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Discussion on Chronic Sinusitis Nightmare

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J4Tiger
New Member
Username: jb4sage

Post Number: 1
Registered: 6-2009
Posted on Monday, Jun 15, 2009 - 12:14 pm:   Edit PostPrint Post

My 25yo appendix, recently diagnosed with Cushing's (not by tests, physical exam only, on 1mg Pergolide/day since 12/15/09), has been treated in various ways for a left side sinus infection since Dec '08. It is still unresolved, $4000 later. SYMPTOMS: low fever on &off, greenish left nostril drainage, very malodorous.
Treatment progression (dates are approx.):
Dec: 2 weeks oral SMZ/TMP, infection not resolved.

JAN '09 - PRESENT: Horse developed 103'F fever, malaise,and reddish slimy urine. He was put in hospital for abdominal & thoracic ultrasound, no significant findings, bloodwork all normal, except slightly elevated GGT liver enzyme.
Head xrays for tooth issue equivocable, shows 3 cracked molars on drainage side. NO teeth extracted, but Sinus tube surgically inserted,flushed AND IM Naxcel, 9 days, unresolved.(no culture done)

2nd sinus tube, flushing and injecting Naxcell.
Sinus tube catheter faulty, fell out, replaced, sinus culture taken,continued with Naxcell regimen while waiting for results and checking progress.

Culture results took 10 days, showed organism is resistant to Naxcell; new tube put in, flushing and injecting switched to Gentocin, sinus also packed with antibiotic-embedded beads. Tube removed, drainage improved for two days, then bloomed again.

Suspected molar from Jan xrays removed, IM gentocin and flushed with another antibiotic that starts with "L" (not on invoice)horse doing MUCH better, but smelly drainage, although slight, is continuing, horse has malaise and right front lameness, eating OK. Vet wants to remove another molar.

MY QUESTIONS:
1. Am I out of line to ask for a reduction of my bill? I feel the case was mishandled, i.e. a culture should have been done the first time the tube was put in, AND the tooth removed (the horse is OLD AND HAS CUSHINGS). From my online research, aggressive treatment of sinus infections in an older Cushings horse is critical. An aggressive approach was not taken, resulting in costly prolonged care.

2. What should I do now? Pull another tooth? I am broke, but I cannot decide if it will clear this up once and for all.

Thank you for any and all advice, I am boggled and beaten.}}
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Robert N. Oglesby DVM
Moderator
Username: dro

Post Number: 23191
Registered: 1-1997
Posted on Tuesday, Jun 16, 2009 - 7:04 am:   Edit PostPrint Post

Welcome J4Tiger,
Taking your 2 questions in answer:

1) In each step a judgement call was made as to what the veterinarian thought was the best next step with consideration with what your goals where. If you feel that this was not handled in this manner, you should discuss your thoughts with them and what you think is an appropriate fix. Keep in mind, it is possible no matter what was done the outcome might be where you are right now. I often take a step wise approach to sinusitis somewhat as you outline above and often have success early on with a simple course of antibiotics, for more see treating sinusitis section of Diseases of Horses » Respiratory System » Nasal Discharge in the Horse.

2) The decision on your next step should be based on your goals and the prognosis and your goals should be somewhat in line with your resources. What prognosis does the veterinarian give for further surgery and what are your goals J4Tiger?
DrO
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J4Tiger
New Member
Username: jb4sage

Post Number: 2
Registered: 6-2009
Posted on Tuesday, Jun 16, 2009 - 2:29 pm:   Edit PostPrint Post

Thank you Dr. Oglesby, I appreciate your prompt response.

I had dug through all the links in HA prior to joining yesterday and writing my post. I gleaned much from them, including some terms that my vet did not mention, such as fistula and diastemata.

With my vet, I emphasized many many times that I was interested in balancing an aggressive approach with financial commitment. I even asked for the tooth to be pulled back in January, and was advised against it.

