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DrRalston
DrRalston, Dog Veterinarian
Category: Dog
Satisfied Customers: 2205
Experience:  Over twelve years of internal medicine, surgery, and preventive care.
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Our cocker spaniel has a tiny pin like hole on the top of her

Customer Question

Our cocker spaniel has a tiny pin like hole on the top of her nose which she has had since birth. However it goes through stages where it fills with white puss which is quite smelly. We have taken her to the vets and they gave her anti-biotic as she had weepy eyes as well. Another symptom she has is what I have read described as a reverse sneeze but she will do this many times in one go - it's as though she is choking. I have read this could be sinusitis or something similar? Could you advise?
Submitted: 2 years ago.
Category: Dog
Expert:  DrRalston replied 2 years ago.

Hello, welcome to JustAnswer! I am Dr Ralston. Thanks for your question.

This sounds like it could be an oronasal fistula. This would be a tunnel or opening between the oral passage (inside the mouth), through the sinus, and out through the skin above it.

It would be unusual to have this happen from birth. However, it could be that a cleft palate or partial cleft palate (hole in the roof of the mouth) is present and that it has caused a communication between the outside, the sinus, and the hole in the palate.

Sometimes an oronasal fistula can form after a tooth becomes infected. The root can fill with pus and die, and the tissue around the tooth dies. The sinus then becomes abscessed and the tissue will go through the skin to get out.

All of these can be seen typically under sedation while looking at the pet. In extreme cases an x-ray might be useful or in really severe cases an MRI might be suggested to find the cause.

In all cases, infections will happen from time to time as bacteria either gets into the hole from the outside, or food and bacteria passes from the mouth into the sinus from the other side.

Surgical correction is available and often necessary to stop this chronic problem.

White pus is not usually as bad as green. It can just mean inflammation versus active infection. But the way this sounds, the smell would tell me it is infected. Antibiotics probably did work. But, it may get to a point where they won't anymore. So, surgical correction should be considered before it gets to that point.

Now, reverse sneeze sounds kind of like a person sniffing or snorting in when they have a lot of discharge in the sinus. Then, it is followed by a breathing out. So, it is sort of a see-saw noise, back and forth, like sawing a log.

It is caused by sinus or pharyngeal irritation in the back of the throat. We think that allergies are often to blame. Some dogs respond to antihistamines like benadryl. But not all.

HOWEVER, in this case it is very likely that there is a sinusitis related to what I believe could be an oronasal fistula that is causing all the signs you are seeing.

So, correct, an MRI scan would be the most informative. Lacking that, sedation and exploratory surgery might be recommended to find the hole, and close it up. That can be a complicated surgery. Some Veterinarians are comfortable with these types of surgeries. I myself have done many of these. But, others will want to consult with a Veterinary Surgeon or Dentist.

But, if present for birth, I would definitely want to get back and look into that soft palate roof of the mouth VERY far back to see if this is a cleft palate that was never diagnosed. Surgery is very likely to be successful if that is the case.

I hope that has been useful. If you have further questions, please reply and feel free to ask, and I will answer them for you.

Just Answer Expert - Dr Ralston

DrRalston, Dog Veterinarian
Category: Dog
Satisfied Customers: 2205
Experience: Over twelve years of internal medicine, surgery, and preventive care.
DrRalston and 2 other Dog Specialists are ready to help you
Customer: replied 2 years ago.
Thank you very much for your response. We were told it could be this when she went on antibiotics. I had a look in her mouth earlier - I couldn't see any holes but what was noticeable is that more puss gathered in the hole when I was looking in her mouth. A sedated examination does seem like the next step. I can't understand how this has happened as she has always had 6 monthly vet checks and her teeth have always been in excellent condition. None of her teeth look rotten. If it is a soft palette problem would it only be visible under sedation?
Expert:  DrRalston replied 2 years ago.
Very good questions Lianne.

It might be difficult to find the hole the communicates inside the mouth to the hole on top of the nose. That is why sometimes MRI is needed. I have also seen studies where a dye is injected through the hole which is radiopaque - meaning it will show up on an x-ray. So, in this way, the hole can sometimes be visualized and this helps in finding where surgery might correct the hole before MRI which would be much more costly.

What's interesting is that while you were examining the mouth you may have been putting pressure on the sinus, or the dog might have been, and the pus was being extruded because of that.

But, yes, sedated exam is probably the next step, and at the same time maybe trying the radiopaque dye technique to see if it would help identify the hole.

ONE thing I should point out about teeth. Just because they look ok on the surface, does not mean that the tooth itself is ok. Sometimes an abscess, or a tooth root has grown through the sinus for example. That can only be seen by radiograph. Many Vets are guilty of this line of thinking. If the tooth isn't loose, or looks attached to the gum and normal, that it must be normal. Unfortunately, that is not always the case. A tooth can be firmly attached to the jaw below it in it's socket, and yet the root has been broken by trauma and is still in the jaw line abscessing... etc. So, that's something to consider as well.

Your question about the soft palate is a good one. A cleft or hole in the palate can be in the hard (bony portion, and floor of the sinus) or the soft palate (the back of the throat and soft tissue portion) or both. Most are visible from oral exam without sedation, and the pups often have signs of that early in life. They might dribble milk from the nostrils while nursing for example. But, with oronasal fistula, it can be more difficult to find where the hole is, especially if it starts around or between one of the teeth.

So, in short, I think we need to find out where that hole starts, and where it goes. Barium sulfate is often used in these tests as a contrast medium for the radiopaque studies. Sometimes under sedation a thin sterile rod might be passed through the hole from the outside in to see if the hole communicates with a hole in the mouth. That is often VERY effective at finding the hole as well, but again, it's done under sedation because a pet will just not tolerate that awake. So, that would be something done under sedation almost automatically : visual exam, probing the fistula, contrast medium. MRI would likely be done at a secondary anesthesia, but in some cases you might be able to have it done all in one location.

Almost definitely the surgery would take place with a secondary anesthesia to imaging. Rarely will they go straight to surgery because the MRI needs time to be analyzed and interpreted to find the best course of action.
Customer: replied 2 years ago.
Thank you very much for your help - she has now seen a vet and they are going to investigate. I have rated your help although I keep receiving emails to do it again but when I try and do it I get a message saying response already rated.
Thanks again.
Expert:  DrRalston replied 2 years ago.
Lianne,

Thank you for your rating. Your question keeps popping up in my unresponded question feed as well. I see your rating though (THANK YOU!) and customer service is all over it. Probably just a glitch in the system.

Please keep me updated though if you remember. You can use this feed to send messages. I'd like to know how it turns out.

Thanks,
DrR

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