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Basics ⬇

Basics

Definition

Bleeding from the nose

Pathophysiology

Results from one of three abnormalities-coagulopathy; local disease or space-occupying lesion; vascular or systemic disease.

Systems Affected

  • Respiratory-hemorrhage; sneezing
  • Gastrointestinal-melena
  • Hemic/Lymphatic/Immune-anemia

Genetics

Varies depending on underlying cause

Incidence/Prevalence

Varies depending on underlying cause

Signalment

Species

Dog and cat

Age, Breed, and Sex Predilections

Varies depending on underlying cause

Signs

Historical Findings

  • Nasal hemorrhage-unilateral or bilateral possible.
  • Sneezing and/or stertorous respiration.
  • Melena.
  • With coagulopathy-hematochezia, melena, hematuria, or hemorrhage from other areas of the body.
  • With hypertension-possibly blindness, intraocular hemorrhage, neurologic signs, cardiac or renal signs.

Physical Examination Findings

  • Nasal hemorrhage.
  • Melena-from swallowing blood or concurrent upper GI hemorrhage.
  • Nasal stridor-may be present with neoplasia, foreign body or advanced inflammatory disease.
  • With coagulopathy-possibly petechiae, ecchymosis, hematomas, intracavitary bleeds, hematochezia, melena, and hematuria.
  • With coagulopathy or hypertension-possibly retinal or intraocular hemorrhages or retinal detachment; with hypertension-possibly heart murmur or arrhythmia.

Causes

Coagulopathy

Thrombocytopenia

  • Immune-mediated disease-idiopathic disease; drug reaction; MLV vaccine reaction.
  • Infectious disease-ehrlichiosis; anaplasmosis; Rocky Mountain spotted fever, babesiosis, FeLV or FIV-related illness.
  • Bone marrow disease-neoplasia; aplastic anemia; infectious (fungal, rickettsial, or viral).
  • Paraneoplastic disorder.
  • DIC.

Thrombopathia

  • Congenital-von Willebrand disease; thrombasthenia; thrombopathia.
  • Acquired-NSAIDs; clopidogrel; hyperglobulinemia (Ehrlichia, multiple myeloma); uremia; DIC.

Coagulation Factor Defects

  • Congenital: hemophilia A (factor VIIIc deficiency) and hemophilia B (factor IX deficiency).
  • Acquired: anticoagulant rodenticide (warfarin) intoxication, hepatobiliary disease, DIC.

Local Lesion

  • Foreign body.
  • Trauma.
  • Infection-fungal (Aspergillus, Cryptococcus, Rhinosporidium); viral or bacterial. Usually blood-tinged mucopurulent exudate rather than frank hemorrhage.
  • Neoplasia-adenocarcinoma; carcinoma; chondrosarcoma; squamous cell carcinoma; fibrosarcoma; lymphoma; transmissible venereal tumor.
  • Dental disease-oronasal fistula, tooth root abscess.
  • Lymphoplasmacytic rhinitis.

Vascular or Systemic Disease

  • Hypertension-renal disease; hyperthyroidism; hyperadrenocorticism; pheochromocytoma; idiopathic disease.
  • Hyperviscosity-hyperglobulinemia (multiple myeloma, Ehrlichia); polycythemia.
  • Vasculitis-immune-mediated and rickettsial diseases.

Risk Factors

Coagulopathy

  • Immune-mediated disease-young to middle-aged, small-to medium-sized female dogs.
  • Infectious disease-dogs living in or traveling to endemic areas; tick exposure.
  • Thrombasthenia-Otter hounds.
  • Thrombopathia-Basset hounds, Spitz.
  • von Willebrand disease-Doberman pinschers, Airedales, German shepherds, Scottish terriers, Chesapeake Bay retrievers, and many other breeds; cats.
  • Hemophilia A-German shepherds and many other breeds; cats.
  • Hemophilia B-Cairn terriers, coonhounds, St Bernards, and other breeds; cats.

Space-Occupying Lesions

  • Aspergillosis-German shepherds, rottweilers, mesocephalic and dolichocephalic breeds.
  • Neoplasia-dolichocephalic breeds.

Diagnosis ⬆ ⬇

Diagnosis

Differential Diagnosis

See “Causes”

CBC/Biochemistry/Urinalysis

  • Anemia-if enough hemorrhage has occurred.
  • Thrombocytopenia-possible.
  • Neutrophilia-infection; neoplasia.
  • Pancytopenia-if bone marrow disease.
  • Hypoproteinemia-if enough hemorrhage has occurred.
  • High BUN with normal creatinine-possible, owing to blood ingestion.
  • Hyperglobulinemia-possible with ehrlichiosis, multiple myeloma.
  • Azotemia-with renal failure-induced hypertension.
  • High ALT, AST, and total bilirubin-with coagulopathy from severe hepatic disease.
  • Urinalysis-usually normal; possible to see hematuria (if coagulopathy), isosthenuria (if renal failure–induced hypertension), and proteinuria (if glomerulotubular disease and hypertension).

