Nasopharyngeal Polyps - Feline Inflammatory Polyps - Ear Polyps

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Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Key Points

Feline inflammatory polyps are not cancerous, but cause major problems for the pet

A simple surgery called polyp traction is a good first line treatment for this condition

Bulla osteotomy may be recommended in some cases

Overall the prognosis is very good following treatment of this condition

Anatomy

The middle ear is a hollow cavity (tympanic bulla) that has two chambers. The dorsal or upper chamber is about one third of the volume of the middle ear and it is bounded by the ear drum on one side, contains the small ear bones called ossicles (stirrup, hammer and anvil), and has a duct or tube called the auditory tube (that drains the middle ear cavity). The ventral chamber consists of the lower portion of the middle ear and it is the larger chamber and is filled with air.

Illustration right: VM = ventromedial compartment of bulla; DL = dorsolateral compartment of bulla; P = promonotory

 

 

 

 

 

Feline inflammatory polyps

Feline inflammatory polyps are pedunculated benign fibrous masses that are infiltrated with inflammatory cells. These masses are also known as nasopharyngeal, otopharyngeal, or middle ear polyps and are most commonly found in cats less than 2 years of age. They originate within the auditory tube or from the rostral aspect of the dorsolateral compartment of the tympanic bulla. These polyps may extend either into the pharynx via the auditory tube, the external ear canal via rupture of the tympanic membrane, or both.

 

 

 

 

 

 

 

Clinical Signs

Clinical signs may include noisy breathing, difficulty breathing, change of the voice, sneezing, coughing, nasal discharge, difficulty swallowing, shaking the head, vestibular signs (head tilt, continuous back and forth shifting of the eyes), Horner’s syndrome (constricted pupil, drooping upper eyelid, and prolapse of the third eyelid), and creamy or bloody discharge from the external ear canal. A mass in the ear canal and/or throat upon examination (requires anesthesia to do a complete exam).

 

Testing

Patients presenting with an inflammatory polyp should have blood tests performed which includes a complete blood count, chemistry profile, urinalysis, feline leukemia virus test, feline immunodeficiency virus test, chest x-rays, skull x-rays and a complete examination of the ears and throat under general anesthesia. Advanced imaging, such as CT scan may also be helpful in determining if the middle ear is involved with the polyp. The x-ray below left shows a very thickened tympanic bulla. The x-ray below right shows a large polyp (open arrows) in the throat of this cat.

 

Preparation for surgery

The pet should be fasted prior to surgery, as instructed by the surgical team. Water is usually permitted up to the time of admission to the hospital. The surgical team should be informed of any medications that your pet is currently receiving. Just prior to surgery, your pet will receive a sedative, have an intravenous catheter placed for the administration of intravenous fluids and intravenous medications, be induced under general anesthesia with medication(s), and have a breathing tube (endotracheal tube) placed to allow delivery of oxygen and gaseous anesthesia. If a ventral bulla osteotomy is to be performed, the surgical site will be clipped and cleansed with an anti-septic solution in preparation for surgery. While under general anesthesia, the pet's breathing will be assisted with a ventilator and vital parameters such as heart rate, respiratory rate, core body temperature, blood pressure, oxygenation of the blood (pulse oximetry), exhaled carbon dioxide (capnography), and heart rhythm (EKG) will be monitored to ensure the pet's well being. Pain will be controlled both during and after surgery with analgesics (pain-controlling medication). Please note that each surgical and anesthesia team may elect to chose a different, but effective analgesia protocol.

 

Polyp traction

As a first line treatment, polyp traction may be recommended. This involves grasping the mass with forceps and gently pulling it out of the throat or the ear canal. This procedure requires general anesthesia. About 40% of patients that have this procedure done will have Horner's syndrome as a complication of the procedure; however, this complication is typically transient. If the polyp is extracted from the throat, the success rate is very high (89 to 100%), but medical therapy must be added to achieve this success rate. The video right demonstrates traction of a polyp from the throat in a cat. An instrument (spay hook) is used to retract the soft palate, the polyp is exposed and grasped with forceps, traction is applied, and the polyp is removed.

