Epistaxis

Question 1

Name 3 UPPER respiratory epistaxis disorders:

Answer 1

1. Trauma - most common one
2. Guttural Pouch Mycosis
3. Progressive Ethmoid Hematoma

Question 2

Name a LOWER respiratory tract epistaxis disorder:

Answer 2

EIPH [exercise induced pulmonary hemorrhage]

Question 3

Guttural Pouch Mycosis signalment:

• age
• sex
• breed

Answer 3

Stabled horses in warm months
Spontaneous epistaxis in mature horse @ rest

No age/sex/breed specifications

Question 4

GPM pathogenesis:

Answer 4

• fungal invasion [aspergillosis usually]

- erosion of internal carotid artery [b/c high O2 tension area]

Question 5

GMP CS:

Answer 5

• epistaxis [uni/bilateral but usually uni]
• dysphasia

50% of the horses die!!

Question 6

Which nerves is the dysphasia CS associated with?

Answer 6

1. Pharyngeal branch of vagus [X]

2. Glossopharyngeal [IX]

Question 7

T/F: bleeding and neuro signs occur simultaneously all the time

Answer 7

False!

They rarely ever occur together

Question 8

How do we diagnose GPM?

Answer 8

CS
History
Endoscopy - plaque visualization

Question 9

How do we treat GPM?

Answer 9

Medical vs surgical tx

**whenever we see bleeding/history of bleeding = SURGICAL

Question 10

What is the medical tx for GPM?

Answer 10

Topical antifungal administration 4-6 weeks

Question 11

What is the surgical tx for GPM?

Do we need topical meds with this too?

Answer 11

BEST tx = transarterial coil [obliterates blow through vessel]

No need for any topical meds

Balloon-cath occlusion is 2nd best

Question 12

What is one major GPM treatment complication?

Answer 12

Blindness [from external carotid occlusion]

Question 13

How long does bleeding last in GPM?

Answer 13

Weeks-months but not much longer because they usually die :(

Question 14

What is EH [ethmoid hematoma]?

Answer 14

Locally destructive angiomatous masses of UNKNOWN cause in ethmoids

Question 15

T/F: EH resembles tumor but it’s NON-neoplastic

Answer 15

True

Question 16

EH signalment:

Answer 16

8+ yo
Male
Thoroughbred/Warmblood

Question 17

T/F: EH can be both uni and bilateral

Answer 17

True!

Mostly uni though

Question 18

EH pathophysiology

Answer 18

Explains in capsule and bleeds when ruptures but then closes up again and bleeding stops

Mild, spontaneous, intermittent epistaxis!

Question 19

T/F: EH can be a large space occupying lesion which can result in noise @ breathing and airflow differences @ diff sides

Answer 19

True

can see facial deformity in EH — you will never see this with GPM/EIPH

Question 20

T/F: EH presents with more hemorrhage than GPM. It can also be fatal.

Answer 20

False, GPM is more! Fatalities are also very rare!

Question 21

T/F: In EH, there are some severe cases which can have both inspiratory and expiratory noise.

Answer 21

True — if expands into significant space occupying lesion

Question 22

How do we diagnose EH?

Answer 22

Skull rads
CT
Endoscopy

check to see if there is cribriform plate involvement

Question 23

How do we treat EH?

Answer 23

Surgical laser ablation is PREFERRED

But we can also do medical intralesional formalin

both are appropriate but it depends on size of mass and $$$

Question 24

If you have a large space occupying lesion with EH, which tx method is preferred?

Answer 24

Surgical laser ablation

Question 25

What is a major contraindication with medically treating EH?

Answer 25

If cribriform plate is NOT intact we CANNOT treat medically

[don’t want formalin getting to brain!!]

Question 26

How long can EH bleeding last?

Answer 26

4+ months!! [longer than GPM]

Question 27

EIPH [exercise induced pulmonary hemorrhage] signalment:

Answer 27

Racehorses and pulling draft horses

More prevalent in older animals [keep tearing lungs over time]

Question 28

T/F: EIPH can be unilateral or bilateral.

Answer 28

False!

This is bilateral as it is a LOWER respiratory issue

Question 29

What is the #1 theory for EIPH?

Answer 29

Capillary Rupture Theory

Question 30

What is the Capillary Rupture Theory?

Answer 30

@ intense exercise the horse generates high CO and high pulmonary capillary pressures. The vessel walls rupture when wall stress goes beyond vessel strength

Question 31

What are some other EIPH theories?

Answer 31

1. Lower airway inflammation theory = continuous inflammation leads t more and more wall weakness
2. Concussive lung injury theory = impact of hoof on ground gets transmitted to chest wall and shears lung tissue

Question 32

EIPH CS:

Answer 32

most cases have NO CS!!!

CS mostly seen in higher grade EIPH: bleeding and exercise intolerance

Question 33

How do we diagnose EIPH?

Answer 33

Endoscopy! Direct visualization of blood in tracheobronchoal tree

Can do rads but not done too often

Question 34

How long after race should you scope them?

Answer 34

Evaluate within first few hours after exercise [usually visible 90min after and fro about 4-6h]

Question 35

What is the pathognomonic EIPH lung pattern that we see @ rads?

Answer 35

Caudal-dorsal lung field

[this is the last place we usually see dz in horses]

Question 36

How do we treat EIPH?

Answer 36

Furosemide [lasix] is #1 tx!

• performance enhancer in low grade bleeders
• helps high grade bleeders

We can also use nasal strips - reduces negative pressure @ inhalation

Question 37

Is EIPH fatal?

Answer 37

Nope

Question 38

What is the most common cause of epistaxis?

Answer 38

Trauma [NG tube intubation]