Destructive rhinitis - probable sinonasal aspergillosis. Is this a euthanasia case or are there any treatment options?

RE: Destructive rhinitis - probable sinonasal aspergillosis. Is this a euthanasia case or are there any treatment options?

Andrew Kent — Sat, 06 Jan 2024 09:10:41 GMT

Glad it went well! Fingers crossed for a good response!

RE: Destructive rhinitis - probable sinonasal aspergillosis. Is this a euthanasia case or are there any treatment options?

Ian Hopkins — Fri, 05 Jan 2024 15:45:11 GMT

Thanks Andrew, great tip, worked really well today and treatment progressing nicely. The O-tube on nylon suture material was pulled fairly easily into the sinus by the scope, simplified the case greatly and halved the GA time. Very grateful for everyone's ideas

RE: Destructive rhinitis - probable sinonasal aspergillosis. Is this a euthanasia case or are there any treatment options?

Pauline Jamieson — Sun, 31 Dec 2023 15:38:37 GMT

That's a great idea Andy! Thank you, I will bear it in mind for the next time if no wire is available.

Pauline

RE: Destructive rhinitis - probable sinonasal aspergillosis. Is this a euthanasia case or are there any treatment options?

Andrew Kent — Mon, 25 Dec 2023 09:21:40 GMT

The other way to get a catheter into the sinus (that avoids the use of a wire) is to tie a loop of suture to the tip of your catheter then grasp the loop with some endoscopic biopsy forceps passed through the working channel of the scope. You then use the scope to guide the scope and catheter into the sinus.

hopefully that makes sense?

Andy

RE: Destructive rhinitis - probable sinonasal aspergillosis. Is this a euthanasia case or are there any treatment options?

Pauline Jamieson — Sun, 24 Dec 2023 10:10:13 GMT

A Bassett wire runs up and down the scope channel much more easily due to the coating and makes the whole procedure easier, especially if you have a long scope, but likely is too wide for your channel in a bronchoscope. It depends on your scope. I use the Bassett wire down a gastroscope.

https://infinitimedical.com/devices/guide-wires/

Like Mayank, I don't soak, just install the cream as the evidence doesn't really support the soak adding to effectiveness.

In unilateral cases, I also instill the other side afterwards, using a clean catheter obviously. Just up the nostril until I can't get more in as you can't access the sinus, but I've seen these cases present with disease on the side that was thought to be unaffected a few weeks later.

On the first debridement, I always find this really hard indeed as the plaques are soggy and break up. It takes hours. On the second procedure, they tend to have shrivelled up and peel off as hard plaques like lichen making the procedure quicker and more thorough, but that can be scary if overlying a vessel as the usually do (no disasters so far though).

Pauline

RE: Destructive rhinitis - probable sinonasal aspergillosis. Is this a euthanasia case or are there any treatment options?

Mayank Seth — Thu, 21 Dec 2023 19:16:16 GMT

Hi Ian

Glad to hear that the first step went well!

I tend to use Weasel wires for no other reason than I typically have old ones lying around from some other procedure and they are 180cm. A stiffer wire would probably be better in msot instances!

I pass one of these through the scope into the sinus then remove the scope leaving it in palce. I then put the scope alongside the wire to check it hasn't moved and thread a cathter over the wire into the sinus. I typically use a soft silicone tube lie a suction cathter or O-tube rather than a urinary catheter as it bends much more easinly and is typically much wider so easier to push Canedten through it. You can get a 14Fr tube of some description into most medium sized dogs and it makes the procedure so much easier on the wrists!

With the throat well packed I lavage as you did and then instill enough canesten so its coming out through the nostril. I know some protocols have a soak first but it adds so much time compared ot a quick cathterise, lavage and instill, I'm not convinced that the evidence supports it helping and I always repeat at 10-14 day intervals until I see no more fungus (and then 1 more treatment while I'm there for good luck!)

