Veterinary Surgery, 19, 6,418-423, 1990

Excision of Tumors in the Nasal Vestibule of Two Dogs

DAVID HOLT, BVSC, CAROLINE PRYMAK, BVSC, and SYDNEY EVANS, VMD, MS, Diplomate ACVR

Two dogs with tumors in the left nasal vestibule were treated by surgical excision of the affected part of the nose. Radiation and chemopotentiation were used in one dog, which remained tumor-free after 12 months. When recovering from anesthesia, the second dog developed respiratory distress associated with upper airway obstruction and failure to mouth breathe. The dog was successfully treated by temporary tracheostomy and remained tumor- free after 3 months. Surgery preserved the function of the right nostril and gave an acceptable cosmetic result in both cases.

Case Reports

Dog 1

Medical History and Examination. In November 1987, an 11 year old intact female Collie dog weighing I5 kg was examined because of epistaxis and sneezing. An in- cisional biopsy of a mass visible in the left nasal vestibule was taken and squamous papilloma was diagnosed his- tologically. Sneezing with intermittent epistaxis continued. The mass was debulked by curettage in February 1988, and the histologic diagnosis was a highly proliferative and infiltrative nonencapsulated squamous cell carcinoma without apparent vascular invasion. Epistaxis and sneez- ing recurred, the mass was again visible and the dog was referred to the Veterinary Hospital, University of Penn- sylvania (VHUP). A raised, ulcerated mass 0.5 cm in di- ameter, was visible in the left nasal vestibule, extending laterally from the nasal midline into the vestibule (Fig. 1). The left submandibular lymph node was not enlarged. Thoracic and nasal radiographs, a complete blood count, serum biochemical examination, and clotting profile were normal.

Surgical Technique. Oxymorphone* and atropine? were administered. General anesthesia was induced with thiopentalt and maintained with isofluraneg and oxygen

delivered through a cuffed endotracheal tube. The dog was placed in sternal recumbency and the nose was pre- pared for aseptic surgery.

A 12 cm incision was made from the nasal plane cau- dally along the dorsal midline of the nose. The incision was made to the right of the nasal philtrum (Fig. 2). The skin, mucosa and cartilages on the left side were removed, including the median cartilaginous septum, to the level of the bony nasal aperture (Figs. 3 , 4). Hemorrhage was controlled by ligation and electrocautery. The subcuta- neous tissues were closed with single interrupted sutures of 3-0 chromic gut. The pigmented skin ofthe right nostril was sutured to the skin on the left of the incision with 4-0 nylon in a simple interrupted pattern. An excellent cosmetic appearance was achieved (Fig. 5). The left sub- mandibular lymph node was removed and submitted for histologic examination. The mass in the nasal vestibule was diagnosed as a squamous cell carcinoma. There was no microscopic evidence of neoplastic infiltration in the surgical margin but only a small margin of normal tissue was present medially. There was reactive hyperplasia of the lymph node without evidence of metastasis.

Immediate Postoperative Course. Recovery from anes- thesia was uneventful. Several episodes of sneezing and mild epistaxis occurred during the first 12 hours. The dog was moving air through the remaining nostril but inter- mittently breathed through its mouth. Exudate from the * Numorphan@, Dupont Pharmaceuticals, Wilmington, DE.

Atropine sulphate, Astra Pharmaceutical Products, Westboro, MA. $ Thiopental sodium, Abbott Laboratories-Pharmaceutical Product

right no& was ,-leaned periodically and petrolatum was Division. North Chicago, IL. applied to the nasal plane. The discharge became more

9 AErrane, Anaquesi, Madison. WI. serous, and ceased 48 hours after surgery.

From the Sections of Surgery (Holt, Prymak) and Radiology (Evans), Department of Clinical Studies, School of Veterinary Medicine, University

Presented at the 1990 ACVS Meeting, February 21, 1990, New Orleans, Louisiana. Reprint requests: David Holt, BVSc, Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, 3850 Spruce

of Pennsylvania, Philadelphia, Pennsylvania.

Street, Philadelphia, PA 19104.

