Epistaxis (Nose Bleed) in Cats

Cats

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Epistaxis refers to bleeding from the nose. It is usually from damaged vessels in the nasal mucosa but can also be due to an increased fragility of capillaries or bleeding tendencies. Any breed can develop epistaxis and there is no gender predilection.

The bleeding may be acute (sudden) or chronic (long standing). How ill the animal becomes often is determined by the underlying cause of the nasal bleeding. It is important to determine if the bleeding is unilateral (one-sided) or bilateral (both nostrils) because some causes of epistaxis are associated with unilateral bleeding whereas others are associated with bilateral bleeding.

Epistaxis may be caused by:

  • Trauma
  • Nasal foreign bodies
  • Dental disease, like tooth root abscess
  • Nasal tumors
  • Infections (bacterial, fungal, parasitic)
  • Certain blood disorders, such as clotting abnormalities, excessively viscous blood, tick-borne diseases that can cause low platelet counts

    What to Watch For

  • Sneezing, accompanied by a large spray of blood
  • Nasal swelling
  • Severe dental disease
  • Fractured teeth
  • Black, tarry stool (caused by swallowing blood)
  • A foul odor from the mouth or nose
  • Noisy breathing
  • Loss of appetite

    Diagnosis

  • Your veterinarian will take a complete history and perform a thorough physical examination, which may lead to a prompt diagnosis with minimal diagnostic testing, especially if trauma is the cause. Careful oral and nasal examinations under anesthesia may be needed to completely inspect the mouth, back of the throat, and front part of the nasal cavity (just within the nostrils)

  • A complete blood count (CBC or hemogram) to identify anemia, inflammation or infection, or a low platelet count that may be contributing to the epistaxis

  • Serum biochemistry tests to evaluate the overall health of your pet and to evaluate vital organ function

  • A urinalysis to evaluate kidney function, check for infection, and to identify proteinuria that can be associated with some causes of epistaxis

  • Tests of blood clotting including a platelet count, von Willebrand's factor (to check for von Willebrand's disease, a relatively common inherited clotting abnormality in dogs), and other tests of blood clotting (e.g. prothrombin time, partial thromboplastin time, activated clotting time)

  • Serologic tests for infectious diseases, especially fungal diseases (histoplasmosis, blastomycosis) and tick-borne rickettsial diseases, like ehrlichiosis and Rocky Mountain Spotted Fever

  • Nasal and dental radiographs may be recommended based on these findings

    Additional tests may be recommended if a diagnosis cannot be established from the previously described evaluations. These include:

  • Fine detail X-rays of the nasal cavity

  • Computerized tomography (CT) (a specialized type of X-ray procedure that allows individual "slices" of the head to be examined). This test has somewhat limited availability but is not extremely expensive.

  • Magnetic resonance imaging (MRI) (a specialized test the provides highly detailed views of "slices" of the head). This test has limited availability and can be very expensive.

  • Rhinoscopy (evaluation of the nasal cavity with a fiberoptic endoscope) and nasal biopsy. You may be referred to a specialist in veterinary internal medicine for this procedure, which must be performed under general anesthesia

  • Exploratory surgery of the nasal cavity for definitive diagnosis and possible treatment

    Treatment

    Treatment is focused at stopping the bleeding. In addition, minimize stress for your pet. Sedation may be necessary to decrease excitement and agitation. The following may also help:

  • Cold compresses and direct pressure to help decrease bleeding

  • Adrenaline (i.e. epinephrine) can be applied in the nose to control bleeding

  • In severe cases, general anesthesia may be required to allow packing of the nasal cavity with gauze so as to provide direct pressure to control bleeding

    Home Care

    Often a blood clot will form and the bleeding will stop on its own. Your veterinarian still should evaluate your pet, but an emergency visit probably is not required. Meanwhile, do the following:

  • Limit stress and decrease excitability (sedation may be required for this purpose).

  • Apply cold compresses and direct pressure to help decrease the bleeding.

  • If the bleeding does not stop, gets worse or if bleeding is observed at other sites, consider it an emergency and call your veterinarian immediately.

  • Epistaxis or nasal bleeding is generally caused by either an acute (sudden) event, or by more insidious chronic problems.

