouch disease and may
result in abnormalities, such as Homer's
syndrome, that are not readily recognized as being
caused by guttural pouch disease.
The pouches are separated from each other on the Figure 1: Anatomical location of Guttural pouches
midline by the rectus capitis ventralis and the
longus capitis muscles and the median septum. Each is in close contact rostrally with the
basisphenoid bone, ventrally with the retropharyngeal lymph nodes, pharynx, and the
esophagus, caudally with the atlantooccipital joint, laterally with the digastricus muscle and
the parotid and mandibular salivary glands, and dorsally with the petrous part of the temporal
bone, tympanic bulla, and auditory meatus. Each guttural pouch is divided ventrally into a
medial and a lateral compartment by the stylohyoid bone, and it communicates with the
pharynx through the pharyngeal orifice of the eustachian tube.

Functions of Guttural Pouch

Possible functions of the guttural pouches include
 pressure equilibration across the tympanic membrane
 contribution to air warming
 a resonating chamber for vocalization
 a flotation device.
A role more recently proposed, on the basis of measurement of lower arterial
temperatures in the cerebral side of the internal carotid artery compared with the cardiac side,
is brain-cooling. Based on cadaver studies, opening of the pharyngeal orifice of the guttural
pouch involves the levator and tensor veli palatini muscles and the pterygopharyngeus and
palatopharyngeus muscles. Passive opening of the auditory tube involves a reduced tone in
the stylopharyngeus and pterygopharyngeus muscles, accompanied by increased inspiratory
pressure. Although guttural pouch filling was previously reported to occur on expiration, the
latter study demonstrated that filling occurs on inspiration.
Relations:2
Dorsally: Base of the cranium and atlas
Ventrally: Pharynx, Origin of Oesophagus
Laterally: Relations are numerous and complex. Pterygoideus, Stylohoideus muscles,
external carotid artery, maxillary artery, Vagus nerve, parotid and mandbular
glands, ventral articular muscles etc.
Medially: In apposition in part and rectus capitis ventralis muscles
Rostral end: Is a small cul-de-sac, which lies ventral to the presphenoid bone, between
auditory tube and the median recess of the pharynx.
Caudal end: Ventral to the atlantal attachment of the longus coli muscles
Each pouch communicates with the pharynx through the pharyngeal orifice of the
auditory tube and is in direct continuity with the mucous membrane of the latter. It is lined
with ciliated epithelium and has mucous glands. Numerous lymph nodules are present in the
young subjects.

Major Affections of the Guttural Pouch

It includes the following affections. They are
a) Empyema
b) Tympany
c) Mycosis
d) Rupture of the longus capitis muscle
e) Neoplasm
Empyema
Empyema is accumulation of exudates within the guttural pouch and is usually sequel of
Upper Respiratory tract infection. In recent survey, Streptococcus equi was isolated from
32% of case evaluated as empyema.1 Initially, the purulent material is liquid, although it is
usually viscid, but over time becomes inspissated and is kneaded into ovoid masses called
chondroids. Chondroids occur in approximately 20% of horses with guttural pouch
empyema.2 the condition is most commonly associated with S equi var. equi infection and is a
recognized sequel to strangles. Therefore, any horse with guttural pouch empyema should be
isolated and treated as if it were infected with S. equi var, equi until proven otherwise. The
empyema may be associated with other conditions of the guttural pouches, especially if there
is impaired drainage of the pouch through the pharyngeal opening of the eustachian tube.
PATHOGENESIS3
The pathogenesis of guttural pouch empyema is unclear although when secondary to
strangles it is usually due to the rupture of abscessed retropharyngeal lymph nodes into the
medial compartment. Continued drainage of the abscesses presumably overwhelms the
normal drainage and protective mechanisms of the guttural pouch, allowing bacterial
colonization, influx of neutrophils and accumulation of purulent material. Swelling of the
mucosa, especially around the opening to the pharynx, impairs drainage and facilitates fluid
accumulation in the pouch. The accumulation of material in the pouch causes distension and
mechanical interference with swallowing and breathing. Inflammation of the guttural pouch
mucosa may involve the nerves that lie beneath it and result in neuritis with subsequent
pharyngeal and laryngeal dysfunction and dysphagia.
Clinical Finding
The symptoms comprise:
1. An intermittent discharge, which only appears during feeding or when the head is
lowered to eat from the ground or to take the bit or during exercise. It usually liquid
containing yellowish white flocculi of variable size.
2. Swelling of the submaxillary lymphatic glands
 3. Swelling of parotid region only noticed when the pouch is much distended. Pressure
on it causes escape of discharge through the nose.
4. Interference with swallowing and respiration observed when the guttural pouch
becomes greatly distended owing to stenosis or partial obstruction of Eustachian tube.
The patients have difficulty in swallowing and make respiration noisy and show
dyspnea.
5. Rupture of pouch due to excessive distension to repeated efforts of swallowing and to
snouting. It is rare occurrence.
6. Holding of head towards the sound side when the horse is being ridden.
7. A rattling noise in pouch during exercise due to agitation of the
contents.
Treatment
The principles of treatment are removal of the purulent material, eradication of
infection, reduction of inflammation, relief of respiratory distress and
provision of nutritional support in severely affected horses. Removal of
purulent material may be difficult but can be achieved by repeated flushing of
the affected guttural pouch. The guttural pouch can be flushed through a
catheter (10-20 French, 3.3-7 mm male dog urinary catheter)or Gunther
Catheter inserted as needed via the nares, or a catheter (polyethylene 240
tubing) with a coiled end inserted via the nares and retained in the pouch for
several days. The choice of fluid with which to flush the guttural pouch is
arbitrary but frequently used fluids include normal (isotonic) saline, lactated
Ringer's solution or 1% (v/v) povidone-iodine solution.
In severely dyspneic horses caused by guttural pouch distention, a tracheotomy
should be performed. If the response to medical treatment is poor or if the
purulent material becomes inspissated or forms chondroids, surgical drainage
of the guttural pouch should be considered Fig: Gunther Catheter

