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Bleeding from the Nose: Epistaxis in Horses

Description
Introduction

Nosebleeds are a very common event with horses. The medical term for nosebleeds is epistaxis. Though frequently just a one time event they can also be the indication of serious disease. Some of the causes are ethmoid hematoma, guttaral pouch mycosis, and exercise induced pulmonary hemorrhage. This article concerns itself with the differentiation of the various causes of nosebleeds and the treatment and prognosis of the various conditions. Links are provided to more detailed articles on the diseases.




When is a Nose Bleed Serious?

That can be a difficult question to answer with certainty. The incidence of minor nose bleeds for no apparent cause is common in horses. We assume most of these one time events represent unobserved trauma. Usually these events do not have a lot of bleeding: just the short duration of dripping blood that may reoccur for short periods several times over the next couple of days. Then it never returns. However each of the serious problems will start in this same way and in the case of guttural pouch mycosis may lead to a rapidly terminal event. So how do you evaluate a nose bleed the first time you see it?
First is to assess how much blood is being loss and how quickly. A full size horse can lose up to 1.5 gallons of blood. This translates to a drop a second (drip thousand, drip thsousand, drip thousand, etc...) for at least 12 hours as maybe as long as 24 hours before life threatening consequences occur. If the blood is pouring out of the nose first aid may be helpful and of course, you should seek professional help. For first aid: unless coughing or difficult breathing is occuring, elevate the head to above its normal position. If the bleeding is coming from the upper respiratory tract this will significantly lower the pressure at the bleeding location to help slow and clot. It will also make it more difficult for the horse to clear the blood out of the way of his trachea, so be careful that this does not impair breathing or cause coughing.

Just because the bleeding is not rapid or intermittent does not mean that it is not serious. Early on, disease that may require extensive treatment might present with minor bleeding. However the bleeding will generally return and worsen over time. Recurrent bleeding from the nose that worsens over time deserves a closer investigation.

So we are back to the original question: when should a nose bleed be taken seriously and have a examination and work up? Well blood pouring from the nose needs immediate help and some first aid. For milder bleeding I guess it depends on your tolerance for risk. Those with a very low tolerance for risk probably will call the vet out the first time a little pink appears at the nose. Most will probably wait out a single incident of dripping that stops in less than 30 minutes. Though that first incident of dripping is very likely to be a minor event, you cannot be sure without an exam.




Diagnosis

To some degree the diseases causing nosebleeds can be divided by the amount of hemorrhage present but you should realize there is a lot of overlap, and this alone should not be used as a firm diagnosis. All of the diseases below are diagnosed with endoscopy but may require rdadiographs and/or biopsy to further define the problems. Race horses that have some mild bleeding from the nose following hard work outs or races are probably suffering from EIPH, for detailed information see: EIPH.


Diseases associated with Mild Hemorrhage:
  • Ethmoid Hematoma: Easily diagnosed with endoscope. In the past surgical treatment through a frontal sinus flap was the recommended treatment and has a good prognosis though there is occasional recurrence. Laser therapy is a bit easier on the horse and the early numbers suggest about the same prognosis as surgery. There is mounting evidence that intralesional injection of formalin using an endoscope for guidance is an effective therapy though may require 5 or more treatments.
  • Infections of the Sinuses and Nasal Passages: Though rare phycomycosis, cryptococcosis, coccidioidomycosis, aspergilliosis, have all been responsible for bleeding lesions of the upper respiratory tract. Biopsy of the lesion is needed for diagnosis. Surgical removal in combination with topical and systemic antifungals yield only a guarded prognosis. Some of these infections are of public health significance.
  • Neoplasia
  • Foreign Bodies


    Diseases Associated with Moderate Hemorrhage:
  • Wounds and Fractures
  • Naso gastric intubation

    Diseases Associated with Severe Hemorrhage:
  • Guttural Pouch Mycosis: This is the most common cause of severe hemorrhage from the nose of horses. The mortality rate is high for this disease as the hemorrhage is very difficult to control. Because there are other possible causes of blood coming from the guttural pouch confirmation requires obseving the mycotic lesion on the medial and posterior walls of the pouch.
    Medical treatment of the fungus is inconsistent and surgery is always recommended. There have been a few reports of success using a combinaiton of systemic itraconaazole and topical enilconazole. Surgical treatment is recommeded for all horses. Ballon catheter techniques have also been successful for preventing fatal hemorrhage. A ballon catheter is inserted into the vessels leading to the ehmmorage and inflated. There have been few complications associated with this procedure and greatly aids in the resolution of the fungus.
  • Rupture of the Longus Capitis Muscle: Rupture as the site of insertion can cause severe hemorrhage from the nose. Usually there is a history of thehorse going over backward. Endoscopically blood will be issuing from the guttural pouch. Once in the pouch the back wall will appear OK but by completly retro flexing the scope but a wound, hematoma, and bleeding can be seen coming from the rostral aspects of the pouch. Treatment is conservative with broad spectrum antibiotics for a week. In horses without signs of neurological disease. The prognosis is fair to good.
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