Flap Technique for Management of Horn Affections and Horn Amputation.
The flap method of horn amputation was performed in nineteen (19) bovines (13 cases of horn fracture and 06 cases of horn cancer). The technique provided adequate closure of horn base. Post-operatively, the animals served their utility without any complications.
Keywords: Flap technique; horn affection; horn amputation; management
A horn is one of a pair of hard, pointed projection on the head of ungulates. Horn consists of central, conical core of living bone (cornual process), that grows out from frontal bone of skull. The dermis of horn is supplied by corneal nerve which is a branch of maxillary nerve (CN.V).
The four most common conditions encountered in horn affections are horn facture, horn cancer, avulsion of horn and overgrown horns. Tyagi and Singh (2015) stated that dehorning is indicated in adult animals following irreparable injuries or horn cancer. The procedure is also indicated if horns are misdirected or overgrown to the extent of causing cutaneous injuries due to pressure.
Horn fracture is one of the common affections encountered leading to huge economic losses due to decrease in working capacity and/or decrease in milk yield. The horn usually gets fractured as a result of trauma due to fighting with other animals, automobile accidents or falling (Tyagi and Singh, 2015). The incidence of horn fracture was 55%, 48.8%, 84% and 2.18% respectively by Patil and Bhokre (1981), Makkena and Rahul (2006), Shivaprakash et al. (2006) and Patel et al. (2012). Incidence of horn facture is noticed more commonly in bullocks (62%) and right horn is more commonly involved with base of horn. Manjunath (2013) reported incidence of horn facture to be 4.35% of all surgical cases and concluded that incidence of horn fracture to be more than other horn affections.
The clinical signs of horn fracture include bleeding at site, foetid smell, infection, nasal discharge and / or bent and fractured horn (Fig 1a-c). The horn core may be exposed and frontal sinus may be exposed with white to brownish pus at the site. Maggots may or may not be found. Shaking of head and bleeding from nostrils will be noticed in many cases.
Horn cancer is a widely prevalent disease in Indian cattle causing huge economic losses due to decrease in draught capacity as a result of prolonged morbidity and mortality. The tumor was reported for the first time in 1905 from Bombay Veterinary College, (Tyagi and Singh, 2015). Horn cancer (squamous cell carcinoma) is a malignant neoplasm of stratified squamous epithelium. It originates from squamous cell lining of core at base of horn. Damodaran et al. (1979) and Joshi et al. (1985) opined that horn cancer was common in breeds which had long, thick, massive and prominent horns. The incidence was more common in mid aged bullocks (6-8 years), which may be related to hormonal imbalances as reported by Kulkarni (1953) and Nair and Sastry (1954). Shivprakash et al. (2006) reported an incidence of 62% cases of horn injuries and 4% of horn cancer cases among all horn affections in bullocks. Ramakrishnan et al. (2013) reported that castrated bullocks appear to be very susceptible than bulls and cows. The disease is associated with chronic irritation of the horns at their base of yoke (Tyagi and Singh, 2015) stated that exact etiology of horn cancer is obscure and cause of tumor is considered to be multifactorial.
The clinical signs of horn cancer in early stages include painful swelling at base of horn, with dull sounds on percussion. The animal frequently shakes the head or striking of head to hard objects or striking it with leg, slight bending (Fig. 2) of horn may be noticed along with slimy sero-sangunious discharge from ipsilateral nostril. In later stages, head may be kept a little lowered or inclined towards the side of affected horn. The horn may be clearly bent as the case advances exposing an open wound studded with cauliflower like growth which may invade into sinuses (Fig. 8a and Fig. 8b). The animal becomes weak, anaemic, emaciated and if not treated may die in 3-6 months (Kulkarni 1953; Naik et al., 1969; and Pachari and Pathar,1970).
The present paper discusses about amputation of horn by flap method, as a salvage treatment for horn cancer and for horns fractured at the base or those in which, frontal sinus was exposed.
