A 9-year-old sexually intact male client-owned Miniature Rex rabbit (Oryctolagus cuniculus; rabbit 1) with a body weight of 1.66 kg (3.65 lb) was referred to the University of Wisconsin-Madison for evaluation of a 3-week history of reduced appetite and right-sided mucopurulent nasal discharge. Initial physical examination revealed right-sided facial swelling at the level of the maxilla and right-sided mucopurulent nasal discharge. The remainder of the physical examination findings were unremarkable, and results of a CBC and serum biochemical analysesa were within reference limits.
The patient was sedated with midazolam (0.5 mg/kg [0.23 mg/lb], IM) and butorphanol (0.5 mg/kg, IM), and CT of the head was performed. Fine-needle aspirates of the maxillary mass were obtained. Review of CT images revealed a well-circumscribed, soft tissue–attenuating, subcutaneous mass located at the rostrolateral aspect of the right maxilla (Figure 1). Additionally, soft tissue–attenuating material with central amorphous mineralization was evident in the right nasal cavity and ipsilateral maxillary sinus. The nasal turbinates were absent in the areas of soft tissue attenuation.
CT images and photograph of the head of a 9-year-old sexually intact male Miniature Rex rabbit (Oryctolagus cuniculus; rabbit 1) evaluated because of right-sided facial swelling and mucopurulent nasal discharge. A—Transverse CT image at the time of initial evaluation. Notice the dystrophic mineralization and soft tissue–attenuating material within the right nasal cavity. There is a well-circumscribed, soft tissue–attenuating, subcutaneous mass at the rostrolateral aspect of the right maxilla measuring approximately 2.5 × 2.0 × 1.8 cm (height × width × length). The provisional diagnosis was right-sided rhinitis with erosion through the maxillary bone and associated maxillary sinusitis. The rabbit underwent a right lateral rhinostomy. B—Immediate postsurgical appearance of the lateral rhinostomy site. Notice the marsupialization of the surgical site. C—Transverse CT image obtained 13 months after initial evaluation and surgery. There is no evidence of the previously noted right-sided chronic rhinitis or sinusitis. The CT images are displayed in a bone algorithm at the level of the nasal cavity (window width, 2,000 Hounsfield units; window length, 300 Hounsfield units).
Citation: Journal of the American Veterinary Medical Association 252, 1; 10.2460/javma.252.1.103
CT images and photograph of the head of a 9-year-old sexually intact male Miniature Rex rabbit (Oryctolagus cuniculus; rabbit 1) evaluated because of right-sided facial swelling and mucopurulent nasal discharge. A—Transverse CT image at the time of initial evaluation. Notice the dystrophic mineralization and soft tissue–attenuating material within the right nasal cavity. There is a well-circumscribed, soft tissue–attenuating, subcutaneous mass at the rostrolateral aspect of the right maxilla measuring approximately 2.5 × 2.0 × 1.8 cm (height × width × length). The provisional diagnosis was right-sided rhinitis with erosion through the maxillary bone and associated maxillary sinusitis. The rabbit underwent a right lateral rhinostomy. B—Immediate postsurgical appearance of the lateral rhinostomy site. Notice the marsupialization of the surgical site. C—Transverse CT image obtained 13 months after initial evaluation and surgery. There is no evidence of the previously noted right-sided chronic rhinitis or sinusitis. The CT images are displayed in a bone algorithm at the level of the nasal cavity (window width, 2,000 Hounsfield units; window length, 300 Hounsfield units).
Citation: Journal of the American Veterinary Medical Association 252, 1; 10.2460/javma.252.1.103
CT images and photograph of the head of a 9-year-old sexually intact male Miniature Rex rabbit (Oryctolagus cuniculus; rabbit 1) evaluated because of right-sided facial swelling and mucopurulent nasal discharge. A—Transverse CT image at the time of initial evaluation. Notice the dystrophic mineralization and soft tissue–attenuating material within the right nasal cavity. There is a well-circumscribed, soft tissue–attenuating, subcutaneous mass at the rostrolateral aspect of the right maxilla measuring approximately 2.5 × 2.0 × 1.8 cm (height × width × length). The provisional diagnosis was right-sided rhinitis with erosion through the maxillary bone and associated maxillary sinusitis. The rabbit underwent a right lateral rhinostomy. B—Immediate postsurgical appearance of the lateral rhinostomy site. Notice the marsupialization of the surgical site. C—Transverse CT image obtained 13 months after initial evaluation and surgery. There is no evidence of the previously noted right-sided chronic rhinitis or sinusitis. The CT images are displayed in a bone algorithm at the level of the nasal cavity (window width, 2,000 Hounsfield units; window length, 300 Hounsfield units).
