Causes

1
Canine Nasal Disease

• Causes
• Idiopathic/allergic/autoimmune
• Neoplasia
• Viral
• Fungal
• Primary bacterial - Rare
• Foreign body
• Parasitic

2
Canine Nasal Disease

• Clinical signs/physical exam
• Sneezing typically first sign
• May be seasonal/intermittent and chronic
• Nasal discharge
• Serous ?Mucopurulent ?Hemorrhagic
• Cough/gag
• Nasal pain
• Ocular retropulsion
• Airflow present?
• Stertor

3
Canine Nasal Disease

• 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 /-

4
Canine and Feline Nasal Disease

• Epistaxis
• Local disease
• Neoplasia
• Fungal
• Chronic idiopathic rhinitis
• Systemic disease
• Thrombocytopenia
• Hypertension
• Hyperviscosity
• Vasculitis

5
Canine and Feline Nasal Disease

• Initial work-up
• General bloodwork
• Thoracic radiographs
• /- skull radiographs
• /- cytology
• Coagulation profile
• Blood pressure if epistaxis present

6
Canine and Feline Nasal Disease

• 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

7
Canine Nasal Disease

• Advanced work-up
• CT scan
• MRI scan
• Rhinoscopy and biopsy
• Blind biopsy

8
Canine Nasal Disease

• 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

9
Canine Nasal Disease

• 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

10
Canine Nasal Disease

• 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)

11
Canine Nasal Disease

• 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

12
Canine Nasal Disease

• 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!!

13
Canine Nasal Disease

• 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

14
Canine Nasal Disease

• 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

15
Canine Nasal Disease

• 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

16
Canine Nasal Disease

• 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

17
Canine Nasal Disease

• 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

18
Canine Nasal Disease

• 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
  

19
Canine Nasal Disease

• 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

20
From Peeters, D. and Clerx C., Update on Canine
Sinonasal Aspergillosis. Vet Clin North Am Small
Anim Pract 2007 37 (5) 909.
21
Canine Nasal Disease

• 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

22
Canine Nasal Disease

• 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

23
Canine Nasal Disease

• Lymphoplasmacytic rhinitis
• Fairly common disease of dogs
• Diagnosis may obtained with other underlying
  causes
• Fungal
• Foreign body
• Neoplasia
• Parasitic
• Mites
• True bacterial infection

24
Canine Nasal Disease

• Lymphoplasmacytic rhinitis
• Causes
• Idiopathic
• Inhaled allergens
• Irritants
• Hypersensitivity to bacteria or fungi?
• Dust mites? (n3)

25
Canine Nasal Disease

• 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

26
Canine Nasal Disease

• 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

27
Canine Nasal Disease

• 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.

28
Canine Nasal Disease

• 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

29
Canine Nasal Disease

• 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

30
Canine Nasal Disease

• 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

31
Canine Nasal Disease

• 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

32
Canine Nasal Disease

• 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

33
Canine Nasal Disease

• 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

34
Canine Nasal Disease

• 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

35
Canine Nasal Disease

• 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

36
Canine Nasal Disease

• CT
• Very good at determining neoplasia vs.
  non-neoplastic 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

37
Canine Nasal Disease

• 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?

38
Canine Nasal Disease

• Nasal neoplasia
• Prognosis - Carcinomas
• No therapy MST 95d (73-113)
• Epistaxis
• Present 88d
• Absent 224d

39
Canine Nasal Disease

• 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

40
Canine Nasal Disease

• 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

41
Canine Nasal Disease

• 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

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