Tympany
Tympany, as the name implies, is the distention of the guttural pouches with air under
pressure, sometimes accompanied with some fluid accumulation. This condition is usually
unilateral but can be bilateral and is more common in fillies than in colts. In 51 foals with
guttural pouch tympany seen at a German clinic between 1994 and 2001, there were
approximately three times as many fillies as colts, regardless of breed 1. Possible causes
include a mucosal flap that acts as a oneway valve and traps air and fluid in the pouch,
inflammation from an upper airway infection, persistent coughing, and muscle dysfunction. 1
In most cases, there is no gross anatomic abnormality at the guttural pouch opening.
Clinical Finding:
Include marked swelling of the parotid region of the affected side with lesser swelling of the
contralateral side. The swelling of the affected side is not painful on palpation and is elastic
and compressible. There are stertorous breath sounds in most affected foals due to
impingement of the distended pouch on the nasopharynx. Respiratory distress may develop.
Severely affected foals may be dysphagic and develop aspiration pneumonia.2
Treatment
Temporary alleviation can be achieved by needle decompression or by placing an indwelling
catheter in the pharyngeal orifice; however, surgery is required for definitive treatment. The
affected guttural pouch is usually entered through Viborg’s triangle or through a modified
Whitehouse approach. The prognosis for long term resolution of the problem after surgery is
approximately 60 %.2
Mycosis:
Guttural pouch mycosis affects the roof of one guttural pouch, rarely both. There is no
apparent age, sex, breed, or geographic predisposition to this disease. The cause of guttural
pouch mycosis is unknown, although Aspergillus can be identified in the lesion. The typical
lesion of guttural pouch mycosis is a diphtheritic membrane of variable size, composed of
necrotic tissue, cell debris, a variety of bacteria, and fungal mycelia. Aneurysm formation
does not appear to precede or follow arterial invasion consistently and, therefore, is not
essential to the pathogenesis of arterial rupture.
Clinical Signs1
The most common clinical sign is moderate-to-severe epistaxis, which is caused by fungal
erosion of the internal carotid artery in most cases and of the external carotid and maxillary
arteries in approximately one third of cases. However, any branch of the external carotid
artery, such as the caudal auricular artery, can be affected. Several bouts of hemorrhage
usually precede a fatal episode. Mucus and dark blood continue to drain from the nostril on
the affected side for days after acute hemorrhage ceases. The second most common clinical
sign is dysphagia caused by damage to the pharyngeal branches of the vagus and
glossopharyngeal nerves. Aspiration pneumonia may develop in severe or protracted cases.
Abnormal respiratory noise can arise from pharyngeal paresis or laryngeal hemiplegia, the
latter as a result of recurrent laryngeal nerve damage. Horner’s syndrome may develop from
damage to the cranial cervical ganglion and postganglionic sympathetic fibers. The classic
signs associated with this denervation are ptosis, miosis, and enophthalmos; patchy sweating;
and congestion of the nasal mucosa. The reason for equine sweat glands to increase their
activity when denervated is unclear. Less common signs of guttural pouch mycosis are
parotid pain, nasal discharge, abnormal head posture, head shyness, sweating and shivering,
corneal ulcers, colic, blindness, locomotion disturbances, facial nerve paralysis, paralysis of
the tongue, and septic arthritis of the atlantooccipital joint.
Treatment
NONSURGICAL TREATMENT
The response to topical treatment is generally slow and inconsistent. Daily direct lavage
through the endoscope can macerate the diphtheritic membrane, and the biopsy forceps or
cytology brush of the endoscope can be used to detach it, provided any eroded artery was
occluded beforehand. Topical povidone-iodine or thiabendazole, with or without dimethyl
sulfoxide, has been used with mixed results. Nystatin, natamycin, and miconazole have little
activity against Aspergillus, but amphotericin B is effective against this organism, although
its use in the horse is limited by its toxicity. Successful treatment of dysphagia from guttural
pouch mycosis has been reported with a combination of traconazole (5 mg/kg body weight
PO) and topical enilconazole (60 mL of 33.3 mg/mL solution per daily flush) in one horse
and with topical enilconazole alone in another. Itraconazole at 3 mg/kg twice a day in the
feed can be effective against Aspergillus and other fungi in the nasal passage of horses, but
treatment may be required for up to 4 or 5 months.
SURGICAL TREATMENT
The diphtheritic membrane can be detached by gentle swabbing and lavage through a
modified Whitehouse approach. This treatment does not eliminate the risk of hemorrhage
completely, and it does not retard or reverse progression of neurologic signs, but it does carry
the risk of iatrogenic nerve damage and hemorrhage. In horses with epistaxis, the affected
artery should be identified by endoscopy and surgically occluded