41 8

HOLT, PRYMAK, AND EVANS 41 9

Fig. 1. Squamous cell carcinoma in the left nasal vestibule

Radiation Therapy. Radiation therapy was begun on day 12. Radiation (240 KVP, 3.0 mm Cu halfvalue laycr)P was delivered through 5 X 5 cm parallel opposed lateral portals centered at the mucocutaneous junction of the nasal plane. Dose to the midline was 45 Gy divided into 10 fractions. Two hours before radiation treatments one, three, four. six, scven and nine, cisplatin" (10 mg/M'), mannitol(0.5 g/kg) and normal saline were administct-cd intravenously (IV). Two hours before radiation treatmcnts two and five, 5-fluorouracil# (50 mg/M' IV) was admin- istered. Cisplatin and 5-fluorouracil were dosed to act as radiation potentiators. Radiation and adjuvant chemo- therapy were well tolerated initially. Moist desquamation ofthe nasal plane that developed between the seventh and eighth radiation treatments prompted discontinuation of the 5-fluorouracii. The desquamation did not worsen with further radiation treatment. The nasal plane was not trau- matized by the dog or infected, so no medication was administered,

Follow-up Examinations. Two months after complction of radiation therapy, there were no clinical signs of tumor recurrence. Sneezing and epistaxis had not recurred and the dog was able to breathe easily through its remaining nostril. Epiphora was not present. Post-radiation depig- mentation of the nasal plane had occurred. Twclvc months after completion of the treatment, there were no signs of local tumor recurrence and pigment had not re- turned to the nasal plane.

Dog 2

Medical Ilistory and Examination. In September 1989, a 14 year old intact male miniature schnauzer was cx-

7 Orthovoltage radiation unit. Picker International. Trevose. P A . 'I Platinol@. Bristol-Meyers Oncology Division. Evansville. I N . # Fluouracil". Roclie I A s . Division of tlotfman-1.3 Rochc Inc., N u t -

leq. NJ.

amined because of a mass in the ventral left nasal vesti- bule. The owners initially noticed depigmentation of the area 1 month before. No improvement occurred with topical hydrocortisone treatment, and the dog was referred to VHUP. A raised. nonpigmented, ulcerated, 2 cm di- ameter mass was visible in the left nasal vestibule, ex- tending ventrally and laterally into the lip (Fig. 6). The submandibular lymph nodes were not enlarged. Thoracic radiographs. a complete blood count, and serum bio- chemical examination were normal. Histologic diagnosis of an incisional biopsy was malignant melanoma.

Surgery. Anesthesia and positioning were as previously described. The procedure was modified because the tumor extended into the lip caudally and ventrally. The rostra1 and caudal incisions were continued ventrally into the oral cavity (Fig. 7 ) . Excision and closure were similar to dog 1 (Fig. 8). Removal of the section of lip resulted in deviation of the right nostril to the left of midline. The left submandibular lymph node was removed and sub- mitted for histologic evaluation. The mass in the nasal vestibule was diagnosed as malignant melanoma. A wide margin of normal tissue surrounded the tumor. There was no evidence of metastases in the lymph node.

Immediate Post-Operative Course. Recovery from anesthesia was lengthy. The dog was not breathing through its mouth and became progressively more dyspneic while attempting to breathe through the remaining nostril dur- ing the first half hour after surgery. The dog was reanes- thetized and a large amount of bloody froth was aspirated from the pharynx and trachea before tracheal intubation. Furosamide (0.5 mg/kg IV) was administered. A trache- otomy was performed and a double-lumen metal trache- ostomy tube was inserted. Deviation of the right nostril appeared to obstruct adequate air flow. so a wedge of the right alar fold was removed to widen the nostril and pro- vide a functional airway.

Complete recovery from anesthesia took several hours. Supplemental oxygen was administered at the tracheos- tomy site. The inner cannula of the tracheostoniy tube was removed and cleaned every 2 hours and the dog was

Incision line

Fig 2 level of the piriform aperture

Incision line for removal of the left side of the nose to the

420 NASAL VESTIBULE TUMORS

Fig. 3. Left side of the nose removed to the level of the piriform aperture Black and white arrows indicate the piriform aperture and the intact alar fold of right nostril

nebulized** for 15 minutes every 4 hours. When the tube was partially occluded. the dog breathed through the re- maining nostril but would mouth breathe if necessary. The tube was removed on day 3.

Follow-up Examination. Three months after surgery, there were no clinical signs of tumor recurrence and thc owners were pleased with the dog's appearance (Fig. 9). The dog was able to breathe easily through the remaining nostril and no epiphora was present. There was no evi- dence of metastatic disease in repeated thoracic radio- graphs.

