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Avian Sinusitis
WESTERN VETERINARY CONFERENCE 2002
Agnes E. Rupley, DVM, ABVP-AVIAN
All Pets Medical & Laser Surgical Center
College Station, TX, USA
18271247
OBJECTIVES
Provide a diagnostic approach to sinusitis in birds.

KEY POINTS
Respiratory disease is a common cause of illness in pet birds. Many etiologies must be considered and ruled in or out.
Successful treatment requires accurate diagnosis.
OVERVIEW
The section begins with general information and definitions of terms, followed by a list of differential diagnoses. This is followed by
appropriate signalment information. Common causes of the group of clinical signs are presented for each group of pet birds. Pertinent
information as to which species and ages of birds may be affected by the diseases in the differential diagnosis is also given. The history
section is useful to explore important historical information that may narrow the differential diagnosis. The physical examination section
guides interpretation of the physical findings seen with the clinical signs of that section. An algorithm is included to provide a quick
reference for recommended tests. The diagnostic plan suggests useful tests. General treatments are discussed at the end of the section.
This paper concludes with additional readings and references for further information.

ADDITIONAL DETAIL
All birds sneeze occasionally. However, an increase in the frequency or repeated sneezing warrants investigation. Sneezing is caused by
irritation or infection. Sneezing and nasal discharge are signs of nasal or sinus disease or may be caused by lower respiratory or systemic
disease. Sinusitis may be localized or accompanied by lower respiratory tract or systemic disease. Head shaking may be associated with
sinusitis or nasal, sinus, or choanal foreign bodies or tumors.
Differential Diagnoses for Sneezing, Nasal Discharge, Head Shaking, or Sinusitis
Infectious:
Bacterial: *gram-negative (Escherichia coli, Haemophilus, Klebsiella, Pasteurella, Pseudomonas, Salmonella, Yersinia, other),
gram-positive (Mycobacterium, Streptococcus, Staphylococcus, other)
Chlamydial: *Chlamydophila psittaci
Mycoplasma: Mycoplasma

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Fungal: *Aspergillus, Candida, Cryptococcus

Viral: Amazon tracheitis, Pacheco's disease, poxvirus, reovirus, infectious laryngotracheitis, avian influenza
Allergic: tobacco, other
Neoplastic: papilloma, other
Nutritional: vitamin A deficiency
Physical: foreign body, trauma
Metabolic: coagulopathy
Iatrogenic: prolonged antibiotic treatment
Other: conure bleeding syndrome
*Common causes.

Signalment
Common causes of sneezing, nasal discharge, head shaking, or sinusitis in larger psittacines include chlamydiosis, gram-negative bacteria,
and aspergillosis. Cockatiels and budgies are commonly affected by gram-negative bacteria, chlamydiosis, and Mycoplasma. Vitamin A
deficiency is often a primary cause or concurrent problem in all psittacines. Common infections in passerines include gram-negative
bacteria, Mycoplasma, and aspergillosis.

Pacheco's disease affects only psittacines. Conure bleeding syndrome affects only conures. The cutaneous form of poxvirus is rare except
in blue-fronted Amazons, lovebirds, passerines, raptors, and pigeons. Reovirus is commonly reported in imported birds and primarily
affects African gray parrots, cockatoos, and other Old World psittacines. Avian mycobacteriosis is most commonly associated with the
intestinal tract in psittacines but affects the respiratory tract in pigeons, some finches, and some other species. Infectious
laryngotracheitis affects gallinaceous species and canaries. Avian influenza may cause respiratory signs in gallinaceous birds and
waterfowl.

History
A complete history may reveal trauma; allergic, iatrogenic, or nutritional problems; or exposure to infectious diseases. Birds recently
exposed to other birds are commonly ill as a result of infectious diseases, including bacterial, chlamydial, Mycoplasma, and viral infections.
Some diseases have carrier states. Previously infected birds, especially conures, can be carriers of Pacheco's disease, which can cause
illness and death in exposed susceptible birds.

Birds recently acquired from a pet store or aviary may be at a higher risk of having been exposed to contagious pathogens. Many birds
in this category are also stressed by prior group contact and a change of environment, predisposing them to disease. Knowledge of
common diseases in the breeder facility or pet store may provide insight to the possible cause of disease.

