Lecture 4 Flashcards
Nasal disease: clinical findings
- Sneezing (paroxysmal? sporadic? reverse?)
- Nasal discharge (symmetry? character? onset/duration? progression? inciting cause?)
- Stertor
- Pawing/rubbing face
- Masses/facial distortion
- Nasal planum ulceration
- Seizures, mentation changes
Nasal discharge: unilateral
Unitlateral:
- Neoplasia
- Tooth root abscess
- Foreign body
- Fungal
- Trauma
Nasal discharge: bilateral
Bilateral
- Inflammatory rhinitis
- Systemic disease (hypertension, coagulopathy)
- Neoplasia
- Fungal
- Viral
- Trauma
NOTE: if a tumor is close to the choanae, it can cause BILATERAL nasal discharge
Nasal Discharge - Serous/serosanguineous
Serous/serosanguineous
- HOW MAJORITY OF NASAL DISCHARGE STARTS
- Often associated w/: viral, allergic, or inflammatory rhinitis
- Sanguineous (bloody) usually indicates:
- Progressive
- Erosive
Nasal Discharge - Mucopurulent
Mucopurulent
- Usually indicates SECONDARY bacterial infection
- Primary nasal bacterial infections = VERY RARE
Note: if you just give antibiotics for mucopurulent nasal discharge, you might not be able to clear infection - it may recur since it’s a secondary infection
Nasal Discharge - Hemorrhagic
Hemorrhagic (epistaxis)
- Severely errosive disease
- Neoplasia
- Aspergillosis
- SYSTEMIC disease
- Coagulopathy
- Inherited vs. acquired
- Rickettsial disease - Hypertension
- Coagulopathy
Physical Exam (really important)
- Visual exam of mouth/nose
- Facial symmetry? - Palpate bones/muscle
- Palate too if able - Ocular retropulsion
- Does one side retropulse 1/2 as far as other side?
…space occupying mass?! - Nasal patency
- Fundic exam
- Look esp. for fungus and neoplasia - Lymph node palpation
- Submandibular LN are most likely the first place a nasal infection will spread - Neurologic exam
- Cranial nerves
First-tier diagnostic testing
- CBC (& blood smear -> platelets)
- Cytology
- Nasal discharge
- LN/masses - Thoracic radiographs
- Check for metastasis/fungal infection - Coagulation profile (do a BMBT)
- If epistaxis
- Don’t just check platelet #’s, check platelet function - Blood pressure
- If epistaxis
Second - tier diagnostic testing
- Anesthetized oral exam
- Periodontal probe
- Dental rads - Nasal CT (nasal radiographs less useful)
- Rhinoscopy w/ biopsy
- bacterial/fungal cultures
- Cytology
If you do a blind biopsy of the nasal cavity, where should you measure your instruments to?
Measure instruments to MEDIAL CANTHUS of the eye.
Common Nasal Diseases - Dogs
- Lymphoplasmacytic Rhinitis*
- Aspergillosis*
- Neoplasia*
- Oral Disease
- Oronasal fistulae
- Tooth root abscess - Foreign bodies
- Coagulopathies
- Trauma
Common Nasal Diseases - Cats
- Viral rhinitis*
- Commonly secondary bacterial infection - Chronic rhinosinusitis*
- Cat version of lymphoplasmacytic rhinitis - Nasopharyngeal polyps*
- Neoplasia
- Carcinoma, lymphoma - Cryptococcosis
Lymphoplasmacytic Rhinitis
- Doliocephalics (Dachshunds and Whippets)
- Clinical signs:
- Chronic nasal discharge (often bilateral; may or may not be blood)
- Nasal congestion (stertor)
- Sneezing
- Nasal inflammation of unknown etiology (multifactorial?)
- ~ 1/3 of K9 disease referrals
- DIAGNOSIS OF EXCLUSION
- Definitive: nasal biopsy, rule out infectious causes of inflammation w/ bacterial and fungal cultures
- Difficult to manage
- NOT GOING TO CURE
Lymphoplasmacytic Rhinitis: treatment
- Anti-inflammatories
- Glucocorticoids (systemic or inhaled) - minimal improvement anecdotally
- Immunomodulatory antibiotic and NSAID (doxycycline + piroxicam)
- Anti-histamines
- Itraconazole (anecdotal improvements in some humans)
- Treat secondary infections (controversial)
- Environmental modification
- Cigarette smoke
- Perfume/cleaners/air fresheners
- Litters
Fungal Rhinitis
Cryptococcus neoformans
- Cats
- Nasal, cutaneous (get skin cytology if you see any skin issues), CNS
- Typically causes a mutated nose!
- Dogs
- Disseminated disease more common (ie. skin, bone, CNS signs)
- Nasal disease frequently subclinical
NOTE: if there are skin issues, it is easier to diagnose a fungal infection thro skin issues than it is thro nasal sampling!
Cryptococcus
- Diagnosis
- Organism ID (visual)
- Cytology, histopath culture
- Antigen assay (not definitive as it may pick up other fungal Ag; can be used to monitor response to treatment)
- Organism ID (visual)
- Treatment (depends on where disease is localized)
- Fluconazole
- Amphotericin B
Fungal Rhinitis - Aspergillus
Aspergillus fumigatus
- Common fungal organism affecting K9
- Sino-nasal disease
- GS and other dolicocephalic breeds predisposed
- Clinical signs:
- Nasal discharge*: serous ==> mucopurulent +/- epistaxis
- NASAL PLANUM DEPIGMENTATION* (non-specific, but classic w/ Aspergillus)
- Sneezing*
- Nasal pain, systemic signs (lethargy, hyporexia), rarely neurologic signs (it can infiltrate thro cribiform plate)
Nasal Aspergillus
- Diagnosis
- CT* (really important since the best treatment is topical)
- Rhinoscopy + cytology/histopathology
- Treatment
- TOPICAL CLOTRIMAZOLE*
- Topical enilconazole
- Relapse is common, systemic therapy isn’t really effective
NOTE: Aspergillus may not invade locally, but it can secrete pro-inflammatory molecules that lead to turbinate atrophy!
