Guttural pouch

Guttural pouches are large, auditory-tube diverticula that contain between 300 and 600 ml of air. They are present in odd-toed mammals, some bats, hyraxes, and the American forest mouse. They are paired bilaterally just below the ears, behind the skull and connect to the nasopharynx.[1]

Due to the general inaccessibility of the pouches in horses, they can be an area of infection by fungi and bacteria, and these infections can be extremely severe and hard to treat. The condition guttural pouch tympany affects several breeds, including the Arabian horse. The condition predisposes young horses to infection, often including severe swelling and often requires surgery to correct. The guttural pouch is also the site of infection in equine strangles.[1]

Structure

The guttural pouches are located behind the cranial cavity, caudally the skull and below the wings of the atlas (C1). They are enclosed by the parotid and mandibular salivary glands, and the pterygoid muscles. The ventral portion lays on the pharynx and beginning of the esophagus, with the retropharyngeal lymph nodes located between the ventral wall and pharynx. The left and right pouches are separated by the longus capitis and rectus capitis ventralis muscles dorsomedially. Below these muscles, the two pouches fuse to form a median septum.[2]

The guttural pouches connect the middle ear to the pharynx. The opening into the pharynx is called the nasopharyngeal ostium, which is composed of the pharyngeal wall laterally and a fibrocartilaginous fold medially. This opening leads to a short soft tissue passageway into the respective guttural pouch. The openings are located rostrally to enable drainage of mucous when the head is lowered and prevent fluid build-up.[3] The plica salpingopharyngea, a mucosal fold at the caudal portion of the Eustachian tube, forms an uninterrupted channel between the medial lamina of the Eustachian tube and the lateral wall of the pharynx. The plica salpingopharyngea can sometimes act as a one-way valve trapping air in the pouch, causing guttural pouch tympany[4]. Each pouch is moulded around the stylohyoid bone which divides the medial and lateral compartments. The medial compartment is much larger, and protrudes more caudally and ventrally.[2]

The epithelium is pseudostratified and ciliated containing mucous-secreting goblet cells; lymph nodules are also present.[4] The compartments of each guttural pouch contain many important structures including several cranial nerves and arteries that lie directly against the pouch as they pass into and out of foramina in the caudal aspect of the skull. The glossopharyngeal, vagus, accessory and hypoglossal nerves; the sympathetic trunk leaving from the cranial cervical ganglion; and the internal carotid all cause a mucosal fold indent within the medial compartment, visible when viewed endoscopically.[5] The facial nerve is in contact with the dorsal part of the pouch. The external carotid artery passes ventral to the medial compartment before crossing to the lateral wall of the lateral compartment.[5] The pouch also covers the temporohyoid joint.[5]

Function

For many years, the functionality of the guttural pouches remained an unsolved mystery. Recent studies have shown that they play a role in cooling the blood from the internal carotid destined for the brain during hyperthermia.[6] Even-toed artiodactyls possess a carotid rete, responsible for heat exchange, to cool arterial blood before it enters the cranial cavity. This anatomical adaptation acts to protect brain tissue from injury due to overheating.[7] Odd-toed perrisodactyls such as horses lack a carotid rete, but since the internal carotid artery passes through the guttural pouches, it has been discovered that the air within the pouches cools the blood during exercise.[7] Brain cooling by convection in the cerebral blood also occurs.[7]

Pathology

If the drainage tract becomes blocked for any reason, the mucous secretions can accumulate and cause the pouch to distend, producing a visible and palpable protrusion behind the mandible. The exudate may become contaminated with pathogens. The bacteria Streptococcus equi, the causative agent of strangles, is commonly involved. Mycotic infections can also occur.[5] Some visible symptoms of guttural pouch disease include abnormal head and neck carriage, nasal discharge, painful swelling and occasional abnormal functioning of the structures associated with the pouch.[5] Secondary problems may include inflammation of the middle ear due to migration of the infection along the auditory tube; nasal bleeding caused by damage to the internal carotid artery; with vagus nerve involvement there may be laryngeal hemiplegia (roaring) or difficulty swallowing (also if glossopharyngeal nerve is involved); and Horner’s syndrome from the involvement of sympathetic nerves. Involvement of the facial nerve is rare.[5]