Infectious and toxic etiologies are suspected when multiple birds are affected.

Isolated birds and those in closed collections are commonly ill as a result of vitamin A deficiency, trauma, neoplasia, allergic disease, or
chronic infections such as chlamydiosis and aspergillosis. Some bacterial diseases are also common, especially gram-negative infections.

Stress may play a role in precipitating clinical signs. Chronic diseases such as chlamydiosis may go undetected until the bird is stressed.
Stressful situations for birds include going to a new home, the addition of a new bird, changing to a new cage, a change in diet, or

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temperature extremes.

The diet can affect the health of the bird. Diets deficient in vitamin A, such as an all-seed diet, can lead to vitamin A deficiency. Vitamin
A deficiency causes squamous metaplasia of mucous membranes, causing sinusitis, obstructing airways, or increasing susceptibility to
respiratory tract infections.

Consider the bird's environment. Birds allowed out of their cages are more susceptible to trauma. Contact with tobacco smoke or other
allergens can cause an allergic reaction and rhinorrhea.

The duration of the illness is important. Note the owner's description of the clinical signs and the course of the disease. Note previous
illnesses, including signs, treatment, and response to treatment. A history of worsening of signs during treatment with antibiotics is
common with aspergillosis.

Physical Examination
The physical examination may reveal obvious trauma or vitamin A deficiency. Common findings in birds with sneezing, nasal discharge,
head shaking, or sinusitis are discussed below.

Observe the bird in the cage before handling. The normal bird shows little movement while breathing. Open-mouth breathing or
rhythmic movement of the tail is abnormal. Note the posture. Rapid breathing after the examination is normal. A healthy bird should
completely recover from the stress of examination within 5 minutes of release.
Nasal discharges are characterized as serous, mucopurulent, or hemorrhagic. Serous discharges occur with viral and bacterial
infections, allergies, and nutritional deficiencies. Mucopurulent discharges occur with viral, bacterial, and fungal infections;
neoplasia; sinus foreign bodies; and lower respiratory tract infections. Hemorrhagic or serosanguinous discharges occur with sinus
foreign bodies, neoplasia, trauma, reovirus, conure bleeding syndrome, and coagulopathies.
Nasal discharges may be unilateral or bilateral. Diseases that can result in a unilateral discharge include fungal infections, bacterial
infections, and neoplasia. Trauma and sinus foreign bodies also may cause unilateral discharges.
Differential diagnoses for a nonpatent nostril include sinusitis, granuloma, foreign body, or neoplasia.
Swellings around the eye or between the eye and beak may be caused by sinusitis, trauma, or neoplasia. The infraorbital sinus is
lateral to the nasal cavity and lacks outer bony walls. Externally, it occupies the area between the commissure of the beak and the
eye. The sinus has diverticula into the upper beak, mandible, around the eye, and pneumatized bones of the skull.
The choana can become inflamed or contain a discharge caused by viral, yeast, or primary bacterial infections or be secondarily
infected because of vitamin A deficiency, neoplasia, or allergies. Granulomas in the mouth are common with vitamin A deficiency.
A thick, white oral exudate can be caused by yeast or bacterial infections.
Vitamin A deficiency causes squamous metaplasia of mucous membranes. On physical examination, this is evidenced by swollen
margins of the choana in the roof of the mouth. Associated papillae may be blunted or absent, and sterile granulomas of the oral
and lingual mucosa and sinuses may be present.
Viral infections often are seen with signs of involvement of multiple body systems. Cutaneous or diphtheritic poxvirus lesions may be
seen on physical examination. Signs of poxvirus vary with the type of poxvirus and species of bird. There are cutaneous and
diphtheroid forms. The diphtheroid form is characterized by gray or brown fibrinous lesions in the oropharynx and larynx. Clinical
signs include nasal discharge, coughing, and dyspnea. The cutaneous form is characterized by cutaneous proliferative growths or
scabs on featherless areas of skin and around eyes, nares, beak, and feet.