 

Traction of polyps from the ear canal is about 50% successful when medical therapy is added. The video right demonstrates traction of a polyp from the ear in a cat.

 

 

Medical therapy

Medical therapy alone likely will not resolve the problem, but should be used as adjunctive treatment following traction of a polyp. This involves administration of analgesics for 2 to 4 days, administration of an antibiotic such as marbofloxacin or clavamox for 1 month, administration of or corticosteroid (dexamethasone or prednisolone) for 1 month, and administration of a cocktail ear medication (50:50 mix of Baytril/Synotic) into the affected ear canal twice daily for 1 month. This treatment is well tolerated by most cats.

 

Indications for Ventral bulla osteotomy

In some cases, the middle ear will be surgically entered in order to remove the "root" of the polyp. Ventral bulla osteotomy has a 98% success rate. Indications for surgery are subjective and include the following:

  • Pet owner wishes to have only one procedure performed on their feline companion and have the best possible success rate
  • Marked radiographic changes of bulla – some cats will still respond to traction and medical therapy
  • Polyp extending into the external ear canal – some will still respond to traction and medical therapy
  • Polyp is located behind an intact tympanic membrane
  • Polyp that has been incompletely removed and remaining portion cannot be removed with forceps via manual traction
  • Polyp that has recurred following manual traction removal  

 

Ventral bulla osteotomy

An incision is made on the under side of the head, just behind the lower jaw bone (M) to expose the bulla (B). A thin layer of muscle, is incised over the bulla. Care is taken to avoid transection of large lingual and facial veins (LV and FV) located over along the sides of the bulla. The hypoglossal nerve frequently is seen and can be gently retracted medially.

 

 

 

 

 

 

 

A Steinman pin is used to make an initial hole in the bulla. The pin should be directed laterally so that the oval promonotory or other vital structures are not penetrated by the pin. A Lampert rongeur is used to continue the bulla osteotomy via the initial hole made with the Steinman pin (illustration right). A sufficient amount of the bulla wall is removed to give good exposure to the ventromedial compartment of the bulla and the septum of the dorsolateral compartment of the bulla.

 

 

 

 

 

 

 

 

Care must be taken to not disturb sympathetic nerve fibers (yellow fibers) that pass through the occiptotemporal fissure located on the dorsal caudomedial aspect of the bulla (see illustration right). In cats, these fibers are spread out along the promonatory, run dorsal to the bony septum, and then exit the bulla rostrally via another foramen. The septum is penetrated with a Steinman pin in order to enter the dorsolateral compartment.

 

A Lampert Rongeur is used to remove the septum. The most dorsal aspect of the septum may be left intact, thus protecting the sympathetic nerves as they pass in this region. Fluid from the bulla and a portion of the polyp should be submitted for culture.

 

The remaining root of the polyp located in the dorsolateral compartment is removed using a small dental or ear curette. The “root” may be located at the entrance to the auditory tube. Care must be exercised to prevent damage to the sympathetic nerve fibers. The bulla is lavaged with saline, and the muscle layer, subcutaneous layer, and skin are closed routinely. Surgical drains do not need to be placed.  