Discussion

The nasal vestibule in dogs is the recess immediately within the nostril opening. It is bounded dorsally and lat-

erally by the dorsal lateral nasal cartilage. medially by the nasal septum and ventrally by the accessory and ventral lateral nasal cartilages (Fig. 10)' and is lined by stratified squamous epithelium continuous with that of the nasal plane.' Air flow through the vestibule is directed into the ventral nasal mcatus by the alar fold.7 which may also make the flow of air more turbulent, aiding olfaction, humidification. filtering, and temperature regulation. The duct of the lateral nasal gland opens on the lateral nasal vestibule wall at the rostral end of the dorsal nasal ~ o n c h a . ~ The fluid secreted by this gland increases with the dog's heat load' and contains high levels of IgA," indicating involvement in evaporative cooling and local immune function. The opening of the left lateral nasal gland was probably removed in both dogs. although it was not seen. The nasolacrirnal duct opens on the floor of the vestibule ventral to the rostra1 part of the alar fold.' Fifty percent of dogs have a second opening of the nasolacrimal duct ventral to the ventral nasal concha.' Although the rostral opening was removed in both dogs, neither had epiphora from the left eye at follow-up, implying continued drain- age, perhaps through this second opening. The aim of the surgical procedure was to remove the tumor with as wide a margin as possible while attempting to preserve the anatomy and function of the right nostril.

Cancer of the nasal passages and paranasal sinuses is rare in dogs.'-'(' Studies of 5854, 4187. and 2917 canine neoplasms included 45. 3 1. and 30 tumors of the nasal passages and paranasal sinuses, respectiveiy.x-'o In one study of nasal and paranasal sinus neoplasms, 18 of 193 intranasal tumors were squamous cell carcinomas and two were melanomas. Eleven of 46 paranasal sinus tumors were squamous cell carcinomas." Involvement ofthe na- sal vestibule was not mentioned. Metastases were not de-

Alar fold

Dorsal nasalcartilage (cut edsel

Ventral nasal cartilage (cut edge1

** Monaglian ultrasonic nebulizer. Gotti Respiratory Products. Willow Grovc. PA.

Fig. 4. Lateral view with the left side of the nose and median nasal septum removed showing the alar fold of the right nostril.

HOLT, PRYMAK, AND EVANS 421

Fig. 5. Appearance of the nose on day 10 (dog 1).

scribed in the dogs with melanoma. In eight dog5 with squamous cell carcinoma of the nasal plane. the tumors obciously arose from the stratified squamous epithcliuni of the plane." I t is possible that some of these tuition extended into the vestibule. Dog 1 appeared to be unique because the tumor arose from the nasal vestibule epithe- lium.

Fig. 6. Malignant melanoma of the left nasal vestibule

Fig 7 margin of lip (dog 2)

Incision for removal of the left side of the nose including a

In humans, tumors of the nasal vestibule are also rare, with squamous cell carcinoma the most common histo- logic type.'"I5 Successful treatment modalities in humans include surgery. radiation therapy, and radiation therapy with subsequent salvage surgery. " L I " Radiation modalities include interstitial implantation, external beam therapy radioactive molds, or a combination of techniques.''-'"

In dog I , only a small margin of normal tissue was present medial to the tumor. A surgical margin of at least 1 cm is recommended to ensure complete removal o f a neoplasm." Treatment results with orthovoltage radiation alone have been poor." Cisplatin and 5-fluorouracil are known radiation potentiators. ix-20 Treatment of human head and neck squamous cell carcinoma with radiother- apy and cisplatin gave no improvement in survival," and results with orthovoltage and cisplatin potentiation in two dogs were poor.:' However, improved control has been

Fig. 8. Left side of the nose and part of the left upper lip removed to the level of the piriform aperture (dog 2).

422 NASAL VESTIBULE TUMORS

reported in humans with fractionated radiotherapy and simultaneous cisplatin and 5-fluorouracil ~ensitization.'~-'" Aggressive excisional surgery was therefore combined with orthovoltage radiation. using cisplatin and 5-fluorouracil as radiation potentiators.

Moist desquamation after radiation therapy is the result of destruction of the basilar layer of the epidermis with subsequent epidermal sloughing and exudative inflam- mation." It has been reported in dogs after a single x-ray dose of 18.3 Gy and total (fractionated) doses of 42 ( I4 fractions, 14 days) and 50 Gy (10 fractions, 30 days)."-'" The appearance of moist desquamation in this dog after only 3 1.5 Gy (7 fractions) and a report of severe mucositis associated with radiation therapy and high doses of 5-fluorouracil chemopotentiation in humans" prompted discontinuation of the 5-fluorouracil. Cisplatin sensitization or inherent radiation sensitivity of the nasal plane epithelium after surgery cannot be excluded as causes for the moist desquamation.

