Transcript Slide 1
Causes ◦ Idiopathic/allergic/autoimmune ◦ Neoplasia ◦ Viral ◦ Fungal ◦ Primary bacterial - Rare ◦ Foreign body ◦ Parasitic Clinical signs/physical exam ◦ Sneezing typically first sign May be seasonal/intermittent and chronic ◦ Nasal discharge Serous Mucopurulent Hemorrhagic ◦ Cough/gag o Nasal pain o Ocular retropulsion o Airflow present? o Stertor Localization of nasal discharge ◦ Unilateral Neoplasia Fungal Foreign body Idiopathic/allergic/chronic rhinitis Systemic disease – Coagulopathy, pneumonia ◦ Bilateral Idiopathic/allergic/chronic rhinitis Systemic disease - Coagulopathy, pneumonia Fungal +/- Epistaxis ◦ Local disease Neoplasia Fungal Chronic idiopathic rhinitis ◦ Systemic disease Thrombocytopenia Hypertension Hyperviscosity Vasculitis Initial work-up ◦ General bloodwork ◦ Thoracic radiographs ◦ +/- skull radiographs ◦ +/- cytology ◦ Coagulation profile ◦ Blood pressure if epistaxis present Initial work-up ◦ Culture? ◦ Sedated oral exam Use spay hook and good light source Deep sedation sometimes necessary Maxillary 3rd incisor and premolars 1, 2, 3 (mesial root) Dental probe indicated in many cases Advanced work-up ◦ CT scan ◦ MRI scan ◦ Rhinoscopy and biopsy ◦ Blind biopsy CT scan ◦ Always image nasal passages prior to biopsy ◦ Best for detailed evaluation of nasal passages and frontal sinus ◦ Differentiation of inflammation, fungal, neoplasia ◦ Use iodinated contrast Rhinoscopy ◦ Practice, practice, practice! Use CT to guide biopsies in many cases Always biopsy both sides Guided biopsy combined with and followed by “blind” sampling is preferred Rhinoscopy ◦ Posterior/retroflexion Useful for identification of unusual causes of nasal discharge or stertor (esp. cats) Removal of inspissated discharge can be therapeutic Biopsy of lesions may be difficult 3.9mm or 8.6mm flexible scope ◦ Anterior – rigid scope Often limited visualization even with much experience 2.7mm rigid scopes (4, 10mm may be used) Blind biopsy ◦ Indicated in cases with financial limitations ◦ Accuracy of samples must always be questioned ◦ Procedure Sedated with intubation mandatory Pack throat Have epinephrine on hand Obtain samples from both sides Aspiration may be considered if externally visible mass Limitations of all nasal biopsies ◦ Inflammation surrounding masses ◦ Differentiating neoplasia from true/primary ◦ Owners should always be made aware of: Potential need to repeat scope and biopsy if biopsy results do not coincide with physical exam, imaging findings, or clinical impressions Rhinoscopy and biopsy procedures are rarely, if ever therapeutic!! Cytology ◦ Indicated for cats with nasal discharge and clinical suspicion of fungal disease ◦ Not useful for diagnosis of neoplasia, idiopathic rhinitis, fungal rhinitis in dogs, or true bacterial infection ◦ Brush cytology generally does not correlate with biopsy results Nasal culture ◦ ◦ ◦ ◦ Fairly useless in most cases False positive for fungal and bacterial infection False negative often found in dogs with Aspergillosis Mainly indicated in cats with chronic rhinitis/nasal discharge and dogs with non-responsive to therapy for “chronic rhinitis” Fungal rhinitis ◦ Potential pathogens Aspergillosis Rhinosporidium seeberi Penicillium ◦ Differentiating signs Dramatic Depigmentation and nasal pain (tip of nose) Severe turbinate loss on CT or radiographs Fungal plaques seen on rhinoscopy Typically unilateral Fungal rhinitis ◦ Serology and fungal culture are not sensitive or specific ◦ Empirical therapy may be considered if: Nasal depigmentation Nasal pain Positive serology Owner refuses or cannot afford rhinoscopy Fungal rhinitis ◦ CT scan/radiographs Severe turbinate loss Fluid/granuloma opacity in nasal passage and possibly frontal sinus +/- bone erosion +/- erosion of cribiform plate ◦ Histopathology Generally sensitive for obvious infection, but can miss in presence of severe inflammation Fungal rhinitis ◦ Rhinoscopy Severe turbinate loss in most (too much room!) Friable mucosa, erythema, hyperemia, edema White fungal plaques Seen in 83% of cases within the nasal cavity 17% localized exclusively in sinus(‘) Need ability to reach sinus for this reason as well as for catheter placement during therapy Very time consuming during therapeutic phase $$$ Fungal rhinitis ◦ Rhinoscopic topical therapy best Enilconazole 1% (nasal) and 2% (sinus), compared to 1% clotrimazole infusion May have long term nasal signs following infusion with both treatments Approximately 50% of the time Typically antibiotic responsive Discouraged, but can be done if cribiform plate is not intact From Peeters, D. and Clerx C., Update on Canine Sinonasal Aspergillosis. Vet Clin North Am Small Anim Pract 2007; 37 (5): 909. Fungal rhinitis therapy ◦ ◦ ◦ ◦ Meticulous debridement Follow-up rhinoscopy Combine with oral antifungals? Surgery For inaccessible suspected sinus infection Clotrimazole liquid topical combined with cream instillation as depot therapy Oral antifungal therapy ◦ ◦ ◦ ◦ Oral therapy alone is not recommended Use if cribiform plate is not intact Reported 50-70% cure rate (best case scenario) Options (best to worst) Itraconazole 5mg/kg BID X 10 weeks Fluconazole 2.5mg/kg BID X 10 weeks Ketoconazole 5mg/kg BID 12 weeks Thiabendazole 10mg/kg BID X 6-8 weeks Terbinafine 5-10mg/kg BID X 10 weeks ◦ Cost, GI side effects, and hepatotoxicity Lymphoplasmacytic rhinitis ◦ Fairly common disease of dogs ◦ Diagnosis may obtained with other underlying causes Fungal Foreign body Neoplasia Parasitic Mites True bacterial infection Lymphoplasmacytic rhinitis ◦ Causes Idiopathic Inhaled allergens Irritants Hypersensitivity to bacteria or fungi? Dust mites? (n=3) Lymphoplasmacytic rhinitis radiographic findings Turbinate destruction Soft tissue/fluid opacity Obvious bone lysis/remodeling ◦ CT findings May be difficult for differentiation of inflammation from neoplasia in cats, but fairly good in dogs Allows clinician to target biopsy collection from areas of interest Turbinate destruction can mimic fungal rhinitis Fluid in nasal passages and sinuses Suspect fungal disease or neoplasia if bone destruction noted Lymphoplasmacytic rhinitis ◦ Rhinoscopy Erythema, hyperemia, edema, normal Not sensitive for detection of turbinate destruction Right and left sides may differ on gross inspection considerably, but disease present on both sides in most ◦ Histopathology Biopsy results may not correlate with disease severity or clinical signs Always correlate with imaging findings Lymphoplasmacytic rhinitis ◦ Therapy – General considerations FRUSTRATING!!!!! Owner preparation is critical if suspected diagnosis No cure, but hope to decrease signs to acceptable level Lifelong treatment often required Seasonal or unpredictable relapse is common Allergen avoidance Smoke, forced air heat, wood burning stoves, fireplace, etc. Lymphoplasmacytic rhinitis ◦ Drug therapy Antihistamines Many formulations, but none evaluated critically Sometimes effective but durable response rarely achieved Oral corticosteroids Prednisone 0.5-1mg/kg BID to start with taper over 2-3 weeks Use at beginning of combined therapeutic regimen in selected cases Only in those with serous discharge Generally poor response overall esp. when used alone Lymphoplasmacytic rhinitis - Therapy ◦ Antibiotic therapy Combine with oral or topical anti-inflammatory therapy Doxycycline 3-5mg mg/kg BID X 2 weeks Reduce to once daily if responsive Azithromycin 10mg/kg daily 5 days Reduce to 2X/week if initially responsive Use at standard dose intermittently