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Month: September 2018

Palm Beach Equine Clinic Case Study: Ethmoid Hematoma

A horse was recently admitted to Palm Beach Equine Clinic (PBEC), based in Wellington, FL, with symptoms that included bleeding from the nostril. The patient’s referring veterinarian had diagnosed the horse with an ethmoid hematoma, which in layman’s terms is essentially a mass that fills with blood in the nose or sinus cavity.

The patient was placed under the care of PBEC’s board-certified surgeon Dr. Weston Davis and Dr. Michael Myhre. They performed an airway endoscopy to locate and evaluate the hematoma that the referring veterinarian had identified. After confirming the diagnosis, Dr. Davis and Dr. Myhre were eager to ensure that it was the one and only hematoma they were battling.

Computed Tomography

PBEC is one of an elite group of equine veterinary clinics to have a computed tomography (CT) machine in their arsenal of diagnostic imaging equipment. A CT gives veterinarians a unique look at the head, neck, and spine of a horse that they would never be able to accomplish with other imaging modalities. After a CT of the patient’s sinuses, more masses were indeed identified.

Watch the CT scan that spotted the additional masses in progress!

“This was a fairly typical presentation of an ethmoid hematoma, but there were certainly more masses than normal,” said Dr. Myhre. “It’s for this reason that the CT was very useful. If we were not able to obtain the scans that we did, we may have missed the masses that were located deeper in the sinus.”

The cause of an ethmoid hematoma is unknown, but the mass resembles a tumor in appearance and development without being neoplastic. Horses with extensive masses may have reduced airflow and an expanding hematoma can cause pressure necrosis of the surrounding bones, but rarely causes facial distortion. Treatments of the ethmoid hematoma can range from conservative management to surgery. The conservative treatment route includes the injection of formalin – a mixture of formaldehyde gas and water – into the mass using a guarded endoscopic needle. Once injected, the mass typically regresses rapidly, but recurrence is common. For some cases, surgical excision is achieved via a frontonasal bone flap procedure.

The Approach

Palm Beach Equine Clinic Case Study: Ethmoid Hematoma
Palm Beach Equine Clinic Case Study: Ethmoid Hematoma

Due to the location and advances nature of the masses in this case, injection was not an option and the CT imaging was used to plan a surgical approach. “After sedation and a local block, we went into the sinus through a flap approach where we took a section of bone, cut it into a flap, and moved it back so we could go into the sinuses through a nice window,” said Dr. Myhre. “We removed a mass four centimeters in diameter as well as several smaller masses two to three centimeters in diameter, then flushed the area and closed.”

According to Dr. Myhre the advantages of a standing procedure included fewer risks from bleeding and fewer risks of recovering from anesthesia.

Post-surgery, the bone flap will require several weeks to heal, but the skin itself healed within one to two weeks, which is when the horse was cleared to return to normal activity.


Get to Know Palm Beach Equine Clinic Veterinarian Dr. Santiago Demierre

At first glance, Dr. Santiago Demierre appears to be a young veterinarian making a name for himself in the field of equine medicine. A closer look, however, reveals that he is not only that but also an exceptional example of diligence; he’s also working to become an extraordinary veterinarian while speaking a second language all in a country that is 5,000 miles from his home.

Palm Beach Equine Clinic veterinarian Dr. Santiago Demierre
Palm Beach Equine Clinic veterinarian Dr. Santiago Demierre

Born in San Antonio de Areco, a small town in the countryside outside Buenos Aires, Argentina, Dr. Demierre is now a 32-year-old veterinarian working with some of the most cutting-edge veterinary technology in the industry at Palm Beach Equine Clinic (PBEC) in Wellington, FL. He attended vet school at Universidad de Buenos Aires and graduated as Medico Veterinario in 2012 before setting a goal to validate his degree in the U.S. While mastering the English language, he enrolled in a certification program called the Educational Commission for Foreign Veterinary Graduates (ECFVG) through the American Veterinary Medicine Association and officially validated his degree in the U.S. in January 2017.

Today, Dr. Demierre is one of 40 veterinarians on staff at PBEC, which includes six boarded specialists and more than 80 technicians and staff members, making it one of the largest sport horse practices in the world.

