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Nasal Flush



SYNONYM


Nasal lavage



OVERVIEW AND GOALS



• To obtain cells and/or tissue for diagnostic sampling of intranasal inflammation, infection, or neoplasia

• To remove small nasal foreign bodies


INDICATIONS



• Chronic nasal discharge (unilateral or bilateral)

• Intranasal obstruction

• Chronic sneezing

• Nasal foreign body

• Epistaxis with normal coagulation profile and blood pressure (BP)

• Maxillary mass/deformity


CONTRAINDICATIONS



• High-risk anesthetic animals (i.e., severely compromised metabolic, cardiac, or neurologic disease)

• Documented loss of integrity of cribiform plate (relative contraindication)

• Coagulopathy/bleeding disorder


EQUIPMENT, ANESTHESIA



• General anesthesia

• Endotracheal intubation

• Bowl of lukewarm tap water

• Rolls of gauze to pack the pharynx (one to three rolls, depending on size of animal)

• A 60-mL feeding tip syringe; the larger the diameter of the syringe tip, the more forceful the water jet can be generated by pushing on the plunger.

• Sterile saline solution for flush (1-L bag)

• Two bath towels

• Sterile water-soluble lubricant


ANTICIPATED TIME



• Time for general anesthesia

• Actual procedure takes <10 minutes per nostril.


PREPARATION: IMPORTANT CHECKPOINTS



• Thoroughly soak the rolled gauze in tap water, and then wring it out just before using it.

• Fill the 60-mL syringe to capacity with sterile saline solution.


POSSIBLE COMPLICATIONS AND COMMON ERRORS TO AVOID



• Improper placement or insufflation of the cuffed endotracheal tube, thus allowing water to enter the trachea of the anesthetized animal.

• Unevenly distributed or insufficient gauze, allowing the diagnosis (cells and tissue) to be flushed back into the esophagus.

• Forgetting to remove the gauze from the pharynx once the flush procedure is finished.

• Excessive force of flushing in patients with uncertain or compromised cribiform plate structure

• Using loose 4 × 4 gauze sponges—some may be forgotten after the procedure is finished and occlude the larynx or trachea.

• In case of severe nasal destruction, epistaxis may develop.


image NASAL FLUSH Large-bore syringe is inserted into nostril of anesthetized patient to perform nasal flush procedure. End of gauze roll can be seen protruding from mouth.


PROCEDURE



• General anesthesia induction and maintenance; endotracheal intubation:
○ Verification of appropriate endotracheal tube cuff inflation

• Sternal recumbency, head and neck extended

• Unwind gauze and soak in water, and then retrieve and wring out excess water.

• Place damp gauze dorsal to and on both sides of the endotracheal tube as far caudally as possible, past the caudal edge of the soft palate.

• Gently insert lubricated end of syringe into the ventral meatus of the nose as far as it will go. This is most easily achieved by pushing the philtrum of the nose dorsally while aiming the tip of the syringe toward the septum. Slide into the nasal passage without using force.

• Place towel over the head and nose of the dog to avoid a spray of back flush onto the operator.

• While holding the syringe firmly in place, briskly empty the 60 mL of saline into the nasal passage using moderate pressure on the plunger.

• A powerful stream of fluid is required to dislodge foreign bodies or pieces of abnormal tissue.

• Repeat several times for each nostril; other towel may be used to control spillage if saline flows from mouth.

• When finished, gently pull gauze from the pharynx, and examine carefully for foreign bodies or tissue clumps.


POSTPROCEDURE



• Remove the gauze from the caudal pharynx.

• Once the gauze is removed, examine the animal’s mouth and pharynx for any material that was flushed out of the nose but not trapped into the gauze.

• Observe the animal for sneezing and bleeding after termination of general anesthesia.


ALTERNATIVES AND THEIR RELATIVE MERITS



• Rhinoscopy, nasal radiography series, CT scans, or MRIs normally precede nasal flush.

• Nasal radiography series, CT scans, and MRIs provide specific information on intranasal structure that is not obtained with nasal flush.

AUTHOR: HANS GELENS



Nasal Infusion of Clotrimazole



AUTHOR: LILLIAN. GOOD



IST EDITION AUTHOR: SHARON. DRELLICH




OVERVIEW AND GOAL


Intranasal infusion of clotrimazole is a minimally invasive technique for treating confirmed nasal aspergillosis in dogs. Treatment is performed for 1 hour. Resolution of clinical signs is achieved in one half to two thirds of dogs with fungal rhinitis after a single treatment.



INDICATIONS


Dogs with confirmed nasal aspergillosis; confirmation requires either histopathologic confirmation of fungal hyphae in nasal tissues or at least two of the following: positive Aspergillus fumigatus serum titer, positive Aspergillus culture, radiographic/CT scan findings suggestive of fungal rhinitis (turbinate loss, fungal granulomas; see p. 96).