Citation: Journal of the American Veterinary Medical Association 252, 1; 10.2460/javma.252.1.103
Cytologic examination of fine needle aspirates revealed evidence of septic heterophilic inflammation, with heterophils admixed with granular debris, and intracellular and extracellular cocci. These findings were consistent with a diagnosis of severe right-sided rhinosinusitis with lateral extension to the subcutaneous tissues overlying the maxilla. The patient was admitted to the hospital, and lateral rhinostomy for exploration and debridement of the right nasal cavity was scheduled for the following day.
The rabbit was sedated with butorphanol (0.5 mg/kg, IM), midazolam (0.5 mg/kg, IM), and ketamine (10 mg/kg [4.5 mg/lb], IM). A 26-gauge, 1.9-cm-long catheter was placed in the left lateral ear vein, and a balanced electrolyte solution was administered at a rate of 5 mL/kg/h (2.3 mL/lb/h) IV, throughout the procedure. After an appropriate level of sedation was achieved, the patient was preoxygenated for 5 minutes with administration of 100% oxygen by means of a tight-fitting face mask, and then general anesthesia was induced with administration of isoflurane in oxygen via mask. A 3-mm-diameter uncuffed endotracheal tube was placed, and anesthesia was maintained with delivery of isoflurane (1.5% to 2.5%) in oxygen for the duration of surgery. Indirect blood pressure (measured with Doppler oscillometry), heart rate and rhythm (lead II ECG), arterial oxygen saturation (measured with pulse oximetry), and end-tidal carbon dioxide concentration (measured with capnography) were monitored throughout the procedure. The rabbit was positioned in left lateral recumbency with the head lower than the body to facilitate nasal drainage and decreased the possibility of aspiration. After standard skin preparation and draping for surgery, a 1.5-cm-long craniocaudal skin incision was made over the facial swelling. Blunt and sharp dissection through the subcutaneous tissues and musculature, with care to preserve nerves and vasculature, were performed to explore the swelling. The swelling was incised, and a large volume of purulent material was removed. The surgical site was then carefully lavaged with warm sterile saline (0.9% NaCl) solution. The residual cavity was then explored with a rigid endoscopeb for gross evidence of infection (ie, residual purulent material) and for evidence of a communication with the nasal cavity or paranasal sinuses. At the dorsal aspect of the mass, at the level of the facies cribrosa of the maxillary bone, a small communication with the right maxillary sinus was identified and enlarged by means of insertion of blunt hemostatic forceps to allow access to the right nasal cavity via the maxillary sinus (Figure 1). Additional purulent material located in the right nasal meatus and the right maxillary sinus was then removed with a combination of lavage and suction with endoscopic guidance. Several fragments of abnormal-appearing mineralized material were present in the nasal cavity and were retrieved for subsequent histologic examination and aerobic and anaerobic microbial culture.
After endoscopic exploration and debridement of the affected area, marsupialization of the surgical site was performed by suturing the facial skin to the opening of the nasal cavity with 4-0 nylon suture in a simple interrupted suture pattern. A sustained-release antimicrobial gelc was then instilled in the wound (Figure 1). The rabbit recovered from anesthesia without complications. Meloxicam (0.5 mg/kg, SC) was administered just prior to extubation to reduce inflammation and provide analgesia. Histologic examination of tissue samples obtained during surgery identified the mineralized material as nasal bone surrounded by pockets of heterophilic inflammation with evidence of bony remodeling. Moderate growth of an α-hemolytic Streptococcus strain was identified on microbial culture of specimens collected from the maxillary sinus; however, the isolate could not be grown for antimicrobial susceptibility testing.
The patient was eating well by the evening of surgery and was discharged the next day with instructions to follow up with the referring veterinarian. Medications dispensed at discharge included meloxicam (0.3 mg/kg [0.14 mg/lb], PO, q 12 h for 7 days), gentamicin ophthalmic solution (1 drop topically in the right eye and 1 drop topically at the surgical site, q 12 h for 14 days), enrofloxacin (10 mg/kg, PO, q 12 h for 21 days), and penicillin G procaine–penicillin G benzathine (50,000 U/kg [22,727 U/lb], SC, q 5 d for 3 doses). At a follow-up visit 1 month after surgery, the referring veterinarian removed the sutures and reported that the ostium had apparently healed by means of second intention, with patent nares bilaterally. The owners reported that the rabbit had apparently normal behavior and appetite.
