Week 1 - Nasal disease and sneezing

Question 1

What are some clinical signs of nasal disease?

Answer 1

Clinical signs can be similar irrespective of the cause:

Nasal discharge – serous, mucoid, mucopurulent, sanguinous/epistaxis, mixed Sneezing
Pawing or rubbing at muzzle
Facial deformity, asymmetry (more likely with neoplasia)
Loss of pigment on the nasal planum
Ulceration
Epiphora -> excessive tears/watery
Open-mouth breathing
Halitosis (bad breath)
Stertor
Coughing
Seizure (rare)

Question 2

What questions should you ask owners when concerned with nasal disease?

Answer 2

When last normal
Vaccination – cats
Previous episodes
One/both nares – did it start unilaterally
Nature of discharge/presence of blood
Reverse sneezing?
Pain/difficulty eating
Halitosis

Question 3

Nasal disease can be primary or secondary. List some examples

Answer 3

Primary
- Viral/bacterial/fungal rhinitis
- FB
- Neoplasia

Secondary
- Dental disease (inflammation and nasal damage)
- Bacterial rhinitis secondary to viral rhinitis

Question 4

Nasal signs can be caused by non-nasal disease. List some examples

Answer 4

Systemic disease
- respiratory disease
- coagulapathy
- severe hypertension
- infectious disease (e.g distemper)

Disease close by:
- Dental disease
- Nasopharyngeal abnormalities
- Reverse sneezing
- Vomitting/regurgitation

Question 5

What is reverse sneezing and what are the clinical signs?

Answer 5

Reverse sneezing is the act of forceful convulsant inhalation. It is generally harmless and self-limiting (but owners are worried).

Triggered by nasopharyngeal iteration.

Loud inspiratory noise
Laboured respiratory effort

Question 6

What are common causes of nasal disease?

Answer 6

Nasal neoplasia
Inflammatory or infectious rhinitis * Fungal rhinitis
Structural/ periodontal disease
Foreign body
Stenotic nares
Other, or no definitive diagnosis

Question 7

What elements of the clinical exam are important with nasal disease?

Answer 7

Facial symmetry
Submandibular and reteropharyngeal lymph nodes
Teeth
Eye position/displacement
Facial pain
Air flow (glass slide to see condensation or tiny strand of cotton wool to ensure equal air flow).

Question 8

What diagnostic methods are available for nasal disease?

Use image, look, sample

Answer 8

Image
- CT (preferred)
- Radiography

Look
- Rhinoscopy

Sample
- Blind nasal flush/biopsy (cytology)
- Blood tests (coagulation, serology)

Question 9

What should you be worried about when an animal presents with acute onset epistasis (nose bleed).

Answer 9

Thrombocytopenia = a low blood platelet count = decreases ability to clot.

Before doing any investigation ensure that the patient is able to clot their blood!

Question 10

In nasal disease - list the advantages and disadvantages of radiography

Answer 10

Advantages
- Non invasive
- Quick
- Available in most practises

Disadvantages
- Sedation/GA
- Poor visualisation of nasal cavities as there is an overlay of teeth and bone

Question 11

In nasal disease - list the advantages and disadvantages of CT

Answer 11

Advantages
- Non invasive
- Good visualisation of anatomy
- Shows soft tissue

Disadvantages
- Sedation/GA
- Referral and expensive
- Not readily available

Question 12

In nasal disease - list the advantages and disadvantages of Rhinoscopy

Answer 12

Advantages
- Visualise anatomy
- Dynamic real-time image
- Can treat/sample (remove FB or flush and sample)

Disadvantages
- Traumatic = can cause nose bleed that impacts image

Question 13

In nasal disease - list the advantages and disadvantages of a blind nasal flush

Answer 13

Advantages
- Can take sample
- Cheap and quick
- Relatively non-invasive
- Immediate relief for patient
- Sometimes gain tissue sample of histopath

Disadvantages
- Unreliable sample as sampled the whole cavity
- GA required

Output = cytology, C & S and relief of symptoms

Question 14

What structure has been affected in this radiograph?

Answer 14

Loss of turbinates/bone destruction
Increased opacity in nasal cavity

Question 15

Why is CT the imaging modality of choice for nasal disease?

Answer 15

Increased detail and often easier to interpret areas like the sinuses and
nasopharynx as there’s no superimposition.

Allows distinction of soft tissue vs fluid(contrast)

Question 16

What problems are evident in this CT and what would your differential be?

Answer 16

• Loss of turbinated on L hand side
• Bone loss on edges

Soft tissue neoplasm in the caudal left nasal cavity. Resulted in osteolysis and obstructive frontal sinus effusion

Question 17

What nasal neoplasia is common in dogs and cats?

Answer 17

Dogs = carcinoma, sarcoma, (polyps rare)

Cats = Polyps (young cats), lymphoma, nasal carcinomas

Question 18

For nasal neoplasia, what are the signs, diagnostic tests, treatment and prognosis?