RE: Destructive rhinitis - probable sinonasal aspergillosis. Is this a euthanasia case or are there any treatment options?

Ian Hopkins — Thu, 21 Dec 2023 17:24:44 GMT

Thank you everyone and Mayank for all your replies, really, really helpful.

This morning I passed a bronchoscope into the frontal sinus, debrided what I could with biopsy forceps and flushed with 600mls saline.

Tried to leave an aspiration catheter in place to guide a urinary catheter into the sinus to instill clotrimazole cream but too flimsy so instead flushed the frontal sinus with clotrimazole ointment and left in there for 30 minutes (also put some in left nasal chamber).

I will repeat the procedure in 2 weeks. We are trying to get hold of a guide wire long enough to put down the bronchoscope and then introduce a urinary catheter to instill the clotrimazole cream.

If anyone has any tips on how to catheterise the frontal sinus that would be wonderful to hear.

The dog recovered well with no neurological signs, on clinical exam the tick the owner reported wasnt there, hopefully they may have over interpreted an itchy ear. Fingers crossed

A few snap shots for interest

RE: Destructive rhinitis - probable sinonasal aspergillosis. Is this a euthanasia case or are there any treatment options?

Mellora Sharman — Thu, 21 Dec 2023 09:36:09 GMT

My only additions to Mayank's responses are:

- Debridement is often key in these cases, and dogs with more complete debridement tend to do better. This would in this case necessitate trephination to access disease in the sinuses, in order to remove material via flushing / suction and manual debridement. I tend to use sinuscopy (rigid scope via trephination holes, or flexible via the nose if you can gain access) for this.

- Debridement with cribriform platelet involvement may risk complication - and ventricular pneumocephalus has been documented post-procedures for aspergillosis see: https://pubmed.ncbi.nlm.nih.gov/26829276/ . But I'd still consider it for the best outcome.

- Enilconazole may be slightly safer than clotrimazole for topical use when we have cribriform plate lysis. Having said that, the only case I have had with seizures / neurologic signs post-treatment had no evident cribriform plate lysis and was managed with enilconazole as I recall - so... *shrug*

- My personal preference is to use depot therapy based upon the literature - with a short 15-20 minute soak with a liquid formulation, followed by deposition of clotrimazole cream. The publication Mayank shared included cases with depot therapy of several types.

- I would agree that were I am concerned about CNS involvement I do tend to ensure use of a systemic therapy as well as topical. Overall aspergillosis at least is not considered invasive, so the cribriform plate lysis and any focal meningitis may be more the result of destructive fungal toxins and inflammatory change than invasive disease per say. But if we can't be sure, and don't know what fungus is involved I'd err on the side of caution generally either way.

- My experience treating these more advanced cases is that they can do ok, but are definitely more challenging given the risks mentioned already - so prognosis would be very guarded here, and I think Mayank's comment around euthanasia is very valid.

- I'd consider that the environmental risk that this dog poses to the family is likely minimal, but with the same caveats mentioned.

Good luck!

Mellora

RE: Destructive rhinitis - probable sinonasal aspergillosis. Is this a euthanasia case or are there any treatment options?

Clive Ansell — Wed, 20 Dec 2023 09:08:58 GMT

[quote userid="2131" url="~/f/clinical-questions/30851/destructive-rhinitis---probable-sinonasal-aspergillosis-is-this-a-euthanasia-case-or-are-there-any-treatment-options/243239#243239"]Having said all that, I think euthanasia would be a very respectable course of action.[/quote]

I would agree.

The few cases I have dealt with have not done well. Some referred for surgical application of antifungals, and others treated systemically with Itraconazole.

Last one was a young SBT, seemed to be responding well to systemic Itraconazole, then finished up OOH with uncontollable epistaxis and was PTS.

RE: Destructive rhinitis - probable sinonasal aspergillosis. Is this a euthanasia case or are there any treatment options?

Evelyn Barbour-Hill — Mon, 18 Dec 2023 01:32:28 GMT

Clotrimazole (Canesten liquid) is the stuff for the topical application.

