The paranasal sinus system of horses is complex, comprising six pairs of sinuses. Disease processes that can develop in the sinuses include ethmoid hematomas, cysts, neoplasia, and bacterial and fungal infections. Horses that develop paranasal sinus disease vary widely in age. A significant number of clinical conditions involving the paranasal sinuses require a combination of diagnostic tests to determine the specific pathologic process. Because of the anatomic location of the paranasal sinuses and associated chronic conditions that affect many patients, many disease processes involving the paranasal sinuses require surgical correction for a favorable prognosis. Fungal and neoplastic processes of the equine paranasal sinuses have a less favorable prognosis than bacterial and other disease processes.