As the guttural pouches are covered by respiratory epithelium and mucosa, they have the potential to be affected by all respiratory pathogens.[8] Most infections are self-limiting, requiring no or little medical intervention. Upon endoscopy, affected guttural pouches often house mucopurulent fluid that is in the process of draining.[8]

Guttural Pouch Empyema

Guttural pouch empyema is characterized by the accretion of purulent, bacteria infested exudate in the pouch. The bacteria is primarily Streptococcus equi, the infectious agent of strangles. Clinically apparent symptoms include painful swelling of the parotid area and recurrent infected nasal discharge, and in severe circumstances, difficulty breathing and abnormal head carriage may be observable.[9] Fever, anorexia, difficulty swallowing and soft palate displacement may or may not be seen.[10] Empyema is often secondary to guttural pouch tympany (distention of the pouches with air) in foals and weanlings. Arabians, in particular, are inclined to guttural pouch tympany, as many have a congenital defect in the pharyngeal orifices of the pouches.[11] The infection can also be due to the rupture of the nearby retropharyngeal lymph nodes, usually caused by an abscess.[12]

Diagnosis is established through and endoscopic examination. Radiographic examination of the area will show an opaque fluid line in the pouch and if a retropharyngeal lymph node is involved, it may reveal a mass.[9] In mild, acute cases of empyema, a saline or polyionic solution lavage is often performed via an endoscope or catheter repeatedly until the exudate drains.[12] Antimicrobial therapy without a lavage seldom remedies the infection.[9] In more complex cases, where concretions have formed, surgical intervention may be necessary to ensure appropriate drainage and removal of the hardened material. The area can be accessed surgically through the Viborg’s triangle[9],.[12]

Guttural Pouch Tympany

Guttural pouch tympany is an uncommon ailment in which excessive amounts of air become trapped in the pouch, resulting in abnormal expansion. Tympany is usually unilateral, but in some cases can affect both pouches. It is seen most often in young foals and is more common in females than in males.[13] Tympany results in non-painful, soft swelling beneath the ear and behind the jaw. Additional symptoms may include roaring, difficulty breathing, and difficulty swallowing and/or aspiration pneumonia.[14] Diagnosis is achieved through radiography and endoscopic evaluation. The specific cause of guttural pouch tympany is not known, but it is suspected that it is more common when there are defects of the plica salpingopharyngeus, and/or the pharyngeal orifice where they act as a one-way valve that does not allow air to escape.[14] Because of the risk of secondary infection, it is crucial that tympany be treated as soon as possible. Treatment protocols may include, but are not limited to, surgical intervention and in cases where surgery is not an option, insertion of a transnasal Foley balloon catheter in an attempt to remodel the pharyngeal orifice.[15]

Guttural Pouch Mycosis

Guttural pouch mycosis (GPM) is a fungal disease that is rare but potentially life-threatening. GPM is of unknown pathogenesis currently and no predisposing factors have been identified. Fungal plaque is usually located in the medial guttural pouch, near the internal carotid artery.[9] Clinical signs include unilateral or bilateral epistaxis due to erosion of the artery walls,[9] nasal discharge and cranial nerve dysfunction.[16] GPM is a dangerous condition as spontaneous fatal hemorrhaging can occur, usually within a few days to weeks after the first bout of epistaxis[9],.[13] The most common fungus associated with GPM is Aspergillosis.[17]

Diagnosis is made based on the history of the animal, presenting clinical signs and endoscopic exploration. Pharmaceutical treatment is not suggested without coinciding surgery.[18] Treatment typically consists of topical as well as systemic antifungal medication, paired with surgery to occlude or embolise affected arteries.[17] Early intervention is necessary to ensure the best chance of survival. Horses that experience dysphagia or other forms of nerve dysfunction as a result of GPM have a poorer prognosis that those who have not exhibited those symptoms.[19]