Materials and Methods
19 cases (06 cases of horn cancer and 13 cases of horn fractured at base of horn or in mid of the horn) presented for treatment of horn disorders formed material of study. The animals were kept off feed and off water for 12 hours. All animals were restrained in standing position and subjected for dehorning by flap method. The site around the base of affected horn was surgically prepared. Pre-operatively, all animals were prophylactically administered with a dose of hemostyptic along with inj Streptopencillin @ 5 gm O.D. i/m and inj Maxxtol (a) (Tolfenamic acid) @ 0.4 mg/kg b.wt i/v to provide intra-operative analgesia. Inj Xylazine @ 0.1 mg/kg b.wt i/v diluted with distilled water (1:10) was administered to achieve sedation and provide intra-operative and post-operative analgesia. Local analgesia was achieved with cornual nerve block (Fig. 3) and/or ring block at base of horn (Fig. 4a and Fig. 4b) using inj 2% Lignocaine HCl.
An elliptical skin incision was performed all along base of horn (Fig. 5b). Further, an incision was taken from the frontal crest to base of horn to unite with the dorsal elliptical incision (Fig. 5c). The skin on frontal bone was undermined using B.P blade no.24 and everted to prepare skin flap (Fig. 5d). The skin on the ventral side was then undermined as necessary, to get another flap. The cornual artery was identified and ligated using catgut no.1-0 or 1, though ligation not always seemed necessary to be performed. The capillary bleeding noticed during undermining of skin was arrested by mopping and retaining the mops under pressure until bleeding was arrested. The muscles on frontal bone, approximately 1-2 cm to the base of horn (depending on the shape of the horn) were incised and separated until bony surface was felt. The horn along with a portion of frontal bone was cut using hack saw blade (Fig. 6a and Fig. 6b) from both rostral to caudal aspect of horn until the whole horn was amputated (Fig. 6c and Fig. 6d). Normal saline solution was flushed at the site to avoid thermal necrosis during sawing of one.
In cases following removal of cancerous tissues, affected part of frontal bone was removed and bony surface was curated. The epithelium of frontal sinus was also removed and sinus was thoroughly irrigated with warm normal saline solution in order to flush out cancerous tissues (Fig. 7a and Fig. 7b). A broad spectrum antibiotic powder was instilled in frontal sinus cavity. The skin flaps were sutured using vertical mattress sutures with nylon no.2 (Fig. 8). In cases where the base of horn was too broad or skin was not adequate to create flaps, additional undermining of skin was performed to obtain sufficient elasticity of skin and wound edges were sutured using preplaced vertical mattress sutures (Fig. 9a-c).
The incisional site was surgically dressed twice daily with fly repellent ointment and broad spectrum antibiotic injection (inj Streptopencillin @ 5 mg TD i/m) was administered daily for 5 days. An anti-inflammatory injection was administered for two days. Skin sutures were removed between 10-15th post-operatively day depending on healing (Fig. 10a-b).
Results and Discussion
Horn fracture is as an emergency condition, as it may lead to sinusitis in bullocks having massive horns as opined by Tyagi and Singh (2015) and Shivaprakash (2011) and they recommended primary dehorning with flap method as an emergency treatment for such cases. Cases of horn cancer and complete horn fracture may not heal with medical therapy and hence require amputation as a salvage method for treatment. Dehorning as a method for treatment of horn cancer by flap method was described by Wilson (1905). Sahu and Mohanty (1963) reported an improved method of horn amputation for horn cancer. Rishendra and Naveen (1999) suggested amputation of horn at the base as a treatment for complete fracture of horn in bullocks. Treatment indicated by Shivaprakash et al. (2006) is surgical removal of affected horn along with resection of some parts of frontal bone. In present study, surgical technique of amputation of horn by flap method was found to be satisfactory to amputate horn from base in all cases of horn fracture and horn cancer.
The techniques was found satisfactory for restraint and analgesia during amputation of horn. Manjunath (2013) opined that dehorning for horn fracture performed under general anaesthesia using Xylazine and Ketamine was better than dehorning under Xylazine sedation with cornual nerve block as former caused less pain and stress. However, dehorning under general anaesthesia requires a good surgical team and patient monitoring.
Intra-operative bleeding was noticed more in cases of horn cancer in comparison to horn fracture due to new capillary bed formation around cancerous growth. Hence in cases of horn cancer, we advice to ligate the cornual artery first and then go ahead to undermine the skin. Proper ligation of cornual vessels before amputation of horn by flap method resulted in lesser bleeding during dehorning. Sahu and Mohanty (1963) described dehorning in cattle by ligating cornual artery at two parts. It is advised to administer adequate intra-operative fluid therapy in order to cover the fluid losses due to bleeding and due to dehydration. Administration of preoperative styptics was very beneficial in controlling intra-operative bleeding.
