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Canine Nasal Disease

Canine Nasal Disease . Causes Idiopathic/allergic/autoimmune Neoplasia Viral Fungal Primary bacterial - Rare Foreign body Parasitic. Canine Nasal Disease . Clinical signs/physical exam Sneezing typically first sign May be seasonal/intermittent and chronic Nasal discharge

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Canine Nasal Disease

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  1. Canine Nasal Disease • Causes • Idiopathic/allergic/autoimmune • Neoplasia • Viral • Fungal • Primary bacterial - Rare • Foreign body • Parasitic

  2. Canine Nasal Disease • Clinical signs/physical exam • Sneezing typically first sign • May be seasonal/intermittent and chronic • Nasal discharge • Serous MucopurulentHemorrhagic • Cough/gag • Nasal pain • Ocular retropulsion • Airflow present? • Stertor

  3. Canine Nasal Disease • Localization of nasal discharge • Unilateral • Neoplasia • Fungal • Foreign body • Idiopathic/allergic/chronic rhinitis • Systemic disease – Coagulopathy, pneumonia • Bilateral • Idiopathic/allergic/chronic rhinitis • Systemic disease - Coagulopathy, pneumonia • Fungal +/-

  4. Canine and Feline Nasal Disease • Epistaxis • Local disease • Neoplasia • Fungal • Chronic idiopathic rhinitis • Systemic disease • Thrombocytopenia • Hypertension • Hyperviscosity • Vasculitis

  5. Canine and Feline Nasal Disease • Initial work-up • General bloodwork • Thoracic radiographs • +/- skull radiographs • +/- cytology • Coagulation profile • Blood pressure if epistaxis present

  6. Canine and Feline Nasal Disease • Initial work-up • Culture? • Sedated oral exam • Use spay hook and good light source • Deep sedation sometimes necessary • Maxillary 3rd incisor and premolars 1, 2, 3 (mesial root) • Dental probe indicated in many cases

  7. Canine Nasal Disease • Advanced work-up • CT scan • MRI scan • Rhinoscopy and biopsy • Blind biopsy

  8. Canine Nasal Disease • CT scan • Always image nasal passages prior to biopsy • Best for detailed evaluation of nasal passages and frontal sinus • Differentiation of inflammation, fungal, neoplasia • Use iodinated contrast

  9. Canine Nasal Disease • Rhinoscopy • Practice, practice, practice! • Use CT to guide biopsies in many cases • Always biopsy both sides • Guided biopsy combined with and followed by “blind” sampling is preferred

  10. Canine Nasal Disease • Rhinoscopy • Posterior/retroflexion • Useful for identification of unusual causes of nasal discharge or stertor (esp. cats) • Removal of inspissated discharge can be therapeutic • Biopsy of lesions may be difficult • 3.9mm or 8.6mm flexible scope • Anterior – rigid scope • Often limited visualization even with much experience • 2.7mm rigid scopes (4, 10mm may be used)

  11. Canine Nasal Disease • Blind biopsy • Indicated in cases with financial limitations • Accuracy of samples must always be questioned • Procedure • Sedated with intubation mandatory • Pack throat • Have epinephrine on hand • Obtain samples from both sides • Aspiration may be considered if externally visible mass

  12. Canine Nasal Disease • Limitations of all nasal biopsies • Inflammation surrounding masses • Differentiating neoplasia from true/primary • Owners should always be made aware of: • Potential need to repeat scope and biopsy if biopsy results do not coincide with physical exam, imaging findings, or clinical impressions • Rhinoscopy and biopsy procedures are rarely, if ever therapeutic!!

  13. Canine Nasal Disease • Cytology • Indicated for cats with nasal discharge and clinical suspicion of fungal disease • Not useful for diagnosis of neoplasia, idiopathic rhinitis, fungal rhinitis in dogs, or true bacterial infection • Brush cytology generally does not correlate with biopsy results

  14. Canine Nasal Disease • Nasal culture • Fairly useless in most cases • False positive for fungal and bacterial infection • False negative often found in dogs with Aspergillosis • Mainly indicated in cats with chronic rhinitis/nasal discharge and dogs with non-responsive to therapy for “chronic rhinitis”

  15. Canine Nasal Disease • Fungal rhinitis • Potential pathogens • Aspergillosis • Rhinosporidium seeberi • Penicillium • Differentiating signs • Dramatic • Depigmentation and nasal pain (tip of nose) • Severe turbinate loss on CT or radiographs • Fungal plaques seen on rhinoscopy • Typically unilateral