  • Acute epistaxsis many times is the result of nasal fractures or lacerations caused by traumatic episodes. If there is no history of trauma, acute bleeding is often caused by the sudden erosion of a nasal blood vessel due to some primary problem within the nasal cavity, or perhaps metabolic conditions. Many times, acute epistaxis will occur, but the underling condition is a chronic or long-standing condition. Tumors, foreign bodies, and tooth root abscesses often present with acute epistaxis, yet the problem may have been present for some time.

  • Intermittent recurrent or chronic nosebleeds are common as blood clots form to stop the bleeding. Clots dislodging or new blood vessels becoming affected may cause future episodes of bleeding. It is also important to note whether the epistaxis is unilateral (one sided) or bilateral (both sides). Tumors, foreign bodies, and tooth root abscesses are usually unilateral. Infections and metabolic conditions are usually bilateral. If the animal has been losing weight or has been ill for some time before epistaxis is noted, it may indicate a more serious condition. It is rare for the volume of blood loss from the nose to be life threatening, rather the epistaxis is an important clinical sign that warrants further evaluation. Unless caused by trauma, epistaxis is a significant finding that often will recur if a definitive diagnosis is not reached.

    Causes

    The most common causes of epistaxis include:

  • Trauma, such as nasal fractures caused by automobile accidents, bite wounds and nasal lacerations caused by sharp objects

  • Nasal foreign bodies. Epistaxis will occur if a nasal foreign body punctures a blood vessel. Inflammation associated with a nasal foreign body can cause blood-tinged nasal discharge.

  • Dental disease. A tooth root abscess may develop if dental disease is severe or a fractured tooth becomes infected. The roots of the teeth in the maxilla (upper jaw bone) are very long. If infection develops at the base of the tooth root, it may cause swelling and break into the nasal cavity. Epistaxis occurs because the nasal blood vessels are affected. A swelling on the bridge of the nose or under the eye may be observed in a pet with a tooth root abscess.

  • Nasal tumors are a common cause of unilateral (one-sided) epistaxis in older cats. The most common tumors in affected cats are adenocarcinoma, chondrosarcoma, fibrosarcoma, osteosarcoma and squamous cell carcinoma.

  • Bacterial, fungal and parasitic infections may cause epistaxis. Only severe bacterial infections are likely to cause epistaxis. Bacterial infection may be due to trauma or a foreign body that is no longer present. Aspergillosis in cats is a fungal infection that affect the nasal cavity and may lead to epistaxis. Nasal parasites also can cause epistaxis but episodes of sneezing and rubbing at the face are more common symptoms of nasal mite infection.

  • Many bleeding disorders can cause epistaxis. Bleeding at other sites also may be observed. Thrombocytopenia (low platelet count) is a common cause of such bleeding problems. Platelets are blood cell fragments that are vital to the clotting process and may be decreased by several different disorders including tick-borne diseases caused by a type of bacteria called rickettsia. Rodenticides containing vitamin K antagonists are frequently the cause of generalized bleeding in cats because they interfere with activation of several clotting factors by vitamin K.

  • Hyperviscosity (thickening of the blood) can result from extremely high concentrations of blood proteins in pets with certain diseases. The high protein concentration leads to poor platelet function and abnormal coagulation. Occasionally, epistaxis is the first symptom of this problem. Common causes of hyperviscosity syndrome are multiple myeloma (overproduction of antibody proteins by malignant antibody-producing plasma cells), lymphoma (cancer of lymphoid tissue and lymphocytes) and erhlichiosis (a tick-borne rickettsial disease).

  • Diagnosis In-depth

    Many times a diagnosis can be made on the basis of a good history and physical exam. If the diagnosis cannot be established, then certain basic lab tests are indicated:

  • Complete blood test (CBC) checks for anemia, evaluating how significant the blood loss might be. The white blood cell analysis may show evidence of infection or certain types of cancer. The platelet count is also estimated.

  • The biochemical profile rarely identifies a primary problem causing the epistaxis, although the total proteins are measured (hyperviscosity syndrome). It is still a valuable test to rule out any secondary diseases, concurrent problems, and to minimize anesthetic risk.
            