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Signs of Pacheco's disease include acute onset of anorexia, biliverdinuria, polyuria, diarrhea, sinusitis, and sometimes central
nervous system (CNS) signs. Sudden death without premonitory signs is common. The course of the disease is frequently swift,
such as a bird appearing normal in the morning and being found dead by evening.
Reovirus may present with a bloody brown nasal discharge, diarrhea, labored breathing, and ataxia.
Signs of Amazon tracheitis include nasal and ocular discharges, dyspnea, and coughing. The disease may be peracute, acute,
subacute, or chronic.
Signs of infectious laryngotracheitis in canaries include severe dyspnea, inspiratory wheeze, expectoration of bloody mucus, ocular
and nasal discharge, and sinusitis.
Signs of avian influenza in gallinaceous birds and waterfowl include depression, dyspnea, sinusitis, diarrhea, and anorexia. Lethargy,
CNS signs, and diarrhea may occur in psittacines infected by avian influenza.
Signs of conure bleeding syndrome include periodic recurrences of bleeding, epistaxis, dyspnea, polyuria, diarrhea, and occasionally
ataxia.
Gastrointestinal signs in conjunction with sneezing, nasal discharge, head shaking, or sinusitis may occur with bacterial infections,
chlamydiosis, candidiasis, aspergillosis, coagulopathies, Cryptococcus, Mycoplasma, conure bleeding syndrome, Pacheco's disease,
reovirus, and papillomas.
Neurologic signs may accompany sneezing, nasal discharge, head shaking, or sinusitis with chlamydiosis, Pacheco's disease, reovirus,
or Cryptococcus infection.
Algorithm for Sinusitis
See Figure 1. Algorithm for Sinusitis, separate document.

Diagnostic Approach for Sinusitis

Provide supportive care as needed during diagnostic testing. Obtaining a complete history and performing a complete physical

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examination are the first steps in evaluating the bird with sneezing, nasal discharge, head shaking, or sinusitis. Dietary and iatrogenic
causes must be sought from the history. Trauma, papillomas, poxvirus lesions, and typical vitamin A or candidiasis lesions may be
suspected based on physical examination findings. Vitamin A deficiency is diagnosed through diet history and physical examination.
Cytology of aspirates of keratin cysts reveal cornified epithelial cells and debris. Biopsy of keratin cysts may reveal hyperkeratosis or
squamous metaplasia. Allergic disease is suspected based on clinical signs and history, e.g., exposure to tobacco smoke or cockatoo
feather dust. If allergic disease is suspected and cytology of sinus aspirate is not diagnostic, confine the bird to an allergen-free
environment for a trial period. A reduction in clinical signs can take weeks to months.

After signalment and history are considered and the physical abnormalities are noted, cytology of the sinus is usually the most useful
diagnostic test.

Infectious, allergic, and neoplastic diseases may be identified with cytology. Sinus aspirates are superior to nasal exudates for sample
evaluation because nasal exudates may be contaminated by insignificant bacteria in or around the nostril. Sampling of one sinus is usually
adequate in psittacine birds; both sinuses may need to be sampled in some passerines when signs are bilateral.

If an adequate sample cannot be obtained with a sinus aspiration, flush the nostril with sterile saline (0.5–1 ml) and collect a sample
with a sterile swab from the rostral choana. The mouth is held open with a speculum or gauze to collect the sample. This sample is usually
adequate for Gram's staining, cytology, and culturing. Contamination by oral and nasal bacteria and yeast must be considered. Normal
flora of the choana are gram-positive bacteria, including Bacillus spp., Corynebacterium spp., Lactobacillus spp., Staphylococcus
epidermidis, and Streptococcus spp.

Cytologic evaluations of a normal sinus usually demonstrate few cells and no intracellular bacteria. A few extracellular bacteria and an
occasional squamous epithelial cell with associated bacteria may be present in a cytologic sample from a normal infraorbital sinus. An
increase in inflammatory cells indicates sinusitis. The number and type of inflammatory cells present depends on the etiology. Bacterial
phagocytosis in leukocytes indicates primary or secondary bacterial sinusitis. Secondary bacterial sinusitis may occur as a result of vitamin
A deficiency, neoplasia, allergy, fungal infection, or a foreign body. Bacterial cocci in chains suggests Streptococcus sinusitis. Fungal
elements may be identified. Aspergillus is characterized by septate branching hyphae. Hyphae may stain poorly or basophilic with Wright's
or quick stains. New methylene blue stain may be used to better visualize hyphae. Basophilic staining fungal spores or conidiophores may
be seen. Candida is identified by the presence of many oval budding yeasts. Cryptococcus neoformans is an oval to round yeast with a
mucopolysaccharide capsule. Yeast cells stain basophilic with Wright's or quick stains. The Cryptococcus capsule portion of the yeast does
not stain with Wright's or quick stains but forms a clear halo around the yeast.

