Epistaxis: The Bloody Nose

EPISTAXIS: THE BLOODY NOSE

bloody noseSome blood-tinged droplets sneezed on the floor might be the only sign or there might be a steady inexorable bloody drip from one or both nostrils. These findings are alarming as well as messy in the home and we want to identify the cause and take care of it promptly if it is possible to do so. The problem is that there are many causes and not all of them are localized to the nose and many are very serious diseases. The following is a review of tests typically necessary to get to the bottom of the bloody nose as well as the conditions that might be responsible.

FIRST AID

So, you are at home with your pet and a bloody nose starts and does not seem to be stopping. Here are some tips to get the bleeding controlled in the time prior to your vet appointment:

  • Keep your pet calm. Increased blood pressure that occurs with excitement will increase the bleeding. Tranquilizers such as acepromazine are often prescribed for nosebleed patients for this purpose.
    Do not use medication in your pet with veterinary instruction to do so, however.
     
  • Keep yourself calm. If your pet sees you getting frantic, your pet will get frantic, too. Again, excitement = higher blood pressure = more bleeding.
     
  • Get an ice pack and apply it to the bridge of the nose (obviously, be sure your pet can breathe around the ice pack). The cold will constrict small blood vessels which and as they constrict the bleeding will slow.

If these steps do not stop the bleeding or the pet is having difficulty breathing, go to your vet’s office or local emergency clinic at once.

Don’t forget that a pet with a bloody nose will likely swallow
a great deal of the draining blood. This may lead
to an especially black stool or even to vomit with blood clots in it.
After a bloody nose, such findings are usually just a reflection of the bloody nose
and do not necessarily indicate bleeding in the GI tract.

INFORMATION YOUR VETERINARIAN WILL NEED

You can help your veterinarian tremendously by taking some time to think about the following information and bringing up anything pertinent.

  • Does your pet take medication? Non-steroidal anti-inflammatory medications (aspirin in particular) will inactivate blood clotting factors. Do not assume your vet knows all the medications your pet is taking; list them for your vet.
     
  • Do you have any rat poison or has your pet been consuming any dead rodents that might have been poisoned? Most rat poisons act by disabling the ability to clot blood.
     
  • Look closely at your pet’s face. Is there any deformity or asymmetry? Is the bridge of the nose swollen? Are either of the third eyelids elevated. Does one eye seem to protrude. Does one eye tear more? Does the actual leather of the nose look normal?
     
  • Could there have been any trauma to the nose? Does your pet play rough with another animal?
     
  • Is your pet exposed to foxtails or other grass awns that could become lodged in the nose?
     
  • Has your pet been sneezing? Has the pet been rubbing at the nose?
     
  • Open your pet’s mouth if possible. Look at the gums under the lips. Is there blood in the mouth? Do the gums seem pale (if so, this suggests a serious loss of blood and you may have an emergency on your hands)?
     
  • Is there any evidence of bleeding anywhere besides the nose? Intestinal bleeding may present with a black tarry stool. Any unusual bruising should be reported. Any unexplained swelling that might represent bleeding under the skin should also be noted.
     
  • Is this the first nosebleed or have there been others? Do both nostrils bleed or only one?

WHERE TO START

After your veterinarian performs a general examination of your pet some more specific tests are needed with the idea of prioritizing the most likely conditions and least invasive forms of testing.

Blood tests first:

A basic blood panel and urinalysis will probably be needed as a database for the animal’s health as well as to assess the degree of blood loss and ability to withstand anesthesia which will likely be necessary. A platelet (a blood cell involved in blood clotting) count will be needed as will coagulation tests (common tests are the “PT” or prothrombin time, the “PTT” or partial thromboplastin time, the “ACT” or activated clotting time, and/or the buccal bleeding or “symplate” time.) These tests evaluate a very complicated biochemical cascade responsible for clotting blood. The pattern of abnormalities found in these tests will sort out blood clotting disorders.

Other blood tests that may be helpful involve titers for fungal infections, a classic cause of the nosebleed. Fungi are inhaled and if the patient is immune-compromised or excessively exposed, the fungus can take root and begin to grow in the nasal cavity.

In cats, the most common nasal fungal infection is caused by Cryptococcus neoformans. The good news here is that a blood test for fungal antigen is very accurate. Any positive number is significant and warrants treatment.

In dogs, fungal infections are not so simple. The most common organisms are Aspergillus fumigatus and Penicillium species. Blood tests are not as accurate especially since there are other species of Aspergillus besides fumigatus and each requires its own blood test. Complicating matters is the fact that nasal tumors predispose a dog to fungal infections so a dog can easily have both problems in the same nose. Blood tests for fungal infections may be included in the initial battery of tests. A negative Aspergillus test does not rule out Aspergillus infection.

Another condition worth mentioning is hyperviscosity syndrome. In this situation, an extremely high blood protein level makes the blood so thick that blood vessels break from the pressure. Certain types of cancer (multiple myeloma, lymphoma, and certain types of leukemia) as well as infection with Ehrlichia canis, a blood parasite can cause this syndrome. A routine blood panel should be show the unusual globulin levels that typify hyperviscosity syndrome.