  • Infectious disease titers for fungal diseases such as aspergillosis may be indicated, as well as an Erhlichia titer. Erhlichiosis can cause a decreased platelet count and an increased plasma protein level.
  • Clotting tests are indicated to rule out any clotting abnormalities. Clotting abnormalities may be inherited, caused by toxins, metabolic conditions or inherited.

  • An oronasal exam under anesthesia is useful to evaluate for dental disease, obvious nasal masses or foreign bodies. This procedure is often combined with other procedures that require general anesthesia, such as nasal x-rays and biopsies.

  • Nasal and dental radiographs require anesthesia and may show a tooth root abscess or an area of bony destruction caused by a tumor. In general nasal X-rays, although widely available, are not as good a diagnostic tool as CT or MRI scans.

  • Nasal biopsies may be obtained using X-rays as a guide. These are generally considered blind biopsies, since the mass is not visualized during the biopsy procedure. Typically a long thin probe with a cutting tip is inserted through the nares to an approximated area. Biopsies may be taken at the point where a lesion is suspected.

    Your veterinarian may recommend that more specialized testing is needed to diagnose the primary problem. These tests may only be available at larger referral practices and include:

  • Computed tomography (CT) and magnetic resonance imaging (MRI) are useful in imaging nasal masses and the extent of bony involvement. Knowing the exact location of the mass is useful in order to biopsy the mass to get an accurate diagnostic sample.

  • Rhinoscopy is the procedure of using a very small flexible fiber optic scope to visualize the structures in the nose. The tube is placed through the nares and advanced. Tumors, foreign bodies and the specific bleeding area may be identified. Foreign bodies may be recovered and biopsies obtained.

  • Surgery or a nasal exploratory is generally the last step taken if a diagnosis has not been made. An incision along the bridge of the nose allows for visualization of the nasal cavity. Masses and foreign bodies may be removed, or biopsies obtained.

    Treatment In-depth

    Your veterinarian may recommend one or more of the diagnostic tests described above. In the meantime, treatment of the symptoms might be needed, especially if the problem is severe. The following non-specific (symptomatic) treatments might be applicable to some, but not all pets with epistaxis. These treatments may reduce severity of symptoms or provide relief for your pet. However, nonspecific therapy is not a substitute for definite treatment of the underlying disease responsible for your pet's condition.

  • Stress should always be minimized. Stress, excitement and panting can cause animals to dislodge clots and further bleeding to occur. Stress also increases blood pressure, which could further increase bleeding. If the animal is in good health, drugs that sedate as well as decrease blood pressure like acepromazine are very useful.

  • Cold compresses and direct pressure on the nose will promote the constriction of the blood vessels and help in decreasing the blood flow and promote clot formation.

  • General anesthesia is occasionally required to stop the bleeding, especially if the patient is uncooperative. Epinephrine causes a powerful constriction of the blood vessels and may be instilled in the nose using a syringe. If needed, gauze-like material (e.g. umbilical tape) can be packed into the nose producing more direct pressure on a bleeding area and thus promote faster clotting.

  • In traumatic injuries usually the bleeding stops on its own or with supportive care. Nasal tumors may be surgically removed, treated with chemotherapy or have radiation therapy. Fungal infections often respond to intranasal antifungal or oral antifungal agents. Tooth root abscesses improve with tooth removal and antibiotics. Many bleeding disorders are very treatable once the primary problem is identified. Specific therapy requires the specific cause to be identified.

  • Although it frequently looks like a lot of blood, the volume of blood lost during epistaxis usually is not life threatening. Rather, the epistaxis serves as an important marker of an underlying clinical condition that warrants further evaluation.

    Often a blood clot will form and the bleeding will stop on its own. Your veterinarian still should evaluate your pet, but an emergency visit probably is not required. Except when caused by trauma, epistaxis in cats usually is a significant finding that often will recur if a definitive diagnosis is not obtained. Meanwhile, do the following:

  • Limit stress and decrease excitability (sedation may be required for this purpose).

  • Apply cold compresses and direct pressure to help decrease the bleeding.

  • If the bleeding does not stop, gets worse or if bleeding is observed at other sites, consider it an emergency and call your veterinarian immediately.

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