Blessi’s mys­te­ri­ous nose­bleed

On the day be­fore a hol­i­day, a geld­ing’s sud­den nasal prob­lem wor­ries his owner as a vet­eri­nar­ian searches for the cause.

EQUUS - - Equus - By Pamela Nolf

On the day be­fore a hol­i­day, a geld­ing’s sud­den nasal prob­lem wor­ries his owner as a vet­eri­nar­ian searches for the cause.

On the day be­fore Thanks­giv­ing last year, I re­ceived one of those calls from my board­ing sta­ble you never want: “Blessi is bleed­ing from his nose,” the barn man­ager told me. “You should come check him out.”

I dashed out the door. Blessi is my 20-year-old Ice­landic geld­ing. He’d never had a nose­bleed be­fore, and my mind raced with pos­si­bil­i­ties about what could be wrong.

When I ar­rived at the barn, Blessi was stand­ing with his head over the stall door. He was alert, cu­ri­ous and seem­ingly nor­mal---ex­cept for the blood seep­ing from both nos­trils. I im­me­di­ately called Blessi’s vet­eri­nar­ian, Bo Weeks, DVM, of Rocky Bay Equine in nearby Gig Har­bor, Wash­ing­ton.

Be­cause Blessi had been galloping in the pas­ture with an­other horse when the sta­ble owner spot­ted his nose­bleed, my first thought was that he had been kicked. I men­tioned this to Weeks as he en­tered the barn, but he pointed out that there was no swelling, bruis­ing or abra­sions around Blessi’s muz­zle. Nor was he sen­si­tive to touch any­where on his face. A horse kick is quite pow­er­ful and usu­ally re­sults in con­sid­er­able vis­i­ble trauma.

In med­i­cal terms, Blessi was ex­hibit­ing bi­lat­eral nasal epis­taxis, the tech­ni­cal term for bleed­ing from both nos­trils, and noth­ing else---or at least no other signs that we’d been able to de­tect so far.

As Weeks checked Blessi’s heart­beat and tem­per­a­ture, he ex­plained some of the pos­si­ble causes of the bleed­ing. The equine nasal cav­ity con­nects with a num­ber of other struc­tures--in­clud­ing the trachea and lungs, the eu­stachian tubes lead­ing to the in­ner ear, the gut­tural pouches and the si­nuses---any of which could be the ori­gin of the bleed­ing.

As for other po­ten­tial causes, one of the more be­nign pos­si­bil­i­ties was a spon­ta­neous rup­ture in a small artery in the lin­ing of the nasal pas­sage or si­nus cav­i­ties. This hap­pens in peo­ple, too, and these nose­bleeds usu­ally clear up by them­selves. Other pos­si­ble causes of the bleed in­cluded in­jury from a for­eign ob­ject, an in­fec­tion, an ab­scess or a tu­mor.

Weeks asked if Blessi had had any episodes of bleed­ing af­ter stren­u­ous ex­er­cise. Work­ing hard can cause a more se­ri­ous type of bleed­ing called ex­er­ci­sein­duced pul­monary hem­or­rhage (EIPH). Dur­ing an in­tense work­out, small cap­il­lar­ies in the alve­oli (air sacs) in the lower part of the lungs may burst. If the rup­tures are se­vere enough, blood may even­tu­ally drip out the nos­trils. EIPH is mostly seen in horses who reg­u­larly ex­ert them­selves, such as Thor­ough­bred and Stan­dard­bred race­horses, but other equine ath­letes, in­clud­ing polo ponies or com­bined-train­ing horses, can also de­velop this con­di­tion.

This cer­tainly didn’t sound like Blessi. At the time, I was rid­ing him at a walk, which was not enough to keep him in shape. A dres­sage in­struc­tor was rid­ing him pe­ri­od­i­cally for low level sup­pling and con­di­tion­ing. A walk­ing warmup, pe­ri­ods of trot­ting, a bit of can­ter­ing, and a long cooldown hardly

qual­ify as stren­u­ous. And, no, Blessi had not been bleed­ing from the nose af­ter his train­ing ses­sions.

Then Weeks men­tioned an­other pos­si­bil­ity---one that was much more alarm­ing. Nasal epis­taxis can be the first sign of a po­ten­tially lifethreat­en­ing con­di­tion called gut­tural pouch my­co­sis (GPM), a fun­gal in­fec­tion in a gut­tural pouch. A horse has two gut­tural pouches, which are air­filled sacs that ex­tend from each eu­stachian tube and empty into the phar­ynx0. Their func­tion is to keep the brain cool as the horse ex­er­cises by en­abling air to cir­cu­late around the in­ter­nal carotid artery, which sup­plies blood to the brain. Other ma­jor ar­ter­ies, such as the in­te­rior and ex­ter­nal carotids, and ma­jor nerves serv­ing the face and head also run through the walls of the gut­tural pouches.

