1.  Causes ◦ Idiopathic/allergic/autoimmune ◦ Neoplasia ◦ Viral ◦ Fungal ◦ Primary bacterial - Rare ◦ Foreign body ◦ Parasitic

2.  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

3.  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.  Epistaxis ◦ Local disease  Neoplasia  Fungal  Chronic idiopathic rhinitis ◦ Systemic disease  Thrombocytopenia  Hypertension  Hyperviscosity  Vasculitis

5.  Initial work-up ◦ General bloodwork ◦ Thoracic radiographs ◦ +/- skull radiographs ◦ +/- cytology ◦ Coagulation profile ◦ Blood pressure if epistaxis present

6.  Initial work-up ◦ Culture? ◦ Sedated oral exam  Use spay hook and good light source  Deep sedation sometimes necessary  Maxillary 3 rd incisor and premolars 1, 2, 3 (mesial root)  Dental probe indicated in many cases

7.  Advanced work-up ◦ CT scan ◦ MRI scan ◦ Rhinoscopy and biopsy ◦ Blind biopsy

8.  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.  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.  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.  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.  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.  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.  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.  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.  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.  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.  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.  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.  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.  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.  Lymphoplasmacytic rhinitis ◦ Fairly common disease of dogs ◦ Diagnosis may obtained with other underlying causes  Fungal  Foreign body  Neoplasia  Parasitic  Mites  True bacterial infection

24.  Lymphoplasmacytic rhinitis ◦ Causes  Idiopathic  Inhaled allergens  Irritants  Hypersensitivity to bacteria or fungi?  Dust mites? (n=3)

25.  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.  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.  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.  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.  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.  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. ◦ 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.  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.  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.  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.  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. ◦ 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.  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.  Nasal neoplasia ◦ Prognosis - Carcinomas  No therapy = MST 95d (73-113)  Epistaxis  Present = 88d  Absent = 224d

39.  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.  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.  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