Unilateral epistaxis

RE: Unilateral epistaxis

Rob Davis — Thu, 02 Mar 2017 19:32:38 GMT

This case is still doing fine with no further episodes so far. As I've just worked out how to save the CT series as a video clip, I though I would post this for interest - it's pretty cool!

https://youtu.be/WXD1qamV_GA

RE: Unilateral epistaxis

Anthony Todd — Fri, 30 Dec 2016 10:04:03 GMT

[quote user="Rob Davis"] I will update if there are any further developments.[/quote]

Thanks Rob, this is an illustration of the big change in the approach to the job compared with "back in the day".

Then, the main aim was to get the animal better via symptomatic relief rather than diagnosis [hence the common practice of steroids ad lib ad infinitum] whereas now the main aim is to get a diagnosis [which, logically, should therefore get the animal better, and quicker].

Classic example is a cat with a PUO, we'd say "probably an undiscovered cat-bite", shot of pen and come back [usually they didn't, so who knows].

Of course, if they did, you'd know it probably wasn't a CBA.....

Now it is many tests etc., usually without any concurrent treatment, until a diagnosis is established.

RE: Unilateral epistaxis

Rob Davis — Fri, 30 Dec 2016 09:28:18 GMT

[quote user="Anthony Todd"]

[quote user="Rob Davis"]The unilateral nature of the presentation with no other signs of bleeding [/quote]

As I said I have no knowledge of the pathology, or the condition, but don't you think, after 10 years there would have been other significant episodes?

Not being argumentative or aggressive but sort of basing it on the history.

[/quote]

My (very limited) understanding of these greyhound coagulopathies is that they don't necessarilly present early in life. They are apparently seen frequently post amputation for osteosarcomas (which are not likely to be young dogs).

[quote user="Anthony Todd"]It just seems to me that this is a one-off bleed, and probably won't ever occur again, or at least not seriously

[/quote]

I hope you are right, and I agree (as I think I said in my initial post) that the history did not suggest a coagulation issue to me.

[quote user="Anthony Todd"]and should be dealt with as such, at least initially.[/quote]

Which is what the owners and I have decided to do. Perhaps my phrasing wasn't clear... I am in no way furstrated with the owners - they are lovely people who I have known for a number of years. I am frustrated (partly on their behalf) that we have been unable to reach a diagnosis despite considerable investment from themselves. Hopefully, as you suggest, this will not matter in the long term. I will update if there are any further developments.

RE: Unilateral epistaxis

Anthony Todd — Thu, 29 Dec 2016 20:03:59 GMT

[quote user="Rob Davis"]The unilateral nature of the presentation with no other signs of bleeding [/quote]

As I said I have no knowledge of the pathology, or the condition, but don't you think, after 10 years there would have been other significant episodes?

Not being argumentative or aggressive but sort of basing it on the history.

It just seems to me that this is a one-off bleed, and probably won't ever occur again, or at least not seriously, and should be dealt with as such, at least initially.

RE: Unilateral epistaxis

Rob Davis — Thu, 29 Dec 2016 19:14:06 GMT

[quote user="Anthony Todd"]

I know nothing about "coagulopathy" but, if you thought that was a real possibility wouldn't it have been a nice thing to test for, and not too expensive [I've no idea]?

Would there not have been other signs which would make one think of a generalised blood problem?

[/quote]

The unilateral nature of the presentation with no other signs of bleeding made me feel that a coagulopathy was not the most likely cause. The absence of changes on CT and the very useful suggestions of others above has made me consider that this is a significant possibility. Unfortunately greyhounds appear to be susceptible to to odd fibrinolytic coagulopathies which will not be dectected on the normal coagulation tests. If there are further episodes of haemorrhage then this will be something that we may need to investigate, but it is unlikely to be straightforward.

RE: Unilateral epistaxis

Anthony Todd — Thu, 29 Dec 2016 18:13:18 GMT

[quote user="Rob Davis"]This wasn't a one-off nose bleed[/quote]

Yes I realised that.

I know nothing about "coagulopathy" but, if you thought that was a real possibility wouldn't it have been a nice thing to test for, and not too expensive [I've no idea]?

Would there not have been other signs which would make one think of a generalised blood problem?

RE: Unilateral epistaxis

Rob Davis — Thu, 29 Dec 2016 17:29:07 GMT

[quote user="Anthony Todd"]I doubt if many single, one-off, "nose bleeds" in humans are ever investigated at all, and I don't imagine the medical profession are frustrated by it.[/quote]

This wasn't a one-off nose bleed. At the initial presentation I did take a "wait and see" attitude as it appeared to be settling on its own. The persistent and relatively severe haemorrhages were not something which the owner (or I) were inclined to ignore (in fact the owner brought the dog in out of hours on the night before the CT scan as she was concerned about the amount of ongoing haemorrhage).

