CASE RE­PORT

A large lump on a mare’s face was as­sumed to be an ag­gres­sive tu­mor un­til a biopsy re­vealed the startling and smelly truth.

EQUUS - - Contents - By Chris­tine Barakat

Some­thing she ate: A large lump on a mare’s face was as­sumed to be an ag­gres­sive tu­mor un­til a biopsy re­vealed the startling and smelly truth.

At first Ash­ley Jenk­ins thought her 19-yearold mare, Belle, had a res­pi­ra­tory in­fec­tion. “She had a slight trickle of yel­low fluid com­ing from her left nos­tril,” Jenk­ins says. “I as­sumed she had a cold.” A cold wouldn’t have been sur­pris­ing, given the weather. The win­ter had been un­char­ac­ter­is­ti­cally long and harsh for Vir­ginia, and by March 2014, a warm spell fol­lowed by another plum­met in the tem­per­a­tures had left ev­ery­one feel­ing a lit­tle out of sorts.

But then, says Jenk­ins, “I no­ticed she also had a large lump un­der her left eye.”

Jenk­ins had owned Belle for 16 years and had shown the mare un­der the name Skip Ea­gles Star in Amer­i­can Quar­ter Horse As­so­ci­a­tion-rec­og­nized com­pe­ti­tions and all-around and hunter-un­der-sad­dle classes. Now Belle was re­tired to Jenk­ins’ par­ents’ farm. Apart from a bout of ty­ing up when she was younger, the bay mare had al­ways been healthy. “I still ride her oc­ca­sion­ally,” says Jenk­ins. “But she’s mostly a pretty pas­ture or­na­ment.”

De­spite the runny nose and the odd lump on her face, Belle seemed happy and com­fort­able. She was eat­ing well and showed no signs of pain, dis­tress or ill­ness. Nev­er­the­less, Jenk­ins called Chris Robert­son, DVM, of Blue Moun­tain Equine, to in­ves­ti­gate.

Robert­son im­me­di­ately had a bad feel­ing about the lump on Belle’s face. The swelling had a low pro­file, but it cov­ered a wide area. “It had the con­tours of a base­ball, as if it was shoved up into her nose and I could see the top sixth of it,” he says. Even more disturbing was the fact the lump was ap­par­ently formed by bone be­ing pushed out from the mare’s face.

“I could tell that the lump we were feel­ing was ac­tu­ally her skull bulging from the inside out,” says Robert­son. “The only thing I could think of that would cause a lump like that on the face was a very large and ag­gres­sive tu­mor within the si­nus cav­ity.”

Si­nus tu­mors can be dif­fi­cult to treat in horses. “Even if you can re­move some, you can’t ex­pect them to go away com­pletely,” says Robert­son. “They tend to come back and grow un­til the horse is re­ally un­com­fort­able. We had seen a horse a few years ago with a fi­brosar­coma in his si­nus, and it didn’t end well.”

Robert­son in­serted a small hy­po­der­mic nee­dle into the lump on Belle’s face in an at­tempt to as­pi­rate some fluid. “If a lump is caused by an in­fec­tion or ab­scess, you’ll be able to pull stuff out with a nee­dle,” he says, “but you won’t get much if it’s a tu­mor.” When mul­ti­ple tries yielded only a very small amount of bloody fluid, the grim di­ag­no­sis seemed all the more cer­tain.

As Robert­son ex­plained his sus­pi­cions to Jenk­ins, her heart sank. “He said that he was pretty sure it was a tu­mor and the out­look wasn’t good,” she says. “He also said he could re­fer us to a large clinic for x-rays and a biopsy to be cer­tain, and that they might at­tempt to treat it. The sit­u­a­tion didn’t sound en­cour­ag­ing at all, but she’s my pride and joy. I didn’t hes­i­tate to ask for the re­fer­ral.”

Robert­son ar­ranged for Belle to be seen by Paul Stephens, DVM, at Blue

Ridge Equine Clinic in Earlysvill­e, Vir­ginia, the next day. In the mean­time, he started the mare on a course of an­tibi­otics, in case the lump was in­deed an in­fec­tion, along with an an­ti­in­flam­ma­tory med­i­ca­tion.