 

Potential complications

Horner’s syndrome (photo right) is caused by injury to the sympathetic nerves that run through the bulla. It is seen in about 80% of the cats undergoing a bulla osteotomy procedure and about 40% of cats receiving polyp traction. This complication usually resolves within weeks to months after surgery. Polyp recurrence can be reduced with adjunctive medical therapy Vestibular signs (head tilt, continuous shifting of the eyeballs, walking in circles, rolling) are unusual and are typically due to aggressive debridement of the bulla with damage to the semicircular canals of the inner ear. This complication frequently will resolve with time unless severe irreversible damage to the inner ear has occurred. Vestibular syndrome, when present prior to surgery, likely will not resolve after surgery. Facial and hypoglossal nerve paralysis are rare. Infection is rare with appropriate antibiotic therapy  

 

References

  1. Anderson DM, Robinson RK, White RAS. Management of inflammatory polyps in 37 cats. Vet Record, 147:684-87, 2000.
  2. Donnelly KE, Tillson DM. Feline Inflammatory Polyps and ventral bula osteotomy. Comp Cont Ed Vet; 2004, 446 -54l
  3. Faulkner JE, Budsberg SC: Results of ventral bulla osteotomy for treatment of middle ear polyps in cats. JAVMA 26:496–499, 1990.
  4. Pope ER, Constantinescu GM: Feline respiratory tract polyps, in Bonagura J (ed): Kirk’s Current Veterinary Therapy XIII. Philadelphia, WB Saunders, 2000, pp 794–796.
  5. Kapatkin AS, Matthiesen DT: Results of surgery and long-term follow-up in 31 cats with nasopharyngeal polyps. JAAHA 26:387–392, 1990.
  6. Muilenburg RK, Fry TR: Feline nasopharyngeal polyps. Vet Clin North Am Small Anim Pract 32(4):839–849, 2002.
  7. Trevor PB, Martin RA: Tympanic bulla osteotomy for treatment of middle ear disease in cats: 19 cases (1984–1991). JAVMA 202(1):123–128, 1993.
  8. Boothe HW: Ventral bulla osteotomy: Dog and cat, in Bojrab MJ (ed): Cur- rent Techniques in Small Animal Surgery, ed 4. Baltimore, Lippincott, Williams & Wilkins, 1998, pp 109–111.
  9. Parker NR, Binnington AG: Nasopharyngeal polyps in cats: Three case reports and a review of the literature. JAAHA 21:473–478, 1985.
  10. Little JL: Nasopharyngeal polyps, in August JR (ed): Consultations in Feline Internal Medicine, ed 3. Philadelphia, WB Saunders, 1997, pp 310–315.
  11. Bradley RL, Noone KE: Nasopharyngeal and middle ear polypoid masses in five cats. Vet Surg 14(2):141–144, 1985.
  12. White RA: Middle ear, in Slatter DH (ed): Textbook of Small Animal Surgery, ed 3. Philadelphia, WB Saunders, 2003, pp 1760–1767.
  13. Little CJ, Lane JG: The surgical anatomy of the feline bulla tympanic. J Small Anim Pract 27:371–378, 1986.
  14. Smeak D: Ventral bulla osteotomy in cats. Proc 12th Annu Vet Symp ACVS:122–124, 2002.
  15. Hudson LC, Hamilton WP: Atlas of Feline Anatomy for Veterinarians. Philadelphia, WB Saunders, 229–234, 1993.
  16. Smith MM, Waldron DR: Atlas of Approaches for General Surgery of the Dog and Cat. Philadelphia, WB Saunders, 1993, pp 115–117.  

Frequently Asked Questions After Surgery - General Information

When should my cat have the first bowel movement after surgery?

  • Many cats will not have a bowel movement for the first 4 to 5 days after surgery
  • Reasons that a cat will not have regular bowel movements after surgery include:
    • The cat has been fasted prior to surgery
    • Cats do not eat well during the hospital stay
    • They frequently do not eat well when the go home
    • They are fed highly digestible food that produces little stool
    • Pain medication that contain narcotics (such as fentanyl patches, tramadol, morphine) can be constipating
  • If a pet does not have a bowel movement on the 5th day of being home a stool softener such as metamucil can be fed
    • Dose of metamucil 1/4 tsp per mixed in with each meal (canned cat food)

My cat had surgery and will not eat.  What can be done?

