Weird Case Files with Dr. Amy: George
My favorite foreign body, and unilateral rhinitis in general
Case Files is a new column where we examine weird, inscrutable and illuminating cases our doctors have encountered. Today, we investigate George, a 12-year-old cat with an unusual case of rhinitis.
This was a fun case because it was dramatic, provided immediate gratification, and came at the end of a long day in which most of my appointments were sick, and most of them were not easy to help.
Signalment: 12-year-old MC DSH
Indoor/outdoor cat, coughing and sneezing x 4 days. Presented because owner noticed a blade of grass sticking out of the cat’s nose and she couldn’t remove it. Slightly decreased appetite, normal activity level, no vomiting or diarrhea noted. No abnormality noted in water consumption or urination.
- Weight: 11 lbs. T: 102 P: 180 R: 32 BCS: 5/9
- EENT: Eyes – cornea clear OU; mild nuclear sclerosis OU; fundus appears normal OU; no discharge, blepharospasm or scleral injection. Ears – clean, no erythema/swelling. Mouth – grade 2/4 dental disease, no oral ulcers or masses noted. Throat – no thyroid nodule palpated. Nose – coarse, thick blade of grass or pine needle protruding from right nostril about ½ inch; mild serosanguinous discharge from right nostril; mild audible nasal congestion and stertor; no discharge from left nostril.
- CV/Resp: No murmur/arrhythmia, pulses s/s; normal bronchovesicular sounds all fields; audible nasal congestion with right-sided unilateral serosanguinous discharge.
- Abdomen: No pain, organomegaly or fluid wave noted on palpation.
- LN: No peripheral lymphadenopathy.
- Integument: No evidence of ectoparasites; healthy coat; no skin lesions, dermal or SQ masses noted.
- Musculoskeletal: Ambulatory x 4, lean and well-muscled, normal ROM, no pain or swelling.
- Neuro: Mentation alert, no ataxia, CP’s and CN’s intact.
- U/G/Anus: external MN genitalia normal in appearance, anus normal in appearance.
- Nasal foreign body right nostril
- Unilateral nasal discharge
- Grade 2/4 dental disease
- Dx: Unilateral rhinitis, nasal foreign body
- Removed nasal foreign body with gentle but constant traction. The blade of grass was about 4.5 inches long!
- Rx: Azithromycin 40 mg q 24 hrs. x 10 days.
- Discussed with owner that if nasal discharge continued, patient could need further diagnostics and treatment under anesthesia such as CT, nasal flush and/or rhinoscopy.
Unfortunately, I did not take a “before” picture of George, but here is the blade of grass, and a picture of George’s nose after it was removed.
Rhinitis is a common condition recognized in both dogs and cats. Primary etiologies can include allergies/irritants, viruses (most commonly herpes or calici in cats), parasites (cuterebra, nasal mites), foreign bodies, fungal infections, and neoplasia. Bacterial infections are usually secondary, but we can also occasionally see Bordetella as a primary cause of rhinitis.
When we see unilateral rhinitis in a senior cat, neoplasia is very high on the differential list. If the blade of grass in George’s nose had not been visible, I would have been discussing the possibility of neoplasia with this owner very early on to prepare her for the possibility.
Previous to this case, the most dramatic and satisfying cause of rhinitis I had seen was parasitic, and was caused by cuterebra in a kitten. In the end, George’s blade of grass was very similar, except that I could remove it without anesthesia.
I was very grateful that George was a relaxed, gentle cat, and that he allowed me to remove the blade of grass easily, helping me at the end by twisting his head slightly while I pulled out the last inch of grass.
Where did the blade come from?
The most likely scenario for the blade of grass ending up in George’s nose is that he was probably eating grass, vomited, and the grass entered his nasopharanx when he vomited. After a couple days of coughing and sneezing, it started to work its way out, and the owner could see it.
When I told the owner how long the blade of grass was, she told me that she had already cut approximately 2 inches of it off when she first saw it because it seemed to be bothering him. She also told me that she had tried to remove it herself, but was nervous because it seemed too deeply attached.
I was so excited when I removed this blade of grass that I ran around the clinic showing everyone how long it was, and the mucopurulent discharge that was covering it.
Since this appointment was curbside due to COVID-19 and the owner didn’t get to be present for the extraction of the blade of grass, I couldn’t help but go outside to show the owner what we had removed so she could appreciate how incredible it was.
We also discussed the possibility of more plant material being in George’s nose, and I told her that if George’s symptoms did not completely resolve with removal of this blade of grass, he would probably need to see a specialist for rhinoscopy and/or CT.
When deciding on an antibiotic, I chose azithromycin because of its anti-inflammatory properties, and the fact that in an indoor/outdoor cat, the owner was more likely to be able to reliably administer medication q 24 hours instead q 12 hours. In an indoor cat, I would have been just as likely to choose doxycycline.
I work at several feline only hospitals with some frequency, and all of them use the dosing schedule that I used above instead of once a day for 5 days followed by q 3 day dosing. Since working at the feline hospitals and using a 10-day dosing schedule, my personal experience with more typical cases of rhinitis has been that dosing sid for 10 days is very effective.
I also would have used Onsior if it had been available, but would have recommended bloodwork first, especially since George is a senior cat.
Potential diagnostic pitfalls
I have to admit that with only having removed anything significant from a cat’s nose once before (the cuterebra that I removed from a friend’s foster kitten about 8 years ago), foreign body has been relatively low on my differential list when treating rhinitis in cats, especially in senior cats.
Over my career in veterinary medicine, I have done nasal flushes, cultures, occasional PCR testing, skull radiographs, and referred cats for CT and rhinoscopy. For the most part, these diagnostics have been relatively unrewarding.
When I have seen senior cats with unilateral rhinitis in the past, and we have been able to obtain a definitive diagnosis, it has almost invariably been neoplasia, most commonly lymphoma.
What I learned from George
This case made me grateful and opened my eyes. If that blade of grass had not actually been protruding from George’s nose, the owner and I would have been having a very different conversation, and she may or may not have been willing to do multiple diagnostic tests to better elucidate the cause of unilateral rhinitis.
While I always talk about imaging early in cases of unilateral rhinitis, I might not have given her much to hope for in doing those diagnostics because of my previous experience and consequent bias. If George’s blade of grass had not been visible, how long could he have been uncomfortable before it would have been found?
This case makes me wonder how many cats and dogs could have grass or other foreign material that is never found – how many of them are uncomfortable and could have a relatively easy and complete resolution to their discomfort.
Next time I see a cat with unlateral rhinitis, especially if it is acute, whether I can see something or not, I will be able to give an owner hope thanks to the fact that I met George.
Amy Lloyd, VMD, is an area medical director for IndeVets.