Intracytoplasmic inclusions in macrophages or epithelial cells may be observed with Chlamydophila or Mycoplasma infection.
Chlamydophila inclusions appear as small blue or purple spherules when stained with Wright's or quick stains. Mycoplasma inclusions are
basophilic coccoid intracytoplasmic inclusions when stained with Wright's or quick stains. Gimenez or Macchiavello's stain aid in cytologic
identification of Chlamydophila inclusions.

Large macrophages or giant cells containing phagocytized foreign material may be seen with nasal, sinus, or choanal foreign bodies.
Because foreign bodies may be secondarily infected, aspirates may contain inflammatory cells and bacteria.

Aspirates may contain inflammatory cells without an etiologic agent being apparent. Culture or other diagnostic tests are used to make
a diagnosis.

Aspirates and swabs can also be evaluated with Gram's stain. Normal flora of sinuses and the choana are gram-positive rods and cocci;

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an occasional gram-negative bacterial rod or Candida organism can be seen in normal birds. Yeast stain deeply basophilic. An increase in
gram-negative bacteria or yeast is abnormal. An increase in gram-negative bacteria can be the result of either primary bacterial infection
or secondary to vitamin A deficiency, nasal or sinus foreign body, or neoplasia. Cultures must be performed to identify the bacteria and
susceptibility. A Gram's stain is useful if bacterial or yeast sinusitis is suspected. Initial antibiotic therapy can be chosen based on Gram's
staining characteristics. The staining procedure is quick, and results are easy to interpret. However, because limited information is
obtainable with a Gram's stain, cytology is often much more informative.

If conjunctivitis is present and chlamydiosis is suspected, a conjunctival smear will sometimes reveal intracytoplasmic inclusion bodies in
macrophage-like cells.

A complete blood count (CBC) and plasma biochemistries rarely provide a diagnosis, but they are useful in supporting the diagnosis of
infectious and systemic diseases and aid in evaluating the general health of the bird. Perform a CBC when systemic disease is suspected,
when a bird is unresponsive to treatment, or to help determine the general health of the bird. Changes in the hemogram commonly seen
in birds with sneezing, nasal discharge, head shaking, or sinusitis are detailed below.

Leukocytosis may be caused by stress, inflammatory diseases, or neoplasia. Many normal young psittacines have a mild heterophilia.
Regenerative left shifts may be seen with chronic or severe bacterial sinusitis, aspergillosis, chlamydiosis, and neoplasia. Differentials to
consider with a white blood cell (WBC) count between 25,000 and 40,000 WBC/ul include Pseudomonas, salmonellosis, chlamydiosis,
aspergillosis, and mycobacteriosis. Chlamydophila, Aspergillus, and Mycobacterium infections often cause a WBC count in excess of 40,000
in larger psittacines. Toxic heterophils and monocytosis may occur with severe bacterial, chlamydial, viral, and Aspergillus infections. Toxic
changes include degranulation, vacuolation, increased cytoplasmic basophilia, and nuclear degeneration. Lymphocytosis can be associated
with infectious agents. Monocytosis is common with chronic fungal and bacterial infections (e.g., chlamydiosis, mycobacteriosis) and tissue
necrosis. Basophilia may be seen with chlamydiosis.

Leukopenia may be associated with overwhelming bacterial or viral infection, chlamydiosis, or aspergillosis.

Nonregenerative anemias may be seen with chronic inflammatory diseases such as chlamydiosis, aspergillosis, mycobacteriosis, and
neoplasia. Regenerative anemias may be seen with coagulopathies, trauma, and neoplasia.