Rupture of the longus capitis muscle

Avulsion of its insertion on the basisphenoid bone .causes epistaxis and is usually associated
with trauma to the head, such as is caused by rearing and falling over backwards. Endoscopic
examination reveals: Compression of the nasopharynx that is asymmetric. Blood in the
guttural pouch. Sub mucosal hemorrhage and swelling of the medial aspect of the medial
compartment of the guttural pouch. Radiographic examination reveals ventral deviation of the
dorsal pharynx and loss of the usual radiolucency associated with the guttural pouch.
Treatment is conservative and consists of supportive care, monitoring the hematocrit, and
administration of broad-spectrum antibiotics if there is concern of the development of
secondary infection. The prognosis for complete recovery is guarded.
Various neoplasms have been recorded as involving the guttural pouches. The presenting
signs are: swelling of the parotid region, epistaxis, dysphagia or signs of cranial nerve
disease. Neoplasms include melanoma, lymphosarcoma, hemangiosarcoma, squamous cell
cardnoma and sarcoma. Diagnosis is made by physical, endoscopic and radiographic
examination and biopsy. The prognosis is very poor to hopeless.

SURGICAL DRAINAGE OF THE GUTTURAL POUCH1

The following approaches can be used to open the guttural pouch for removal of pus, mycotic
plaques, and foreign bodies and to establish drainage.

Hyovertebrotomy
A 10-cm-long incision is made 2 cm craniad to and parallel with the wing of the atlas (see
Fig. 45-14). The dense parotid fascia is incised, and the parotid gland and overlying
parotidoauricularis muscle are reflected cranially. The guttural pouch lining is exposed
beneath a covering of areolar tissue and grasped with rat-toothed or Allis tissue forceps. It is
punctured with the closed tips of scissors or a hemostat, and this opening is enlarged by
spreading its edges with a hemostat or the fingers. To establish ventral drainage, the pouch is
opened ventrally through an incision in Viborg’s triangle, guided by a finger within the
pouch. The hyovertebrotomy can be closed or left partly open for infusion of irrigating
solutions.

Viborg’s Triangle Approach

Viborg’s triangle is bordered by the tendon of the sternocephalicus muscle, the linguofacial
vein, and the vertical ramus of the mandible . A vertical or horizontal incision is made in this
area, taking care to avoid the parotid duct and branches of the vagus nerve along the floor of
the guttural pouch. The incision is usually kept open with a soft rubber drain to establish
ventral drainage.

Whitehouse Approach
With the horse in dorsal recumbency, a skin incision is made on the ventral midline over the
larynx. Dissection is continued between the paired sternohyoideus and omohyoideus muscles
and along the larynx to the affected guttural pouch. The guttural pouch is opened medial to
the stylohyoid bone, and care is taken to avoid the pharyngeal branch of the vagus nerve and
the cranial laryngeal nerve, which are close to the incision.
Modified Whitehouse Approach
In the modified Whitehouse approach,
the skin incision is made along the
ventral edge of the linguofacial vein
and extends rostrally for about 12 cm
from the jugular vein. The underlying
fascia is incised to expose the lateral
aspect of the larynx, and blunt
dissection is continued until the
guttural pouch cavity has been
entered. The major advantage of this
modification is that dissection is
through a natural fascial plane and
does not involve an incision between
the sternohyoideus and omohyoideus
muscles. Advantages of both
Whitehouse approaches are direct
access to the roof of the guttural
pouch, digital access to the lateral
compartment, excellent ventral
drainage, and simultaneous access
through the septum to both pouches.
Although both approaches involve
deep dissection, they do not appear to
have a higher rate of complications
than other approaches.
Reference
1 Auer J.A, J.A Stick, 2006, Equine Surgery 3rd Edition, Saunder Elsivier St. Louis Missouri

2 Kumar A.,2010, Veterinary Surgical Techniqus, Vikash publishing House Pvt. Ltd.
Noida U.P.

3 Radostits O.M, C.C Gay, K.W Hinchcliff, P.D Constable, 2006, Veterinary Medicine, A
textbook of the diseases of cattle, Horses, sheep, pigs and goats 10th edition,
Saunders Elsevier St Louis

4 Reed S.M, W.M Bayly, D.C. Sellon, 1998, Equine Internal Medicine 2nd Edition,
Saunders St. Louis Missouri