Diseases of the nasal cavity Flashcards Preview

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Flashcards in Diseases of the nasal cavity Deck (49):
1

What are the clinical signs associated with nasal disease?

  • Nasal discharge
  • Sneezing
  • Pawing at face/pain
  • Resiratory difficulty on inspiration
  • Stertor--noisy respiration (blockage)

2

Nasal discharge: what should we consider

Signalment?

History and PE findings?

  • Signalment
    • Age--young vs. old
    • Breed--dolichocephalic and brachycephalic
  • History and physical exam findings
    • Character of discharge--unilateral vs. bilateral, serous, mucoid, purulent, hemorrhagic
    • Facial symmetry/asymmetry (soft vs. firm)
    • Dental disease--always check
    • Depigmentation of nasal area (ex: aspergillosis)
    • Local lymph nodes
    • Oropharyngeal examination and otic examination--when polyp is suspected
    • Ocular examination--ocular retropulsion 

3

Nasal discharge: what should we consider

Advanced clinical tests?

  • Bloodwork (make sure animal can clot)
  • Imaging
    • Rads (not usually helpful)
    • CT/MRI
  • Endoscopy--rhinoscopy
  • Cytology/biopsy/culture and sensitivity
  • Serology titres and PCR--infectious diseases

4

Nasal discharge--differential list?

  • Neoplasia--important in dogs
  • Rhinitis--important in cats
    • Infectious
      • Fungal, viral (feline upper respiratory disease complex), bacterial, parasitic
    • Inflammatory
      • Lymphocytic/plasmacytic
  • Nasal foreign body
  • Dental disease/oronasal fistulas
  • Trauma
  • Congenital
    • Ciliary dyskinesia
    • Nasopharyngeal stenosis
  • Systemic disorder
    • Coagulopathy
    • Pneumonia (occasionally) 

5

Nasal foreign bodies

History

  • Sudden onset
  • Acute sneezing
  • Gagging/reverse sneezing
  • Pawing at nose
  • Discharge--serous to mucoid purulent (won't show immediately)

6

Nasal foreign bodies

Diagnostic/therapy

  • Rads--only good for radiodense material
  • CT/MRI
  • Rhinoscopy (endoscope vs. otoscope)
    • Remember to examine caudal nasopharynx
  • Nasal flush
  • Alligator forceps/biopsy
  • Cytology of discharge (rule out other dz)
  • Culture/sensitivity (usually unnecessary)
  • Explorative sx (unlikely)

7

Infectious rhinitis--feline upper respiratory disease complex

Potential infectious agents?

  • 90% of cases
    • Feline herpes virus
    • Feline calicivirus
  • 10% of cases
    • Chlamydophila felis
    • Mycoplasma spp
    • Coronavirus
    • Bordetella spp

8

Infectious rhinitis--feline upper resp. disease complex

Clinical signs

  • Similar for all agents
  • Differences include:
    • Herpes virus
      • Ulcerative keratitis
      • Punctate or dendritic ulcers
    • Calicivirus
      • Ulcers on nose, tongue, hart palate
      • Pneumonia
      • Lameness
    • Chlamydophila felis
      • Conjunctivitis w/ chemosis
    • Carrier states w/ all
      • Herpes virus shed during stress
      • Calicivirus and chlamydophila can be shed w/ or w/o stress

9

Feline herpes virus--rhinotracheitis

Spread?

Shed?

Disease?

Latency?

Diagnosis?

  • Spread--direct contact, fomites
  • Shed in ocular, nasal, pharyngeal secretions
  • Nasal disease--serous then mucopurulent due to secondary bac. infection
  • Establishes lifelong latency--esp. trigeminal nerve ganglia
  • Diagnosis--clinical signs, viral isolation, PCR

10

Feline herpes virus--rhinotracheitis

Sequelae?

  1. Chronic rhinitis/sinusitis--feline chronic rhinosinusitis
    1. Short nosed breeds
    2. Turbinate damage predisposes to secondary bac. infections of the nasal cavity--chronic snuffler
  2. Chronic conjunctivitis
  3. Fibrosis of lacrimal ducts--epiphora

80% of recovered cats become carriers and shed when stressed

11

Feline herpes virus--rhinotracheitis

Transmission cycle?

12

Feline herpes virus

Treatment

  • Topical antivirals for ocular disease
    • Idoxuridine, trifluridine, cidofovir
  • Oral antivirals
    • Famciclovir, acyclovir
  • Supportive care
    • Antibiotics for secondary bac. infection
    • Fluid therapy if required
    • Humidify environment
    • Nasal decongestant
    • L-lysine?
      • Not effective, but >80% of vets use it--DON'T USE

13

Feline herpes virus

Vaccine

  • Does not prevent infection
  • Does reduce severity
  • Parental or intra-nasal
    • Parental--blocked by maternal antibodies, does not prevent a carrier state
    • Intranasal--useful in outbreaks, not blocked by maternal antibodies
      • Post-vaccine sneezing common
      • May prevent a carrier state
      • Shed

14

Feline calicivirus (FCV)

Survival?