Blood Clotting Disorders of Pets

Diseases Causing a Low Platelet Count    

  • Rat Poisoning
  • Von Willebrand’s Disease
  • Hemophilia
  • Liver Failure
  • Disseminated Intravascular
       Coagulation
  • Immune-mediated Thrombocytopenia
  • Bone Marrow Disease
  • Drug Reactions (methimazole, chemotherapy drugs,
       excess estrogens, sulfa class antibiotics)
  • Feline Leukemia Virus infection
  • Feline Immunodeficiency Virus Infection
  • Ehrlichia infection (dogs)
  • Rocky Mountain Spotted Fever
  • Hemangiosarcoma
  • Other Cancers
  • Cruising Towards Anesthesia:

    If the basic blood tests and clotting parameters are normal then the chances are that the problem is localized to the nose but there are a few more tests that are required before the patient is anesthetized for a nasal examination.

    • Radiographs of the chest should be performed to rule out obvious cancer spread or obvious disseminated fungal disease.
       
    • Blood pressure should be checked to rule out hypertension (especially a problem for cats). Remember, high blood pressure breaks the small blood capillaries in the nose and leads to bleeding.

    Diagnostics Requiring General Anesthesia:

    If nothing has been revealed by the preceding tests, it is now time for radiographs of the nose, superficial rhinoscopy, and a dental inspection all of which require general anesthesia. Radiographs generally start the procedure as the other procedures might alter the radiographic appearance of tissues. The radiographs help evaluate the tooth roots and sinuses. Nasal tumors are common causes of nosebleeds in elderly dogs and the bone destruction they cause is evident on radiographs. Referral for more advanced imaging such as CT scanning or MRI, may be needed to determine the extent of bone destruction or to clarify radiography findings.

    healthy feline dental radiograph

    feline nasal adenocarcinoma radiograph

    Dental radiograph of a healthy cat

    Cat with nasal adenocarcinoma

    An otoscope (the same gadget used to look in your pet’s ears) can be used to look inside the nasal cavity superficially to remove foreign bodies lodged there. Deeper peeking requires an actual endoscope which may not be readily available in general practice.

    The teeth can be cleaned under anesthesia with specific attention to the tooth roots (remember, an abscessed upper tooth root penetrates into the nasal sinus above.

    If it seems appropriate to do so, some nasal discharge can be flushed through the nose and into a gauze sponge packing the throat. This may be helpful in identifying infectious organisms but may initiate more bleeding so some judgment is required on whether the benefit is worth the risk.

    Then What?

    If the simple tools of general practice do not reveal adequate information, referral for endoscopy may be needed. Deeper visualization of the nasal tissues is possible with this equipment plus biopsy specimens can be taken (though bleeding is the chief risk in this situation). Biopsy is particularly difficult in the nose, not just because of the hemorrhage but because nasal tumors are surrounded by so much inflammation it is difficult to get a representative sample. Often it is not possible to see the area being biopsied directly, especially if prior sampling has led to bleeding.

    If radiographs are diagnostic for cancer and aggressive therapy is contemplated, prognosis is highly dependent on the type of tumor present so biopsy becomes especially important in this situation.

    And Then What?

    At the very end of all these procedures, sometimes the area of bleeding is simply not accessible without surgery. This would be the final and most invasive procedure in retrieving a difficult foreign body or tissue sample. Extensive bleeding is expected and this is generally the last resort after a long road of diagnostics.

    In a study by Bissett et al published in the December 15, 2007 issue of the Journal of the American Veterinary Medical Association, 176 cases of dogs with bloody noses were reviewed to determine which underlying causes were most common. Of these 176 dogs, a definite underlying cause was found in 115 cases.

    • 30% had nasal tumors
       
    • 29% had trauma
       
    • 17% had nasal inflammation of unknown cause (idiopathic rhinitis)
       
    • 10% had low platelets
       
    • 3% had some other blood clotting abnormality
       
    • 2% had high blood pressure
       
    • 2% had tooth abscess

    Conspicuously absent is the nasal fungal infection but since these are frequently regional in nature in dogs, the population studied may not have been in an area where fungi are common pathogens.

    Other Relevant Studies

    Evaluation of factors associated with survival in dogs with untreated nasal carcinoma: 139 cases (1993-2003) by Rassnick et al published in the Journal of the AVMA 229:401-406, 2006.
    This study reviewed the outcomes of 139 dogs diagnosed with nasal carcinoma. Since many dogs are euthanized at the time of this diagnosis, this study included only dogs that were alive 7 days after the initial diagnosis was made. Dogs studied received only pain medication, anti-inflammatories and antibiotics (no surgery, chemotherapy or radiation therapy). The following statistical findings came out:
     

    • 80% of dogs were purebred. The median age was 11 years and the median body weight was 48 lbs.
       
    • 77% had epistaxis (nose bleeds). Median survival time for dogs with nosebleeds was 88 days vs. 224 days for dogs with carcinomas that did not have nose bleeds.
       
    • Approximately half of the patients studied were felt to have improvement with the supportive care described above.

    Page last updated: 2/3/11