636 EQUINE VETERINARY EDUCATION / AE / DECEMBER 2013

Original Article
The nasolacrimal duct of the mule: Anatomy and
clinical considerations
M. F. Adams*, J. R. Castro, F. Morandi†, R. E. Reese and R. B. Reed‡
Departments of Large Animal Clinical Sciences, †Small Animal Clinical Sciences, and ‡Biomedical and Diagnostic
Sciences, College of Veterinary Medicine, University of Tennessee, USA.
*Corresponding author email: madams4@utk.edu
Keywords: horse; mule; nasolacrimal duct; donkey; anatomy; computed tomography; dacryocystography

Summary Mules were administered detomidine hydrochloride

This study investigated the location of the nasolacrimal orifice
(NLO) and course of the nasolacrimal duct in the mule
using visual examination, gross dissection and computed
tomography (dacryocystography [CT-DCG]) and concluded
that the location of the NLO is distinct from that described for
horses and donkeys and is easily located, by visual
examination alone, within the internal cutaneous tissue of the
lateral wall of the external nares. The course of the
nasolacrimal duct caudal to the nasal vestibule is similar to
that of the horse.
(Dormosedan)1 (0.015 mg/kg bwt i.v.) to facilitate
examination. Each nasal vestibule was examined to
determine the location of the NLO. The nasolacrimal duct of 9
mules was lavaged using a technique previously described for
the horse (Michau 2005). Lidocaine hydrochloride gel2 was
applied to the NLO prior to inserting a 14 cm (5.5 inch), 3.5 Fr,
open-end, tomcat catheter3. Once catheterised, the duct
was occluded with digital pressure and lavaged in retrograde
fashion with 6–10 ml of sterile, eye irrigating solution4 injected
slowly until the solution flowed from the medial canthus.

Introduction Computed tomography - dacryocystography

The 4 university owned mules were subjected to euthanasia
The equine lacrimal system consists of both secretory and
immediately before CT-DCG and the heads removed at
drainage portions and is composed of the lacrimal gland, 2
the atlanto-occipital joint. The specimens were positioned
lacrimal puncta, 2 canaliculi, a lacrimal sac, the nasolacrimal
on the CT table in ventral recumbency and CT-DCG was
duct and NLO (Latimer et al. 1984). The anatomy of the
performed using a previously published technique (Nykamp
nasolacrimal duct of the horse and the donkey has been
et al. 2004), which entailed inserting a 14 cm (5.5 inch), 3.5 Fr,
previously described (Said et al. 1977; Latimer et al. 1984) and
open-end, tomcat catheter3 into the NLO of the right and left
several variations exist, most notably the location of the
nares and injecting a radiographic contrast medium (Optiray
nasolacrimal orifice (NLO). The NLO of the horse is located on
350; Ioversol 350 mg/ml organically bound iodine)5 into
the floor of the nasal vestibule near the mucocutaneous
the nasolacrimal duct until it exited the lacrimal puncta.
junction (Latimer et al. 1984), whereas the NLO of the donkey
The volume of contrast medium injected depended on the
is located in cutaneous tissue in the dorsal external nares (Said
size of the head and ranged from 1.0 ml (6-month-old,
et al. 1977). Anecdotally, the location of the NLO of the mule
miniature mule) to 5.5 ml (7-year-old, gaited-horse mule). Thin
(Equus asinus x caballus) has been described as highly
section, transverse images were obtained before and
variable and difficult to locate visually. The aims of this study
immediately after injecting the contrast medium using a
were to determine the location of the NLO in a population of
40 slice multidetector CT scanner (DS Brilliance 40 Hybrid
mules, to describe landmarks for locating the NLO, and to
CT system)6 and the following imaging parameters: 40 ×
determine the course of the nasolacrimal duct of the mule
0.625 mm collimation, 0.474 pitch, 0.5 s rotation time, 120 kV,
using gross dissection and CT-DCG.
2509 mAs/slice. Data were reconstructed using edge
enhancing and standard algorithms. Edge enhancing was
Materials and methods used to optimise evaluation of osseous structures and standard
algorithms were used to optimise evaluation of soft tissues.
Visual examination and nasolacrimal lavage
Results were displayed with bone windows (window width:
The left and right external nares of 40 mules were examined to
2600, window level: 660) and with soft tissue windows (window
establish the location of the NLO and determine if retrograde
width: 350, window level: 50). Images were evaluated using a
lavage of the nasolacrimal duct was possible. Thirty-six mules
dedicated workstation (Philips Extended Brilliance Workspace
were privately owned and the cohort included mules
4.5) and multiplanar and 3D images were reformatted, as
of varying age, sex and breed (gaited-horse mules,
needed, from the transverse thin section data. Measurements
nongaited-horse mules and draught mules). The remaining 4
were obtained on transverse images oriented 90° to the hard
mules were university owned, including a 6-month-old,
palate.
miniature mule, one yearling mule and two 7-year-old
gaited-horse mules. All mules were in good body condition,
had no evidence of ocular or respiratory disease and Gross dissection
appeared clinically healthy. All procedures performed on The tomcat catheter3 was left in place following CT-DCG and
mules were approved by the University of Tennessee’s the left and right nasolacrimal ducts of each of the 4 heads
Institutional Animal Care and Use Committee. were injected retrograde with red latex casting material7 until