or alternative antibiotic based on C & S if persistent purulent or mucopurulent discharge noted Lymphoplasmacytic rhinitis - Therapy ◦ Oral antiinflammatory therapy Oral corticosteroids Prednisone 0.5-1mg/kg BID to start with taper over 2-3 weeks Use at beginning of combined therapeutic regimen in selected cases Only in those with serous discharge Generally poor response overall esp. when used alone NSAIDs - Piroxicam 0.3mg/kg daily Use with misoprostol 3mcg/kg (2-5mcg/kg) BID ◦ Topical antiinflammatory therapy Flovent 110-220mcg/actuation BID to start May reduce to once daily or every other day if effective Lower to once daily if significant improvement noted Less potential side effects Variable responses Nasal confirmation Presence of severe discharge Compliance Lymphoplasmacytic rhinitis – Therapy Ideally 2-3X per week antiinflammatory and intermittent antibiotic courses vs. 2-3X/week of both indefinitely or seasonally May consider pulse therapy with antibiotics If responsive, most require long term/lifelong therapy Compliance is a major issue when patients improve Bacterial rhinitis - Canine ◦ Pasteurella multocida, Bordatella bronchiseptica may be primary pathogens - RARE ◦ Last line diagnostic test if no resolution of clinical signs after treatment of rhinitis Nasal neoplasia – General considerations ◦ Seen in approximately 1/3 of dogs with chronic nasal disease ◦ Nasal carcinoma 2/3 of all nasal neoplasms Adenocarcinoma, undifferentiated, squamous cell ◦ Others = 1/3 Lymphoma Fibrosarcoma Neuroendocrine Hemangiosarcoma MCT TVT – extremely rare ◦ Nasal polyps – Rare and typically secondary to inflammation or underlying neoplasia Neoplasia – General considerations ◦ Metastasis Local lymph nodes Lungs – Rare ◦ Most express COX-2 receptors ◦ Clinical signs Dramatic Unilateral epistaxis and discharge are common Facial deformity – other considerations? Sporotrichosis, severe aspergillosis Angiomatous proliferation of nasal cavity - rare Neurologic signs may be very late Caudal nasal passage Nasal neoplasia ◦ Radiographic findings Non-specific Loss of turbinates May see bone lysis Fluid in frontal sinus Soft tissue opacity late in course of disease ◦ CT Very good at determining neoplasia vs. nonneoplastic disease Bone erosion/lysis usually consistent with neoplasia ◦ MRI Mass effect on MRI not necessarily associated with neoplasia Other factors: cribiform plate erosion, vomer bone lysis etc. must be present to discriminate Bone erosion/lysis usually consistent with neoplasia Nasal neoplasia ◦ Rhinoscopy Sometimes limited by location Difficult in most cases due to presence of hemorrhage, occlusion of nasal passage, and magnification Retroflexion will allow diagnostic specimens in some ◦ Blind biopsy Always followed by rhinoscopic assisted biopsies Help improve diagnostic accuracy? Nasal neoplasia ◦ Prognosis - Carcinomas No therapy = MST 95d (73-113) Epistaxis Present = 88d Absent = 224d Nasal neoplasia – Therapy and prognosis ◦ Surgery alone Mixed results, but generally disappointing MST = 3-6 months ◦ Radiation CT planning is best to prevent normal tissue damage No evidence that CT planning improves prognosis MST = 8-20 months when used alone ◦ IMRT/Cyberknife Nasal neoplasia – Therapy and prognosis ◦ Radiation followed by surgery Best outcome to date 54 dogs 4yr MST vs. 2 yr MST with radiation alone in one study More side effects when compared to either alone Osteomyelitis Fistula formation Fungal rhinitis Nasal neoplasia – Therapy and prognosis ◦ Chemotherapy Single agent cisplatin MST = 5 months Combination adriamycin, carboplatin, piroxicam MST is unknown Clinical response has been favorable in those in which it has been used 81% of canine nasal tumors expressed COX-2 receptors in one study