Diagnostic Approach to Sneezing, Nasal Discharge and Epistaxis

Diagnostic Approach to
Sneezing, Nasal Discharge
and Epistaxis
Sam Trivedi, DVM, DACVIM
(Internal Medicine)
Providing the best quality care and
service for the patient, the client, and
the referring veterinarian.
Canine Differentials
- Bleeding disorder
Thrombocytopenia
Thrombocytopathy
Coagulopathy
–Vasculitis
–Hypertension
–Polycythemia
- Neoplasia
Adenocarcinoma
–Infectious
Aspergillus
–Lymphoplasmacytic
Rhinitis
–Trauma
–Foreign body
–Dental disease
Oronasal fistula
Retrospective Study: Epistaxis
(115 dogs) *


Local causes
– Nasal neoplasia (35)
– Trauma (33)
– Idiopathic rhinitis (20)
– Periapical abscess (2)
Systemic
– Thrombocytopenia (12)
– Thrombocytopathia (7)
– Coaguloapthy (3)
– Hypertension (2)
– Vasculitis (1)
* Prevalence, clinical features, and causes of epistaxis in dogs: 176 cases (1996-2001). Bisset et al, J Am Vet
Med Assoc. 2007 Dec 15:231(12):1843-50.
Feline Differentials

Congenital
Inflammatory
nasopharyngeal polyp
nasopharyngeal stricture/
stenosis

Other
neoplasia: lymphoma,
carcinoma
fungal: Cryptococcus,
Aspergillus (less
common in cats)
chronic rhinosinusitis
foreign body
oronasal fistula
viral
Retrospective Study: Chronic
Nasal Discharge (27 cases)*
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Neoplasia (15 cases)
– Lymphoma (4)
– Adenocarcinoma (3), Carcinoma (3), Squamous Cell
Carcinoma (2)
– Sarcoma (2), Basal cell tumor (1)
Lymphocytic-plasmacytic rhinitis (4)
Cryptococcus (3)
Nasal foreign bodies (2)
Pharyngeal Polyp (1)
Periapical tooth abscess (1)
* Chronic nasal discharge in cats: 75 cases (1993-2004). Demko et al, J Am Vet Med Assoc 2007 Apr 1;230
(7):1032-7.
Nasal Mites
Physical Examination
Abnormalities
• Air flow (unilateral vs bilateral) – q-tip, cotton, slide
Submandibular lymph nodes
• Ocular retropulsion
• Thorough oral examination
• Facial symmetry
• Nasal depigmentation
• Roof of mouth (soft palate)
• Pain
•
• Generalized exam – petechiae, fundic exam, rectal -
melena
Diagnostics
•CBC,
Chemistry
•Thrombocytopenia,
•Coagulation
Globulin, CLL, ALL, Azotemia
panel, BMBT
•Thrombocytopenia
more commonly manifests as
epistaxis, as mucosal surfaces are more often affected
•Sedated
otoscopic examination
•Blood Pressure
Diagnostics (continued)
•
Lymph node aspirate
•
•
Submandibular LN are common sites of
metastasis for nasal neoplasia
Chest radiographs
•
Another site of metastatic spread
Diagnostics (continued)
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•
•
Fungal Serology
Aspergillus Serology (how to submit)
• 98% specificity*
Cryptococcus (Latex Cryptococcus Antigen Test) - Serology
• Sensitivity has been reported 95-98%, specificity has been
reported as high as 100%
*Comparison of serologic evaluation via agar gel immunodiffusion and fungal culture of tissue for diagnosis of nasal aspergillosis in
dogs. Pomrantz et al, J Am Vet Med Assoc. 2007 May 1;230(9):1319-23.
Diagnostics (Equivocal?)
•
•
Skull radiographs ?
• Require anesthesia and can be difficult to interpret and very easy
to miss disease
Nasal culture/cytology ?
• Most infections are secondary to underlying disorder (fungal,
neoplasia, foreign body, etc…)
• Rarely are there primary bacterial nasal infections
• If discharge recurs after course of antibiotic therapy – strong
indicator of another underlying disorder
• Fungal culture – very specific if culture of tissue*
• With cytology can rule in fungal diseases, possibly neoplasia
*Comparison of serologic evaluation via agar gel immunodiffusion and fungal culture of tissue for diagnosis of
nasal aspergillosis in dogs. Pomrantz et al, J Am Vet Med Assoc. 2007 May 1;230(9):1319-23.
Diagnostics (Equivocal?)
•
•
Blind/otoscopic biopsies ?
• Very effective at ruling in specific disease – neoplasia and fungal
• Histopathology consistent with rhinitis ?
• Results must be interpreted very cautiously as again
inflammation may be secondary to another underlying disorder
Bartonella Serology, Culture, PCR *
• Cats with CRS, other nasal diseases, systemic diseases, and
helathy cats had positive results for serologic testing for 1 or both
Bartonella spp
• The PCR assay for Bartonella spp in nasal tissues yielded
negative results for cats with CRS with other nasal diseases.
• A role for Bartonella spp in the pathogenesis of CRS in cats was
not supported by results of this study.
*Microbial culture of blood samples and serologic testing for bartonellosis in cats with chronic rhinosinusitis. Beryessa et al,
J Am Vet Med Assoc. 2008 Oct 1;233(7):1084-9.
Diagnostics (continued)
•
•
CT Scan
Rhinoscopy
•
•
•
Retroflex evaluation of nasopharynx
Evaluate turbinate integrity, evaluate for foreign
bodies, masses, identify fungal plaques
These two diagnostics go hand in hand
•
Can miss disease with just one diagnostic test
•
Neoplasia, foreign body, Fungal
Chester – II yo MC Terrier Mix
History