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EQUINE VETERINARY EDUCATION / AE / DECEMBER 2013
Fig 1: Left naris of mule showing placement of hand prior to
eversion of naris. The NLO is located opposite the tip of the index
finger within the nasal vestibule.
observed to flow from the lacrimal puncta. The lacrimal
puncta and NLOs were clamped with haemostats to prevent
loss of casting material prior to polymerisation. The specimens
were injected with 10% formalin via the common carotid
arteries, submerged in 10% formalin and refrigerated at 7°C for
7 days to allow the latex to solidify. The specimens were
hemisected longitudinally on the median plane using an
electric band saw before dissecting the nasolacrimal duct
from either a medial or lateral approach. The rostral and
caudal maxillary sinuses of 2 specimens were trephined using a
2.54 cm (1 inch) Galt trephine8 using previously published
landmarks for sinusotomy in the horse (Perkins et al. 2009).
Results
Visual examination and nasolacrimal lavage
The NLO of the mule was easily located with visual
examination in all 40 mules (36 live and 4 cadaver specimens).
The average diameter of the NLO was about 1 mm but varied
between 0.25 and 4 mm. The most common location
observed in 35/40 mules (87.5%) was in the internal cutaneous
tissue of the lateral wall of the external nares. This location
(Location A) was easily visualised when the thumb was placed
in the most dorsal aspect of the external naris, the index finger
was placed 6 cm in a caudolateral direction from the thumb
towards the direction of the caudal border of the false nostril
and the internal surface of the naris was everted (Fig 1). The
orifice was found at the level of the tip of the index finger in the
internal cutaneous tissue at the junction where the lateral wall
curved to meet the floor of the nostril, approximately 3.5–5 cm
637
Fig 2: Everted left naris of mule demonstrating the NLO (arrow) in
Location A.
caudomedial from the lateral edge of the naris (Fig 2). In 4/40
mules (10%), the NLO was observed on the floor of the nasal
vestibule (Location B). One mule (2.5%) had a NLO in Location
A and in Location B in both nares.
Catheterisation and retrograde lavage of the nasolacrimal
duct was performed in 9 mules. In these mules, including 3 with
a NLO <1 mm, the tomcat catheter was inserted easily and
with little resistance (Figs 3 and 4) and lavage was performed
without difficulty.
Multiple NLOs were identified in 5/40 mules (12.5%). In 4 of
the 5 mules, 2 orifices, approximately 5–10 mm apart, were
found bilaterally, although not always bilaterally symmetrical in
location or in size. Of the 4 mules, 2 mules had double orifices
in Location A and 2 mules had double orifices in Location B
(Fig 5). In one of these mules, a Jones Test (passage of
fluorescein stain to the NLO after topical application to the
eye) was performed to evaluate patency and produced stain
from both orifices of the right naris in approximately 5–6 min.
One mule had one orifice in Location A and one in Location B
in both external nares. In this mule, catheterisation of both
orifices revealed communication with each other and the
main nasolacrimal duct, allowing for retrograde lavage of the
duct via either of the NLOs.
Gross dissection
The right and left NLO of all 4 heads were found within the
cutaneous tissue of the lateral wall of the external naris (i.e.
Location A). Within the tissue of the external naris, the duct was
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Fig 3: Nasolacrimal catheterisation of the left naris using 5.5 inch 3.5
Fr tomcat catheter. Note the lateral location of the NLO in the
cutaneous tissue of the external naris.
Fig 4: Nasolacrimal catheter in place demonstrating caudomedial
course of initial portion of duct.
flattened dorsoventrally and difficult to dissect from the
surrounding tissue. The duct continued caudally and medially
along the floor of the nasal vestibule passing dorsal to the
caudal portion of the incisive bone (Fig 6). At this point it
entered the basal fold of the ventral nasal concha where it
attained its closest proximity to the median plane. Passing
through the basal fold, the duct coursed ventrally to a lateral
extension of the medial accessory nasal cartilage as it entered
the ventral concha. After passing ventral to the cartilage, the
duct exited the lateral aspect of the ventral concha into the
floor of the ventral nasal meatus. The nasolacrimal duct
immediately coursed laterally onto the lateral aspect of the
middle nasal meatus where it continued to pass caudally and
dorsally in a slightly dorsally arched fashion (Fig 7). At this
location, it lay within the lacrimal sulcus, covered by nasal
mucosa. At the level of the maxillary fourth premolar (Triadan
108 and 208), the duct passed lateral to a ridge of bone, the
rostral terminus of the lacrimal canal, to enter the dorsolateral
aspect of the rostral maxillary sinus. Upon entering this sinus, the
nasolacrimal duct passed dorsocaudally into the maxillary
portion of the lacrimal canal through which the latex was able
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EQUINE VETERINARY EDUCATION / AE / DECEMBER 2013
Fig 5: Double NLO (arrows) observed in Location A of right naris of
mule.
to be visualised. When the duct reached the level of the
caudal maxillary sinus, it entered the lacrimal bone where it
was encased in a substantial amount of bone preventing its