But that night, another win­ter storm rolled through and cov­ered North­ern Vir­ginia with nearly a foot of snow and ice. The trip to the clinic would have to be post­poned. “We couldn’t safely ship her any­where,” says Jenk­ins. “It was very up­set­ting to be able to do noth­ing but wait.” Mean­while, the lump on Belle’s face grew larger.

A week later, the roads were fi­nally clear enough to take Belle on the twohour trip. After ex­am­in­ing the mare, Stephens met with Jenk­ins.

“The lump was just as Robert­son had de­scribed it to me---very large, fo­cal and very firm,” says Stephens. “In that area of the face, there is very lit­tle soft tis­sue---it’s just the skin stretched over bone---so if you get an in­fec­tion or an ab­scess, it tends to be dif­fuse and spread out, not col­lected. The only thing I could think of that could grow and mush­room like this, de­form­ing the bone, was a tu­mor. I was vir­tu­ally cer­tain that’s what we were deal­ing with, and I told Ash­ley that.”

The news was dev­as­tat­ing. “Dr. Stephens told me he still had to biopsy the lump to be cer­tain, but he set the stage to give me some very bad news. I called my dad and started cry­ing, then my friends, just sob­bing about Belle.”

Mean­while, the vet­eri­nary team took a se­ries of ra­dio­graphs in prepa­ra­tion for a biopsy. The images re­vealed some un­ex­pected---and game-chang­ing--in­for­ma­tion: “We saw a dra­matic soft­tis­sue den­sity mass, pretty well cen­tered in the si­nus,” Stephens says. “But what was also very ob­vi­ous was a frac­tured tooth just be­low the mass. Not just split, but with sev­eral mil­lime­ters sep­a­ra­tion. The en­tire bony socket that held the tooth was de­formed and ex­panded.”

This was good news, he adds, be­cause it meant that the mass might not be a tu­mor: “A tu­mor can­not split a tooth. It might in­vade the ad­ja­cent bone and soft tis­sue and push the tooth out of po­si­tion but not cause it to frac­ture.”

A more likely sce­nario was that Belle had frac­tured her tooth first, and that had led to a mas­sive in­fec­tion after feed be­came trapped in the crevice. Belle hadn’t shown any other signs of an in­fec­tion---such as co­pi­ous nose drainage, bad breath or an el­e­vated tem­per­a­ture--but it re­mained the best work­ing the­ory at the mo­ment.

“Our next step was an oral exam,” says Stephens, which con­firmed the frac­ture and the pres­ence of feed in the area. “Then we de­cided to open the mass from the out­side, by cut­ting into the face to see what was in there.” With Belle heav­ily se­dated, the sur­geon made a small in­ci­sion through the de­graded

A game changer

bone di­rectly over the lump and reached in with a for­ceps to see what he could pull out.

Jenk­ins had just hung up the phone and was try­ing to re­gain her com­po­sure when Stephens burst into the wait­ing area. “He was so ex­cited,” she re­calls. “He was say­ing, ‘It’s feed! It’s not a tu­mor. There’s feed com­ing out!’ I was def­i­nitely con­fused, but he seemed re­ally happy.’”

An un­usual ac­cu­mu­la­tion

Nor­mally, when a horse’s tooth frac­tures, the bony socket re­mains in­tact. “Bac­te­ria may cross through the bone at

the tooth root to form an ab­scess, and in the last three up­per cheek teeth this can re­sult in a si­nus in­fec­tion,” says Stephens. But Belle’s case was dif­fer­ent: “When the tooth frac­tured---how­ever it frac­tured---it frac­tured the bone above it as well, in the deep­est part of the tooth socket. Feed was pushed right up through it to col­lect in the si­nus cav­ity above the area. When we cut into the lump, we found it was all packed, rot­ting feed.”

It’s re­mark­able that Belle con­tin­ued to eat nor­mally with such ex­ten­sive dam­age to her mouth, but not un­heard of, says Stephens: “Horses will adapt to sur­vive. I’ve seen horses with tooth frac­tures and nasty in­fec­tions and they’ve never turned down a meal. They just switch to chew­ing on the other side of their mouths. It’s amaz­ing what they can tol­er­ate.”

