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.
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.