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NASAL DISCHARGE IN CATS Douglas Palma, DVM, DACVIM (SAIM) The Animal Medical Center New York, New York CHRONIC OR ACUTE SIGNS OF NASAL DISCHARGE Acute signs (<3 weeks) Epistaxis No additional clinical abnormalities DIAGNOSIS Green/yellow mucoid/ mucopurulent hStructural disease (eg, neoplasia, mycotic or dental disease) hLess likely: systemic disease, coagulopathy, hypertension DIAGNOSIS workup (eg, blood pressure, CBC, serum chemistry profile, coagulation profile) hA dvanced imaging/ diagnostics DIAGNOSIS rhinitis (FHV-1, feline calicivirus) h A llergic/ inflammatory/ bacterial rhinitis (B bronchiseptica, C felis) hV iral NEXT STEPS Peracute nature; unilateral Facial pain Oral/lingual ulceration; ocular signs DIAGNOSIS hForeign h D ental body hInfectious rhinitis rhinitis (bacterial, viral) h S econdary infection h N eoplasia h L ess likely: foreign body NEXT STEPS Abnormal results DIAGNOSIS hInfectious hS ystemic hViral Physical exam NEXT STEPS disease h L ess likely (acute nature): destructive rhinitis (mycotic, chronic viral, immune-mediated) h Neoplasia hydropulsion Serous/ serohemorrhagic PCR testing (FHV-1, feline calicivirus) h S upportive care (eg, hydration, antipyretics, appetite stimulants) h A ntiviral therapy (eg, L-lysine, famciclovir, polyprenyl immunostimulant, intranasal vaccine) h A ntihistamine trials NEXT STEPS imaging/ diagnostics Antibiotics if infectious hD entistry h+/- care h+/- Empirical antibiotics hN asal flushing h+/- Nasal culture (localized pain to teeth) hC ryptococcal LCAT hR adiography (dental, nasal) hA dvanced imaging/ diagnostics Postanesthesia; postemesis DIAGNOSIS hNasopharyngitis hNasopharyngeal stenosis hNasal/ nasopharyngeal foreign body DIAGNOSIS nasopharyngeal exam hS aline hydropulsion h+/- Antibiotics hA dvanced imaging/ diagnostics polyps h Nasopharyngeal stenosis h Fungal granuloma NEXT STEPS hS edated nasopharyngeal exam hR adiography (open-mouth, lateral) hA dvanced imaging/ diagnostics hC ryptococcal LCAT DIAGNOSIS h<1 year: nasopharyngeal polyp h>5 years: neoplasia Ear infection; ear mass hC ryptococcal hS edated h Nasopharyngeal disease testing (PCR) h S upportive care (eg, hydration, antipyretics) h A ntiviral therapy (eg, l-lysine, famciclovir, polyprenyl immunostimulant, intranasal vaccine) NEXT STEPS NEXT STEPS <1 year of age rhinitis (FHV-1, feline calicivirus) hI nfectious hA dvanced hS upportive DIAGNOSIS h V iral NEXT STEPS hS aline NEXT STEPS Deviation of soft palate; palpable nasopharyngeal lesion NEXT STEPS hS edated nasopharyngeal exam LCAT hA dvanced imaging/ diagnostics Neurologic signs >1 year of age DIAGNOSIS h N eoplasia h M ycotic disease FHV-1 = feline herpesvirus-1 FNA = fine-needle aspiration LCAT = latex cryptococcal agglutination test LSA = lymphosarcoma PCR = polymerase chain reaction 84 cliniciansbrief.com December 2016 MANAGEMENT TREE h RESPIRATORY h PEER REVIEWED Chronic signs (>3 weeks) Chronic, intermittent; normal between episodes Abnormal retropulsion; exophthalmos; pain on opening mouth Soft-tissue swelling/mass Predominantly hemorrhagic (intermittent or isolated) Chronic, nonprogressive >1 year duration; >2 years of age at onset Responsive to antibiotics? DIAGNOSIS DIAGNOSIS hRetrobulbar abscess/cellulitis disease/ abscessation hInfiltrative disease (eg, LSA, Cryptococcus spp, Aspergillus spp) hDental disease/ inflammation (periocular swelling, severe conjunctivitis) hFungal granuloma hNeoplasia DIAGNOSIS disease (primary [rare], secondary) hDental disease (eg, fistula, abscess) NEXT STEPS hD ental radiography LCAT hC ryptococcal hO cular ultrasonography hA dvanced imaging/ diagnostics Severe stertor; open-mouth breathing disease exposure history h V iral PCR testing (FHV-1, feline calicivirus) h E mpirical treatment of clinical signs h F NA and/or biopsy (soft-tissue mass) h C ryptococcal LCAT h A dvanced imaging/ diagnostics idiopathic rhinitis h Allergic rhinitis h L ess likely: foreign body, neoplasia, viral disease NEXT STEPS NEXT STEPS systemic workup (eg, blood pressure, CBC, serum chemistry profile, FeLV/ FIV testing, coagulation profile) hA dvanced imaging/ diagnostics NEXT STEPS as needed Nasal flushing/ culture hD ental radiography hE xtraction/cleaning h+/- Advanced imaging/diagnostics h+/- NO (serous, concurrent ocular) DIAGNOSIS rhinitis (FHV-1, feline calicivirus) rhinitis (secondary) hYoung animals: nasopharyngeal stenosis, polyps hAllergic/inflammatory rhinitis hLess likely (acute nature): neoplasia, fungal rhinitis, primary bacterial rhinitis hChronic hR ecommend hA ntibiotics Strong suspicion of dental disease hViral DIAGNOSIS hBacterial hI nfectious NEXT STEPS hChronic disease (eg, neoplasia, mycotic or dental disease) hLess likely: systemic disease YES hViral DIAGNOSIS hNeoplasia hStructural DIAGNOSIS Chronic, progressive, or >5 years of age hA ntihistamine trials hA ntiviral trial (highdose famciclovir) hA nti-inflammatory trials hI mmunomodulatory trials h+/- Advanced imaging/ diagnostics rhinitis (viral recrudescence, recurrent bacterial infection) hFungal rhinitis NEXT STEPS hI nfectious disease testing (PCR, +/- bacterial culture, FeLV/ FIV testing) hCryptococcal LCAT hAdvanced imaging/ diagnostics <1 year of age at onset hBacterial DIAGNOSIS hDental disease DIAGNOSIS hViral rhinitis (FHV-1, feline calcivirus) hAllergic rhinitis DIAGNOSIS hNasopharyngeal stenosis hNasopharyngeal polyp palate hCleft hV iral NEXT STEPS PCR testing (FHV-1, feline calicivirus) hA ntiviral trial (high-dose famciclovir) hN asal flushing/culture (aerobic, mycoplasma) hS edated nasopharyngeal exam hS kull radiography (open-mouth, lateral) hC ryptococcal LCAT hA dvanced imaging/diagnostics NEXT STEPS hD ental radiographs hTooth extraction/ cleaning hViral NEXT STEPS NEXT STEPS hS edated nasopharyngeal exam hN asal radiography hA dvanced imaging/ diagnostics PCR testing (FHV-1, feline calicivirus) hFeLV/FIV testing hSupportive care (eg, hydration, antipyretics, appetite stimulants) hAntiviral therapy (eg, l-lysine, famciclovir, polyprenyl immunostimulant, intranasal vaccine) hAntihistamine trials December 2016 cliniciansbrief.com 85