Three things you may not know about Dr. Santiago Demierre: 

1. Horses are in his blood.

Dr. Demierre: My father was a racehorse breeder and trainer, so while I was growing up I spent hours with him and the horses at the farm. I was always very interested in animals in general, not only horses, so even as a little kid I had the idea and the dream that I would be a veterinarian in order to be able to spend as much time with animals as I could. Now, I enjoy so many things about this work, but what really motivates me is the satisfaction I feel when I have a successful outcome on a case.

2. When the opportunity came to study veterinary medicine, he picked up and moved across the world.  

Dr. Demierre: A fellow veterinarian who is a friend of mine, Dr. Eduardo Beccar Varela, contacted me with his nephew Dr. Axel Beccar Varela, who is a board-certified surgeon, and they offered me an externship at the clinic where he was practicing in Florida. I took that opportunity and began working in the U.S. 

While here, a friend of mine, Gringo Colombres, introduced me to Dr. Scott Swerdlin, president of PBEC.  He offered me an internship at PBEC in Wellington and I am now in my fourth season there. 

The team at Palm Beach Equine Clinic is made up of great veterinarians and now great friends. There is always somebody from whom you can learn something new every day. Also, it is awesome to be in contact with the world’s top equine athletes. That is what I enjoy most about being part of the team at PBEC—working on performance horse cases. More specifically, I really like preventing and treating lameness in sport horses. 

3. True to his Argentinian roots, he does some riding himself.

Dr. Demierre: I love being outdoors. When I am not treating patients or at the clinic, you can probably find me riding polo ponies. If I’m not there, I am either fishing, hunting, or enjoying some time off with my girlfriend. 

Even after treating patients in both Argentina and North America, Dr. Demierre’s trans-continental bucket list is far from fulfilled. Next, he hopes to take the skills he has mastered at PBEC and validate his degree in Europe as well.

Want to learn more about the veterinarians of PBEC and what they have to offer your equine athlete or backyard companion horse? Call the clinic today at 561-793-1599 to learn more.

Internal Medicine: What’s it all about?

Palm Beach Equine Clinic President Dr. Scott Swerdlin often says, “If you want to attract equine veterinary specialists, you have to have impressive facilities and technology in place.” Palm Beach Equine Clinic is one of the few veterinary clinics in the country to offer clients the talents of board-certified specialists in nearly every branch of equine veterinary medicine. One such specialist is Peter Heidmann, DVM, DACVIM, a graduate of Tufts University School of Veterinary Medicine, who joined Palm Beach Equine Clinic in 2016.

Dr. Peter Heidmann Palm Beach Equine Clinic Veterinarian
Dr. Peter Heidmann, DVM, MPH

Dr. Heidmann specializes in the treatment of internal medicine cases at Palm Beach Equine Clinic.

What attracted him? The facilities! In the heart of South Florida’s horse country and at the center of the busiest winter competition schedule in the world, Palm Beach Equine Clinic boasts an internal medicine and infectious disease center at its Wellington-based clinic.

The crown jewel of the center is the ability to stop airborne disease dead in its tracks with the U.S. Department of Agriculture (USDA) approved isolation stalls that completely enclose horses in their own environment with individual filtered airflow systems that do not reach other horses. On top of secure isolation and individual airflow systems in their internal medicine facilities, Palm Beach Equine Clinic also constructed areas for each stall where medications are prepared, equipment is stored, and dirty bedding is handled.

To further mitigate risk, veterinarians, technicians, and staff take every available precaution, including foot baths before entering the stalls and wearing personal protective equipment such as Tyvek suits, gowns, and face masks to provide multiple layers of protection against spreading disease. In some cases, a specific team of doctor, technician, and intern is assigned to a patient and won’t touch another horse for the duration of the treatment.

Accurately Diagnosing Internal Medicine Cases

Diagnostics is not a guessing game at Palm Beach Equine Clinic. With advanced imaging equipment, including a computed tomography (CT) machine, standing magnetic resonance imaging (MRI), and nuclear scintigraphy camera (bone scan), as well as radiography (x-ray) and ultrasonography capabilities, Palm Beach Equine Clinic is armed and ready to quickly and accurately diagnose internal medicine cases.