Perform plasma biochemistries when systemic disease is suspected, when a bird is unresponsive to treatment, or to help determine the
general health of the bird. Hyperproteinemia may be seen with dehydration or chronic diseases such as chlamydiosis, aspergillosis, and
mycobacteriosis. A decrease in total proteins may be seen with trauma, stress, coagulopathies, neoplasia, or poor nutrition. Normal young
psittacines often have total protein levels lower than adults. An elevation in aspartate transferase (AST or SGOT) is usually the result of
liver or muscle damage. Heart, brain, and kidney damage may also result in an elevation of AST. Because of liver damage, AST may be
elevated in chlamydiosis and Pacheco's disease. Muscle damage caused by trauma and irritating intramuscular injections also cause an
elevation in AST. Creatinine kinase activity increases with muscle damage and may be used to differentiate an increase in AST caused by
liver disease from an increase caused by muscle damage. Hypoglycemia may be seen with Pacheco's disease, neoplasia, septicemia,
aspergillosis, or anorexia.

Plasma protein electrophoresis (EPH) is useful in identifying many disease states (e.g., chlamydiosis, aspergillosis, mycobacteriosis).

Radiography is useful in diagnosing sinus and choana foreign bodies and granulomas. Lesions associated with systemic diseases may be
noted radiographically. Radiograph birds with suspected systemic disease and birds with infections unresponsive to appropriate antibiotic
therapy, based on culture and sensitivity results. Generalized soft tissue opacity within the infraorbital sinus may be seen with vitamin A

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deficiency or sinusitis. Circumscribed tissue densities within the sinus may be caused by neoplasia, aspergillosis, or granulomas. These
conditions cannot be differentiated radiographically. Sinus aspirates, cytology, or biopsy of the lesion is used to obtain a diagnosis.

Thickening of the caudal thoracic and abdominal air sacs on lateral radiographs and diffuse increased opacity of these air sacs on
ventrodorsal views indicate airsacculitis. Splenomegaly, hepatomegaly, and airsacculitis support a diagnosis of chlamydiosis. Aspergillus
infection may be visualized radiographically as focal densities in the sinus, trachea, air sac (most common), or lung. Lesions may be
present in more than one site. Tumors and some sinus, nasal, and choana foreign bodies may be visualized with radiography.

Cultures and titers are useful to rule in or out specific diseases. Aspergillosis can sometimes be demonstrated with a fungal culture.
Useful samples to culture include sinus aspirates, tracheal washes, and swabs of the choana. Samples should be sent to a laboratory
familiar with avian aspergillosis. False-negative results occur. False-positive results occur if the sample is contaminated with Aspergillus
from the environment. Serologic testing is available for raptors and psittacines.

Diagnosis of chlamydiosis can be difficult. No single test or combination of tests can detect Chlamydophila infection in all infected or
carrier birds and not result in false-positive results in uninfected birds. Antigen tests are useful in-house tests in birds showing clinical
signs of infection, although false-negative results occur. Serology (EBA, LA, CF, or ELISA) is useful in birds large enough to provide a
blood sample adequate for evaluation (cockatiel or larger birds). False-negative results can occur early in the disease before antibody
production and in some species of birds (e.g., cockatiels). Low serology results may be difficult to interpret. The laboratory performing the
serology will aid in interpretation of results. Chlamydial cultures of nasal or ocular discharges or feces may provide a diagnosis if shedding
of the organism is occurring at the time of sampling. Obtain culture samples before beginning antibiotic therapy. False-negative cultures
occur. Plasma protein electrophoresis is useful for chlamydial diagnosis.

Acid-fast staining can be used to identify acid-fast Mycobacterium. Mycobacterium affects the digestive tract in most birds. Feces or liver
biopsy samples may reveal acid-fast organisms. Samples from the trachea are useful if the organism is causing a respiratory infection.

Various tests are available to aid in diagnosis of viral infections. A suspicion of infection is based on signalment, history, and clinical
signs.

Antemortem diagnosis of Pacheco's disease is difficult. Intermittent shedding by carrier birds may be detected by virus isolation.
Histology (hepatic necrosis, eosinophilic intranuclear inclusion bodies), virus neutralization, enzyme-linked immunosorbent assay (ELISA),
and immunofluorescence may be useful postmortem.