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See also

References
  1. Pollock, P. J. (2007). "Diagnosis and management of guttural pouch mycosis". Equine Veterinary Education. 19 (10): 522–527. doi:10.2746/095777307X240162.
  2. "Guttural Pouches - Anatomy & Physiology - WikiVet English". en.wikivet.net. Retrieved 2017-01-11.
  3. Davis, J. Weston (2015). "The equine guttural pouch: Clinically relevant anatomy and basic treatment options for trauma" (PDF). Equine Veterinary Education. 27 (8): 403–404. doi:10.1111/eve.12399 – via AAEP.
  4. Perkins, Gillian A.; Pease, Anthony; Crotty, Erin; Fubini, Susan L. (2003). "Diagnosing Guttural Pouch Disorders and Managing Guttural Pouch Empyema in Adult Horses". Compendium. 25: 966–973.
  5. Dyce, Keith, M.; Wesing, C. J. G.; Sack, W. O. (2010). Textbook of Veterinary Anatomy. St. Louis, Missouri: Elsevier Inc. pp. 522–525. ISBN 978-1-4160-6607-1.
  6. Baptiste, Keith E.; Naylor, Jonathan M.; Bailey, Jeremy; Barber, Ernest M.; Post, Klass; Thornhill, Jim (2000-02-01). "Physiology - A function for guttural pouches in the horse". Nature. 403 (6768): 382–383. Bibcode:2000Natur.403..382B. doi:10.1038/35000284. ISSN 0028-0836. PMID 10667779.
  7. Mitchell, Graham; Fuller, Andrea; Maloney, Shane K; Rump, Nicola; Mitchell, Duncan (2006-09-22). "Guttural pouches, brain temperature and exercise in horses". Biology Letters. 2 (3): 475–477. doi:10.1098/rsbl.2006.0469. ISSN 1744-9561. PMC 1686210. PMID 17148434.
  8. Dixon, P. M.; James, O. A. (2016-12-01). "Equine guttural pouch empyema, why does it become chronic?" (PDF). Equine Veterinary Education. 30 (2): 80–84. doi:10.1111/eve.12707. ISSN 2042-3292.
  9. Rush, Bonnie, R. "Guttural Pouch Disease in Horses". Retrieved 2017-01-11 – via Merck Veterinary Manual.
  10. Perkins, Justin D.; Schumacher, Jim; Kelly, Ger; Gomez, Jorge H.; Schumacher, John (2006-10-01). "Standing surgical removal of inspissated guttural pouch exudate (chondroids) in ten horses". Veterinary Surgery: VS. 35 (7): 658–662. doi:10.1111/j.1532-950X.2006.00204.x. ISSN 0161-3499. PMID 17026551.
  11. Lavoie, Jean-Pierre; Hinchcliff, Kenneth William (2008-01-01). Blackwell's Five-Minute Veterinary Consult: Equine. John Wiley & Sons. ISBN 9780813814872.
  12. Fjeldborg, J.; Baptiste, Keith (2017-01-03). "Diseases of the Guttural Pouches" (PDF). University of Copenhagen, Denmark.
  13. Robinson, Norman Edward; Sprayberry, Kim A. (2009-01-01). Current Therapy in Equine Medicine. Elsevier Health Sciences. ISBN 978-1416054757.
  14. Bell, Chris (2017-01-11). "Pharyngeal neuromuscular dysfunction associated with bilateral guttural pouch tympany in a foal". The Canadian Veterinary Journal. 48 (2): 192–194. ISSN 0008-5286. PMC 1780239. PMID 17334035.
  15. Caston, S. S.; Kersh, K. D.; Reinertson, E. L.; Cammack, S. (2015-01-01). "Treatment of guttural pouch tympany in foals with transnasal Foley catheter placement". Equine Veterinary Education. 27 (1): 28–30. doi:10.1111/eve.12244. ISSN 2042-3292.
  16. Wilson, David (2010-11-28). Clinical Veterinary Advisor: The Horse. Elsevier Health Sciences. ISBN 978-1437714494.
  17. Lepage, O. M.; Perron, M. F.; Cadoré, J. L. (2004). "The mystery of fungal infection in the guttural pouches". The Veterinary Journal. 168: 60–64. doi:10.1016/s1090-0233(03)00108-4. PMID 15158209 – via Research Gate.
  18. Dobesova, O.; Schwarz, B.; Velde, K.; Jahn, P.; Zert, Z.; Bezdekova, B. (2012). "Guttural pouch mycosis in horses: a retrospective study of 28 cases". Veterinary Record. 171 (22): 561. doi:10.1136/vr.100700.
  19. Kentucky Equine Research Staff (2013). "Fungal Infections of the Guttural Pouch in Horses". EquiNews. Retrieved 2017-01-11 – via Kentucky Equine Research.
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