Nonetheless, I understand your advice, and I do accept that we may still be in this stage no matter what course was followed. However, in my research online, I found an article on equine chronic Pseudomonas sinusitis (his culture came back as Naxcel-resisitant P. aeruginosa) being complicated in protracted infections by the infection spreading to involve local bone tissue. At this stage, resolving the infection with antibiotics is often unsuccessful, and can require surgical intervention (opening the sinus cavity and clearing the diseased tissues) to affect a cure. Can you comment on this finding?

As you suggest, I will discuss my concerns and try and get a prognosis for the "next tooth" scenario.

Thank you for your time and advice, have a great day, Julia
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Robert N. Oglesby DVM
Moderator
Username: dro

Post Number: 23202
Registered: 1-1997
Posted on Wednesday, Jun 17, 2009 - 8:00 am:   Edit PostPrint Post

You are welcome Julia,
I would agree with the statement that "often pseudomonas infections of the bone will require surgical treatment". Pseudomonas infections anywhere are difficult as they often indicate difficult to deal with predisposing conditions to infection.

Let us know what he says. The key to a proper prognosis here will be a good diagnosis of why the problem continues: is this due to ongoing tooth problems or complications from previous surgery. And this may not be an easy question to answer.
DrO
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J4Tiger
New Member
Username: jb4sage

Post Number: 4
Registered: 6-2009
Posted on Thursday, Jul 30, 2009 - 1:30 pm:   Edit PostPrint Post

Hello Dr. O,

Here is an update on my case of chronic sinus infection (unilateral putrid green mucus drainage)
Began Dec 08, still presemt July 09, in my 26yo gelding with Cushings.

Background re:teeth:

JAN 09
Teeth examined for possible cause of unresolved sinus infection. Several cheek teeth on same side as infection were cracked, one had deep pocket and space. Head radiographs had been done to view cheek teeth and sinus. Suspect teeth areas found, but not conclusive, no teeth pulled.

Unresolved putrid sinus drainage continued into May despite trephinig treatments/flushing and antibiotics as previously described in other posts.

MAY 2009
New radiographs done of cheek teeth in preparation for extraction under general anesthesia. Cheek molar extracted, f/u with antibiotics and flushing 2 weeks. Horse quidding hay, eating OK, lost much weight, not gaining back.

Quidding eventually stopped, drainage almost nonexistant. All seemed well, just not gaining weight.

Drainage increased this week, thick bright green slimy mucus very putrid smelling.

QUESTIONS:
1. Is this indicative of another fistula?
2. Would the initial Jan radiographs been recent enough to see the tooth that was extracted?
3. What if they want to extract more?
4. What should I expect next from the vet?
5. How much time is OK to wait for the vet to follow up without risking further deterioration and then more medical expense? The next appointment I could get is 10 days from now. I am concerned the (infection? abcess? fistula? other?) will then progress and bring more complicated condition.

Thank you for your advice,

Julia
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Robert N. Oglesby DVM
Moderator
Username: dro

Post Number: 23522
Registered: 1-1997
Posted on Thursday, Jul 30, 2009 - 5:45 pm:   Edit PostPrint Post

Hello Julia,
I am sorry to hear about the recurrence of the nasal discharge. Taking your questions in order:
1) Not necessarily could be older one has reopened.
2) I don't understand this question.
3) If there is another tooth creating a problem it should be removed.
4) A good thorough exam which should lead to a diagnosis or recommendations for further testing.
5) The sooner this is seen the better but considering the chronic nature of the problem 10 days is probably not going to make much difference.

These can be very frustrating problems with only a fair prognosis Julia. Be sure your decisions are based on a realistic expectation and in line with your goals and resources.
DrO
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Dawn Winans
Member
Username: dwinans

Post Number: 153
Registered: 9-2000
Posted on Thursday, Jul 30, 2009 - 8:07 pm:   Edit PostPrint Post

Julia,

I posted here a few years ago when my gelding had a similar problem as yours. I was very fortunate that the sinus flushing was successful.

I would like to mention that although it only took a couple of weeks for the green/smelly, "infected" looking drainage to clear up it took several months for the drainage to completely disappear. The appearance changed from green to cream to clear before finally stopping.

Good luck! I know how stressful it is!
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