  16. Canine Nasal Disease • Fungal rhinitis • Serology and fungal culture are not sensitive or specific • Empirical therapy may be considered if: • Nasal depigmentation • Nasal pain • Positive serology • Owner refuses or cannot afford rhinoscopy

  17. Canine Nasal Disease • Fungal rhinitis • CT scan/radiographs • Severe turbinate loss • Fluid/granuloma opacity in nasal passage and possibly frontal sinus • +/- bone erosion • +/- erosion of cribiform plate • Histopathology • Generally sensitive for obvious infection, but can miss in presence of severe inflammation

  18. Canine Nasal Disease • Fungal rhinitis • Rhinoscopy • Severe turbinate loss in most (too much room!) • Friable mucosa, erythema, hyperemia, edema • White fungal plaques • Seen in 83% of cases within the nasal cavity • 17% localized exclusively in sinus(‘) • Need ability to reach sinus for this reason as well as for catheter placement during therapy • Very time consuming during therapeutic phase $$$

  19. Canine Nasal Disease • Fungal rhinitis • Rhinoscopic topical therapy best • Enilconazole 1% (nasal) and 2% (sinus), compared to 1% clotrimazole infusion • May have long term nasal signs following infusion with both treatments • Approximately 50% of the time • Typically antibiotic responsive • Discouraged, but can be done if cribiform plate is not intact

  20. From Peeters, D. and Clerx C., Update on Canine Sinonasal Aspergillosis. Vet Clin North Am Small Anim Pract 2007; 37 (5): 909.

  21. Canine Nasal Disease • Fungal rhinitis therapy • Meticulous debridement • Follow-up rhinoscopy • Combine with oral antifungals? • Surgery • For inaccessible suspected sinus infection • Clotrimazole liquid topical combined with cream instillation as depot therapy

  22. Canine Nasal Disease • Oral antifungal therapy • Oral therapy alone is not recommended • Use if cribiform plate is not intact • Reported 50-70% cure rate (best case scenario) • Options (best to worst) • Itraconazole 5mg/kg BID X 10 weeks • Fluconazole 2.5mg/kg BID X 10 weeks • Ketoconazole 5mg/kg BID 12 weeks • Thiabendazole 10mg/kg BID X 6-8 weeks • Terbinafine 5-10mg/kg BID X 10 weeks • Cost, GI side effects, and hepatotoxicity

  23. Canine Nasal Disease • Lymphoplasmacyticrhinitis • Fairly common disease of dogs • Diagnosis may obtained with other underlying causes • Fungal • Foreign body • Neoplasia • Parasitic • Mites • True bacterial infection

  24. Canine Nasal Disease • Lymphoplasmacyticrhinitis • Causes • Idiopathic • Inhaled allergens • Irritants • Hypersensitivity to bacteria or fungi? • Dust mites? (n=3)

  25. Canine Nasal Disease • Lymphoplasmacyticrhinitis radiographic findings • Turbinate destruction • Soft tissue/fluid opacity • Obvious bone lysis/remodeling • CT findings • May be difficult for differentiation of inflammation from neoplasia in cats, but fairly good in dogs • Allows clinician to target biopsy collection from areas of interest • Turbinate destruction can mimic fungal rhinitis • Fluid in nasal passages and sinuses • Suspect fungal disease or neoplasia if bone destruction noted

  26. Canine Nasal Disease • Lymphoplasmacyticrhinitis • Rhinoscopy • Erythema, hyperemia, edema, normal • Not sensitive for detection of turbinate destruction • Right and left sides may differ on gross inspection considerably, but disease present on both sides in most • Histopathology • Biopsy results may not correlate with disease severity or clinical signs • Always correlate with imaging findings

  27. Canine Nasal Disease • Lymphoplasmacyticrhinitis • Therapy – General considerations • FRUSTRATING!!!!! • Owner preparation is critical if suspected diagnosis • No cure, but hope to decrease signs to acceptable level • Lifelong treatment often required • Seasonal or unpredictable relapse is common • Allergen avoidance • Smoke, forced air heat, wood burning stoves, fireplace, etc.