Resistance?

Mutation rates?

Isolates?

Transmission?

Incubation period?

  • Longer survival in the environment
  • Can be resistant to routine disinfectants
  • High mutation rate--new strains always being produced w/ no cross-protection from vaccines or other strains (RNA virus)
  • Many isolates--various antigenic and pathogenic types
  • Direct transmission or via fomites
  • Incubation period short: 2-4 days

15

Feline calicivirus

Transmission cycle?

16

Feline calicivirus

Clinical signs?

Difference from feline herpes virus?

Shedding?

  • Clinical signs
    • Typical signs for feline viral rhinotracheitis
    • Oral and nare ulcers are common
  • FCV vs. FHV
    • Pneumonia more common w/ FCV
    • FCV can result in GI signs
    • FCV can cause lameness
  • 50% of infected cats will shed the virus at 75 days post-infection; don't need stress to shed the virus

17

18

Feline calicivirus

2 other syndromes associated w/ FCV?

  1. Limping kitten syndrome
    • Lameness, ulcers on paws, sore joints, polyarthritis
  2. Virulent hemorrhagic systemic syndrome
    • Outbreak in 2000, group of housed cats
    • Affected even well-vaccinated cats, the traditional vaccine did not protect the cats from this variant
    • Upper resp signs preceded systemic signs
    • Edema, hepatitis, diarrhea, pustular dermatitis, hemorrhagic cystitis found
    • 40-60% mortality w/ this strain

19

Feline calicivirus

Treatment

Sequelae

  • Treatment
    • Largely supportive
      • Antibiotics
      • Nursing care/rehydration
    • Interferon may be effective
  • Sequelae
    • Chronic rhinitis/sinusitis/conjunctivitis
    • Carrier state

20

Chlamydophila felis

Bac. type

Clinical signs

Diagnosis

  • Intracellular bacteria
  • Clinical signs are similar to FHV and FCV
    • Conjunctivitis and chemosis are hallmark signs
  • Diagnosis
    • PCR--swab from conjunctiva, nares, or oropharynx
    • Cytology--conjuntival swab--intracytoplasma inclusion

21

Chlamydophila felis

Treatment?

Prevention?

  • Treatment
    • Topical tetracyclines or erythromycin
    • Systemic signs require oral doxycycline and azithromycin
  • Prevention
    • Vaccination (not a core vaccine)
    • Vaccination is more reactive than other antigens

22

Overview of treatment for cat flu (11 steps)

  1. Outpatient treatment if possible--or isolation
  2. Keep warm and hydrated
  3. Remove crusts from nose and eyes, use saline nasal drops
  4. Humidify air--steam vs. nebulization 
  5. Topical decongestants for 1-2 days
    • Pseudoephedrine, phenylephrine (preferred), oxymetazoline
  6. Systemic antibiotics for secondary bac. infection
    • Enrofloxacin, azithrymycin, amoxicillin, clavulanic acid, doxycycline, marbofloxacin?
  7. Topical opthalmic solutions--antiviral? Antibac? Or both
  8. Interferon
  9. Oral antiviral?
  10. Lysine? Does it work in FHV?
  11. Anti-inflammatories--steroid vs. non-steroidal (piroxicam) for a few days

23

Bacterial rhinitis

Primary disease process?

Discharge?

Antibiotics response?

Usually what?

  • VERY RARELY primary disease process
  • Mucopurulent to purulent nasal discharge
  • Transient response to antibiotics
  • Usually secondary to an underlying disease process
    • Foreign body?
    • Tooth root abscess?
    • Chronic viral infection?
    • Fungal infection?
    • Neoplasia?

24

Fungal rhinitis

Organism?

  • Dogs--predominantly Aspergillus fumigatus
    • Worldwide distribution
    • Dessiminated disease in dogs often involved A. terreus, A. deflectus, or A. niger
  • Cats and dogs--Cryptococcus neoformans var. neoformans
    • Often found in avian droppings/fowl manure (esp. pigeons)
    • C. neoformans var. gatii found in specific eucalyptus trees

25

Nasal aspergillosis--dog

Clinical signs?