Cats and Aspergillosis?
- Cats get sino-nasal disease like dogs
- Also affected by sino-orbital aspergillosis (SOA)
- can be an extension of sino-nasal disease
- prognsosis for SOA is POOR
Feline Upper Respiratory Disease Complex
Feline URDC - usually multifactorial
- Herpesvirus** (majority of cases)
- FHV - up to 38% of URI
- Calicivirus* (#2 cause)
- FCV - up to 36%
- Chylamidia felis, Mycoplasms, Bordetella bronchiseptica
- Coinfections are common, especially in crowded conditions
Feline Viral Rhinotracheitis
Feline Herpes virus 1
- Shed intermittently = “latency”
- they almost all become chronic carriers and may relapse w/ clinical signs during times of stress
- Labile outside host
- Eyes and Nose primarily affected*!
- Keratitis, sneezing, corneal ulceration
Feline Calicivirus
- Shed CONTINUOUSLY (always)
- can persist in environment for weeks
- Clinical signs mostly seen orally
- Often see erosions/ulcers
Feline Viral Rhinitis
- Young or multi-cat households
- Vaccination reduces severity and incidence
- Modified-live FVRCP
- Severity of signs highly variable
- May develp PERMANENT nasal discharge (turbinate remodeling)
Feline Viral Rhinitis - management
- Stress avoidance
- Relative isolation
- Long term (controversial)
- L-lysine (may increase shedding, don’t use in shelter)
- Famciclovir
- Partially anorexic?
- Smelly or warmed food
- Clean nose
- Antibiotics as needed
- Systemically ill?
- Supportive care (NOTE: doxycycline is good vs. Chlamydia, Bordetella and Mycoplasma
Nasal neoplasia
- Older animals
- ADENOCARCINOMA (most common nasal tumor in K9), sarcomas, LYMPHOMA (most common nasal tumor in cats)
- Locally invasive
- Bone destruction
- CNS signs (cribiform plate)
- RADIATION THERAPY is treatment of choice
- NSAIDS (piroxicam)
Large Airway Disease
- Infectious tracheobronchitis
2. Tracheal collapse
K9 Infectious Tracheobronchitis
“Kennel Cough”
- Bordetella bronchiseptica*
- Canine Parainfluenza virus*
- Canine Adenovirus type-2
- Younger dogs, history of recent exposure
- Paroxysmal, non-productive (unless 2nd infection develops), harsh cough
- Typically inducible
Canine Infectious Tracheobronchitis (kennel cough) Treatment/management
- Most cases = MILD and SELF-LIMITING
- 7-10 days of supportive care
- Persistent non-productive cough
- Antitussives +/- anti-inflammatory
- Severe or prolonged cases
- Antibiotics
CITB (kennel cough) “Prevention”
- DHPP vaccination
- H = infectious hepatitis = Adenovirus 1 (CAV-2 is in vaccine ==> cross protective w/ type 1)
- P = parainfluenza virus*
CITB (kennel cough) vaccination
- Modified live intranasal
- B. bronchiseptica (+/- viral pathogens)
- FASTER immunity (early as 72 hours)
- Can initiate YOUNGER (3 weeks)
- Reduces shedding*
- SubQ
- B. bronchiseptica Ag
- Need booster (immunity 1-2 weeks post 2nd injection)
- Initiate at 6 weeks
Tracheal collapse
- Progressive degeneration of cartilage rings
- Dorso-ventral flattening of rings
- Laxity of dorsal tracheal membrane
- Collapse at
- Cervical trachea* ==> inspiration
- Thoracic trachea* ===> expiration
- Mainstem/lobar bronchi
- Collapse may be through entire trachea and lead to various dyspnic signs in both inspiratory and expiratory
Tracheal collapse characteristics
- Middle to older aged dogs (progressive disease)
- Small/toy breed dogs
- “Goose-honk” cough
- Exercise intolerance
- exacerbation of cough w/ excitement is common
Tracheal Collapse Diagnosis
- Clinical signs (may also hear stridor, but often don’t since it’s so dynamic)
- Physical exam
- Radiographs
- Fluoroscopy*
- Bronchoscopy
- Gold standard
Tracheal collapse: grading
Grade 1: <25% closed
Grade 2: 25-50% closed
Grade 3: 50-75% closed
Grade 4: Completely closed
You need a scope down the trachea to grade the collapse
Tracheal Collapse Management
- ANTITUSSIVES (mainstay of therapy)
- Anti-inflammatories (you may use a short, tapering dose of predisone to decrease inflammation)
- Bronchodilators (work on beta-2 adrenergic receptors - in bronchiolar smooth muscle - so it doesn’t help tracheal collapse directly, but it reduces the total resistance to airflow)
- WEIGHT LOSS* (decrease pressure on trachea causing coughing)
- SUPPORTIVE (harness, heat avoidance)
- End-stage: stenting (a finite treatment..)
Tracheal collapse: pathophysiology
Collapse causes inflammation and cough ==> coughing causes tracheal inflammation ==> inflammation perpetuates cough
You may need to “break the cycle” of inflammation to relieve the cough