  28. Canine Nasal Disease • Lymphoplasmacyticrhinitis • Drug therapy • Antihistamines • Many formulations, but none evaluated critically • Sometimes effective but durable response rarely achieved • Oral corticosteroids • Prednisone 0.5-1mg/kg BID to start with taper over 2-3 weeks • Use at beginning of combined therapeutic regimen in selected cases • Only in those with serous discharge • Generally poor response overall esp. when used alone

  29. Canine Nasal Disease • Lymphoplasmacyticrhinitis - Therapy • Antibiotic therapy • Combine with oral or topical anti-inflammatory therapy • Doxycycline 3-5mg mg/kg BID X 2 weeks • Reduce to once daily if responsive • Azithromycin 10mg/kg daily 5 days • Reduce to 2X/week if initially responsive • Use at standard dose intermittently or alternative antibiotic based on C & S if persistent purulent or mucopurulent discharge noted

  30. Canine Nasal Disease • Lymphoplasmacyticrhinitis - Therapy • Oral antiinflammatory therapy • Oral corticosteroids • Prednisone 0.5-1mg/kg BID to start with taper over 2-3 weeks • Use at beginning of combined therapeutic regimen in selected cases • Only in those with serous discharge • Generally poor response overall esp. when used alone • NSAIDs - Piroxicam 0.3mg/kg daily • Use with misoprostol 3mcg/kg (2-5mcg/kg) BID

  31. Canine Nasal Disease • Topical antiinflammatory therapy • Flovent 110-220mcg/actuation BID to start • May reduce to once daily or every other day if effective • Lower to once daily if significant improvement noted • Less potential side effects • Variable responses • Nasal confirmation • Presence of severe discharge • Compliance

  32. Canine Nasal Disease • Lymphoplasmacyticrhinitis – Therapy • Ideally 2-3X per week antiinflammatory and intermittent antibiotic courses vs. 2-3X/week of both indefinitely or seasonally • May consider pulse therapy with antibiotics • If responsive, most require long term/lifelong therapy • Compliance is a major issue when patients improve • Bacterial rhinitis - Canine • Pasteurellamultocida, Bordatellabronchiseptica may be primary pathogens - RARE • Last line diagnostic test if no resolution of clinical signs after treatment of rhinitis

  33. Canine Nasal Disease • Nasal neoplasia – General considerations • Seen in approximately 1/3 of dogs with chronic nasal disease • Nasal carcinoma 2/3 of all nasal neoplasms • Adenocarcinoma, undifferentiated, squamous cell • Others = 1/3 • Lymphoma • Fibrosarcoma • Neuroendocrine • Hemangiosarcoma • MCT • TVT – extremely rare • Nasal polyps – Rare and typically secondary to inflammation or underlying neoplasia

  34. Canine Nasal Disease • Neoplasia – General considerations • Metastasis • Local lymph nodes • Lungs – Rare • Most express COX-2 receptors • Clinical signs • Dramatic • Unilateral epistaxis and discharge are common • Facial deformity – other considerations? • Sporotrichosis, severe aspergillosis • Angiomatous proliferation of nasal cavity - rare • Neurologic signs may be very late • Caudal nasal passage

  35. Canine Nasal Disease • Nasal neoplasia • Radiographic findings • Non-specific • Loss of turbinates • May see bone lysis • Fluid in frontal sinus • Soft tissue opacity late in course of disease

  36. Canine Nasal Disease • CT • Very good at determining neoplasia vs. non-neoplastic disease • Bone erosion/lysis usually consistent with neoplasia • MRI • Mass effect on MRI not necessarily associated with neoplasia • Other factors: cribiform plate erosion, vomer bone lysis etc. must be present to discriminate • Bone erosion/lysis usually consistent with neoplasia

  37. Canine Nasal Disease • Nasal neoplasia • Rhinoscopy • Sometimes limited by location • Difficult in most cases due to presence of hemorrhage, occlusion of nasal passage, and magnification • Retroflexion will allow diagnostic specimens in some • Blind biopsy • Always followed by rhinoscopic assisted biopsies • Help improve diagnostic accuracy?

  38. Canine Nasal Disease • Nasal neoplasia • Prognosis - Carcinomas • No therapy = MST 95d (73-113) • Epistaxis • Present = 88d • Absent = 224d

  39. Canine Nasal Disease • Nasal neoplasia – Therapy and prognosis • Surgery alone • Mixed results, but generally disappointing • MST = 3-6 months • Radiation • CT planning is best to prevent normal tissue damage • No evidence that CT planning improves prognosis • MST = 8-20 months when used alone • IMRT/Cyberknife

  40. Canine Nasal Disease • Nasal neoplasia – Therapy and prognosis • Radiation followed by surgery • Best outcome to date • 54 dogs • 4yr MST vs. 2 yr MST with radiation alone in one study • More side effects when compared to either alone • Osteomyelitis • Fistula formation • Fungal rhinitis

  41. Canine Nasal Disease • Nasal neoplasia – Therapy and prognosis • Chemotherapy • Single agent cisplatin • MST = 5 months • Combination adriamycin, carboplatin, piroxicam • MST is unknown • Clinical response has been favorable in those in which it has been used • 81% of canine nasal tumors expressed COX-2 receptors in one study

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