  • Sneezing, uni/bi nasal discharge
  • Nasal ulceration and depigmentation
  • +/- facial distortion
  • Nasal airflow usually ok; turbinate destruction (compare to neoplasia)
  • Most cases systemically ok

26

Nasal aspergillosis--dog

Cribiform plate invasion--tests

  • Imaging--do before rhinoscopy or nasal flush
  • Rads--can't distinguish between fungal rhinitis or neoplasia
  • CT or MRI--more helpful than rads
  • Rhinoscopy--white plaques
  • Tissue biopsy/cytology--hyphae
  • C/S--best done from plaque, not discharge

27

Nasal aspergillosis--dog

Treatment

  • Debridement
    • Break off plaques, soak in nose to treat nasal passage
    • Can drill hole in frontal sinus to aid in location of plaques
    • Be careful not to damage cribiform plate
  • Infuse 1% clotrimazole or 2% eniloconazole into nasal cavity for 1hr
    • Rotate nose around--turn 90o every 15 min
    • Risks: aspiration pneumonia (severe irritant), neuro signs (damaged cribiform plate--contraindication)
    • Reeat procedure every 4wks, repeat rhinoscopy, remove any plaques and repeat soak if required
  • Systemic antifungal medication
    • Can use in cases of osteolysis arounf cribiform plate
    • Get a fungal sensitivity
    • Itraconazole, posaconazole, voriconazole (last 2 $$$)

28

Nasal aspergillosis--dog

When is it better to NOT do nasal flushes?

When there is osteolysis

29

Fungal rhinitis--overview

Dogs: Aspergillosis

  • Dolichocephalics, young adults
  • Unilateral nasal discharge may become bilateral
  • 20% chance of seeing hyphae on cytology of d/c
  • White plaque on rhinoscopy
  • Antibody titer not reliable
  • C/S: from plaque, not discharge
  • Rule out neoplasia: biopsy
  • Clotrimazole locally

30

Fungal rhinitis--overview

Cats and sometimes dogs: cryptococcosis

  • Localized or systemic
  • Unilateral or bilateral d/c
  • +/- facial asymmetry
  • Submandibular lymph node enlargement
  • Chorioretinitis
  • Organism often in nasal d/c
  • C/S
  • Serum titer very reliable (antigen test, not antibody)
  • Conazoles systemically

31

What is this?

Aspergillus spp.

32

What is this?

Cryptococcus neoformans

33

Parasitic rhinitis--Pneumonyssus caninum

Localize where?

Distribution?

Transmission?

Not found in which species?

Diagnosis?

HW medication?

  • Live in nasal cavities and sinuses
  • Worldwide distribution
  • Direct transmission
  • Not found in cats
  • Diagnosis
    • Visualize mites in nasopharynx (size of ear mites) or visualize them in nasal cavity during rhinoscopy
  • Treatment
    • Ivermectin, milbemycin (Collie breeds?), selamectin
  • Not commonly found in dogs on HW medication (generally one of the ivermectins)

34

Lymphoplasmacytic rhinitis (LPR)

What is it?

Breeds?

Diagnosis?

  • Chronic inflammatory rhinitis caused by a lymphocytic and plasmocytic infiltration into the nasal mucosa in the absence of any obvious underlying etiology
    • Infectious, allergic, immune-mediated mechanisms have all been proposed
  • Usually medium-large breed dogs--which are dolichocephalic
  • Diagnosis made through histopathology on biopsy samples

35

LPR

Clinical signs

DDx

  • Clinical signs
    • Unilateral or bilateral nasal discharge
    • Mucoid/purulent discharge but can be serous or even hemorrhagic
    • Sneezing, ocular discharge, reverse sneezing, stertor
  • DDx
    • Most likely to least likely: neoplasia--> fungal--> foreign body--> LPR

36

LPR

Diagnosis

  • CT/MRI
    • Can be normal, usually get a fluid accumulation or turbinate destruction
    • Sinus involvement--40%
    • Destruction of nasal septum, frontal sinus, cribiform plate--UNLIKELY to be LPR
  • Rhinoscopy
    • Hyperaemic (red), edematous mucosa, easily traumatized, and bleeds
    • Turbinates are atrophied or destroyed
    • Cannot distinguish it between neoplasia and fungal rhinitis occasionally
  • Biopsy and histopathology is needed

37

LPR

Treatment

  • No effective protocols
  • Avoid any smoke (can result in LPR--allergic condition)
  • Possible treatment/aids
    • Nasal steroids
    • Long-term doxycycline (immune modulatory) or azithromycin w/ NSAIDs
    • Long-term itraconazole (antifungal, appears to work)
    • Saline nasal flushes or hypertonic saline nasal drops
    • Maropitant (Cerenia)--5 days on and 2-3 days off
      • Anti-inflammatory, works inside nose

38

Review of Maropitant (Cerenia)

  • Substance P = neuropeptide secreted by nerves and inflammatory cells
  • Cerenia blocks substance P from binding to tissues
    • ​By antagonizing receptors for tachykinins (histamine, prostaglandins, serotonin, TNF-alpha, interleukins, bradykinin)
  • Label use: vomiting/nausea (not licensed to block inflammation)
  • Off label use: pain, inflammation of gut, nose, bladder, CNS, allergies
  • 5 days on, 2 days off dosing; continuous dosing robs body of substance P which results in tremors