Presented to primary veterinarian for 2
weeks of sneezing/thick yellow left-sided
nasal discharge. Rx Cephalexin 15 days
Discharge progressively worsened when
antibiotics discontinued. Explored nostrils
with otoscope:
–
–
Right: wnl
Left: gray discharge, ulcers, friable mucosa,
hemorrhage, no obvious foreign bodies or
masses
History




Fungal culture: negative
Bacterial culture: pasteurella Multocida
Biopsy: scattered hemorrhage and minimal
mixed chronic inflammation
Dental examination - extracted 2 teeth
(LMaxP1 and RMaxM2).
 Rx Baytril X 10 days.
History (referred as refractory
rhinitis)

On presentation to Internal Medicine:
–
–
–
–
–
–

licks at nose constantly
leaves blood behind when sleeping
bloody discharge seems continuous, only from the left side
sneezes blood ~ once an hour
not painful
no change in nasal discharge while on the new antibiotic
Environment: California last 8 years. Yard
landscaped but occasionally foxtails appear from
under fence. Mostly inside dog.
Physical Exam


BARH, muzzled. T=101.8 P=90 R=44, when
muzzled otherwise panting
HEAD: Symmetrical facial features
–
–
–

Eyes: decreased ocular retropulsion OS, fundic
exam unremarkable OU,
Nose: left nostril has mild mucopurulent
discharge, evidence of hemorrhagic residue on
hair by nose. Minimal airflow noted bilaterally.
Did not exam mouth due to temperament
Remainder of physical exam unremarkable
Diagnostic results


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CBC: HCT 45.5, WBC 15,360; Neutrophils
11,750, Platelets 355,000, few small clumps,
few macroplatelets
CHEM: Unremarkable
UA: Urine Specific Gravity 1.039, bili 1+,
many lipid droplets, few amorphous crystals
Thoracic radiographs: Unremarkable geriatric
thorax
Nasal CT

Summary:
– Mass invading into the cranium and left
orbit as well as the right nasal cavity- most
compatible with neoplasia.
Rhinoscopy

Nasopharynx
–

Right nasal cavity
–
–

firm fleshy mass at distal choana
irregular nasal turbinates, focal areas of hyperemia
edematous with moderate mucus, not friable.
Left nasal cavity
–
–
irregular edematous turbinates, marked mucus
focal areas of white opacity that may or may not represent
mass.
Histopathology: Nasal and
nasopharyngeal biopsies
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