Answer 18

Signs
- Nasal discharge
- Epistaxis
- Sneezing
- Snuffling

Diagnosis
- CT, radiography
- Rhinoscopy, biopsy

Treatment
- Radiotherapy +/- chemotherapy or surgery

Prognosis: depends on nature and location

Question 18

What are some clinical signs that can point towards neoplasia?

Answer 18

Unilateral disease

Lytic lesions (bone has been destroyed, leaving a hole in the bone)

Question 19

Which animals are prone to fungal disease?

Answer 19

Most common in young, mesocephalic (intermediate length and width) and doliocephalic (extremely long skulls) dogs

e.g Rotties, golden retrievers, German shepherd

Question 20

What are common fungi that cause nasal disease, where do they come from?

Answer 20

Spores are environmental, breathed in and plaques form in some dogs
- rhinitis, FB or trauma can predispose

Dogs = Aspergillus fumigatus

Cats: Aspergillus or Cryptococcus spp

Question 21

What are common clinical signs of fungal disease and how is it diagnosed?

Answer 21

Common
Cream or greenish nasal discharge (mucoid; mucopurulent or muco-haemorrhagic)
Nasal planum ulceration
Sneezing;
Nasal pain

Sometimes
Depigmentation
Epistaxis
Destruction of terbinates

Diagnosis: CT, rhinos copy, sampling

Question 22

How do you treat nasal fungal disease and what is the prognosis?

Answer 22

Topical treatment is most effective
Remove as much infection as possible (debride)

Treat topically = Clotrimazole, Enilconazole

Prognosis: Good

Question 23

What is feline rhinitis/sinusitis and what are some common clinical signs?

Answer 23

Inflammation of the nose and/ or sinuses

sneezing, snuffling, nasal discharge; anorexia; other URT signs

Question 24

What foreign bodies are common in nasal disease?

Answer 24

Inhalation of grass/grass seeds

In cats -> common to vomit up grass which get stuck above the soft palate -> can use an endoscope to look through the mouth and upwards to the back of the nose

Question 25

What causes feline rhinitis/sinusitis and what is the treatment?

Answer 25

Follows after viral upper respiratory tract infection: FHV, FCV
Fungal (Cryptococcus, Aspergillosis)
Inhaled allergens
Mass lesion: neoplasia; foreign body (grass blade!); NP polyp
Anatomical defects: cleft palate; trauma; NP stenosis
Dental disease
Primary bacterial rhinitis is RARE (Chlamydophila felis; Mycoplasma spp; Bordatella bronchiseptica)

Treatment: treat underlying cause and symptomatic management.

Question 26

What are clinical signs of non-destructive (inflammatory) rhinitis, sinusitis?

Answer 26

Increased soft tissue density conforming to the turbinates
(mucopurulent exudate, haemorrhage).

No evidence of a well-defined mass or bony lysis.

Uni or bilateral.

Linked to viral dx in cats – FCV, FHV

Question 27

How does FIV and FeLV results affect prognosis?

Answer 27

FIV = does not mean prognosis is worse

FeLV = more concerned and can affect prognosis

Question 28

What is a polyp?

Answer 28

A polyp is a growth = most polyps are benign, but some can lead to cancer.

Question 29

Han a polyp be visualised and can it be removed?

Answer 29

Spay hook may be used to draw the soft palate rostrally,
allowing visualization of the nasopharynx with a dental mirror.

A flexible endoscope may be retroflexed around the soft palate to enable visualization.

Yes can be removed -> clamp, twist and pull -> they can grow back

Question 30

What is the nasal planum and what diseases are common?

Answer 30

The nasal planum is the pigmented, hairless, rostralmost surface of the external nose.

Depigmentation
Hyperkeratosis
Ulceration
Autoimmune eg pemphigus, lupus
Neoplasia
- Squamous cell carcinoma
- Cutaneous epitheliotropic lymphoma
- Others ++

Question 31

Which animal is prone to squamous cell carcinoma?

Answer 31

White cats with solar exposure, rare in dogs

Question 32

How do squamous cell carcinomas grow, how are they treated and what is the prognosis?

Answer 32

Stage 1: Carcinoma in situ (not invaded basal membrane)
Stage 2 : superficial SCC
Stage 3P infiltrative SCC, locally invasive, mets rare.

Photodynamic therapy (PDT), planectomy (biopsy may cure!), immunomodulators (imiquimod)

Good prognosis with nose off (look like Voldemort!!), may need repeat PDT

Question 33

What are stenotic nares, what are the clinical signs and how are they treated?

Answer 33

Congenital - component of BOAS (dogs and cats!)

Dorsolateral nasal cartilages are medially displaced, impinging on
the external nasal opening and dramatically decreasing the
available lumen.

Clinical signs:
- Stertorous and stridorous inspiratory noise,
- Coughing,
- Reduced exercise tolerance, sleep disturbances

Treated: Surgery – wedge resection, laser ablation