Lecture 4 Flashcards
1
Q
Nasal disease: clinical findings
A
- 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
2
Q
Nasal discharge: unilateral
A
Unitlateral:
- Neoplasia
- Tooth root abscess
- Foreign body
- Fungal
- Trauma
3
Q
Nasal discharge: bilateral
A
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
4
Q
Nasal Discharge - Serous/serosanguineous
A
Serous/serosanguineous
- HOW MAJORITY OF NASAL DISCHARGE STARTS
- Often associated w/: viral, allergic, or inflammatory rhinitis
- Sanguineous (bloody) usually indicates:
- Progressive
- Erosive
5
Q
Nasal Discharge - Mucopurulent
A
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
6
Q
Nasal Discharge - Hemorrhagic
A
Hemorrhagic (epistaxis)
- Severely errosive disease
- Neoplasia
- Aspergillosis
- SYSTEMIC disease
- Coagulopathy
- Inherited vs. acquired
- Rickettsial disease - Hypertension
- Coagulopathy
7
Q
Physical Exam (really important)
A
- 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
8
Q
First-tier diagnostic testing
A
- 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
9
Q
Second - tier diagnostic testing
A
- Anesthetized oral exam
- Periodontal probe
- Dental rads - Nasal CT (nasal radiographs less useful)
- Rhinoscopy w/ biopsy
- bacterial/fungal cultures
- Cytology
10
Q
If you do a blind biopsy of the nasal cavity, where should you measure your instruments to?
A
Measure instruments to MEDIAL CANTHUS of the eye.
11
Q
Common Nasal Diseases - Dogs
A
- Lymphoplasmacytic Rhinitis*
- Aspergillosis*
- Neoplasia*
- Oral Disease
- Oronasal fistulae
- Tooth root abscess - Foreign bodies
- Coagulopathies
- Trauma
12
Q
Common Nasal Diseases - Cats
A
- Viral rhinitis*
- Commonly secondary bacterial infection - Chronic rhinosinusitis*
- Cat version of lymphoplasmacytic rhinitis - Nasopharyngeal polyps*
- Neoplasia
- Carcinoma, lymphoma - Cryptococcosis
13
Q
Lymphoplasmacytic Rhinitis
A
- 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
14
Q
Lymphoplasmacytic Rhinitis: treatment
A
- 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
15
Q
Fungal Rhinitis
A
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!
16
Q
Cryptococcus
A
- 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
17
Q
Fungal Rhinitis - Aspergillus
A
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)
18
Q
Nasal Aspergillus
A
- 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!
19
Q
Cats and Aspergillosis?
A
- 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
20
Q
Feline Upper Respiratory Disease Complex
A
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
21
Q
Feline Viral Rhinotracheitis
A
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
22
Q
Feline Calicivirus
A
- Shed CONTINUOUSLY (always)
- can persist in environment for weeks
- Clinical signs mostly seen orally
- Often see erosions/ulcers
23
Q
Feline Viral Rhinitis
A
- 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)
24
Q
Feline Viral Rhinitis - management
A
- 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
25
Nasal neoplasia
1. Older animals
- ADENOCARCINOMA (most common nasal tumor in K9), sarcomas, LYMPHOMA (most common nasal tumor in cats)
2. Locally invasive
- Bone destruction
- CNS signs (cribiform plate)
3. RADIATION THERAPY is treatment of choice
- NSAIDS (piroxicam)
26
Large Airway Disease
1. Infectious tracheobronchitis
| 2. Tracheal collapse
27
K9 Infectious Tracheobronchitis
| "Kennel Cough"
1. Bordetella bronchiseptica*
2. Canine Parainfluenza virus*
3. Canine Adenovirus type-2
4. Younger dogs, history of recent exposure
5. Paroxysmal, non-productive (unless 2nd infection develops), harsh cough
- Typically inducible
28
Canine Infectious Tracheobronchitis (kennel cough) Treatment/management
1. Most cases = MILD and SELF-LIMITING
- 7-10 days of supportive care
2. Persistent non-productive cough
- Antitussives +/- anti-inflammatory
3. Severe or prolonged cases
- Antibiotics
29
CITB (kennel cough) "Prevention"
1. DHPP vaccination
- H = infectious hepatitis = Adenovirus 1 (CAV-2 is in vaccine ==> cross protective w/ type 1)
- P = parainfluenza virus*
30
CITB (kennel cough) vaccination
1. Modified live intranasal
- B. bronchiseptica (+/- viral pathogens)
- FASTER immunity (early as 72 hours)
- Can initiate YOUNGER (3 weeks)
- Reduces shedding*
2. SubQ
- B. bronchiseptica Ag
- Need booster (immunity 1-2 weeks post 2nd injection)
- Initiate at 6 weeks
31
Tracheal collapse
1. Progressive degeneration of cartilage rings
- Dorso-ventral flattening of rings
- Laxity of dorsal tracheal membrane
2. 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
32
Tracheal collapse characteristics
1. Middle to older aged dogs (progressive disease)
2. Small/toy breed dogs
3. "Goose-honk" cough
4. Exercise intolerance
- exacerbation of cough w/ excitement is common
33
Tracheal Collapse Diagnosis
1. Clinical signs (may also hear stridor, but often don't since it's so dynamic)
2. Physical exam
3. Radiographs
4. Fluoroscopy*
5. Bronchoscopy
- Gold standard
34
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
35
Tracheal Collapse Management
1. ANTITUSSIVES (mainstay of therapy)
2. Anti-inflammatories (you may use a short, tapering dose of predisone to decrease inflammation)
3. 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)
4. WEIGHT LOSS* (decrease pressure on trachea causing coughing)
5. SUPPORTIVE (harness, heat avoidance)
6. End-stage: stenting (a finite treatment..)
36
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
