65 | Understanding nasal diseases in dogs and cats: how to give great care to your patients as a veterinary nurse

PodcastRespiratoryEndoscopy
Written By Laura Jones

In episode 65 of the Medical Nursing Podcast we’re chatting all about nursing patients with nasal disease.

 


In the first episode of a nasal disease mini-series, I’ll be introducing the common nasal disorders we see, the problems they cause, and the nursing care these patients benefit from - and then we’ll dive deeper into common nasal diseases in the next few episodes.

Which nasal diseases do we see, and why?

Well first, we need to take a little look at the nose itself.

The nose is only one part of the sinonasal system - and this is important for us to note, because many diseases won’t just affect the nose, they’ll cause problems with the surrounding sinuses, too.

Starting rostrally, from the nares air flows through the nasal cavities and over the turbinate bones (scrolls of mucosa-covered bone which warm and humidify inhaled air). The nasal passage continues to the nasopharynx (aka the ‘back’ of the nose), which is where the nose and mouth meet.

Above the nasal cavity are the paranasal sinuses. There are a few of these, each with their own name depending on the facial bone they’re part of. Sinuses are empty, air-filled, bony spaces lined with mucosa. They produce mucous, which moistens the nasal passages and traps pathogens and inhaled particles - and if you’ve had sinusitis you’ll know how uncomfortable it can be if they’re blocked or inflamed!

The nasal cavity is separated from the brain by a sieve-like portion of bone called the cribiform plate. Certain nasal diseases can destroy this bone and encroach on the CNS, causing neurological signs.

We see many sinonasal diseases affecting different areas within the nasal cavity.

These include:

  • Viral, bacterial and fungal infections

  • Chronic rhinitis

  • Foreign bodies (such as a grass blade or grass seed in the nose or nasopharynx)

  • Neoplasia (such as carcinoma or lymphoma)

  • Polyps (a benign mass of mucous membrane)

  • Nasopharyngeal stenosis (a narrowing of the nasopharynx, either congenital or due to scar tissue formation)

So how do we approach a snuffly patient?

Regardless of the type of nasal disease our patient has, many of the clinical signs they present with are the same. Most of these patients have signs such as:

  • Nasal discharge (which can be mucoid, purulent or haemorrhagic and can be unilateral or bilateral)

  • Sneezing

  • Reverse sneezing (which is almost like a big sniff - a paroxysmal episode of inspiratory effort to try and clear material in the nasopharynx)

  • Nasal congestion

  • Stertor

Many patients have a reduced food and fluid intake as their ability to smell and taste is impaired, leading to further changes like anorexia, dehydration and weight loss (depending on the duration of their clinical signs).

In some cases, facial deformities can also be seen. This is usually seen with destructive nasal diseases, like neoplasia or fungal infection. Patients can present with a ‘bump’ on their nose or a so-called ‘Roman nose’.

And what about when we examine these patients?

Physical examination typically reveals evidence of nasal discharge. Ocular discharge may also be present, particularly with viral infections or blocked tear ducts.

We also commonly see reduced nasal airflow as a result of congestion, inflammation or neoplasia. To test nasal airflow, take a microscope slide and place this in front of the nose. Condensation will form on the slide in front of each nostril as the patient breathes, and the amount of condensation present gives you an idea of nasal airflow and patency. No or reduced condensation on one side indicates absent or reduced airflow, respectively.

Facial swelling, asymmetry or exophthalamus may be seen, particularly if the patient has neoplasia, fungal rhinitis or something like a tooth root abscess, and fungal infections can also cause depigmentation around the nostrils in some cases.

Thoracic auscultation should also be performed to look for evidence of concurrent lower airway disease, and the patient’s peripheral lymph nodes should be palpated. An oral examination is also recommended, to look for tooth fractures, palate defects or other abnormalities. This is usually performed under sedation or general anaesthetic at the time of diagnostic imaging.

Speaking of that diagnostic imaging…

There are lots of diagnostics performed in nasal disease patients, and the exact tests depend on the suspected underlying disease.