Treatment of melanoma of the nasal plane has been described.3' Complete removal of the nasal plane was

Fig 9 Appearance of the nose on day 14 (dog 2)

,cartilaginous septum

-Dors. lot. nosal cartiloge

-Vent /at. nosal cart i lage

\Accessory curti luge Fig. 10. The nasal cartilages, rostra1 view. Reprinted with permission from Evans HE, Christensen GC. Miller's Anatomy of the Dog. 2nd ed Philadelphia: WB Saunders, 1979:508.

considered too deforming by the owners of the second dog. The technique described in this paper gave an ac- ceptable cosmetic result (Fig. 9).

Dog 2 had a long anesthetic recovery and became pro- gressively more dyspneic while trying to breathe through the remaining nostril. Removal of a section of the left upper lip and apposition of the right nostril to the re- maining lip resulted in deviation and narrowing of the right nostril. Alar fold resection or the use of an advance- ment flap to decrease tension on the right nostril at the initial surgery might have lessened the upper airway ob- struction. The froth in the pharynx was not present at extubation after the initial surgery and may have resulted from the passage of turbulent air through a nasal passage containing blood and edema fluid. The froth in the trachea and moist rales could be attributed to aspiration of froth from the pharynx, or may have been associated with pulmonary edema secondary to upper airway obstruc- tion.72-3h The dog was breathing normally and the lung sounds were normal after the tracheostomy. so thoracic radiographs were not made. Resolution of the moist rales could have been due to aspiration of the froth in the airway or expansion of collapsed alveoli by positive pressure ven- tilation during the second anesthetic.

Treatment of pulmonary edema secondary to upper airway obstruction in humans involves supplemental ox- ygen, ventilation sometimes combined with positive end expiratory pressure, and possibly furosemide and corti- costeroids."?-'5 In dog 2, respiration was normal after tra- cheostomy and supplemental oxygen. and no abnormal lung sounds were heard, so further ventilatory support was not necessary.

The first dog breathed through its mouth intermittently after a rapid anesthetic recovery. The second dog had a prolonged recovery and did not mouth breathe. The re- luctance to mouth breathe, narrow nasal opening, and fluid in the nasal passages probably contributed to an up- per airway obstruction. We recommend close observation of dogs after this surgery and tracheostomy if reluctance to mouth breathe results in respiratory distress.

HOLT, PRYMAK, AND EVANS 423

References

1 . Evans HE, Christensen GC. Millerk Anaromy qf rhc D ( J ~ . 2nd ed. Philadelphia: WB Saunders, 1979:507-5 10.

2. A d a m DR, Hotchkiss DK. The canine nasal mucosa. Anat Histol Embryo1 1983;12:109.

3. Grandage J , Richardson K. Functional anatomy. In: Slatter DH. ed. Tcxthiok of’Smuf1 Anirnal Surgery Philadelphia: WB Saun- ders. 1985:902.

4. Evans HE. The lateral nasal gland and its duct in the dog. Anat Rec 1977:187:574-575.

5 . Blatt CM. Taylor CR, Habal MB. Thermal panting in dogs: the lateral nasal gland, a source of water for evaporative cooling. Sci- ence 1972:177:804-805.

6. Adams DR, Deyong DW. Griffith R. The lateral nasal gland of the dog: its structure and secretory content. J Anat 1981;132:29.

7. Michel G. Beitrag zur Anatomie der Tranenorgane von Hund und Katze. Dtsch Tierarztl Wochenschr I955;62:347-349.

8. Smith HG. Jones TC. V’crcrinary Parhology Lea and Febiger. Phil- adelphia. 1957:269-274.

9. Cotchin E. Somc tumors of dogs and cats ofcomparative veterinary and human interest. Vet Rec 1959:71:1040-1050.

10. Brodey RS. Canine and feline neoplasia. Adv Vet Sci Comp Med

I I . Madewell BR. Priester WA, Gillette EL, Snyder SP. Neoplasms of the nasal passages and paranasal sinuses in domesticated animals as reported by I3 veterinary colleges. Am J Vet Res 1976:37:85 1 - 856.