I am delighted that the haemorrhage has settled to a more manageable level, and I will be totally happy if there are no more problems, however I am concerned about the possibility of an ongoing underlying aetiology (such as a coagulopathy) which could cause further serious problems in due course. I have discussed all of this including further possible investigations with the owners, and they have decided they would like to monitor the situation for now. This is a completely reasonable decision, which I agree with. I do feel a little frustration at not having been able to reach a diagnosis, but I do not feel frustration at the owners for their decision.

RE: Unilateral epistaxis

Lucy Fleming — Thu, 29 Dec 2016 12:46:03 GMT

[quote user="Rob Davis"]Her owners report that she has only had a couple of very mild episodes of epistaxis over the last week or so[/quote]

I wouldn't say the only symptom has 'gone' based on that description, but I can appreciate your point. Hopefully they will continue to get milder and less frequent until they have gone, even if it does then remain a mystery.

RE: Unilateral epistaxis

Anthony Todd — Thu, 29 Dec 2016 12:28:38 GMT

[quote user="Lucy Fleming"]The ones which get better without a diagnosis can still be a little frustrating to never 'know', even while being pleased that the animal has made a full recovery![/quote]

You could apply that logic to anything that just gets better.....

I doubt if many single, one-off, "nose bleeds" in humans are ever investigated at all, and I don't imagine the medical profession are frustrated by it.

The chances of getting a diagnosis when the only symptom has gone are remote in the extreme, so I'm with the owner, particularly as it was thoroughly investigated when there was a symptom!

RE: Unilateral epistaxis

Lucy Fleming — Thu, 29 Dec 2016 11:29:50 GMT

[quote user="Anthony Todd"]Not "frustrating" because it's getting better, or "frustrating" 'cos it's hard to justify any more investigations as the animal is obviously getting better?[/quote]

I would say frustrating as there's a chance it may not actually be getting better, but still has an underlying problem which could re-present at any time (just happens not to have had another severe bleed).

The ones which get better without a diagnosis can still be a little frustrating to never 'know', even while being pleased that the animal has made a full recovery!

RE: Unilateral epistaxis

Anthony Todd — Wed, 28 Dec 2016 19:20:45 GMT

[quote user="Rob Davis"] Frustrating, but understandable as she is not insured.[/quote]

Not "frustrating" because it's getting better, or "frustrating" 'cos it's hard to justify any more investigations as the animal is obviously getting better?

Hard enough to diagnose when it was bleeding; even harder when it stopped.....!!

Not surprised the owner declined further examinations and tests!

[see why am concerned that "insurance" is now a diagnostic criterion.....]

RE: Unilateral epistaxis

Rob Davis — Thu, 22 Dec 2016 15:41:42 GMT

Thanks for all the further suggestions. Her owners report that she has only had a couple of very mild episodes of epistaxis over the last week or so, and are not wanting to pursue further investigations at the moment. I will update further in due course if there is any progression, or if I do get to investigate further. Frustrating, but understandable as she is not insured.

RE: Unilateral epistaxis

Aine Seavers — Wed, 21 Dec 2016 23:35:20 GMT

[quote user="Robin Grimmer"]

Worth testing for/treating lungworm?

[/quote]

I would as much because here in Oz, unilateral epistaxis was a marker for heartworm infestation so if lungworm in your area cause coagulation disorders then back off from the head now and start examining rest of the body. Have you done simple in house clotting tests and BMT etc? Sighthounds have high BP as norm(except Irish Wolfhounds) and in additional to 1990s papers on thyroid and hormones esp for GH, there have been quite a few papers in maybe last 6 years going in depth into the breeds overall blood parameters so worth doing a search and have a read of a few of those. Also has the dog been overseas?

RE: Unilateral epistaxis

Robin Grimmer — Wed, 21 Dec 2016 20:09:02 GMT

Worth testing for/treating lungworm?

RE: Unilateral epistaxis

Anthony Todd — Wed, 21 Dec 2016 19:43:09 GMT

[quote user="Rob Davis"]Nothing visible externally, and FB should be visible on CT (if you've never scrolled through a series of CT images, it is incredibly cool and a fantastic imaging tool)[/quote]

Wot? you could define a blade of grass??

If there's too much blood or clot in the nostril, tube patient and blast the clot out with saline.

Someone's going to have to look up the nostril sooner of later....

I suppose someone has pulled back/forward the soft-palate 'cos sometimes the grass or stick is poking out?

The old Mk1 eyeball has it's advantages.

Apologies if all this was done initially.

