Epistaxis Flashcards
Epistaxis can be unilateral or bilateral, this is determined by:
- . Actual location of lesion – rostral or not to nasal septum
- Volume
NG intubation or ethmoid hematoma are often bilateral or unilateral
Bilateral bleeding with NG intubation or ethmoid hematoma
Guttural pouch mycosis is often unilateral or bilateral epistaxis:
Unilateral bleeding with GPM
3 main differentials for epistaxis:
Main differentials for epistaxis:
- Ethmoid hematoma
- Guttural Pouch Mycosis
- EIPH
What are the features below characteristics of:
- Older males
- often Ozena
- purulent discharge
- -airway obstruction
- -facial deformity
Ethmoid hematoma
An old male horse presents with epistaxis with purulent nasal discharge and a strong odor present. What is the most likely diagnosis:
Ethmoid hematoma
- present in OLD males
- -Strong odor = ozena
- purulent discharge
Diagnostics used for an ethmoid hematoma
Diagnostics used for an ethmoid hematoma
- Radiography
- CT/MRI
An old male horse presented with facial deformity and epistaxis. What is the most likely diagnosis:
Ethmoid hematoma = facial deformity
What is the medical AND surgical treatment for ethmoid hematoma
Medical tx = Intralesional formalin
Surgical tx= Ablation (laser ablation & standard surgical)
You have an appointment later in the week with an owner that just called who is suspicious of their horse having GPM. Can you wait to see the horse later in the week?
NO- Guttural pouch mycosis is an EMERGENCY.
GPM is usually associated in what age of horses.
Young horse = GPM
Old horse = Ethmoid hematoma
Recurrent episodes of mild frank epistaxis until unpredictable major bleeding episode is associated with:
GPM
– although recurrent do not usually have small episodes for several months.
What is the medical AND surgical treatment for GPM:
Medical tx= Antifungal admin (topical & systemic)
Surgical tx= Occlusion of the affected vessel (ligation/ balloon catheter occlusion/ transarterial coil).
If price is an issue regarding treatment of severe epistaxis in GPM, you can just put the horse on antifungal for longer than the recommended time.
FALSE– it will be just as expensive as surgery due to vet visits for treatment.
Most recent technique used for GPM
Transarterial coil emolisation
What are the 3 surgical techniques used to treat epistaxis in GPM:
3 sx techniques for GPM
- Ligation
- Balloon catheterization
- Detachable self sealing latex balloons
- Transarterial coil embolization
When is medical treatment indicated when dealing with epistaxis in GPM
Medical tx if NO bleeding.
– topical antifungal therapy (Indwelling system & Endoscope guided flush).
How is antifungal infusions usually administered to the horse for GPM
Topical infusions through temporary indwelling catheters
– infusions daily for 4-6 wks
T/F: 50% of GPM patients will succumb to fatal bleeding episode (hemorrhage)
True– prognosis for GPM patients is guarded
Differences with EH & GPM:
- Intermittent purulent =
- Mucoid type =
- Older males=
- Younger horses=
- Less airflow via nasal passage=
- Facial deformity =
- Dysphagia =
Differences with EH & GPM:
- Intermittent purulent = EH
- Mucoid type = GPM
- Older males= EH
- Younger horses= GPM
- Less airflow via nasal passage= EH
- Facial deformity = EH
- Dysphagia = GPM
Out of EH, GPM, and EIPH, which one is associated with racehorses.
EIPH= Racehorses
75% of more of racehorses
T/F: EIPH is associated in high speed sport eventers (<7m/sec)
False–
EIPH is associated with race horses but NOT seen in sports less than 7 m/sec. It is typically seen in high speed sports of >14m/sec
T/F: EIPH is often known to decrease with age.
False – EIPH is known for increasing with age.
Term that refers to disruption of pulmonary capillaries as a consequence of high CO required during intense exercise resulting in stress failure of the vessel wall.