Other Laboratory Tests

  • Coagulation profile-prolonged times with coagulation factor defects; normal with thrombocytopenia and thrombopathia.
  • Platelet function testing (e.g., buccal mucosal bleeding time, von Willebrand factor analysis)-may be abnormal with platelet dysfunction (platelet count and coagulation profile may be normal).
  • Ehrlichia, Anaplasma, Rocky Mountain spotted fever, or Babesia testing-may be positive in thrombocytopenia or thrombopathia-induced epistaxis.
  • Aspergillus serology-may help establish a diagnosis of fungal rhinitis; false negative results are common so results must be interpreted in light of other clinical and diagnostic findings.
  • Thyroid hormone assay-elevated in cats with epistaxis due to hyperthyroid-induced hypertension.

Imaging

  • Thoracic radiograph-screen for metastasis.
  • Nasal series-under anesthesia, including open-mouth ventrodorsal and skyline sinus views when space-occupying or local lesion is suspected; osteolysis with neoplasia and fungal sinusitis; foreign bodies usually not seen; dental disease may be identified.
  • CT or MRI-more sensitive than radiographs.

Diagnostic Procedures

  • Blood pressure evaluation-indicated when coagulopathies and space-occupying lesions have been ruled out and particularly when azotemia or proteinuria is noted.
  • Rhinoscopy, nasal lavage, nasal biopsy (blind or guided via rhinoscopy or CT)-indicated for space-occupying disease; aimed at removing foreign bodies and evaluating and sampling nasal tissue for a causal diagnosis (e.g., evaluate nasal tissue samples for neoplasia, inflammation, and infection via cytology and/or histopathology and bacterial/fungal culture and sensitivity testing).
  • Bone marrow aspiration biopsy-indicated if pancytopenia identified.

Treatment ⬆ ⬇

Treatment

Appropriate Health Care

  • Coagulopathy-usually inpatient management.
  • Space-occupying lesion or vascular or systemic disease-outpatient or inpatient management, depending on the disease and its severity.
  • Nasal tumors-radiotherapy; various response rates.

Nursing Care

Provide basic supportive care if needed (fluids, nutrition).

Activity

Minimize activity or stimuli that precipitate hemorrhage episodes.

Client Education

  • Inform client about the disease process.
  • Teach client how to recognize a serious hemorrhage (e.g., weakness, collapse, pallor, and blood loss >30 mL/kg body weight).

Surgical Considerations

  • Surgery indicated if a foreign body is unable to be removed by rhinoscopy or blind attempt.
  • Fungal rhinitis (e.g., Aspergillus and Rhinosporidium) require debulking (also see “Medications”).

Medications ⬆ ⬇

Medications

Drug(s) Of Choice

General

  • Whole blood, packed RBC, or hemoglobin solution transfusion-can be needed with severe anemia.
  • Acepromazine (0.05–0.1 mg/kg SC, IV if normothermic and no platelet disorder present) to lower blood pressure and promote clotting; may help control serious hemorrhage.
  • Discontinue all NSAIDs.

Coagulopathy

  • Immune-mediated thrombocytopenia-prednisone (1.1 mg/kg q12h; taper over 4–6 months); other drugs can be used in addition to prednisone for refractive cases (see Immune Mediated Thrombocytopenia).
  • Infectious disease-rickettsial disease (doxycycline, 5 mg/kg PO q12h for 3–6 weeks); Babesia (imidocarb, 6.6 mg/kg SC, 2 doses 2 weeks apart, diminazene aceturate 5 mg/kg IM once, or 10 days of atovaquone 13.3 mg/kg PO q8h with azithromycin 10 mg/kg PO q24h).
  • Bone marrow neoplasia-see Myeloproliferative Disorders.
  • Thrombopathia and thrombasthenia-no treatment unless lymphoproliferative disease.
  • von Willebrand disease-plasma or cryoprecipitate for acute bleeding; DDAVP 1 µg/kg SC or IV diluted in 20 mL of 0.9% NaCl given over 10 minutes may help control or prevent hemorrhage prior to invasive procedures (intranasal formulation [less expensive] may be used after passing through a bacteriostatic filter).
  • Hemophilia A-plasma or cryoprecipitate for acute bleeding; no long-term treatment.
  • Hemophilia B-plasma for acute bleeding; no long-term treatment.
  • Anticoagulant rodenticide intoxication-plasma for acute bleeding; vitamin K at 5 mg/kg loading dose followed by 1.25 mg/kg q12h for 1 week (if warfarin formulation) to 4 weeks (longer-acting formulation).
  • Hyperglobulinemia-plasmapheresis.
  • Polycythemia-phlebotomy; hydroxyurea.
  • Liver disease and DIC-treat and support the underlying cause; plasma may be beneficial.