Sahu and Mohanty (1963) and Ramakrishnan et al. (2013) apposed the skin after dehorning using simple interrupted sutures. In present study, vertical mattress sutures were used and it was observed that they provided adequate tension to appose the skin flaps. In cases where horns were massive at the base or adequate skin was not available, undermining the skin to prepare sufficient skin flaps was desired. In cases where the tension was more, pre-placing the sutures in vertical mattress pattern and pulling all sutures at once in opposite direction and then applying knots to all sutures starting from centre to periphery provided adequate tension for closing the skin flaps.
The possible complications of amputation of horn include: secondary haemorrhage due to direct injury, wound dehiscence, sinusitis and maggot infestation (Tyagi and Singh, 2015). Ward (1992) and Sunil et al. (2010) reported frontal sinusitis in 67% of cases after dehorning. In the present study, no complications were noticed with regard to wound dehiscence or maggot infestation owing to proper post-operative care of the cases. In two cases treated for horn cancer, drop by drop bleeding was noticed post-operatively from the ipsilateral nostril for two to three days which got controlled on its own.
Shivaprakash (2008) opined that prognosis was good if base of horn is not affected. Once metastasis extends deeply into sinus or into surrounding frontalis muscle or out of the skin, the prognosis was poor. He reported death within three months after surgery in two of 15 cases of horn cancer. Bulgouda (2014) concluded that dehorning is successful for treatment of horn cancer if it is done in early stages before extensive metastasis has occurred. He reported that dehorning coupled with autogenous and BCG vaccine had better results when compared to dehorning alone for treatment of horn cancer. He observed recurrence of horn cancer at 6 months if auto vaccination was not performed. In the present study, one case of horn cancer was presented after six months of amputation of affected horn with similar complaint for other horn. In this case, metastasis had occurred and other horn was also amputated.
Gundrean (1953) and Tashke and Folsch (1997) reported that milk yield may decrease by 10-12% for a short period of 4-5 days after amputation of horn. They however did not notice abortions in any stage of pregnancy. In the present study, no cases of abortion were noticed post-operatively. The owners were not in a position to observe and appreciate a significant drop in the milk yield. Hence it could not be concluded authentically about the drop in milk yield after horn amputation.
The present study concluded that amputation of horn at base by flap method was adequate as a salvage procedure for management of horn fracture and horn cancer cases as adequate skin flap could be made available for closure of skin and cases healed without any complications. Amputation in cases of horn fracture was associated with lesser bleeding and complications and could be accomplished in lesser time as compared to horn cancer. Sawing of horn base was found to be easier in cases of horn cancer in comparison to horn fracture due to cancer related lytic changes occurring in bone. Lavaging of amputation site during sawing prevents thermal necrosis of frontal bone. Curetting and complete removal of growth in frontal bone are necessary in cases of horn cancer to prevent recurrence. Thorough lavaging of frontal sinus and instilling intra-operative broad spectrum antibiotic into frontal sinus is beneficial in preventing post-operative sinusitis. In cases with inadequate skin flap, undermining of skin and suturing with preplaced sutures as described in procedure provided adequate tension for closure of skin. In the present study no complications were noticed. Proper intra-operative and post-operative fluid and electrolyte therapy was indicated in cases where bleeding was excess. To conclude, amputation of horn base in irreparable cases of horn fracture and horn cancer as a salvage procedure could be achieved using flap method thus preventing economic losses due to culling as animals could be further used adequately for draft and milch purpose as the case may be.
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D. Jahangirbasha (1), B.V. Shivaprakash, D. Dilipkumar and B. Bhagvantappa
Department of Veterinary Surgery and Radiology Veterinary College
Karnataka Veterinary, Animal and Fisheries Science University (KVAFSU) Nandinagar Bidar - 585401 (Karnataka)
(1.) Assistant Professor and Corresponding author. E-mail: firstname.lastname@example.org
(a) - Brand of Intas Animal Health, Ahmedabad
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|Title Annotation:||Clinical Article|
|Author:||Jahangirbasha, D.; Shivaprakash, B.V.; Dilipkumar, D.; Bhagvantappa, B.|
|Date:||Jul 1, 2016|
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