Capillary Rupture theory – stress failure of pulmonary capillaries
Factors that influence capillary stress theory include: 1. 2. 3. 4. 5.
Factors that influence capillary stress theory include:
- high PAP
- high intrathoracic pressures
- inflammation, pulm parenchymal dz
- bronchial angiogenesis
- pulmonary fibrosis
What theory is this in reference to:
“Although alveolar wall and pulmonary capillary of horses are stronger than other species, rupture may occur bc the wall stress in the alveolus exceeds the mechanical strength of the capillary”
Capillary stress theory – lots of theories but the real issue is the stress seen across the capillary wall NOT the capillaries themselves.
What theory is this in reference to:
impact or hoof on grounds transmits wave to scapula –> force transmitted to chest wall –> force travels through lung to caudodorsal area then caudal tip of lung in shearing forces
Concussive lung injury theory
Rheologic changes refer to an increase in:
viscosity
- -Hyperviscosity in exercise
- -Hypercoagulability in exercise
T/F: EIPH will sometimes show no clinical signs.
True
- overall only 1%-10% of EIPH affected horses will show epistaxis
- higher likelihood of epistaxis with high grade bleeders (esp. grade 4)
- thus some low incidences reported of epistaxis 0.2- 0.4% of EIPH horses.
It is expected that horses with severe grade EIPH ( Grade 3 & 4) will have significant _______ ______.
Exercise Intolerance –“quitting”
T/F: in most cases, EIPH has minimal impact on horse and the quality of life
True
CS: non to acute collapse
- if low grade bleeders (<1 ) = no impact– indistinguishable from non-EIPH horses in wins, earnings, career duration.
- rarely: acute collapse/ fatality
Diagnostics of choice for EIPH
- Endoscopy – Direct observation of blood in tracheobronchial tree (grade 1-4)
- Radiography
- TTW/ BAL
Blood can be seen, in the tracheobronchial tree during endoscopy, how long after the race?
30-90 min
- can see up to 7 days
- some only within 2-4 hrs if light bleeders
In grading epistaxis in EIPH, Grade 0 refers to:
No evidence of hemorrhage
In grading epistaxis in EIPH, Grade 1 refers to:
Flecks of blood
In grading epistaxis in EIPH, Grade 2 refers to:
one continuous stream of blood extending atleast 1/2 the length of the trachea
In grading epistaxis in EIPH, Grade 3 refers to:
multiple streams of blood covering more than 1/3 of the tracheal surface
– streaks >5mm wide
In grading epistaxis in EIPH, Grade 4 refers to:
Abundant blood in trachea & pooling into thoracic inlet
Typical location seen on radiography when diagnosing EIPH
Caudodorsal lung lobe –increased interstitial lung pattern
- a focal circular density in a patch is usually seen.
- usually related to fibrosis from repeated episodes of bleeding.
How can TTW/BAL be used as a diagnostic in EIPH:
- -Cytology of resp secretions (either TTW/BAL).
- Some reports greater than 90% of horses in training have hemosiderophages
- -can be recovered for up to 150days after known episodes of EIPH.
Treatment for EIPH:
FUROSEMIDE – improves racing times
- physiologically trying to decrease systemic pressure/ pulmonary artery pressure.
- -Furosemide does NOT for sure decrease the pulmonary artery pressure.
- Furosemide will cause wt & water loss.
T/F: Furosemide (Lasix) is used to cure epistaxis in racehorses
FALSE
– many reports that it does NOT change bleeding
Treatment options for EIPH:
1.
2.
3.
Treatment options for EIPH:
- Furosemide (Lasix)
- Nasal Strip (Flair)
- Conjugated estrogens
T/F: Conjugated estrogens (Premarin) & amicar (aminocaproic acid) have very little evidence that it decreases epistaxis in EIPH horses.
True
Also no efficacy for the following treatments for EIPH:
- Nitric Oxide
- -herbal formulations
- dietary omega 3 FA
- Vit K
- Aerosolized products
