Epistaxis

By | June 27, 2015

Basic Information

Definition

Bleeding from the nasal cavity

Synonyms

Hemorrhagic nasal discharge, nosebleed

Epidemiology

Species, Age, Sex. Dependent on underlying cause:
  • Young purebred animals: coagulopathies
  • Young to middle-aged animals: infectious diseases, trauma
  • Middle-aged animals: acquired immune-mediated diseases
  • Older animals: neoplasia
Genetics, Breed Predisposition, and Risk Factors
  • Immune-mediated thrombocytopenia: young to middle-aged, small to medium female dogs
  • Rickettsial disease: dogs living or traveling to endemic areas
  • Thrombasthenia: otter hounds
  • Thrombopathia: basset hounds
  • von Willebrand disease: Doberman pinscher, Airedale, German shepherd, Scottish terrier, Chesapeake Bay retriever, and many other breeds; cats: Himalayan
  • Hemophilia A: German shepherd and many other breeds; cats
  • Hemophilia B: Cairn terrier, coon-hounds, Saint Bernard, and other breeds; cats
  • Nasal lesions:
  • – Aspergillosis: German shepherd, dolichocephalic breeds
  • – Neoplasia: dolichocephalic breeds
Contagion & Zoonosis

Fungal infections (transmission potential appears low).

Clinical Presentation

History, Chief Complaint: (Some or all may be present.)
  • Nasal hemorrhage
  • Sneezing
  • Pawing at mouth and/or nose
  • With coagulopathy: hematochezia, melena, hematuria, or hemorrhage
  • Blindness, central nervous system (CNS) deficits possible with systemic hypertension
Physical Exam Findings
  • Melena: from swallowing blood
  • Nasal hemorrhage
  • With coagulopathy: petechia, ecchymosis, hematomas, hematochezia, melena, and hematuria
  • With coagulopathy or hypertension: retinal hemorrhages or detachment, CNS deficits

Etiology and Pathophysiology

Bleeding disorder:

Thrombocytopenia:

– Immune-mediated disease: idiopathic disease, systemic lupus erythematosus (SLE), drug reaction

– Rickettsial disease: ehrlichiosis, Rocky Mountain spotted fever

– Bone marrow disease: neoplasia, aplastic anemia, infectious (fungal, rickettsial, or viral)

– Disseminated intravascular coagulopathy (DIC)

Thrombopathia:

– Congenital: von Willebrand disease, thrombasthenia, thrombopathia

– Acquired: nonsteroidal antiinflammatory drugs (NSAIDs), hyperglobulinemia (ehrlichiosis, multiple myeloma), uremia, DIC

Coagulation factor defect:

– Congenital: hemophilia A (factor VIIIc deficiency) and hemophilia B (factor IX deficiency)

– Acquired: anticoagulant rodenticide (warfarin) intoxication, liver disease, DIC

Nasal disease:

Foreign body

Trauma

Infection: fungal (Aspergillus, Cryptococcus, Rhinosporidium), viral, or bacterial

Inflammation: lymphoplasmacytic rhinitis

Neoplasia

Vascular malformations

Systemic disease:

Hypertension: renal disease; hyperthyroidism; hyperadrenocorticism; idiopathic Hyperviscosity: multiple myeloma, ehrlichiosis, polycythemia Vasculitis: immune-mediated and rickettsial diseases

Diagnosis

Diagnostic Overview

The diagnosis is apparent on physical examination. Diagnostic testing first must evaluate the possibility of a systemic disorder (bleeding disorder, systemic hypertension). If none, evaluation of the nasal cavities consists of diagnostic imaging and biopsies.

Differential Diagnosis

See Etiology and Pathophysiology.

