Epistaxis Flashcards
What are etiologies of epistaxis?
Upper resp
- Trauma
- Guttural pouch myosis
- Progressive ethmoid hematoma
Lower resp
- EIPH
- Pulmonary abscess rupture
- Coagulopathies
In what horses do you more commonly see guttural pouch mycosis?
Stabled horses during warmer months of the year
Clinical signs associated with guttural pouch mycosis?
Small amounts of frank blood from nares in a horse at rest
Can be preceded by mucopurulent unilateral discharge
Serosanguinous discharge can be present for days following frank hemorrhage
What is the pathogenesis of guttural pouch mycosis?
Fungal invasion of tissue —> erosion of wall of arterial structures (internal carotid artery)
Results in aneurysm and eventually rupture
Partial thrombosis present but no occlusion of vessel
The predisposition for guttural pouch mycosis to infiltrate the internal carotid artery is thought to be related to what factor?
High oxygen tension in these areas
Clinical signs associated with guttural pouch myosis?
Epistaxis - usually several bouts of mild unilateral epistaxis preceding fatal hemorrhage
Usually unilateral
Dysphagia (slow or sudden onset) — associated with pharyngeal branch of vagus and glossopharyngeal nerve
Head shyness, abnormal position, nasal discharge, abnormal respiration, horners syndrome
How can you diagnose guttural pouch mycosis?
Endoscopy
- plaque/ diphtheria membrane in guttural pouch
- necrotic tissue and debris
- brown, yellow, white, or black
- granuloma like lesion
- blood in lesions or pouch
What are the medical treatments for guttural pouch mycosis? When is this treatment indicated?
Antifungals - miconazole, amphotericin B, mystatin, or ketoconazole
Topical infusion through indwelling catheter for 4-6weeks
Indicated if there is no bleeding
What are the surgical techniques used for guttural pouch mycosis?
Occlusion of affected vessels.
- ligation
- balloon catheter occlusion
- transarterial coil
What are complications to occlusion of the affected vessel as treatment for guttural pouch mycosis?
External carotid - blindness
—> incidence of blindness if higher if both internal and external carotid are occluded
What is the prognosis for guttural pouch mycosis?
Incidence of fatal hemorrhage is 50%
If horse develops ..
laryngeal hemiplegia … usually permanent
Dysphagia … 6-8months recovery
Horner’s and facial nerve paralysis … 6-8months recovery
What is the most important criteria in guttural pouch mycosis that will determine therapy?
If the horse has manifested bleeding at any point —> you will want to occlude blood supply so they dont have fatal hemorrhage
Do you give topical antifungals if you have done surgical obliteration of the vessels to treat GP?
No
If you do the obliteration, the lesion will resolve on its own because of lack of O2
What is an ethmoid hematoma?
Progressive (slowly expanding) and locally destructive angiomatous masses of unknown cause in the ethmoid and paranasal sinus, NOT neoplasia
Signalment associated with ethmoid hematoma?
Older than 4yrs, >8yrs most often
Thoroughbred, warmblood Arabians
Males> females
What is the pathophysiology of an ethmoid hematoma?
Angiomatous mass composed of respiratory epithelium and fibrous tissue —> expansion —> ulceration of capsule —> epistaxis
Acts as space occupying mass in the nasal passage
Clinical signs of an ethmoid hematoma?
Mild, spontaneous, intermittent, unilateral epistaxis
Blood tinged mucoid- mucopurulent discharge (depending on infection and degree of necrosis)
Inspiratory and expiratory sounds can be present if space occupying mass
Malodorous
Present for months to years
T/F fulminant and fatal hemorrhage is common in ethmoid hematoma
False
Can occur but very rare
Diagnosis of an ethmoid hematoma can be done by??
Endoscopy - direct visualization
Skull rads- extent of hematoma involvement
CT
Biopsy and histopathology
DDX for a mass like lesions in the nasal/ distal nasal passages?
Ulcerative/mycotic rhinitis Nasal polyps Neoplasia Fungal granuloma Botryomycosis Trauma to nasal passages
What is the preferred treatment for ethmoid hematomas?
Surgical ablation
- laser
- standard blade resection (high intraop hemorrhage)
What is the medical therapy for ethmoid hematomas?
Intralesional formalin —> necrosis
What is the recurrence rate for ethmoid hematomas?
30-50%
T/F: if EH is large enough, you can have a differential nasal airflow
True