Cloacal swabs and samples from affected organs may be used for reovirus isolation and culture. Viral antigen may be detected by
immunofluorescence in affected tissue.

Pharyngeal swabs are useful for culture of Amazon tracheitis virus.

Intranuclear inclusion bodies may be found postmortem in respiratory epithelial cells of canaries with infectious laryngotracheitis. Virus
isolation is required for definitive diagnosis.

Diagnosis of poxvirus is based on clinical signs, cytology and histopathology of cutaneous lesions, or culture. Cytology and
histopathology may reveal pathognomonic Bollinger bodies, eosinophilic intracytoplasmic inclusion bodies. Virus culture is required for
diagnosis in acute cases lacking lesions.

Swabs from the cloaca and upper respiratory tract may be used for direct virus demonstration from live birds infected with avian

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influenza. Liver, lung, spleen, and brain are the best postmortem samples for virus isolation.

Anemia, heterophilia, hypoproteinemia, and large numbers of immature erythrocytes are common laboratory findings with conure
bleeding syndrome. Bone marrow aspirates show erythemic myelosis. Diagnosis is based on history, clinical signs, laboratory findings, and
necropsy.

Trial treatment with tetracyclines, macrolides, or enrofloxacin for Mycoplasma infection may allow a presumed diagnosis; however,
response to treatment is not definitive.

Aviaries or flock situations benefit from complete necropsy examinations. Submit adequate samples for histopathology, microbiology,
and virus isolation, especially when infectious disease is suspected.

Treatment
Once a diagnosis is made, treat the underlying cause. Provide supportive care as needed. Severely ill birds may die as a result of the
treatment if not stabilized with supportive care before beginning curative therapy.

Treatment of bacterial rhinitis and sinusitis includes oral or parenteral antibiotics (based on culture and sensitivity results) and local
treatment (nasal flushes or nebulization therapy). Systemic therapy can be initiated with later-generation beta-lactams (e.g., piperacillin,
cefotaxime), fluroquinolones (e.g., enrofloxacin), or trimethoprim-sulfa combinations (e.g., trimethoprim-sulfadiazine, trimethoprim-
sulfamethoxazole) until sensitivity can be determined. Nasal or sinus flushes or nebulization with saline and antibiotics will increase
efficacy of treatment. Birds with minor, non-life-threatening illness usually respond well to appropriate oral antibiotics and twice daily
nasal flushes containing diluted antibiotics. Hospitalize very ill birds, begin parenteral antibiotics and nebulization therapy, and provide
supportive care as needed. Heat, oxygen, intravenous or intraosseous fluids, and tube feeding should be provided as needed. Nasal
flushes are started when the bird is strong enough to survive the stress of the procedure.

Sinus, nasal, and choanal foreign bodies may dislodge with nasal or sinus flushes. Some foreign bodies require either flushing through a
catheter placed surgically in the infraorbital sinus or surgical removal. Surgery in this area is complicated by the vascularity of the tissue.

Allergic disease responds to removal of the offending substance, which in some instances may require a new home. The owner should
limit smoking to outdoors and wash hands and arms before contact with the bird. Symptomatic therapy using an antihistamine or
bronchodilator is sometimes useful.

Vitamin A deficiency requires parenteral vitamin A initially, then oral supplementation and correction of the diet. Keratin cysts and
sterile abscesses are debrided. Treat any secondary infections.

Management of viral infections includes symptomatic therapy and prevention of secondary bacterial infection and contagion. Isolate ill
birds. Chlorhexidine in the drinking water is used to decrease spread in flock situations. Antibiotics may be used to prevent and treat
secondary bacterial infections.

SUMMARY
Utilization of a systematic approach allows for an accurate diagnosis to be made. Consideration of an extensive list of differential
diagnoses will aid in further investigations. Knowledge of the common causes of sinusitis in different species will often allow a
diagnosis to be made more quickly.
The diagnostic approach presented is meant to aid in thought processes.

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SPEAKER INFORMATION
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Agnes E. Rupley, DVM, ABVP-AVIAN

All Pets Medical & Laser Surgical Center
College Station, TX, USA

Front Page : Library : WVC 2002 : Avian : Avian Sinusitis

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