LEFT NASAL CAVITY: Moderate diffuse
chronic suppurative and lymphoplasmacytic
rhinitis with hemorrhage
RIGHT NASAL CAVITY: Mild to Moderate
diffuse chronic suppurative and
lymphoplasmacytic rhinitis
NASOPHARYNX: Carcinoma
Nasal Tumors
Canine
Carcinomas:
Feline
Lymphoma
–adenocarcinoma, undifferentiated
Carcinomas
carcinoma transitional cell
carcinoma, squamous cell
–adenocarcinoma
carcinoma,
–undifferentiated carcinoma
–2/3 of intranasal tumors
Sarcomas:
– squamous cell carcinoma
–Fibrosarcomas,
chondrosarcoma,
osteosarcoma, undifferentiated
sarcoma
Round
cell tumors:
–Rare
–Lymphoma,
Transmissible
venereal tumor, plasmacytoma
Nasal Tumors



1% of canine neoplasia (less common in cat)
Median 11 yo
Common signs at diagnosis:
–
–
–
–
–
Epistaxis (77%)
Sneezing (67%)
Non-hemorrhagic nasal discharge (56%)
Facial deformity (40%)
Dyspnea (27%), Ocular discharge (26%)
Nasal Carcinomas
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Progressive local invasion
Bone invasion occurs early
Low metastatic rate at initial diagnosis (012%)
Most common sites of metastasis

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
Lymph node
Lung
Brain
Medical palliation


Median survival with piroxicam, 3.1 months
– [misoprostol rarely necessary, although
monitoring HCT and renal values advised]
Symptomatic therapy with antibiotics and intranasal
application of cold epinephrine may improve quality
of life
Yunnan Paiyao (Baiyao)

Yunnan Paiyao (Baiyao) is a proprietary formula from Yunnan
providence. It contains the herb, San Qi, which is not toxic.
– The only consistent contraindication is to not use during
pregnancy.
– The rationale for using Yunnan Paiyao is for controlling
bleeding, reducing swelling, and it will also relieve pain.
– The recommended dose for dogs is 1 orange capsule 1 to 2
times per day (start with once daily). FIX
– Available at: Santa Monica Homeopathic Pharmacy, Capital
Drugs and various websites
Chemotherapy
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Carboplatin and doxorubicin with daily piroxicam
75% response rate, with medial disease free survival
of 7 months
Shorter response seen with single-agent therapy
Treatment of eight dogs with nasal tumors with alternating doses of doxorubicin and
carboplatin in conjunction with oral piroxicam Langova et al, Aust Vet J. November
2004;82(11):676-80.
Radiation therapy

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Median disease free survival 5.5 months, overall survival 10.8
Acute (temporary) side effects include mucositis, rhinitis, KCS,
corneal ulcers
Cataract(s) may develop long term
Prognostic significance of tumor histology and computed
tomographic staging for radiation treatment response of canine
nasal tumors
Adams et al, Vet Radiol Ultrasound. 2009 May-Jun;50(3):330-5.
Note: Current palliative radiation therapy protocols appear to
offer similar disease-free survival with fewer side effects
Surgery



Rhinotomy rarely indicated, with median survival less than 6
months
Median survival of 47.7 months for exenteration of the nasal
cavity performed after radiation therapy; high risk for significant
chronic complications and generally not recommended
Outcome of accelerated radiotherapy alone or accelerated
radiotherapy followed by exenteration of the nasal cavity in
dogs with intranasal neoplasia: 53 cases (1990-2002)
Adams et al, J Am Vet Med Assoc. September
2005;227(6):936-41.
Prognosis


Poor
Negative prognostic factors
–
–
Epistaxis
Advanced local stage

–
–
bone invasion, crosses septum or cribriform plate,
neuro signs
Metastatic disease
Age (over 10 yo)
Chester’s Management

MEDICATIONS: Piroxicam 0.3 mg/kg PO
SID, Pepcid 0.5 mg/kg PO SID, monitor
kidney values and for GI ulceration

CLIENT EDUCATION: Poor prognosis with
poor prognostic factors
Update

Chester’s clinical signs rapidly progressed

Increased difficulty breathing

Owner euthanized due to poor Chester’s
quality of life
Tori: 9 yo FS Rottweiler
History



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Nasal Aspergillosis, that was diagnosed
previously on cytology and serology
CBC and Chemistry panel unremarkable
Tori has had chronic nasal discharge for over
4 years.
Clinical signs vary from nasal bleeding and
mucopurulent nasal discharge. Recently Tori
has had a decreased appetite.
Physical Examination
Major Abnormalities:
 QARH, some muscle wasting noted
 Integument: Poor quality haircoat with moderate
amount of shedding
 Oral Cavity: moderate mucohemorrhagic-purulent
bilateral nasal discharge, severe crusting noted
around both nares bilaterally,
 Lymphatics: moderately enlarged submandibular
lymph nodes
CT Scan