Leav­ing Jenk­ins to call her fam­ily and friends back with the good news, Stephens re­turned to be­gin treat­ing Belle. “First we needed to get the pocket cleaned out, work­ing from the out­side of her face,” he says. “We spent the next 15 to 20 min­utes pulling out the feed with for­ceps and then flush­ing the area with saline. We also scraped the inside of the pocket to re­move any tis­sue that was necrotic0. The smell was ab­so­lutely hor­ren­dous, but even­tu­ally we were suc­cess­ful.”

Next, Stephens turned to the inside of Belle’s mouth. “Us­ing a specu­lum to keep her mouth open, we were able to use den­tal for­ceps to re­move each half of the tooth,” he says. “I was a bit wor­ried we wouldn’t be able to get the en­tire tooth out, but even­tu­ally we were able to.”

Stephens also re­moved any bone that looked dead, in­fected or dy­ing. “When we were done, we had this huge hole go­ing up through the mouth where the tooth had been, di­rectly into the mare’s si­nus and then out her face straight to the great out­doors,” he says. “It was dra­matic, to say the least.”

Filling the void

Nor­mally, when an up­per cheek tooth is re­moved, the vet­eri­nar­ian fills the socket with an acrylic plug. “This pre­vents feed ma­te­rial from be­ing packed up into the socket,” says Stephens. “If the socket is shal­low, we just pack it for a few days with gauze, like when you get your wis­dom teeth pulled, un­til tis­sue be­gins to fill in.” For deeper sock­ets, the vet­eri­nar­ian may fash­ion an acrylic plug that fits snugly into the area to ac­com­plish the same goal over a longer pe­riod of time.

But in this case, Stephens was go­ing to have to im­pro­vise. “Belle cer­tainly had a deep socket, but be­cause it was very large and didn’t ta­per, it was go­ing to be prob­lem­atic to get a plug to hold in there,” he says. “But I couldn’t leave it open. What I elected to do was pack the hole from the out­side with rolled gauze I’d made into a ball. Then, I packed the socket from the inside of the mouth with ster­ile gauze. By com­ing at the space from both sides, we were able to fill it com­pletely.”

This gauze pack­ing would be changed twice daily as the socket be­gan to heal. “As the tis­sues get healthy, they start to fill in,” says Stephens. “You pack the gauze in tight enough to hold but loose enough to leave room for the new tis­sues. Even­tu­ally, you’re pack­ing less and less into the space.”

Not only would the gauze keep feed out of the socket as Belle ate, but the rough tex­ture of the ma­te­rial would de­bride the wound each time it was re­moved. “Necrotic is­sue will stick to gauze,” says Stephens. “That means that as we changed the pack­ing, we’d be re­mov­ing any dy­ing tis­sue that could lead to an in­fec­tion.” Although Belle was

“I’ve seen horses with tooth frac­tures and nasty in­fec­tions and they’ve never turned down a meal. They just switch to chew­ing on the

other side of their mouths.”

Af­ter­care and unan­swered ques­tions

still on an an­tibi­otic, and would be for a few weeks, any ex­tra pro­tec­tion against in­fec­tion would be ben­e­fi­cial.

Re­mov­ing and repack­ing the gauze wasn’t sim­ple, how­ever. “We had to do it with Belle un­der light se­da­tion,” says Stephens. “We’d re­move all the gauze and lavage the socket, from the out­side down into her mouth. Then we’d repack the en­tire area, hope­fully with less gauze than we needed be­fore.”

Belle re­mained at the clinic for another five days, then she was moved to a lay-up fa­cil­ity where Stephens con­tin­ued to visit daily to tend to her wound. “There wasn’t any way we could do this our­selves at home,” says Jenk­ins. “To help us with the cost, Dr. Stephens ar­ranged to have her moved to the most amaz­ing fa­cil­ity I’ve ever seen, and then he went out there on his own time and his days off to take care of her.”

Belle’s wound healed quickly. Less than two weeks after the tooth was re­moved, the socket had closed enough to be fit­ted with an acrylic plug. Plug­ging the socket would elim­i­nate the need to pack gauze in the wound from the inside of the mouth and pro­vide more pro­tec­tion against feed con­tam­i­na­tion and in­fec­tion. For this pro­ce­dure, Belle was shipped back to the clinic.