CONTRAINDICATIONS



• Cribriform plate erosion/damage secondary to fungal rhinitis. If advanced imaging (CT scan or MRI) of the cribriform plate is not available, owners should be warned that cribriform integrity has not been assessed. Topical therapy in animals with known cribriform damage has not been reported.

• Bulky fungal granulomas within the frontal sinus. Massive fungal disease within the frontal sinuses often recurs following topical therapy. It is assumed that the treatment does not adequately penetrate the center of these granulomas. Either rhinoscopic or surgical (sinusotomy) removal of bulky disease, followed by topical clotrimazole, should be considered.


EQUIPMENT, ANESTHESIA



• General anesthesia is required.

• A cuffed endotracheal tube (mandatory)

• Two 12 Fr Foley catheters, one 24 Fr Foley catheter, and two 10 Fr polypropylene or red rubber catheters

• Laparotomy sponges

• Two 60-mL syringes, one 12-mL syringe

• One pack of 3-0 nylon suture

• Suction canister and tubing

• Three hemostats

• One pair operating scissors

• One long-handled needle holder

• Four 30-mL vials of 1% clotrimazole in a polyethylene glycol base


ANTICIPATED TIME


About 2 hours total: 30 minutes for setup and anesthetic induction, 1 hour for treatment, and 30 minutes for recovery



PREPARATION: IMPORTANT CHECKPOINTS


Imaging studies are followed by rhinoscopic evaluation and then clotrimazole infusion during the same anesthetic episode if diagnostic results are highly suggestive of fungal rhinitis.



POSSIBLE COMPLICATIONS AND COMMON ERRORS TO AVOID


The inflated balloon of the nasopharyngeal Foley catheter must be palpated through the soft palate, just caudal to the hard palate. The balloon is initially held in place with a finger, which is then replaced with laparotomy sponges. Failure to fully inflate the balloon or ensure proper positioning will result in leakage of clotrimazole into the oropharynx.



PROCEDURE



• Place animal into lateral recumbency.

• Pass a 24 Fr Foley catheter orally and then into the nasopharynx with the aid of a long needle holder. Bend the Foley catheter tip 180○ so that the tip flips and comes to be seated dorsal to the soft palate. While palpating through the soft palate, fill the Foley balloon with air. Withdraw the balloon if necessary until it is just caudal to the hard palate. Place laparotomy sponges in the oropharynx to prevent caudal migration of the balloon.

• Pass a 10 Fr polypropylene or red rubber infusion catheter through each nostril and into each dorsal meatus (premeasure to the medial canthus).

• Place a 12 Fr Foley catheter into each nostril to prevent solution from leaking out the nostrils. Place a single nylon suture in each nostril to prevent rostral balloon migration. Fill balloons with air until obstruction occurs.

• Roll animal into dorsal recumbency.

• Fill two 60-mL syringes with the 1% clotrimazole solution (Lotrimin solution [Schering Corp., Kenilworth, New Jersey]). Administer 60 mL per side each hour via the infusion catheters.

• Place hemostats across any Foley if fluid is present within the catheter.

• Position the animal’s head during infusion: 15 minutes dorsal, 15 minutes left lateral, 15 minutes right lateral, and again 15 minutes dorsal. The animal’s body should remain in dorsal recumbency.


image NASAL INFUSION OF CLOTRIMAZOLE Sagittal section of an anesthetized dog in dorsal recumbency. Image shows position of endotracheal tube (et), nasopharyngeal Foley catheter (npf), pharyngeal sponges (s), infusion catheter (ic), and rostral nasal Foley catheter (nf) in relation to the hard palate (hp), soft palate (sp), cribriform plate (cp), rostral frontal sinus (rfs), medial frontal sinus (mfs), and lateral frontal sinus (lfs).

(Reprinted with permission from Mathews KG, Koblik PD, Richardson EF, et al: Computed tomographic assessment of noninvasive intranasal infusion in dogs with fungal rhinitis, Vet Surg 25:309–319, 1996.)



POSTPROCEDURE


Following treatment, the animal is placed in sternal recumbency. All catheters and sponges are removed and counted. Clotrimazole is allowed to drain out of the nares by tilting the animal’s nose downward at the edge of the treatment table. Suction and dry sponges are used for ensuring that the pharynx is dry prior to recovery from anesthesia. Repeat treatment if nasal discharge does not cease by 2 weeks after treatment. Additionally, new evidence suggests that affected dogs should be rhinoscopically reevaluated approximately 1 month post treatment to determine if any fungal plaques persist.



ALTERNATIVES AND THEIR RELATIVE MERITS



• Orally administered antifungal drugs may be used in place of intranasal infusion of clotrimazole or as an adjunct to topical therapy. Itraconazole (5 mg/kg, q 12 h PO with food, for at least 2 months) has been associated with the greatest response rate (60%-70%) and requires intermittent monitoring of liver enzymes. A single 1-hour infusion of clotrimazole is equally effective if the medication is injected via catheters placed in dorsal sinusotomies.
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Jul 24, 2016 | Posted by in SMALL ANIMAL | Comments Off on N

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