visualisation without further dissection. While passing through
the dorsolateral aspect of the maxillary sinus, the nasolacrimal
duct is located dorsal to the recommended site of maxillary
sinus trephination in the horse (Fig 8). After entering the
lacrimal bone, the duct passed caudally through the
continuation of the lacrimal canal to enter the lacrimal fossa
where it terminated in a dilatation, the lacrimal sac.
Computed tomography - dacryocystography
The morphology of the nasolacrimal duct was similar in all
mules. The duct travelled in a caudal and medial direction
from the NLO, arching dorsally over the caudal aspect of the
incisive bone. A saccular dilation of the duct was present at
the level of the diastema between the corner incisor (Triadan
103 or 203) and the second premolar (Triadan 106 or 206)
(Fig 9). Maximum diameter of the duct observed at this level
ranged from 7.5 to 9.8 mm (Fig 10a). The portion of the
nasolacrimal duct within the lacrimal sulcus of the maxillary
bone, at the level of the premolar and molar teeth, was the
narrowest (range: 1.3–1.7 mm) (Fig 10b). The most caudal
aspect of the duct, which was encased in the lacrimal bone,
extended from the level of the first or second molar (Triadan
109/110 or 209/110) to the lacrimal sac (Fig 10c).
Discussion
Historically, the mule has been considered a poor research
subject due to the variability of its genetic make-up (Burnham
2002) and lack of scientific literature often mandates
extrapolation from either the horse or the donkey when
diagnosing and treating clinical disease of the mule. In this
study population, 87.5% of mules displayed NLOs at a site
which has not previously been described in horses or donkeys.
In only 10% of mules, the NLO was in close proximity to the
EQUINE VETERINARY EDUCATION / AE / DECEMBER 2013
Fig 6: Right naris of mule (dorsal aspect of naris has been
removed): Initial caudomedial course of nasolacrimal duct. NLO
(arrow). Lateral edge of naris (arrowheads).
Fig 7: Mid-sagittal section of 1-year-old mule head. Nasolacrimal
duct has been injected with red latex casting material.
location established for horses (Location B) and none of the 40
mules were observed to have a NLO near the location
described in the donkey (Fig 11). These findings demonstrate
that the location of the NLO of the mule is typically different
from that of the horse and the donkey and extrapolation from
other equids in regard to the location of the NLO of the mule
is not reliable.
The NLO was found by visual examination alone in all
mules, although visualisation was slightly more difficult in black
mules, light-coloured mules with spots of pigment on the nares,
639
Fig 8: Left Lateral view of 7-year-old mule head depicting sinus
trephination sites over the rostral and caudal maxillary sinuses in
relation to the left nasolacrimal duct which is visible by removal of
overlying maxillary bone (some latex has been inadvertently
removed with saw blade). Nasolacrimal duct (A); opening into
rostral maxillary sinus (B); opening into caudal maxillary sinus (C);
facial crest (D); medial canthus (E); infraorbital foramen (F) and
incisive notch (G).
or in those with extremely small orifices. In our experience,
many orifices, especially those 1 mm and less, had more of a
‘slit-like’ appearance than the ovoid shape more commonly
observed in the horse. Knowledge of the typical location of
the NLO of the mule was instrumental in finding the NLO in
these cases, as the orifice would have easily been overlooked
or mistaken for debris because of its smaller than expected
diameter and unexpected location in the lateral wall of the
naris. A spot of moisture or a mucoid plug, reported to be
present at most NLOs of horses (Lavach 1990), was present at
the NLO of most mules and aided in identification of the
orifice. In the mules with NLO observed near to the location
described for horses (Location B), there was more variation
rostrocaudally and/or mediolaterally (up to 4 cm lateral to the
mucocutaneous junction in one mule) than is typically
observed in the horse, in our experience. Interestingly, the
mules that had a NLO at Location B were all female. These
individuals were not of common ancestry and different breeds
were represented (e.g. one draught mule, 4 horse mules born
to mares of different breeds). As no mules displayed NLO in the
location of the mule’s sire, these findings suggest that the
location of the NLO may be determined by sex-linked
inheritance but our study population was too small to
conclude the mode of inheritance or even if the location is
heritable.
It has been previously reported that horses and mules may
have multiple NLOs, some of which may end as blind pouches
while others may communicate with the main nasolacrimal
duct (Lavach 1990). In our study, 5/40 mules (12.5%) had
multiple NLOs. All NLOs of 2 of these 5 mules were patent and
communicated with the main nasolacrimal duct, but the
patency of the other 3 individuals was not investigated. The
variability in location and number of NLOs reported in this study
seems greater than that expected to be found in a horse
population of similar size, but we can find no previous studies
that describe the variability in location and number of distal
orifices among horses. These findings prompted us to survey a
random group of clinically healthy university horses for
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Fig 9: Dorsal oblique maximum intensity projection (MIP) CT image