“The plugs are made of two com­pounds you mix,” Stephens says. “They are mold­able for a few min­utes, but then they set up and harden. The idea is to shape it to fit snugly just a half-inch deep into the socket from the gum line. You try to mold a flange to fit over the gum on the sides of the empty socket and then a lit­tle bit at the base of the tooth in front and the tooth be­hind, cre­at­ing a bridge.”

The socket would con­tinue to heal with the plug pro­tect­ing the gum. “Some­times the plug falls out in a few weeks, some­times it’s a few years, and some­times it never falls out---and that’s OK,” says Stephens.

With the plug in place, Belle was sent home and re­turned to Robert­son’s care. “I felt com­fort­able send­ing her home, but we weren’t out of the woods yet,” says Stephens. “It seemed un­likely that the si­nus wouldn’t need ad­di­tional de­bride­ment to re­move pock­ets of resid­ual dis­ease. She was still on an an­tibi­otic, but that wasn’t any guar­an­tee. It was almost too much to hope that it was just go­ing to con­tinue to heal.”

Robert­son vis­ited Belle ev­ery two days. “Her si­nus was still open to the ex­te­rior, so I’d re­move the gauze, flush the area and repack it,” he says. “After the first week, though, enough tis­sue had filled in that I didn’t re­ally have room for the gauze. And a few days after that, the ex­te­rior wound had closed com­pletely.”

Her mouth had healed, and her face was be­gin­ning to look nor­mal, but Belle was still show­ing signs of her or­deal--she had lost a sig­nif­i­cant amount of weight. Part of the loss could be at­trib­uted to the nec­es­sary changes in her diet. The mare hadn’t been al­lowed to eat hay and in­stead was on a com­plete feed. But her tem­per­a­ment prob­a­bly also played a role. “Belle al­ways got anx­ious away from home,” says Jenk­ins. “When we would show, she wouldn’t eat well. I think hav­ing to be at the clinic and the lay-up fa­cil­ity re­ally stressed her out. I’d never seen her that thin.” Once she re­turned home, how­ever, Belle quickly re­gained her weight.

One re­main­ing ques­tion is how Belle had man­aged to frac­ture her tooth so badly. “Ex­ter­nal trauma can­not frac­ture a tooth in a sagit­tal di­rec­tion [with the frac­ture line par­al­lel to the jaw],” says Stephens. “A split tooth like Belle’s would re­quire a force to drive up through the sur­face of the crown, like split­ting a log with a maul. Horses do oc­ca­sion­ally get a rock in with a mouth­ful of hay, but most teeth that ac­quire a sagit­tal frac­ture also have a de­vel­op­men­tal flaw in the tooth that cre­ates a weak spot. This is sim­i­lar to the way a cav­ity would weaken the tooth, though true cav­i­ties are not common in horses. But in this case, the tooth and the socket were driven apart and it would have re­quired ex­cep­tional force to cre­ate this amount of sep­a­ra­tion. There were no other ab­nor­mal­i­ties that we ob­served in Belle’s mouth, and the op­pos­ing mo­lar was not dam­aged. Clearly some­thing un­usual hap­pened.”

By mid­sum­mer, five months after her or­deal, Belle was nearly fully re­cov­ered. She’ll need reg­u­lar float­ing to pre­vent over­growth in the tooth op­po­site the plugged socket, but she prob­a­bly won’t re­quire any other spe­cial­ized care. “It’s re­mark­able that such a mas­sive wound could heal so well,” says Stephens. “That mass of im­pacted, rot­ting feed and the hole it left be­hind was un­like any­thing I’d ever seen. As I was clean­ing it out, I never would have an­tic­i­pated things turn­ing out so well for Belle.”

Robert­son agrees: “Belle is over this and do­ing so well, which is re­mark­able when we were so sure it was go­ing to be re­ally bad. Even when we thought it was a tu­mor, Ash­ley wasn’t ready to quit on her with­out know­ing for sure. And it’s a good thing she didn’t. Belle is a great horse.”

RE­VEAL­ING: Ra­dio­graphs showed that be­neath the large mass cre­at­ing the bulge in Belle’s face was a frac­tured tooth and a de­formed bony socket.

BELLA BELLE: Once the source of her un­usual fa­cial lump was re­solved, Belle’s pro­file re­turned to nor­mal.

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