Hydropulsion as Palliative, Long-Term, Last-Resort Treatment of Nasal Carcinoma in a Dog and a Cat
ABSTRACT
An 8 yr old spayed female domestic shorthair and an 8 yr old neutered male Polish Lowland sheepdog were evaluated for a 3 wk history of sneezing and a 5 day history of left epistaxis, respectively. In both cases, computed tomography revealed a voluminous nasal mass, which was later histologically identified as carcinoma, without cribriform plate involvement. Nasal hydropulsion was performed in both animals in sternal recumbency under general anesthesia. A Poole suction tip was inserted into the orad esophageal opening and adequacy of the endotracheal tube cuff inflation was checked. Sterile saline was forcefully infused into the obstructed nasal cavity to dislodge the tumor. Both patients had temporary resolution of clinical signs. Nasal hydropulsion was repeated as a palliative last-resort treatment at each clinical relapse (four times in both animals over ≥1 yr), allowing long-term survival. Minor complications included a self-limiting retrobulbar and oropharyngeal swelling in the cat and self-limiting epistaxis in both animals. Although this technique is not intended to represent an equivalent alternative to radiation or surgical therapies, nasal hydropulsion may represent an appropriate palliative, last-resort treatment in case of obstructive nasal tumors in dogs and cats, when radiation therapy or surgery is not affordable, available, or desired.
Introduction
Canine and feline nasal tumors (adenocarcinoma, squamous cell carcinoma, undifferentiated carcinoma, fibrosarcoma, chondrosarcoma, osteosarcoma, undifferentiated sarcoma, and lymphoma) are locally aggressive diseases, with a low metastasis rate, estimated between 10% and 40% in both dogs and cats depending on the neoplasm type and the course of the disease.1–5 Although radiotherapy is currently considered as the treatment of choice, it is expensive, requires repetitive anesthesia, and is not always available.5 Surgical removal (via rhinotomy) is also possible, but it is equally expensive and the high morbidity rate limits its use.5 Furthermore, if neither of these two options are desired by the owner, a therapeutic dead-end may be reached, as chemotherapy alone is not highly efficient for most nasal tumors.6 This case series describes the use of repeated nasal hydropulsion as a palliative last-resort treatment in two cases in which radiotherapy and rhinotomy were declined.
Case Reports
Case 1
An 8 yr old, spayed female domestic shorthair was referred with a 3 wk history of sneezing. On presentation, the cat had left nasal purulent discharge, sneezing, and intermittent stertor. Airflow was absent from the left naris at auscultation. The remaining physical examination was unremarkable, and hematology and serum biochemistry results were within the reference ranges. Computed tomography (CT)a revealed a contrast-enhancing soft tissue attenuation obliterating the left nasal cavity, without bone destruction, cribriform plate involvement, or regional lymph node abnormalities. Retrograde rhinoscopy confirmed a mass filling the left choana. Biopsy was taken using a nasal hydropulsion technique.7 The cat was kept anesthetized and positioned in sternal recumbency. Adequacy of cuff inflation was checked by ensuring that all audible air leak through the mouth had disappeared. A Poole suction tip was inserted into the orad esophageal opening. The right nostril was digitally occluded, and a 20 mL syringe filled with sterile saline was inserted into the anterior left nasal cavity. Twenty milliliters of saline were forcefully infused to generate high pressures in the nasal cavity. Following hydropulsion, the oropharynx and rostral trachea were suctioned using the Poole suction catheter. A 2 cm pale, lobulated mass was collected from the oropharynx. The cat was recovered uneventfully and discharged on 0.5 mg/kg prednisoloneb as a result of a suspicion of nasal lymphoma and 10 mg/kg doxycyclinec pending histopathology results. Histologic examination revealed a poorly differentiated nasal carcinoma. Prednisolone was replaced by 0.3 mg/kg piroxicamd after a 1 wk wash-out period, and regular biochemical monitoring of renal function was recommended. Radiotherapy and ventral rhinotomy were declined by the owners because they were considered too expensive and invasive, and the cat had been asymptomatic since nasal hydropulsion. They agreed on repeating nasal hydropulsion at clinical relapse.
The cat was presented back to the hospital at each clinical relapse, 1.5, 3.5, and 6 mo after initial visit, respectively. Nasal hydropulsion was repeated each time to debulk the tumor. Clinical signs improved significantly after each procedure. After the fourth nasal hydropulsion, minimal self-limiting epistaxis was noted, as well as mild left retrobulbar and dorsal oropharyngeal swelling that quickly responded to furosemide injection (2 mg/kg) as previously described.7 Recovery from anesthesia was also prolonged, prompting overnight hospitalization. The cat had completely recovered on the next morning. A recheck CT was recommended before further nasal hydropulsion at the next clinical relapse. The cat was presented to the local veterinarian 6 mo later (12 mo after initial visit) because of recurrence of clinical signs, and facial deformity and exophthalmos, prompting humane euthanasia.
Case 2
An 8 yr old, neutered male Polish Lowland sheepdog was presented with a 5 day history of left epistaxis and sneezing. Hematology and serum biochemistry results were unremarkable. On physical examination, airflow was severely decreased from the left naris at auscultation. The remaining physical examination was unremarkable. Routine coagulation test results were within the reference ranges. Fundic examination was unremarkable.
CT revealed a contrast-enhancing soft tissue attenuation obliterating the left nasal cavity and destroying the nasal turbinates. Focal maxillary bone destruction and septum deviation to the right, but no cribriform plate involvement were noted.