outlining the right nasolacrimal duct in a 7-year-old mule. The
portion of the duct located medial to the premandible at the level
of the diastema is the largest (arrows), a consistent finding in all
specimens. Notice the tomcat catheter (open arrows) and contrast
extravasation rostral to the duct opening (open arrowheads).
Asterisk: first maxillary premolar.

comparison purposes and we found 24/24 horses to have NLO

in the established location for the horse and only 1/24 (4%) of
these horses had multiple orifices (bilaterally), as compared to
12.5% of the mules in our study cohort.
The nasolacrimal drainage apparatus of the horse is a
common source of clinical problems, most often from
obstruction (Freestone and Seahorn 1993). Obstruction of the
nasolacrimal drainage system may be caused by congenital
atresia or, more commonly, may be an acquired condition.
Acquired obstruction is often secondary to dacryocystitis Fig 10: Representative transverse cross-sectional CT images of the
arising from a number of causes, such as foreign bodies, nasolacrimal ducts at the level of diastema (a), fourth maxillary
trauma, dacryoliths, rhinitis or neoplasia (Freestone and premolar (b) and second maxillary molar (c). Notice the
Seahorn 1993). Recently, dacryocystitis has been reported to symmetric appearance of the ducts, which are largest in the rostral
portion (arrows, a), smaller and in close apposition to the bone
occur secondary to suture exostoses (Carslake 2009) and to
margins at the level of the premolars (arrows, b) and contained
periapical dental infection in both the horse and donkey
within the lacrimal canal caudally (arrows, c).
(Ramzan and Payne 2005; Cleary et al. 2011). Clinical signs of
nasolacrimal obstruction include epiphora, mucoid ocular
discharge and conjunctivitis of the affected side. A negative When disorders of the nasolacrimal apparatus are
Jones test (failure of fluorescein stain applied to the eye to suspected, methods of diagnosis (e.g. endoscopy and
appear at the NLO) is suggestive of obstruction which can be CT-DCG) and treatment (e.g. catheterisation and lavage) are
confirmed with failure of normograde or retrograde lavage more easily performed by accessing the nasolacrimal duct
(Carslake 2009). through the NLO because catheterisation of the lacrimal