  • Offer smelly foods that contain fish such as tuna or smelly cat foods
  • Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
  • Hand feeding;  place a small amount of food in the mouth so that they get the flavor
  • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature with your finger; it should  be only luke-warm.
  • Some cats will only eat dry food, try kibble if your cat normally has been fed that food
  • Petting and stroking your cat frequently will help to stimulate appetite
  • Remember that most pets will not eat the first day or two after they get home from surgery
  • Appetite stimulants such as cyproheptadine may be helpful
  • If your cat refuses to eat anything for 7 days a stomach tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My cat is vomiting now that he/she is at home.  What can be done?

  • The first thing for you to discern is whether your pet is vomiting or regurgitating.  Both will result in fluid or food being brought up.  Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus.  Regurgitation is not associated with heaving and the cat usually just opens the mouth and fluid or food will be expelled.  Usually the regurgitant will be clear or brown colored fluid. 
  • Next is to identify the cause of the vomiting or regurgitation.
  • Causes and treatment of vomiting after surgery
    • When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be happening the water should be limited to frequent smaller amounts.
    • Medications such as antibiotics are a common cause of vomiting after surgery.  In order to see which medication is causing the problem the administration of each drug should be separated 2 hours apart.  Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to.  The antibiotic in some cases may be changed to a different one, or may be discontinued. 
    • Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days. 
    • Unusual cause of vomiting after surgery is internal organ failure.  Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
    • If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present.  Do not ignore this sign.
    • Symptomatic treatment of vomiting involves with holding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then.  In order to decrease the acidity of the stomach Pepcid AC 0.5 mg/kg given by mouth twice daily for 5 days can sooth an upset stomach.  Metoclopramide is a good anti-vomiting medication for cats.  You should always consult a veterinary healthcare professional before administering medication.
  • Causes and treatment of regurgitation after surgery
    • The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia.  Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, which is called esophagitis.  This results in poor motility of the esophagus so water and food will accumulate in this structure.  In most cases esphagitis is self-eliminating and will resolve within two or three days. 
    • Regurgitation also can be caused by a neuromuscular degeneration of the esophagus and this problem will persist.  It is not associated with surgery, rather other underlying diseases.
    • If the esophagitis is severe the esophagus may develop one or more strictures.  A stricture is a narrowing or stenosis of the esophagus, does not allow passage of food down the esophagus, thus the pet has persistent regurgitation.  This problem should be brought to the attention of your doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure as it is done with the aide of an endoscope).  If an esophageal stricture is chronic surgery is needed.
    • Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent such as sucralfate.  You should consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my cat is in pain following surgery?

  • Pain is more difficult to assess in cats versus dogs as signs can be more subtle and they usually do not vocalize
  • Signs of pain in a cat include the following:
    • biting if you get near the surgical site
    • growling or deep cry
    • not wanting to eat
    • hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?

  • Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
  • Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
  • Anti-inflammatories can be used, but the dose is much less than dogs and they should be given only for a few days

Is it okay for my cat to lick or scratch the incision?

  • If a cat licks the incision it will actually delay the healing process because they usually lick too much and traumatize the area.
  • Cats have a barbed tongue, therefore a lot of damage can be done in a short period of time
  • Licking can remove stitches and cause the incision to open
  • Licking can become a severe habit that is difficult to break
  • Licking can cause infection as the mouth has many bacteria
  • Cats will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
  • To stop your pet from licking/scrtaching the following can be tried:
    • Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
    • Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
    • If the incision is over the chest an infant tee shirt can be put on your pet and the waist of the shirt fastened in place with an ace bandage or duct tape.
    • If the incision is over the paw or lower limb a bandage or sock could be put on and kept up with tape.
    • Bitter apple can be applied around the incision; many dogs will continue to lick  after application of this topical
    • Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
    • Antipsychotic medication in some cases is needed

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  • Experience in the development of new surgical treatments

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  • Assurance that a veterinarian is a surgical specialist

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