Diagnostic Approach to Sneezing, Nasal Discharge and Epistaxis

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Diagnostic Approach to Sneezing, Nasal Discharge

and Epistaxis

Sam Trivedi, DVM, DACVIM

(Internal Medicine)

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

nasopharyngeal polyp

nasopharyngeal stricture/

stenosis

Other

neoplasia: lymphoma,

carcinoma

fungal: Cryptococcus,

Aspergillus (less

common in cats)

Inflammatory

chronic rhinosinusitis

foreign body

oronasal fistula

viral

Retrospective Study: Chronic Nasal Discharge (27 cases)*

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, Globulin, CLL, ALL, Azotemia

•Coagulation 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)

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

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 – firm fleshy mass at distal choana

Right nasal cavity – 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

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:

–adenocarcinoma, undifferentiated carcinoma transitional cell carcinoma, squamous cell carcinoma,

–2/3 of intranasal tumors

Sarcomas: –Fibrosarcomas, chondrosarcoma, osteosarcoma, undifferentiated sarcoma

Round cell tumors: –Rare

–Lymphoma, Transmissible venereal tumor, plasmacytoma

Feline Lymphoma

Carcinomas

–adenocarcinoma

–undifferentiated carcinoma

– squamous cell carcinoma

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

Progressive local invasion

Bone invasion occurs early

Low metastatic rate at initial diagnosis (0-12%)

Most common sites of metastasis 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

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

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

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

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

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.

Soft palate examination with spay hook

performed, revealed a large mass suggestive

of a nasopharyngeal polyp.

Anesthetic Examination

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?

Email: strivedi@asecvets.com

Animal Specialty and Emergency Center

310-473-5906