Dr. Heidmann refers to the facilities and his work at Palm Beach Equine Clinic as a luxury, saying, “I’ve managed many cases in various facilities going all the way back through internship, fellowship, and residency, but this is as nice as any place I have ever worked. It makes the risk to the horses so much lower, but also removes the anxiety for myself because I’m able to look a client in the eye and tell them that there is no risk. I don’t have a concern about disease spreading from one patient to another because at Palm Beach Equine Clinic we have the tools that we need.”

Understanding Internal Medicine

To understand how diagnostic tools are most effective, one must understand what exactly internal medicine is. In an effort to define internal medicine, Dr. Heidmann noted, “What you’ll see on the American College of Veterinary Internal Medicine (ACVIM) website is an emphasis on organ systems and organ system problems – respiratory disease, gastrointestinal disease, and neurologic disease being three of the most prevalent.

“What it really entails is a way of analyzing problems specific to the organ systems,” he continued. “It can be all over the map, and that’s part of what makes the specialty so fun and interesting.”

The most common internal medicine cases can be split into three categories:

  • gastrointestinal (GI) problems
  • neurological system issues
  • respiratory diseases.

Gastro-Intestinal Problems in Horses

“When it comes to GI issues, I usually see horses in two categories,” said Dr. Heidmann. “Number one are the horses that may need to go to colic surgery and the horses that just had colic surgery. The other is horses with intestinal infections, often colitis in which they have heavy diarrhea.”

According to Dr. Heidmann, all of the treatments for colitis tend to boil down to the same thing: replacing their ongoing losses and letting the intestine heal itself. It doesn’t matter if it’s colostrum, salmonella, Potomac Horse Fever, or any other kind of infection.

Equine Neurologic System

The nervous system in a horse is made up of the brain, spinal cord, and several different kinds of nerves that are found throughout the body. These create complex circuits through which animals experience and respond to sensations. Unfortunately, many different types of diseases can affect the nervous system, including birth defects, infections, inflammatory conditions, poisoning, metabolic disorders, nutritional disorders, injuries, degenerative diseases, or cancer.

“Palm Beach Equine Clinic has an incredible ability to do advanced imaging and diagnostics on neurologic conditions,” said Dr. Heidmann. “With equipment like the standing CT, we can do scans of the head and neck with contrast – a CT myelogram – which really increases our ability to diagnosis a condition.”

Palm Beach Equine Clinic is able to locate problems not only on the top or bottom of a horse’s neck, but also on the sides of the neck – an area previously inaccessible to view even from myelograms under anesthesia.

“That’s part of the satisfaction of the job that I do; It’s not just ‘here is my experience and here is what I guess is going on.’ I have all of these options at my fingertips for diagnostics and tests. We can confidently confirm our clinical suspicions and then do treatment based on that.”

Respiratory Disease in Horses

As common as a cold for a human or acute in nature, Dr. Heidmann further breaks down the different kinds of common respiratory disease in horses into three categories:

Equine Asthma “Heaves”

The majority of the horses competing in Florida during the winter season are cared for impeccably, which reduces the occurrences of chronic respiratory conditions or significant lung conditions. As a result, what is most commonly seen is equine asthma or heaves. According to Dr. Heidmann, equine asthma is treatable through a combination of nebulized medications, nebulized steams, oral medications, or injections. These methods serve to quiet the inflammatory response similar to how an inhaler helps relieve a human with asthma problems.

Acute Infections

Viral cases of respiratory disease include flu and Rhinopneumonitis, or rhino, caused by one of two types of equine herpesviruses; EHV-1 and EHV-4. While vaccinations are the easiest method to prevent cases of flu and rhino, these problems are a big concern because they spread so readily. While proper biosecurity protocols go hand in hand with vaccinations, isolation is key when it comes to infectious diseases affecting the respiratory system, according to Dr. Heidmann.

Shipping Fever

The most severe kind of respiratory disease found in horses is shipping fever, which is an infection that takes advantage of a horse’s stress while traveling and results in an immune compromise. While treatable, these infections require two to three or more months on antibiotics that transition from injectable to oral, according to Dr. Heidmann.

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