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Thursday, April 9, 2015

Sinuses Or Esophagus? What To Do Next?

Here is a recent question from Joanne....
My husband is a cardiac surgeon and I am a PA. We therefore tend to have differential dx in our head when there is a problem with our canine kids.
We have a now 5 yo neutered yellow lab named Oliver.
In July 2014 Oliver started to reverse sneeze on a daily basis approx 2-4 times a day. He had bilateral clear nasal discharge and started swallowing at night when he slept. He sounded as if he had a cold when breathing.
We took him to the University of FL to be seen by IM. Bloods and urine WNL. They took him in the back for an exam. The resident dx Oliver with allergies. No meds were given.
There was no reverse sneezing Aug, Sept or Oct. it started again in Nov and lasted 3 weeks.
I began to notice that Oliver sounded as if he refluxed at night (GERD) and again sounded like he has a cold when he breathes.
March 1st at 3 a.m. And 5 a.m. He vomited clear thick mucous. At 6 a.m. He vomited mucous streaked with blood. His stool also had some blood in it.
At that point we brought him to a specialty hospital to be seen by critical care. During all of this he was acting normal and wanted to eat and drink. Bloods, urine, fecal were normal as was an abdominal ultrasound.
Dx was reflux and he was placed on sucralfate 1 g po bid ac and pepcid 20 mg qhs for 2 weeks. Reverse sneezing stopped as did night time reflux. Fifteen days after the tx ended his sx's began again.
I questioned why an eval of his esophagus wasn't done either via barium swallow or upper endoscopy and was told that we usually don't do that since vomiting blood doesn't have the same implications as it does in a human. I'm not a vet but I don't buy that reasoning. Please explain if you could.
So now we are on sucralfate 1 g po bid ac and pepcid 20 mg po q12h for 3 weeks. Then d/c the sucralfate and continue peocid for 2 weeks then d/c all meds.
Today Oliver was having a Beams dehydrated fish skin treat which is about 5 inches long and an inch wide and rigid. He put the entire piece in his mouth and he usually chews it. This time he attempted to swallow it and started rapidly swallowing to no avail. The treat was not visible in his mouth but luckily I was able to put my fingers down his throat to grab it and pull it out.
When I did there were a few specs of blood on it with clear thick mucous. I am assuming that just like a person, with his repeated swallowing, the treat could have scratched the mucosal surface causing it to bleed. Can that assumption hold true for dogs?
Oliver seems to produce a large amount of clear thick mucous which he is always swallowing and again sounds as if he has a cold since last July when all of this started. I am at a loss since a university dismisses it as allergic rhinitis and a specialty hospital critical care vet does only an abdominal ultrasound without evaluating the esophagus.
Local vets do not have the capability to scope. How useful is a barium swallow in dogs? I am assuming it would delineate a mass if present as it does in people by indicating what we refer to as an "apple core" appearance. Wouldn't this also tell us about his esophageal motility as well as stomach emptying?
Are these symptoms due to diet? I asked my local vet who admitted she hasn't a clue about nutrition. Right now I am at a loss.
Interesting case, Joanne. And I don't think you're off base with your concerns and thoughts. While there are significant differences in anatomy and physiology of dogs and humans, there are also a lot of similarities.
I would start by investigating the cause of the reverse sneezing. There isn't anything about reflux that would affect the sinus passages. However, problems in the sinus passage could drain down into the throat and esophagus. Reverse sneezing is typically due to minor sinus irritation and isn't harmful by itself. Usually over-the-counter antihistamines are sufficient to help the symptoms. But this sounds like there is something else to the case. And I could see a situation where the persistent nasal drainage is leading to reflux and esophagitis.
Based on your descriptions, if this was my patient here's how I would proceed.
1. Sedate/immobolize and do radiographs of his skull and sinuses. Any good general practitioner should be able to do this. While it won't typically give you a specific answer, you can see destruction of the nasal turbinates and possibly an increased radiopacity in one area to indicate a mass effect. This may help you localize if there is a lesion in the sinuses.
2. If that doesn't give a clear answer, refer to a facility with a small, flexible endoscope. This is commonly used to go into the pharynx and then retrograde above the soft palate to visualize the caudal nasal sinuses. At the same time the endoscope could be used to evaluate the esophagus and stomach.
3. A barium swallow is really most effective when done with fluoroscopy, which not even many referral practices have. You may have to end up at a veterinary college for that. It's the only way to actually see the true motility of the esophagus. And upper GI barium series could determine gastric emptying time and could potentially outline an esophageal mass, but could also miss a small mass. I'd rule out the sinus problems before focusing on the esophagus, as it seems like it all started there.
4. If none of the above gives answers, then a CT or MRI would be indicated to get better imaging of the inside of the sinuses and look for subtle changes.
As medical professionals you and your husband know that some cases aren't exactly straightforward. The patient and the clinician must both be politely persistent in pursuing the diagnosis. I certainly think that empiric treatment has it's place, and that's what's being tried. But when that doesn't work you go to the next step. If you strongly requested any of the above diagnostics, I'd be surprised if any vet would refuse to do any of it. Other than minor risks inherent to sedation or anesthesia all of these procedures are safe and minimally invasive to non-invasive. I would agree with the other vets that upper GI studies aren't first on our list and we don't jump at these diagnostics for a potential case of reflux. However, if the symptoms persist we have to re-consider doing them.
I don't see that the reverse sneezing would be in any way related to diet. While I'm no expert, I do find pet nutrition interesting and can't think of any dietary disorder that would lead to sinus inflammation. Reflux could be related to it, but I don't know that this is the primary problem.
It's always hard (if not impossible) to make a diagnosis based merely on a written description. But I can certainly see a situation where there is a mass or foreign body in the nasal passages that are causing drainage into the esophagus. In fact, that makes the most sense to me based on the description. My thoughts might change after looking at Oliver myself, so I'll hedge my bets a bit.
In the end, a lot of this depends on how much you are able and willing to do. All of these diagnostics aren't cheap, but they are absolutely possible in veterinary medicine. You might want to respectfully and politely push for more advanced diagnostics. But keep in mind how you or your husband would feel if a client pushed you in this way. There is an appropriate way to do it.
I hope some of this helps, and I hope you can get Oliver's problem figured out!