12. Thrall DE, Adams WM. Radiotherapy ofsquamous cell carcinomas of the canine nasal plane. Vet Radiol 1982:23:193-195.

13. Des Prez JD. Kiehn CL. Carcinoma of the nasal vestibule. Am J Surg 1967;l 14:587-591.

14. Wang CC. Treatment of carcinoma of the nasal vestibule by irra- diation. Cancer 1976:38: 100-106.

15. Chobe R. McNeese M, Weber R, Fletcher GH. Radiation therapy for carcinoma of the nasal vestibule. Otolaryngol Head Neck Surg 1988;98:67-7 I .

16. Wong CS. Cummings BJ. The place of radiation therapy in the treatment ofsquamous cell carcinoma of the nasal vestibule. Acta Oncol 1988:27:203-208,

17. Levine SH, Caywood DD. Surgical therapy. In: Slatter DH, 7i.t-rhook oJ’Srnull Animd Surgwy. Philadelphia: WB Saunders, 1985:2384.

18. Douple EB. Richmond RC. Platinium complexes as radiosensitizers of hypoxic mammalian cells. Br J Cancer 1978:37(Suppl 3):98- 102.

19. Murthy AK, Rossof AH. Anderson KM, Hendrickson FR. Cyto- toxicity and influence on radiation response curve of cis-diam- minecichloroplatinum (cis-DDP). Int J Radiat Oncol Biol Phys 19795: 141 1 - 1 41 5.

1970; I 4: 3 I 1-354.

20. Vietti T, Eggerding F, Valenote F. Combined effects of x-radiation and 5-fluorouracil on survival of transplanted leukemic cells. J Natl Cancer Inst 197 1;47:865-870.

2 1. Marcia1 VA, Pajak TF, Al-Sarraf M, et al. Concurrent radiotherapy and cis-platinum chemotherapy in inoperable mucosal squamous cell carcinoma of the head and neck: a Radiation Therapy On- cology Group report. Proc 27th annual ASTRO-meeting. Int J Radiat Biol Phys 1985;l I(Supp1 1):89.

22. Evans S. Personal communication. 1989. 23. Taylor SG, Murthy AK, Showel JL. et al. Improved control in ad-

vanced head and neck cancer with simultaneous radiation and cisplatin/SFU chemotherapy. Cancer Treat Rep 1985;69:933- 939.

24. Rooney M, Kish J, Jacobs J, et al. Improved complete response rate and survival in advanced head and neck cancer after three course induction therapy with 120 hour 5-FU infusion and cisplatin. Cancer 1985;55:1 123-1 128.

25. Murthy AK, Taylor SG, Showel J, e t al. Treatment of advanced head and neck cancer with concomitant radiation and chemo- therapy. Int J Radiat Oncol Biol Phys 1987; 13: 1807- I 8 13.

26. Wendt TG, Wustrow TPU. Hartenstein RC, et al. Accelerated split course radiotherapy and simultaneous cis-dichlorodiammine- platinum and 5-Ruorouracil chemotherapy with folinic acid en- hancement for unresectable carcinoma of the head and neck. Radiother Oncol 1987;10:277-284.

27. Johnston GR, Feeney DA. Radiotherapy of the extremities. Tissue tolerances and complications. Vet Radiol 1983:24: 130-137.

28. Park RD, O’Brien TR, Barket BB, et al. Acute radiodermatitis in the beagle dog: gross observations after single dose exposure with x-irradiation. Vet Radiol 1973; 14:49-56.

29. Hartung K. Radiation damage in dogs after x-ray therapy. Vet Radiol 1974;15:98-103.

30. Pommer A. Jakisch H, Traxler H. Einfluss der einfach und Protrahiert Fraktionierten Rontgenbestrahlung auf die Reaktion der Be- haarten Haut des Hundes. Wien Tierarztl Mschr 1955:42:872- 885.

3 I . Withrow SJ, Straw RC. Resection of the nasal planum in nine cats and five dogs. J Am Anim Hosp Assoc 1990:26:219-222.

32. Kanter RK. Watchko JF. Pulmonary edema associated with upper airway obstruction. Am J Dis Child 1984;138:356-358.

33. Weissman C. Damask MC. Yang J. Noncardiogenic pulmonary edema following laryngeal obstruction. Anesthesiology I 984;60:

34. Jenkins JG. Pulmonary edema following laryngospasm. Anesthe- siology 198460:611-612.

35. Karnal RS, Agha S . Acute pulmonary edema: a complication of upper airway obstruction. Anesthesia 1984;39:464-467,

36. Kerr. LY. Pulmonary edema secondary to upper airway obstruction in the dog: a review of nine cases. J Am Anim Hosp Assoc 1 9 8 9 3 : 207-212.

163- 165.