Mayank and Alasdair have given you the answers.

I'd only add that I think this one needs attacking from all directions, so instillation via the nostrils and via sinusotomy, and quite a big hole in the sinus at that. After the liquid's drained fill the sinus with Canesten cream.

Whatever you do, don't instill liquid up the nostrils with any great force. It's not impossible to force liquid through the cribriform plate.

Having said all that, I think euthanasia would be a very respectable course of action.

RE: Destructive rhinitis - probable sinonasal aspergillosis. Is this a euthanasia case or are there any treatment options?

janine redman — Sat, 16 Dec 2023 13:53:43 GMT

Intranasal clotrimazole has been successful in all six cases of aspergillosis I have treated , usually in dolichocephalic breeds , collies mainly . One required a second treatment. The last four treated with canesten liquid instilled into nasal passages and sinuses . Time consuming and fiddly but remarkably well tolerated compared to when we drilled holes into the frontal sinus and flushed daily

RE: Destructive rhinitis - probable sinonasal aspergillosis. Is this a euthanasia case or are there any treatment options?

Alasdair Hotston Moore — Sat, 16 Dec 2023 11:30:18 GMT

I agree with all you say. I think however that this dog may deteriorate very rapidly and both dog and one become distressed.

So eitehr they need to get on with treatment asap (I think this might be. case where both systemic and topical therapy, itraconazle plus clomtrimazole) would be sensible, but if they can't commit to treatment soon and with high intensity, it would be better to euthanise now

RE: Destructive rhinitis - probable sinonasal aspergillosis. Is this a euthanasia case or are there any treatment options?

Mayank Seth — Fri, 15 Dec 2023 17:05:07 GMT

Oh Dear! I would certainly be worried about this dog - the prognosis is guarded and treatment isn't quick/easy/cheap but if the owner is up for it I don't think it needs to be pts just yet.

To break down the concerns:

-I have no doubt this is fungal rhinitis. Its very common to only identify the organisms/granulomas in the sinus so if this area was not visualised/biopsied then it’s not surprising you didn’t get the report you were hoping for.

-While dogs and people can get aspergillosis I've never really considered this to be any more zoonotic than things like E.Coli or MRSA - the organisms are pretty common and infection is more a reflection of an individual's immune response than it is of exposure. I wouldn't let the dog sneeze all over a neonate but beyond that I wouldn’t consider it a huge concern. CAVEAT - I am not a paediatrician or a public health expert, but this is how I have always understood the situation to be.

-While topical treatment used to be considered contraindicated in the face of cribriform destruction, at least one study has suggested that it makes little difference to response and side effects with clotrimazole instillation: www.ncbi.nlm.nih.gov/.../

Admittedly, only 1 dog in that dog had neurologic signs but it still did ok!

If this were my case I would definitely offer to treat. My preference with cases with cribriform destruction would be open sinusotomy for debridement but I am very aware that the literature suggests that endoscopic debridement via trephination or through nasal access are equally efficacious and likely quicker/cheaper and I would be happy to offer those treatments if cost were a concern or I was not working with a surgeon comfortable with the procedure (a medics time tends to be much cheaper than a surgeons time, but that’s a different thread altogether!)

-With neurologic signs and evidence of meningitis, one could argue about the merits of concurrent systemic treatment. In most instances, this is due to reactive meningitis rather than direct fungal infection - one could consider a CSF tap to see if you identify anything on cytology/culture or you could just treat regardless. This adds to the cost as one typically treats for months and need to monitor for drug side effects (depending on the protocol chosen).

With all that said, if the owner doesn’t want to treat a dog that Amy still die a horrible neurologic death, may sneeze all over the household for weeks to come, will likely require multiple procedures costing several thousand pounds, euthanasia would be a very reasonable option and I would not pressure you or the owner into thinking otherwise.

Do let us know what they decide!

Mayank