Soft tissue attenuation in the caudal left nasal
cavity, and erosion of the right dorsal
cribriform plate
Mixed air and soft tissue attenuation in the
right frontal sinus and right caudal nasal
cavity, marked destruction of the right nasal
cavity
Rhinoscopy


Rhinoscopy was performed on both nasal
cavities. There were severe fungal plaques
noted in the right nasal cavity with severe
turbinate destruction
The left nasal cavity had mild to moderate
turbinate destruction with a much smaller
degree of fungal plaques.
Rhinoscopy
Rhinoscopy
Rhinoscopy
Sinuscopy
Nasal Aspergillus
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Species Aspergillus Fumigatus
Found in caudal part of nasal cavity or frontal sinus
Destroy mucosa, bone resorption, and periostitis
Major clinical signs
– Mucopurulent nasal discharge
– Nasal pain
– Depigmentation of nasal planum
– Epistaxis
Nasal Aspergillus (Treatment)

Fungal debridement
– Rhinotomy vs Rhinoscopy
– Trephination vs Sinuscopy




Frontal sinus involvement is common in dogs with nasal aspergillosis
and suggest that frontal sinus trephination and/or sinuscopy may aid in
the diagnosis of aspergillosis in dogs, particularly dogs that lack
detectable fungal plaques in the nasal cavity*
Topical treatment
– Clotrimazole or Enilconazole
Repeat Debridement and topical therapy after one month
Oral Antifungal therapy is of little benefit
Results of rhinoscopy alone or in conjunction with sinuscopy in dogs with aspergillosis: 46 cases (2001-2004).
Johnson LR, et al. J Am Vet Med Assoc. 2006 Mar 1;228(5):738-42.
Miss Snow: 2 yr old FS DSH
Pertinent History
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
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Owner rescued when a few days old
Started having URI and sneezing when kitten
Multiple ear infections
Has been on Clavamox, Convenia, Baytril
with no improvement
FIV/FeLV negative
Not very active
Miss Snow (Physical Examination)




Integument: full, unkempt hair coat
EENT: ears--moderate black/brown debris
present AU, no odor; nose mucopurulent
discharge from both nostrils, R>L, nasal
airflow absent bilaterally
Resp: severe stertor present on inspiration,
LN: popliteal, prescap WNL, mandibular
prominent
Remainder of exam NSF
CBC and Chemistry


HCT 32.3 %, WBC 15,000, Neutrophils 6500,
Platelets adequate
Chem: K 5.2, otherwise WNL
CT scan findings

The left tympanic bulla is diffusely, moderately
thickened and irregular. The middle ear and
horizontal external ear canal are diffusely filled with
soft tissue material.

A large (~1.5 x 1.6 x 2.5 cm) poorly defined
hypoattenuating mass with a strongly contrast
enhancing rim is present extending from the left
tympanic bulla rostrally into the caudal nasopharynx.
Anesthetic Examination
Soft palate examination with spay hook
performed, revealed a large mass suggestive
of a nasopharyngeal polyp.
Options for removal
•Surgery
Ventral bulla osteotomy
• definitive cure
•
•Traction
•50%
recur after removal
Nasopharyngeal Polyp
Nasopharyngeal polyps



Non-neoplastic mixture of inflammatory and
epithelial cells
Originate in tympanic bulla of cats
Cause unknown: infection, congenital
Complications
Horner’s syndrome: miosis, enophthalmus with
protrusion 3rd eyelid, ptosis
Biopsy Report



The tissue is soft, white to light pink,
multilobulated, and measures 3.0 x 1.6 x 1.3
cm at its maximum dimensions.
…circular section of tissue composed of a
central core of dense, mature, slightly
edematous, fibrous connective tissue
…multifocal perivascular to scattered
aggregates of lymphocytes and plasma cells,
with lesser numbers of neutrophils and
macrophages…
Consistent with nasopharyngeal polyp
Update
“…she is all over the house and playing in a way I
never thought she would be able to do…she is a
happy kitty.”
Questions?
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Email: [email protected]
Animal Specialty and Emergency Center
310-473-5906