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EQUINE VETERINARY EDUCATION / AE / DECEMBER 2013
Fig 11: Right naris of donkey showing the dorsal location of the
nasolacrimal orifice (arrow). Asterisk: Alar fold.
punctum is more difficult and often requires heavy sedation or
general anaesthesia (Carslake 2009). Knowledge of the
variations in location of the NLO among species of equids is
important when performing these procedures. Catheterisation
of the nasolacrimal duct of the mule is easy to perform when
using a small diameter catheter (circa 3.5 Fr) and the duct can
be flushed effectively in retrograde fashion, eliminating the
need for cannulation of the lacrimal punctum in many cases.
Endoscopy of the nasolacrimal duct, as previously described
for the horse (Spadari et al. 2011), may be difficult to perform
in the mule because the diameter of the NLO is small in many
cases and the flattened and tortuous path of the duct in the
tissue of the external naris may prevent introduction of the
endoscope in retrograde fashion.
The anatomy of the nasolacrimal apparatus of the equid
must be considered before performing common surgical
procedures of the head (e.g. repairing nasal lacerations,
resection of redundant alar folds and sinusotomy). Lacerations
of the external naris are common in equids (Hendrickson 2006),
and a laceration of the external naris of the donkey and mule,
unlike that of the horse, can be associated with damage to
the nasolacrimal duct. Failure to locate the NLO of a donkey or
mule preoperatively before suturing a laceration of an
external naris or before resecting flaccid or redundant alar
folds, could result in iatrogenic damage to the nasolacrimal
duct. Gross dissection of the 4 cadaver heads confirmed that,
except for the size and location of the NLO and the first few
centimetres of the nasolacrimal duct, the course of the
nasolacrimal duct of the mule resembled that of the horse
641
(Fig 7). Anatomic landmarks for sinusotomy of the rostral and
caudal maxillary sinuses of the horse were reliable when used
for sinusotomy of the 2 mule heads and based on observations
of the course of the nasolacrimal duct of the 4 cadaver heads,
sinusotomy performed ventral to a line drawn from the medial
canthus of the eye to the infraorbital foramen should not
interfere with the nasolacrimal duct of the mule.
Computed tomography is superior to radiography when
evaluating the skull and CT-DCG has proven superior to
radiographic dacryocystorhinography in the evaluation of the
nasolacrimal apparatus for the presence of disease (Nykamp
et al. 2004; Cleary et al. 2011; Rached et al. 2011). In this study,
the morphology of the ducts was similar in all mules and
appeared to be normal. Parasagittal and dorsal oblique
reconstructions were especially useful because they allowed
the entire length of the nasolacrimal duct to be evaluated in
one image. Three-dimensional reconstructions were of limited
use, because the mid-portion of the duct could not be clearly
separated from the underlying bone margin. The variation in
diameter observed along the course of the duct was a
consistent finding in all mules. In this study, in order to avoid
personnel exposure to ionising radiation, CT acquisition was
performed immediately at the end of and not during contrast
injection. It is possible that if the acquisition was performed
during injection, additional distention of the duct, especially in
its mid-portion, could be achieved. Although CT-DCG in mules
is easy to perform and provides consistently good images of
the nasolacrimal duct, it does require dedicated equipment
(e.g. a large animal table) and general anaesthesia in live
animals, which limit its widespread application.
Conclusion
The NLO and rostral portion of the nasolacrimal duct of the
mule are anatomically different from that of the horse and
donkey. The NLO of the mule is typically located in the internal
cutaneous tissue of the lateral wall of the external nares and is
easily located by visual examination alone. Knowledge of the
anatomy of the nasolacrimal duct in the mule and especially
the location of the NLO is essential for treatment of certain
ocular diseases or disorders of the nasolacrimal system and the
location of the NLO should be established prior to performing
some surgical procedures of the head to avoid iatrogenic
damage.
Authors’ declaration of interests
No conflicts of interest have been declared.
Source of funding
Funding for this project was provided by an internal grant from
the Department of Large Animal Clinical Sciences, College of
Veterinary Medicine, University of Tennessee, Knoxville,
Tennessee.
Acknowledgements
Reese Brothers Mule Company with special thanks to Rufus,
Vivian and Richard Reese, Mrs Kathy Pinkston, Drs Claude
Ragle, James Schumacher and Melissa Hines.
Manufacturers’ addresses
1Pfizer Animal Health, New York, New York, USA.
2Akorn Pharmaceuticals, Lake Forest, Illinois, USA.
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642 EQUINE VETERINARY EDUCATION / AE / DECEMBER 2013

3Covidien, Mansfield, Massachusetts, USA.
4Major Pharmaceuticals, Livonia, Michigan, USA.
5Mallinckrodt Inc., Hazelwood, Missouri, USA.
6Philips Healthcare, Andover, Massachusetts, USA.
7Carolina Biological Supply, Burlington, North Carolina, USA.
8American Hospital Supply, McGaw Park, Illinois, USA.
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