The rabbit was reexamined at the University of Wisconsin-Madison 13 months later for evaluation of an odontogenic abscess of the left mandible. Computed tomography of the head was repeated (Figure 1). There was no evidence of the previously noted soft tissue– attenuating mass adjacent to the right maxilla, and signs of right-sided rhinitis had resolved. However, there was persistent irregularity and thinning of the rostrolateral aspect of the right maxilla and absence of nasal turbinate anatomy in some areas of the right nasal cavity when compared with the left.
A 10-year-old sexually intact male client-owned Miniature Rex rabbit (rabbit 2) weighing 1.85 kg (4.07 lb) was evaluated because of a 4-year history of intermittent signs of upper respiratory tract disease. Clinical signs of upper respiratory tract disease included intermittent right-sided oculonasal discharge, recurrent right dacryocystitis, and persistent sneezing. The rabbit had been treated with repeated lavage of the right nasolacrimal duct, nebulization with warmed saline solution, gentamicin ophthalmic drops (2 drops, topically in the right eye, q 8 h), trimethoprim sulfomethoxazole (30 mg/kg [13.6 mg/lb], PO, q 12 h), and meloxicam (0.5 mg/kg, PO, q 24 h). Microbial culture of a sample of the purulent nasal discharge performed 5 months prior to examination produced heavy growth of Pseudomonas aeruginosa, susceptible to a large number of antimicrobials. The owners had previously repeatedly declined further diagnostic evaluation including CT because of financial constraints.
On evaluation, the patient had a lack of air flow through the right nostril, a right-sided oculonasal discharge and a palpable swelling between the right eye and right nostril. The rabbit was sedated for CT of the head, which revealed findings consistent with right-sided chronic rhinitis, maxillary sinusitis, and bony lysis (Figure 2). A large, mildly heterogeneous, fluid-attenuating mass with several soft tissue–attenuating foci was evident in the right nasal cavity, extending to the right maxillary sinus and involving the rostral aspect of the nasal cavity to the level of the palatine bone. The mass completely occluded the right nasal cavity, with associated deviation of the nasal septum to the left and an apparent septal defect rostroventrally. Because of the extent of the lesion, surgical exploration and debridement by means of lateral rhinostomy were elected.
CT images of the head of a 10-year-old sexually intact male Miniature Rex rabbit (rabbit 2) evaluated because of intermittent chronic upper respiratory tract disease. Severe right-sided chronic rhinitis and maxillary sinusitis were diagnosed, and the rabbit underwent right lateral rhinostomy. Transverse (A) and dorsal (B) CT images obtained at the time of initial evaluation. Notice the expansion of the maxillary sinus of the right nasal cavity and the presence of soft tissue–attenuating material and lysis of the right maxillary bone (arrows). Transverse (C) and dorsal (D) CT images obtained 5 months after surgery. Soft tissue–attenuating material is now absent (arrows). Images were obtained at the level of the nasal cavity and are displayed in a bone window (window width, 2,000 Hounsfield units; window length, 300 Hounsfield units).
Citation: Journal of the American Veterinary Medical Association 252, 1; 10.2460/javma.252.1.103
CT images of the head of a 10-year-old sexually intact male Miniature Rex rabbit (rabbit 2) evaluated because of intermittent chronic upper respiratory tract disease. Severe right-sided chronic rhinitis and maxillary sinusitis were diagnosed, and the rabbit underwent right lateral rhinostomy. Transverse (A) and dorsal (B) CT images obtained at the time of initial evaluation. Notice the expansion of the maxillary sinus of the right nasal cavity and the presence of soft tissue–attenuating material and lysis of the right maxillary bone (arrows). Transverse (C) and dorsal (D) CT images obtained 5 months after surgery. Soft tissue–attenuating material is now absent (arrows). Images were obtained at the level of the nasal cavity and are displayed in a bone window (window width, 2,000 Hounsfield units; window length, 300 Hounsfield units).
Citation: Journal of the American Veterinary Medical Association 252, 1; 10.2460/javma.252.1.103
CT images of the head of a 10-year-old sexually intact male Miniature Rex rabbit (rabbit 2) evaluated because of intermittent chronic upper respiratory tract disease. Severe right-sided chronic rhinitis and maxillary sinusitis were diagnosed, and the rabbit underwent right lateral rhinostomy. Transverse (A) and dorsal (B) CT images obtained at the time of initial evaluation. Notice the expansion of the maxillary sinus of the right nasal cavity and the presence of soft tissue–attenuating material and lysis of the right maxillary bone (arrows). Transverse (C) and dorsal (D) CT images obtained 5 months after surgery. Soft tissue–attenuating material is now absent (arrows). Images were obtained at the level of the nasal cavity and are displayed in a bone window (window width, 2,000 Hounsfield units; window length, 300 Hounsfield units).