Initial Database

CBC:

– Anemia if sufficient hemorrhage has occurred

– Thrombocytopenia or thrombocytosis

– Neutrophilia: infection; neoplasia

– Pancytopenia: bone marrow disease

Urinalysis:

– Usually normal

– Hematuria (coagulopathy), isosthenuria with renal failure, proteinuria

Serum biochemistry profile:

– Hypoproteinemia if sufficient hemorrhage has occurred

– Elevated urea with normal creatinine: gastrointestinal blood

– Hyperglobulinemia: ehrlichiosis, multiple myeloma

– Azotemia (with isosthenuria): renal failure-induced systemic hypertension

– Elevated liver enzymes and total bilirubin: severe hepatic disease causing coagulopathy

Advanced or Confirmatory Testing

Other laboratory tests:

– Coagulation profile: prolonged times with coagulation factor defects; normal with thrombocytopenia and thrombopathia

– Antinuclear antibody test for SLE

– Platelet function testing (bleeding time, von Willebrand factor analysis)

Ehhichia and Rocky Mountain spotted fever titers/PCR

– Thyroid hormone assay in middle aged to old cats

Diagnostic imaging:

– Thoracic radiograph: metastatic neoplasia

– Nasal series: open mouth and frontal sinus views

– CT scan: more sensitive than radiographs for many nasal diseases

Other diagnostic procedures:

– Rhinoscopy, nasal flush, nasal biopsy indicated for suspected space-occupying disease, removing foreign bodies, and sampling nasal tissue

– Cytologic and histopathologic examination

– Bacterial and fungal culture and sensitivity testing

– Bone marrow aspiration and cytology (± core biopsy) with pancytopenia

– Blood pressure evaluation

Epistaxis: Treatment

Treatment Overview

Stop epistaxis

Treat primary cause

Acute General Treatment

Minimize activity or stimuli that precipitate hemorrhage episodes:

– Environment

– Consider tranquilization (e.g., opiates)

Whole blood or packed red blood cell (RBC) transfusion; may be needed with severe anemia.

In life-threatening cases of refractory, exuberant arterial epistaxis, both carotid arteries may be ligated without adversely affecting perfusion of the head (vertebral artery collaterals).

Specific Treatment

Coagulopathy:

von Willebrand disease: plasma or cryoprecipitate for acute bleeding

Hemophilia: plasma or cryoprecipitate for acute bleeding; no long-term treatment

Anticoagulant rodenticide intoxication: plasma for acute bleeding and vitamin K supplementation

Liver disease and DIC; treat underlying cause; plasma may be beneficial.

Discontinue all NSAIDs.

Hyperglobulinemia: plasmapheresis

Nasal disease:

Radiotherapy: nasal tumors

Topical clotrimazole therapy for fungal disease

Surgery: if foreign body irremovable by rhinoscopy; fungal rhinitis (Aspergillus and Rhinosporidium), neoplasia

Systemic disease:

Hyperviscosity: treat underlying disease (e.g., ehrlichiosis and multiple myeloma); plasmapheresis

Vasculitis: doxycycline for rickettsial disease; prednisone for immune-mediated disease

Hypertension: treat underlying disease (e.g., renal disease, hyperthyroidism, and hyperadrenocorticism); reduce weight if obesity is present; restrict sodium; antihypertensive medication.

Possible Complications

Anemia and collapsed state

Recommended Monitoring

Platelet count with thrombocytopenia

Coagulation profile with coagulation factor defects

Blood pressure with hypertension

Monitor clinical signs

Prognosis and Outcome

Dependent on cause

Pearls & Considerations

Comments

Remember that epistaxis may indicate a systemic coagulopathy; use care when deciding which vein to use for blood sampling (prefer limb to jugular for compression), whether to perform centeses, and so forth.

Epistaxis is not a diagnosis but a clinical sign.

A systemic bleeding disorder may present as unilateral epistaxis.

Rule out systemic diseases and coagulopathy before focusing on nasal disease.

Client Education

Monitor for recurrence of presenting signs.

Recommended Reading

Madden SN: Diseases of the nasal cavity and paranasal sinuses. In Morgan RV, Bright RN, Swartout MS, editors: Handbook of small animal practice, ed 4, Philadelphia, 2003, WB Saunders, pp 136-143.

 

Selections from the book: “Clinical Veterinary Advisor: Dogs and Cats”, Second Edition, Editor-in-Chief Etienne Côté, 2010