Violet is a bichon frisé. No, that’s not a kind of lettuce. It’s a canine breed the AKC describes as a “small, sturdy, white powder puff of a dog” with a “merry temperament.” Bichons generally range in size from 11 to 22 pounds, but Violet is one of the smaller ones, weighing in at a mere 13 pounds. Now a senior, she had been having a series of troubles lately. She had inadequate tear production in one eye, causing a gooey crusting all around the eyelids, but she strenuously resisted efforts to clean and medicate the eye and surrounding area. Her mother recently reported occasional discharge from one nostril, but Violet was becoming steadily more irascible when we tried to examine her head closely. We couldn’t check her teeth at all. Small dogs are notoriously prone to serious dental disease, and since clearly something around her muzzle was hurting, we suggested anesthetizing her for a thorough assessment and dental cleaning. “I bet she has loose or infected teeth,” I said, thinking there might be even more extensive dental problems.
Maybe she had a tooth root abscess. This can start as a result of injury, like a broken tooth, or from bacterial invasion in or around the tooth. In dogs, the big upper fourth premolar, called the carnassial tooth, is particularly susceptible. When this chomper gets infected, a tract often forms extending upward, causing a swelling just below the eye which sometimes opens and drains pus. Affected dogs may drool excessively, rub their faces, and often stop eating because of the pain. Oral antibiotics may be sufficient treatment, but extraction of the offending tooth is often necessary to prevent recurrence. Untreated infected tooth roots can progress to infection in the actual bone of the jaw, called osteomyelitis. Another dental issue that impacts more than just the mouth is oronasal fistula. This typically involves the big upper canine tooth, which has an exceedingly long root that extends upward almost all the way to the nasal passage. When this fang gets infected, an open tract can develop, going from the mouth along the tooth root into the nasal passage. Affected dogs may sneeze and have chronic nasal discharge.
Before proceeding with our plan to explore Violet’s mouth, we ran blood tests — SOP before anesthesia, especially for older pets. Wouldn’t you know it? The results indicated potentially serious liver problems. We needed to delay the anesthesia while we gave her medication to support liver function and antibiotics to cover for oral infections. Over time, her condition improved, until she finally seemed well enough, and we proceeded with the anesthesia and dental cleaning.
Violet felt better for a while, but soon her malaise recurred. “I’d like you to see a specialist,” I advised. “Actually, several specialists.” An ideal workup might include consults with a veterinary dentist (for dental x-rays and evaluation of her teeth), an internal medicine specialist (for ultrasound-guided biopsy of her liver), and an ophthalmologist (to check that crusty eye.) Her owner was amenable, but the referral was delayed several times. First the dentist was having problems with his x-ray machine. Then the referral coordinator didn’t call the owner back. Finally things were arranged, but before Violet could see the dentist or ophthalmologist, bad news from the internal medicine specialist put a stop to any further consultation. The specialist suspected that Violet had a tumor growing deep inside her nasal passage that was the source of all her troubles.
Tumors inside the nasal passages occur most commonly in middle-aged or elderly dogs. The vast majority are malignant. Although they don’t tend to metastasize, i.e., spread to other parts of the body, they are usually highly destructive right where they are, often leading to euthanasia as a pet’s quality of life rapidly declines. Clinical signs can include sneezing; nasal discharge, sometimes bloody, from one or both nostrils; ocular discharge; and facial distortion. If both nasal passages are involved, the pet may exhibit trouble breathing or excessively noisy breathing. Occasionally such tumors eat through the bones separating the nasal passages from the brain. When this happens, signs can include seizures, behavioral changes, dull mental status, blindness, circling, and abnormal gait.
These tumors are not visible from the outside, at least not until they are so advanced that the cancer causes facial distortion. Diagnosis relies on radiographs, MRI, or optimally CT scan, to reveal the presence of a mass. These can also show if there is destruction of the bones surrounding the nasal cavity, a finding highly suggestive of cancer, but not definitive. Definitive diagnosis requires biopsy, usually obtained by rhinoscopy, in other words, looking up the nose with a fiberoptic scope and taking a tissue sample to be evaluated by a pathologist.
Long-nosed dogs have a higher risk, and breeds reported to be particularly prone include Airedale, basset hound, Old English sheepdog, Scottish terrier, collie, Shetland sheepdog, German shorthaired pointer, golden retriever, and Labrador retriever. Secondary bacterial infections occur frequently, often fooling veterinarians, just as we were fooled initially, into thinking the problem stems from infected tooth roots. Radiation therapy is the treatment of choice, but the prognosis is guarded at best, and recurrence is common.
Now, don’t panic if your dog gets a nasal discharge. There are many other things that might cause that. Some cases actually are caused by dental disease, or bacterial or fungal infections, even allergies. Foreign bodies like blades of grass or plant awns can get caught up inside the nose. Benign nasal polyps or even little critters called nasal mites are sometimes the culprits.
Violet was not so lucky. Her CT scan revealed advanced cancer, extending into both nasal passages, behind her eye, and into her sinuses. We will try to keep her comfortable with pain medications as long as she shows her “merry temperament” at home … but when this sweet little flower begins to fade, when her quality of life is failing, we will know it’s time to say goodbye.