39

Nasal neoplasia

Clinical signs

  • Progressive clinical signs
    • Nasal discharge will often start unilateral and become bilateral
  • Decreased airflow through nasal cavity due to the mass effect
  • Sneezing, facial deformity, epiphora, exophthalmos, dyspnea, open-mouth breathing, hard palate abnormalities
  • Dysphagea
  • Neuro signs if cribiform plate is invaded
  • Cannot distinguish these signs from fungal rhinitis

40

Nasal neoplasia

Diagnostics

  • Nasal discharge cytology--occasionally get lucky
  • Fine needle aspirates of draining lymph nodes--occasionally get lucky
  • Radiography
    • GA required
    • Could potentially rule it in, but cannot guarantee that it is ruled out
  • CT/MRI
    • Much more sensitive in seeing the soft tissue destruction
  • Rhinoscopy
    • See mucosal inflammation, hemorrhagic mucosa, change in mucosa
    • See mass effect w/in nose
  • Nasal biopsy
    • Traumatic nasal flush
    • Rhinoscopy w/ biopsy (best)
    • Rhinotomy w/ surgical biopsy

41

Nasal neoplasia--treatment

What's required first?

Surgery?

Radiation?

Chemotherapy?

No treatment?

Death?

  • Histopathology required to plan treatment
    • Adenocarcinoma--most common
    • Sarcoma (undifferentiated)
    • Carcinoma, SSC, fibroma
    • Lymphoma
  • Surgery--palliative, doesn't prolong survival unless used w/ radiation
  • Radiation--treatment of choice for most nasal neoplasias
    • Survival 12-16 mo if used w/ surgical debulking
  • Chemotherapy--used w/ lymphoma
  • No treatment--prognosis poor--survival 3-6mo
  • Death due to airway obstruction, euthanasia usually performed due to resp distress, persistent epistaxis or nasal discharge

42

Nasal neoplasia

Prognosis

  • What type of neoplasm is it?
    • Better survival w/ adenocarcinomas and sarcomas after radiation
    • Undifferentiated carcinomas and SCC's have shorter survival time
  • Clinical stage--how extensive is the disease?
  • Species--cats live longer than dogs post-radiation therapy

43

Nasal neoplasia--summary

Age?

Predisposed?

Characteristics?

Most common in dogs vs cats?

Diagnosis?

Treatment of choice?

 

  • Older dogs usually >8yrs
  • Dolichocephalic dogs predisposed
  • Most are malignant, locally invasive, and can metastasize to regional LN
  • Adenocarcinoma and SCC are most common in dogs
  • Lymphoma and adenocarcinoma most common in cats
  • Need biopsy for diagnosis
  • Radiation treatment of choice for most

44

Primary ciliary dyskinesia (PCD)

What is it?

Common?

Locations?

  • Immotile ciliary syndrome
  • Rare but is recognized in many dog breeds
  • Inherited (autosomal recessive) trait
    • Affects cilia in upper and lower resp tract (bronchopneumonia)
    • Auditory tubes (ear infection)
    • Brain and spinal cord (hydrocephalus)
    • Uterine tubes
    • Ducts of the testes (male infertility, sperm incapable of mvt)
    • Some dogs will have situs inversus--Kartagener syndrome (chronic sinusitis, bronchiectasis, and reversal of the internal organs)

45

PCD

What kind of disease?

Affects what?

Clinical signs?

Classic presentation?

  • Respiratory disease
    • Structural and functional changes of the cilia in the resp tract
    • Results in poor clearance of mucous from airways
    • Chronic mucous plugging and inflammation
  • Affects nasal cavities, trachea, and lower airways
  • Clinical signs include rhinosinusitis, bronchitis, bronchopneumonia, and bronchiectasis
  • Classic presentation--young, purebred dog w/ recurrent resp tract infection/signs

46

PCD

Diagnosis

  • Biopsy or brush swab
  • Culturing cilia cells from biopsy/BAL
  • EM to assess ciliary structure
  • Genetic testing available for some breeds

 

47

Explain this picture:

  • Primary ciliary dyskinesia
  • a = normal dog
    • 1 central pair of microtubules and 9 peripheral microtubule doublets 
  • b = PCD
    • The central pain of microtubules are eccentric

48

PCD

Treatment?

  • No treatment is available
  • Clinical signs are progressive
    • Dogs' response to supportive therapy is progressively weaker over time

49

T/F:

Nasal neoplasia can result in exophthalmia, facial distortion, and sneezing.

The main clinical sign associated w/ nasal mites is sneezing.

Nasal aspergillus does not respond to systemic antifungal therapy.

"Wisp of cotton" in front of nares could indicate obstructive process if 'wisp' does not move with dog's breaths.

  • TRUE
  • TRUE
  • FALSE
  • TRUE