Some­times, how­ever, one or both gut­tural pouches can fill with mu­cus or pus as a re­sult of some sort of in­fec­tion, with causes rang­ing from stran­gles to res­pi­ra­tory in­fec­tions. GPM is a spe­cific type of in­fec­tion caused by a fun­gus, usu­ally as­pergillus, which forms plaques on the wall of the gut­tural pouch around the un­der­ly­ing ar­ter­ies. Over time, these plaques can erode through the walls of the ma­jor blood ves­sels, caus­ing spon­ta­neous nose­bleeds that may be fa­tal. GPM can also dam­age the nerves that con­trol the horse’s fa­cial move­ments---in more se­vere cases, the in­fec­tion may in­hibit his abil­ity to swal­low.

GPM can be­come se­ri­ous very quickly, and early di­ag­no­sis and treat­ment is crit­i­cal. An­ti­fun­gal drugs, ad­min­is­tered sys­tem­i­cally and/or top­i­cally, are of­ten suc­cess­ful. A vet­eri­nar­ian may also opt to block off ar­ter­ies at risk of hem­or­rhag­ing to pre­vent fa­tal bleed­ing.

Wait and see?

As we dis­cussed all these pos­si­bil­i­ties, Blessi’s nose con­tin­ued to slowly drip blood. The blood loss it­self wasn’t a worry; the av­er­age horse has a lit­tle over 12 gal­lons of blood and can lose about 10 per­cent of it be­fore shock sets in, so Blessi’s blood loss was cer­tainly mi­nor. Since the bleed­ing came from both nos­trils, the source was prob­a­bly high in the skull, Weeks ex­plained, above the point where the sep­tum di­vides the nasal cav­ity into two sep­a­rate cham­bers.

The only way to be cer­tain of where the blood was com­ing from and what the prob­lem was, I was told, would be to use an en­do­scope---a long, flexible tube equipped with a cam­era and a light--to look di­rectly into Blessi’s nasal cav­ity. Be­cause the bleed­ing was mild, and Blessi was oth­er­wise nor­mal with no prior his­tory of nose­bleeds, Weeks said it would be fine if I sim­ply wanted to wait and see what hap­pened. The bleed­ing was likely to stop on its own in the next day or so.

I had been given a lot to think about, and I con­sid­ered my op­tions care­fully. “Wait and see” sounded good, but then I re­mem­bered that the fol­low­ing day was Thanks­giv­ing. If the bleed­ing in­ten­si­fied over the next 24 hours I would have to drag my vet­eri­nar­ian away from his fam­ily gath­er­ing. Plus, I would un­doubt­edly spend my own hol­i­day ob­sess­ing about as­pergillus. And I re­ally wanted to know where that bleed­ing was com­ing from. “Get the en­do­scope,” I said. Like a ma­gi­cian mak­ing a rab­bit disappear, Weeks calmly but con­fi­dently ran the 20-inch-long in­stru­ment up one of Blessi’s nos­trils. I was amazed at how much empty space there must be in a horse’s head to ac­com­mo­date all of that. I found out later that cold-cli­mate

breeds like Ice­landic Horses tend to have more space in their nasal cav­i­ties to bet­ter en­able warm­ing of air be­fore it gets to the lungs. Older horses, too, have more space, left be­hind as their erupt­ing teeth wear away.

Blessi looked sur­prised as the en­do­scope trav­eled up his nose, but he must have de­cided it was an­other treatearn­ing op­por­tu­nity and stood calmly. Some en­do­scopes project an im­age via a cam­era back to an ex­ter­nal mon­i­tor, but Weeks was able to see in­side Blessi’s si­nuses di­rectly via an eye­piece at the end of the scope.

“Ah, there’s the ori­gin of the bleed­ing,” he fi­nally said. “Want to see?”

I took my turn at the eye­piece. There was blood slowly ooz­ing from the bone in what Weeks iden­ti­fied as one of the frontal si­nuses---lo­cated roughly be­tween Blessi’s eyes. “What caused this?” I asked. “Blunt force trauma,” Weeks replied. “Blessi prob­a­bly hit his head on

some­thing---some sort of pas­ture ac­ci­dent. The bleed­ing should stop in the next 24 to 48 hours.”

He went on to ex­plain that this type of in­jury is more fre­quent among young­sters ca­vort­ing about the pas­ture, even flip­ping over and strik­ing their poll on the ground, but adult horses, too, can cer­tainly find ways to crack their heads on fence boards, trees, trailer roofs and other ob­jects. We’d never know what caused Blessi’s in­jury, but he had es­caped his ac­ci­dent with only mi­nor con­se­quences, so it wasn’t par­tic­u­larly im­por­tant.

Weeks packed up his gear and departed for a well-earned hol­i­day. Blessi got his treat.

As pre­dicted, Blessi’s nasal bleed­ing slowed and stopped com­pletely within two days. And I spent my Thanks­giv­ing hol­i­day feel­ing grate­ful that my equine anatomy les­son at Blessi’s ex­pense was noth­ing more than a rel­a­tively sim­ple nose­bleed.

MISHAP: How Blessi in­jured him­self will never be known, but the 20-year-old Ice­landic geld­ing has fully re­cov­ered.

ANATOMY: The equine nasal cav­ity con­nects with a num­ber of other struc­tures, in­clud­ing the trachea and lungs and the eu­stachian tubes lead­ing to the in­ner ear. frontal si­nus nasal cav­ity

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