Page 1345 - Cote clinical veterinary advisor dogs and cats 4th

Nasal Discharge 679

nasal neoplasia, fungal rhinitis, or progressive Differential Diagnosis • Nasal lavage, hydropulsion may be used to
severe dental disease Differential diagnoses are provided on p. 1255. • Nasal culture is rarely rewarding. Nasal
dislodge FB or tissue for exam.
VetBooks.ir disease (e.g., neoplasia, mycoses) crossing the Initial Database discharge should never be cultured, but Diseases and Disorders
• Seizures raise concern about an infiltrative
culture of nasal biopsy or deep nasal swabs
cribriform plate.
• CBC, serum chemistry profile, urinalysis,
is occasionally useful.
PHYSICAL EXAM FINDINGS feline retroviral serology: assess health before • Biopsies are required for histologic diagnosis
anesthesia, rule out thrombocytopenia if
In addition to typical exam, note character hemorrhagic discharge of nasal neoplasia or inflammatory rhinitis.
and laterality of discharge (p. 1255), assess • If platelet count is normal with epistaxis, Ideally, biopsy collection is guided by
nasal airflow; condition of teeth, gums, and consider buccal mucosal bleeding time, imaging.
roof of mouth; facial symmetry; nasal planum coagulation profile, infectious disease serology
pigmentation; eye position and ability to (e.g., E. canis, Bartonella spp, Anaplasma spp), TREATMENT
retropulse globes; and percussion of muzzle blood pressure
and frontal sinuses. • Aspirate any enlarged submandibular lymph Treatment Overview
• Airflow can be assessed by 1) occlusion node for cytologic exam. Treatment is aimed at addressing the cause for
of each nostril one at a time, 2) holding • Obvious mass or deformity may be amenable nasal discharge.
a microscope slide in front of each nostril to fine-needle aspiration for cytology.
to visualize condensation, and 3) holding • Consider serologic tests for cryptococcosis Acute General Treatment
a wisp of cotton in front of each nostril to (p. 223), sinonasal aspergillosis (p. 81), or • Nasal flush can be diagnostic and thera-
watch movement. Airflow may be reduced systemic infection. peutic.
by neoplasia, granuloma, or mucus occlusion. • Consider thoracic radiographs to rule out • Dental disease or oronasal fistulas (pp. 7,
• Oral exam: look for tooth root abscess, oro- pneumonia, metastatic lung disease. 720, and 776)
nasal fistulas, cleft palate, or other structural • Consider cytology of impression from nasal • Nasopharyngeal polyp (p. 681)
abnormalities discharge; has extremely low sensitivity but • Nasal mites
• Facial deformity suggests neoplastic or fungal occasionally recognizes fungal elements or • Nasal stenosis
disease. Feline cryptococcosis often causes a neoplastic cells • Sinonasal aspergillosis (p. 81)
Roman nose. • Cryptococcus spp (p. 223)
• Nasal planum depigmentation is commonly Advanced or Confirmatory Testing • Idiopathic lymphoplasmacytic rhinitis
identified in nasal aspergillosis (ventral The choice of advanced diagnostic modalities (p. 890)
depigmentation), immune-mediated disease depends on a patient-specific list of differentials, • Nasal neoplasia (p. 680)
(e.g., discoid lupus erythematosus) availability of diagnostics, and cost. • Antibiotics are not routinely recom-
• Inability to retropulse eye suggests a space- • Thorough oral exam requires anesthesia and mended. Many causes of nasal discharge
occupying lesion (e.g., abscess, neoplasia, may be combined with dental radiographs result in secondary infection and improve
granuloma). and cleaning. temporarily with antibiotics, but discharge
• Ocular discharge suggests concurrent systemic ○ In older animals or those with obvious recurs unless the underlying issue is
disease (e.g., infection, dysautonomia, kerato- dental disease, this is often the first addressed.
conjunctivitis sicca with neurogenic rhinitis) step in evaluation of chronic MP nasal
or occlusion of nasolacrimal duct (tumor). discharge. Possible Complications
• Dysphonia, stertor, or Horner’s syndrome • Imaging studies are often the next step in Nasal neoplasia may metastasize or invade
suggests nasopharyngeal polyp. evaluation of chronic or progressive discharge. into brain. Severe epistaxis can cause anemia/
• Pyrexia suggests systemic disease (e.g., canine ○ Skull radiographs: multiple views (includ- hypovolemia.
distemper virus). ing open mouth) under general anesthesia;
• Harsh lung sounds not referred from upper- difficult to distinguish soft tissue from PROGNOSIS & OUTCOME
airway or adventitial sounds suggest systemic nasal discharge; generally inferior to other
disease. imaging modalities Depends on cause
• Submandibular lymphadenopathy suggests ○ Skull CT: modality of choice; ability to
oral disease, metastatic neoplasia, or fungal use contrast allows soft tissue to be distin- PEARLS & CONSIDERATIONS
infection guished from discharge, provides excellent
bony detail (e.g., loss of turbinates) and Comments
Etiology and Pathophysiology better anatomic detail than radiographs, • Bacterial culture of nasal discharge is not
• Nasal discharge may be a sign of systemic allows assessment of cribriform plate useful.
illness or may be due to local nasal pathology. integrity, allows planning for radiation • For devoted owners of pet with chronic
• Nasal pathology includes inflammatory, therapy nasal discharge, early referral for advanced
infectious, and neoplastic disorders, as well ○ Skull MRI: excellent soft-tissue detail; diagnostics can save money and time.
as structural issues. sometimes used in place of CT • Rhinoscopy alone has limited diagnostic
○ Findings on advanced imaging (CT/MRI) value and should be paired with advanced
DIAGNOSIS may be pathognomonic for some disease imaging.
processes. • If advanced imaging is not possible, blind
Diagnostic Overview ○ If owner is likely to consider radiation biopsies can be performed; it is important
Signalment, history, and exam influence therapy should the diagnosis be nasal to educate the client that a diagnosis may
the type and order of diagnostics. In some carcinoma, pet should be referred for be missed.
circumstances (e.g., young animals with acute- advance imaging rather than starting with • For blind biopsy, premeasure the biopsy
onset MP discharge thought to be from upper skull radiographs. forceps to the medial canthus of the eye,
respiratory infection, chronic serous discharge ○ Imaging studies should precede rhinoscopy and do not biopsy beyond that.
believed to be from nasal mites), empirical because bleeding will obscure images. • Identifying the cause of chronic nasal
therapy is appropriate without additional • Rhinoscopy allows direct visualization of the discharge is often more rewarding in dogs
testing. Additional considerations include the nasal passages and the choanae. Although than in cats.
owner’s goals as well as diagnostic availability tumors or fungal plaques are often recog- • Without specific identification of an
and costs. nized, FB may remain hidden (p. 1159). underlying cause, treatment of chronic nasal
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