Nasal hydropulsion was performed using a slightly modified technique, owing to the difference in body size. Fifty milliliters of saline were forcefully infused into the left nasal cavity using a 60 mL catheter-tip syringe (Figure 1). Numerous large, pale, and irregular tissue fragments were retrieved in the oropharynx after the procedure (Figure 2). The dog was recovered uneventfully and discharged on 0.3 mg/kg piroxicamd and a 4 day course of tramadole (2 mg/kg q 8 hr). Piroxicamd had never been given for fear of side effects. Stertor and persistent mild epistaxis had been reported for 2 days, after which complete resolution of clinical signs was achieved. Histopathology revealed a mildly differentiated nasal carcinoma. Radiotherapy and ventral rhinotomy were declined because of cost and invasiveness. The owners agreed on repeating nasal hydropulsion at clinical relapse.
Citation: Journal of the American Animal Hospital Association 55, 5; 10.5326/JAAHA-MS-6901
Citation: Journal of the American Animal Hospital Association 55, 5; 10.5326/JAAHA-MS-6901
The dog was presented back to the hospital 7, 11, and 18 mo after the initial visit because of clinical relapse. A recheck CT was performed at each presentation and consistently showed a mild tumor progression to the right nasal cavity. However, the cribriform plate remained intact. Nasal hydropulsion was repeated after each CT and always permitted dislodgement of large tissue fragments and temporary clinical remission. To date, 20 mo after the initial visit, the dog had remained free of clinical signs.
Discussion
To our knowledge, this small case series is the first to report long-term successful management of intranasal tumors using repeated nasal hydropulsion. Nasal tumors are usually considered locally aggressive, with a low metastasis rate but a high recurrence rate despite treatment (exceeding 60–70% in most reports).3,8,9 Median survival time is estimated around 3 mo without treatment.10,11 Radiotherapy is currently considered the preferred therapy in dogs and cats. Median survival time of dogs with nasal tumors treated by radiotherapy has been reported between 6.5 and 19.7 mo.3,8,9,12 In cats, median survival time following radiotherapy for nonlymphoproliferative nasal neoplasms has been estimated between 12 and 15 mo.13,14 Unfortunately, radiotherapy may not always be doable as a result of availability, high cost, and the need for repetitive anesthesia. Acute and delayed side effects have been commonly reported and include rhinitis, oronasal fistula, dental pulp death, and various degrees of ocular, cutaneous, and neurological toxicities.8,9 All these factors incited both owners to decline radiotherapy in our cases.
Surgical exenteration of the nasal cavity is another possible treatment.5 Ventral rhinotomy may achieve similar survival as radiotherapy alone, but it is equally expensive, and postoperative complications such as infections and osteonecrosis may be more common.8,15,16 For these reasons, surgery was also declined.
With the exception of nasal lymphoma, use of chemotherapy alone for nasal tumors has not been granted with great success.1,6,17,18
Nasal hydropulsion has previously been described as a highly efficient biopsy technique.7 Furthermore, Ashbaugh et al. reported immediate relief of nasal obstruction in about one-third of their patients.7 Because clinical remission was achieved in both our patients after the first nasal hydropulsion, and because all other therapeutic options were declined, repeated nasal hydropulsion was offered as a palliative, unexpansive, and minimally invasive last-resort treatment. No conclusions can be drawn regarding median survival time owing to the limited number of cases of this report. Our case series simply shows that long-term management is possible in at least some patients, with good quality of life.
Although nasal hydropulsion can be considered minimally invasive, minor complications, including sneezing, reverse sneezing, self-limiting epistaxis, and submucosal or retrobulbar swelling, have been described.7 Similarly, self-limiting epistaxis was noted in both of our patients. Because epistaxis is to be expected after the procedure, a minimal platelet and coagulation check should be recommended before nasal hydropulsion. If abundant nasal bleeding occurs, similar interventions as for iatrogenic epistaxis following rhinoscopy would be appropriate. The cat also developed retrobulbar and oropharyngeal swelling following the last nasal hydropulsion, which responded completely to furosemide administration. More serious potential side effects could also develop in case of cribriform plate involvement. These include flushing of saline, nasal bacteria, and nasal tumor into the central nervous system, or increased intracranial pressure, if the cribriform plate is not intact. Actually, in the cat of our case report, anesthesia recovery was significantly prolonged, possibly as a result of increased intracranial pressure associated with cribriform plate destruction. For this reason, we strongly recommend pursuing a CT scan prior to each nasal hydropulsion, and the consent of owners should be obtained for these potential complications.
Conclusion
In conclusion, although repeated nasal hydropulsion is not intended to represent an equivalent alternative to radiation or surgical therapies, it may be offered as a palliative, last-resort treatment to temporarily alleviate clinical signs when radiotherapy or surgery are not available, affordable, or desired. Our cases clearly demonstrate that long-term management is possible in some animals with this technique. However, a large-scale study would be necessary to confirm the therapeutic benefit on survival, better define the complication rate, and identify prognostic factors.
Photograph of the nasal hydropulsion procedure in an 8 yr old neutered male Polish Lowland sheepdog, later diagnosed with nasal carcinoma. The inflation of endotracheal tube cuff was checked prior to the procedure to prevent fluid aspiration. A Poole suction tip was inserted into the orad esophageal opening (arrow). The right nostril was occluded with the thumb while 50 mL of sterile saline was forcefully infused into the left nasal cavity to dislodge the tumor.
Photograph of tissues obtained after nasal hydropulsion in the same 8 yr old neutered male Polish Lowland sheepdog as in Figure 1 . Bar = 1 cm.
Contributor Notes
CT (computed tomography)