Patients with ongoing epistaxis or chronic clinical signs usually require extensive workup, including bloodwork, diagnostic imaging and rhinoscopy. Epistaxis patients could have either a primary nasal disease or a coagulopathy, and it’s important to evaluate this before proceeding with things like imaging or a scope.

Let’s start by looking at the common blood tests we perform.

We don’t typically see specific changes on biochemistry and haematology - instead we’re looking at general body function and checking for underlying diseases that might impact their anaesthetic.

We should always check the patient’s platelet levels +/- their coagulation times ahead of rhinoscopy, since the procedure carries a high risk of haemorrhage. In patients with underlying bleeding disorders these may be abnormal.

And then we move on to diagnostic imaging.

Once our patient’s bloods are done, the likely thing we’ll do next is anaesthetise them for some kind of diagnostic imaging. 

Ideally this would be a CT scan of the head +/- thorax, as this provides more detail than radiographs and can be used to spot subtle changes. But if this isn’t available, radiographs can identify severe boney destruction and tooth root disease.

In most cases we’ll follow this with endoscopy.

A rhinoscopy procedure allows us to evaluate the upper respiratory tract. We can use a rigid rhinoscope to evaluate the rostral aspect of the nasal cavity, and a flexible bronchoscope to view the nasopharynx. 

We can take either guided or blind biopsies from these areas, and identify abnormalities such as masses, foreign bodies and stenosed areas. Polyps can be manually retracted, stenosed areas can be dilated endoscopically, and foreign bodies can be removed.

What other tests might we perform in nasal disease patients?

Biopsies can be submitted for histology, bacterial culture and fungal culture, guiding appropriate treatment. Infectious disease testing is also commonly performed, particularly in cats to detect infectious upper respiratory diseases, such as calicivirus, herpesvirus-1 and mycoplasma. 

Ok, so that’s the diagnostics we use - but what about treating and nursing these patients?

Whilst the specific treatment we use will vary depending on the individual patient and their underlying nasal disease, all patients with nasal disease benefit from supportive treatment and nursing care.

Common treatments used include antibiotics, anti-inflammatories or immunosuppressive medications, radiation therapy for certain tumours, and topical antifungal soaks for fungal rhinitis.

Alongside these, patients should receive appropriate analgesia based on their pain levels, appetite support if needed, and appropriate fluid therapy based on their dehydration level. 

Patients with epistaxis (either pre-existing or following rhinoscopy and biopsies) may benefit from medications like tranexamic acid either administered systemically or topically at the time of their procedure.

And as far as nursing goes?

Nursing care is aimed at supporting comfort, hydration and nutrition, alongside clearing nasal congestion (if possible) and keeping the patient clean.

Nasal and ocular discharge should be cleaned regularly, and saline nebulisation can be considered to loosen nasal secretions.

Patients with epistaxis should be monitored closely for signs of progressive anaemia and for any transfusion triggers, depending on the extent of their haemorrhage.

And patients with destructive nasal diseases (like neoplasia or fungal disease) can develop neurological signs, too - so these must be closely monitored.

That was a whirlwind tour of nasal disease, so let’s recap. 

There are lots of different causes, from neoplasia, to foreign bodies, to bacterial, viral or fungal infection and much more. Whilst there will be some variation between them, many patients present with similar clinical signs - sneezing, nasal discharge, and congestion. We diagnose chronic cases with imaging and endoscopy and sampling as needed, and treat and nurse these patients supportively whilst managing the specific underlying disease.

Whilst there’s a lot to think about with them, it’s often good nursing care, with attention to the basics, that makes a real difference. Keeping these patients clean, hydrated, comfortable and breathing as well as they can makes an enormous difference to their wellbeing, so don’t underestimate the importance of those fundamentals.

Did you enjoy this episode? If so, I’d love to hear what you think. Take a screenshot and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!

Thanks for learning with me this week, and I’ll see you next time!


References and Further Reading

Laura Jones
Next

64 | How to confidently manage laryngeal paralysis as a vet nurse