Citation: Journal of the American Veterinary Medical Association 252, 1; 10.2460/javma.252.1.103
The patient was premedicated with midazolam (0.5 mg/kg, IM), butorphanol (0.5 mg/kg, IM), and ketamine (5 mg/kg [2.3 mg/lb], IM), and general anesthesia was induced and maintained as described for rabbit 1. Surgical exploration, debridement, and lavage were also performed as described. Tissue samples were obtained for microbial culture and susceptibility testing. Heavy growth of a Pasteurella sp and Streptococcus intermedius, both susceptible to a large number of antimicrobials (including fluoroquinolones) on susceptibility testing, was obtained. The patient recovered from anesthesia without complications and was active and eating the same day. The animal was discharged the day after surgery, with meloxicam (0.5 mg/kg, PO, q 24 h for 7 days), enrofloxacin (10 mg/kg, PO, q 24 h for 28 days), and gentamicin 0.3% ophthalmic drops (1 or 2 drops topically to the right eye, q 4 to 6 h for 14 days). The rabbit was reexamined 3 days later. The rhinostomy site was covered with a scab, and a small amount of purulent material had accumulated. The area was cleaned, and the surgical site was lavaged to remove the purulent material. Three additional visits over a 1-month period included similar treatments. At the third visit (20 days after surgery), the ostium had healed, with visible granulation tissue (Figure 3); both nares were patent and the owner reported no recurrence of upper respiratory signs. The rabbit was evaluated again 5 months after surgery because of a mild recurrence of sneezing. Computed tomography of the head was repeated, revealing persistent enlargement of the right nasal cavity but nearly complete resolution of signs of rhinosinusitis. A small amount of fluid was evident in the right nasal passage, consistent with a diagnosis of mild chronic rhinitis.
Photograph of the head of rabbit 2 showing the appearance of the lateral rhinostomy site 20 days after surgery.
Citation: Journal of the American Veterinary Medical Association 252, 1; 10.2460/javma.252.1.103
Photograph of the head of rabbit 2 showing the appearance of the lateral rhinostomy site 20 days after surgery.
Citation: Journal of the American Veterinary Medical Association 252, 1; 10.2460/javma.252.1.103
Photograph of the head of rabbit 2 showing the appearance of the lateral rhinostomy site 20 days after surgery.
Citation: Journal of the American Veterinary Medical Association 252, 1; 10.2460/javma.252.1.103
Discussion
Upper respiratory tract disease is commonly diagnosed in domestic rabbits.1 Reported causes include bacterial infection, a foreign body, dental disease, and trauma. Neoplasia, including adenocarcinoma of the nasal turbinates, has also been reported.2–4 Bacterial infection is common, with Pasteurella multocida, Bordetella bronchiseptica, Pseudomonas spp, and Staphylococcus spp (in descending order of prevalence) the most commonly isolated bacteria.5 Deeb et al6 reported that 25% of rabbits had nasal colonization with P multocida and 75% had infections with B bronchiseptica at the time of weaning. In most cases, these infections remain subclinical, and these bacteria are considered by some to be commensal organisms.7 However, environmental and physiologic factors (eg, poor air quality, low humidity, and immunosuppression) can result in clinical signs of disease.6,7
Signs of upper respiratory tract disease in rabbits include nasal discharge, sneezing, epiphora, dyspnea, and bony deformities of the skull.8 Bacterial infections of the nasal passages can produce a large volume of purulent material that accumulates in the nasal passages and the adjacent maxillary sinuses, causing mucosal erosion, atrophy of nasal turbinates, and deformation of nasal bones.7 Various diagnostic modalities may be used to evaluate affected rabbits. Radiographs of the skull are difficult to interpret because of lack of anatomic detail and the interposition of overlapping tissue planes.9 Direct examination of the nasal passages with rhinoscopy may be performed with a rigid endoscope. However, a complete examination in rabbits may be limited by the small size of the nares and the presence of the nasal turbinates.9,10 Currently, CT of the head is preferred for evaluation of rabbits with signs of upper respiratory tract disease. This technique provides detailed anatomic information and is most suitable for surgical planning.9 Evaluation of the severity of disease by means of CT is beneficial in determining whether to treat the patient medically or surgically. Patients that benefit from surgery include those that have failed to respond to medical management and those with evidence of chronic disease (eg, destruction of the normal anatomy).3,11 Purulent material in rabbits tends to rapidly acquire a semisolid consistency, which impedes spontaneous drainage and response to simple lavage.12,13 In affected patients, this material and associated necrotic tissue require debridement via curettage, with appropriate antimicrobial treatment as determined by