Space-Occupying Lesion

  • Secondary bacterial infection-antibiotics based on culture and sensitivity testing.
  • Fungal infection-for aspergillosis, topical treatment of nasal cavity and frontal sinuses with 1% clotrimazole in polyethylene glycol (see “Precautions”) or 1–5% enilconazole (see Aspergillosis, Nasal, for protocol); for cryptococcosis-oral and injectable antifungal agents (see Cryptococcosis); for rhinosporidiosis-surgery followed by dapsone (1 mg/kg PO q8h for 2 weeks, then 1 mg/kg PO q12h for 4 months).

Vascular or Systemic Disease

  • Hyperviscosity-treat underlying disease (e.g., ehrlichiosis, multiple myeloma, or polycythemia); plasmapheresis.
  • Vasculitis-doxycycline for rickettsial disease (5 mg/kg q12h for 3–6 weeks); prednisone for immune-mediated disease (1.1 mg/kg q12h; taper over 4–6 months).

Hypertension

  • Treat underlying disease-renal disease, hyperthyroidism, hyperadrenocorticism.
  • Reduce weight if over-conditioned.
  • Restrict sodium.
  • Calcium channel blockers-amlodipine (dogs, 0.1 mg/kg PO q12–24h; cats, 0.625–1.25 mg/cat PO q12–24h)-treatment of choice.
  • ACE inhibitors-benazepril (0.5 mg/kg q24h); enalapril (0.25–0.5 mg/kg q12–24h).
  • -blockers-propranolol (0.5–1 mg/kg q8h); atenolol (0.25–1.0 mg/kg q12–24h).
  • Diuretics-hydrochlorothiazide (2–4 mg/kg q12h); furosemide (0.5–2 mg/kg q8–12h).
  • Phenoxybenzamine 0.2–1.5 mg/kg q12h for pheochromocytoma.

Contraindications

  • Avoid drugs that may predispose patient to hemorrhage-NSAIDs; heparin; clopidogrel; phenothiazine tranquilizers.
  • Topical antifungals-do not use in patients with disruption of the cribriform plate.

Precautions

  • Chemotherapeutic drugs (Immune-mediated thrombocytopenia therapy, e.g., azathioprine)-monitor neutrophil counts and liver enzymes weekly until a pattern has been established that shows that the patient is tolerating the drug.
  • Enalapril and/or diuretics-closely monitor patients with renal failure; avoid severe salt restriction when using ACE inhibitors
  • Avoid topical clotrimazole preparations with propylene glycol as life-threatening mucosal irritation, ulceration, and nasopharyngeal swelling can occur.

Follow-Up ⬆ ⬇

Follow-Up

Patient Monitoring

  • Platelet count with thrombocytopenia
  • Coagulation profile with coagulation factor defects
  • Blood pressure with hypertension
  • Clinical signs

Prevention/Avoidance

  • Restrict access to areas that might contain anticoagulant rodenticides.
  • Practice dental preventative care.

Possible Complications

Anemia and collapse (rare)

Expected Course and Prognosis

Varies depending on underlying cause.

Miscellaneous ⬆

Miscellaneous

Pregnancy/Fertility/Breeding

Avoid teratogenic drugs (e.g., itraconazole).

Abbreviations

  • ACE = angiotensin converting enzyme
  • ALT = alanine transaminase
  • AST = aspartate aminotransferase
  • CT = computed tomography
  • DDAVP = 1-desamino-8-d-arginine vasopressin
  • DIC = disseminated intravascular coagulation
  • FeLV = feline leukemia virus
  • FIV = feline immunodeficiency virus
  • MLV = modified live virus
  • MRI = magnetic resonance imaging
  • NSAID = nonsteroidal anti-inflammatory drug
  • RBC = red blood cell

Suggested Reading

Bissett SA, Drobatz KJ, McKnight A, Degernes LA. Prevalence, clinical features, and causes of epistaxis in dogs: 176 cases (1996–2001). J Am Vet Med Assoc 2007, 231:1843–1850.

Brooks MB, Catalfamo JL. Immune-mediated thrombocytopenia, von Willebrand disease, and platelet disorders. In: Ettinger SJ, Feldman EC, eds., Textbook of Veterinary Internal Medicine, 7th ed. St. Louis, MO: Saunders Elsevier, 2010, pp. 772–783.

Dunn ME. Acquired coagulopathies. In: Ettinger SJ, Feldman EC, eds., Textbook of Veterinary Internal Medicine, 7th ed. St. Louis, MO: Saunders Elsevier, 2010, pp. 797–801.

Venker-van Haagen AJ, Herrtage ME. Diseases of the nose and nasal sinuses. In: Ettinger SJ, Feldman EC, eds., Textbook of Veterinary Internal Medicine, 7th ed. St. Louis, MO: Saunders Elsevier, 2010, pp. 1030–1040.

Author Mitchell A. Crystal

Consulting Editor Lynelle R. Johnson

Client Education Handout Available Online