result of bacterial culture and susceptibility testing of samples. The primary goal of surgical debridement is to reestablish patency of the nasal cavity to facilitate breathing, with a secondary goal of salvaging unaffected tissues.14 The most commonly reported technique for surgical debridement is by means of a dorsal rhinostomy.2,3,10,11,14,15 With this technique, the skin is incised over the nasal bone, and an osteotomy is performed for direct access to the nasal cavity. Debridement and lavage are then performed. The skin around the rhinostomy site is then either marsupialized to the adjacent mucosa for ongoing treatment, with subsequent healing by means of secondary intention, or the bone flap is replaced and the surgical site is closed primarily.11,14 Commonly reported complications of this procedure include repeated premature occlusion of the rhinostomy site, major postoperative hemorrhage, severe postoperative signs of pain, delayed healing, and poor cosmesis.2,11,14,15
Both rabbits of the present report were treated with lateral rhinostomy as an alternative to dorsal rhinostomy. The lateral approach to the nasal cavity and associated maxillary sinuses may also be referred to as pararhinostomy because the procedure accesses a maxillary sinus versus the nasal cavity.15 Some authors have suggested that rabbits lack a sinus cavity lateral to the nasal cavity; rather, there are the dorsal and ventral maxillary recesses located immediately lateral and adjacent to the nasal cavity. These recesses communicate via a small stoma with the nasal cavity.15 The facies cribrosa is a porous region of the maxillary bone located approximately halfway between the medial canthus of the eye and the ipsilateral naris (Figure 4). It is an area where the maxillary bone separating the maxillary sinus from the overlying facial musculature becomes very thin and perforated.9,15 This porous structure means that the facies cribrosa as an ideal location for surgically accessing the nasal cavity and associated structures in affected patients.14,15 We suggest that the relative weakness of this portion of the maxillary bone likely predisposes rabbits with chronic rhinitis to secondary infiltration of purulent material into the maxillary subcutaneous tissues, as for both patients of the present report.
Photograph of the skull of a rabbit illustrating the thin perforated region of the maxillary bone (facies cribrosa; arrows) that facilitates surgical access to the maxillary sinus and nasal cavity via a lateral rhinostomy.
Citation: Journal of the American Veterinary Medical Association 252, 1; 10.2460/javma.252.1.103
Photograph of the skull of a rabbit illustrating the thin perforated region of the maxillary bone (facies cribrosa; arrows) that facilitates surgical access to the maxillary sinus and nasal cavity via a lateral rhinostomy.
Citation: Journal of the American Veterinary Medical Association 252, 1; 10.2460/javma.252.1.103
Photograph of the skull of a rabbit illustrating the thin perforated region of the maxillary bone (facies cribrosa; arrows) that facilitates surgical access to the maxillary sinus and nasal cavity via a lateral rhinostomy.
Citation: Journal of the American Veterinary Medical Association 252, 1; 10.2460/javma.252.1.103
During lateral rhinostomy, particular care should be taken to avoid iatrogenic damage to the infraorbital neurovascular bundle, which is located ventral to the lateral rhinostomy site. In patients in which some portion of the facies cribrosa remains intact and unaffected, the involved bone can be bluntly excised to permit access to the maxillary sinus and ipsilateral nasal cavity. After debridement and lavage, rhinoscopy is then performed to explore the maxillary sinus and nasal cavity and ensure that all purulent material has been removed. Finally, creation of a temporary nasal ostium by means of marsupialization facilitates topical antimicrobial treatment and prevents reaccumulation of purulent material. The rhinostomy site is then allowed to heal by second intention.
A lateral rhinostomy avoids the need to penetrate the relatively thick nasal bone in affected rabbits, as is necessary with the dorsal approach.2,11,12,14,15 This approach may be associated with fewer perioperative complications (eg, hemorrhage, premature closure of the ostium, avascular necrosis of the bony flap, and poor cosmesis).2,11,15 It is also our opinion that the lateral rhinostomy technique described is a less technically challenging procedure, and it does not require specialty instruments such as a bone burr or saw. Repeated CT in both rabbits of the present report suggested that this was a useful and effective surgical technique that effectively resolved the signs of chronic upper respiratory tract disease.
Footnotes
VetScan Comprehensive Diagnostic Profile, Abaxis Inc, Union City, Calif.
Hopkins II telescope (30°, 2.7 mm, 18 cm; 64019BA), Karl Storz Veterinary Endoscopy America Inc, Goleta, Calif.
Silvasorb Gel, Medline Industries Inc, Mundelein, Ill.
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