RE: Unilateral epistaxis

Andrew Kent — Tue, 20 Dec 2016 19:02:38 GMT

Hi Rob,

Thanks for posting the update - sounds like this is going to be one of those frustrating ones.

I would revisit the systemic causes now if you haven't already done so (coagulation + blood pressure).

Next for me would be endoscopy with biopsy (even if nothing visibly abnormal) then potential for tranexamic acid trial.

Last resort in these cases for me if the epistaxis is severe/persistent would be angiography and then potentially targeted embolisation but its exceptionally rare we get that far!

Andy

RE: Unilateral epistaxis

Evelyn Barbour-Hill — Tue, 20 Dec 2016 18:18:06 GMT

Well, maybe there isn't an underlying cause. Maybe there's just a fragile blood vessel.

RE: Unilateral epistaxis

Rob Davis — Tue, 20 Dec 2016 18:05:38 GMT

Update with CT report:

Small amount of soft tissue and mineral attenuating material within the left external ear canal, just lateral to the tympanic membrane
Teeth 206, 208 and 402 are absent
Well defined defects with sharp margins are present withing the buccal aspects of teeth 103, 104, 203, 204 and 211 at the gingival margins. There is mild soft tissue swelling at the level of the defects, which is isoattenuating and contrast enhancing compared to the adjacent gingiva.
Manidbular and medial retropharyngeal lymph nodes are within normal limits.
The brain is symmetrica, with contrast enhancement of the dorsal sagittal sinus and the lateral ventricles are within normal limits for size and location.
The nasal and ethmoturbinates are symmetrical and within normal limits.

Conclusions:

Periodontal disease of 103, 104, 203 and 204 with associated gingivitis
Normal nasal cavities with no aetiology of epistaxis. No eveidence of nasal mass or fungal rhinitis
Absence of 206, 208 and 402
Left mild otitis externa vs horizontal canal debris

No evidence of focus of nasal disease that may cause epistaxis

So back to square one....!

RE: Unilateral epistaxis

Rob Davis — Fri, 16 Dec 2016 17:36:11 GMT

Update: the owner has agreed to pay for a specialist CT report, so will update further once we receive that.

RE: Unilateral epistaxis

Rob Davis — Fri, 16 Dec 2016 09:41:18 GMT

[quote user="Andrew Kent"]I would suggest to them that specialist review of the images would be very useful and that the cost would be minimal compared to the CT. If you really can't convince them feel free to send me the disk and I'll have a look at it with one of our imagers but may take a bit longer.[/quote]

That is a very kind offer, Andy. I will try to persuade them to allow me to send the disc away, but if they really don't want to then I will take you up on your offer. Thank you for the info re tranexamic acid.

[quote user="Anthony Todd"]I suppose there isn't a FB up the nostril and the suspect tooth isn't sensitive when tapped with the fingers end of the scissors?[/quote]

Nothing visible externally, and FB should be visible on CT (if you've never scrolled through a series of CT images, it is incredibly cool and a fantastic imaging tool)

[quote user="Evelyn Barbour-Hill"]

Wot everybody said about coagulopathies, but also: endoscopy. Eyeball the inside there.

Oh, and oldfashioned radiography of the suspect tooth.

[/quote]

I had booked this dog in for endoscopy initially, but we decided given the ongoing haemorrhage at the time that visualisation may be difficult. After discussing the options with the owner we opted for CT as we felt that if we didn't find anything on endoscopy then we were likely to recommend CT as the next step. I would love to radiograph the tooth, but the owners are currently reluctant to spend more money without being fairly certain it will give us the answer. Obviously I can't give any guarantees, so I'm trying to decide what is likely to be the most productive way of spending more money.

[quote user="Hannah Wynne Richards"]

Total novice at reading CT scans, but the tubinates appear finer on 1 side than the other.

Wynne

[/quote]

[quote user="grumpyoldman"]I do remember reading something in the CT book about a daily unilateral fluctuation in the thickness of some dogs nasal mucosal turbinate coverings, that is not always symmetrical and can sometimes be misleading[/quote]

I agree that in this slice the turbinates look assymmetrical, but I am not convinced that this is significant - I think that the slice is slightly oblique and the difference was not apparent in the surrounding slices.

RE: Unilateral epistaxis

Hannah Wynne Richards — Fri, 16 Dec 2016 08:16:49 GMT

Total novice at reading CT scans, but the tubinates appear finer on 1 side than the other.

Wynne

RE: Unilateral epistaxis

Evelyn Barbour-Hill — Fri, 16 Dec 2016 02:22:49 GMT

Wot everybody said about coagulopathies, but also: endoscopy. Eyeball the inside there.

Oh, and oldfashioned radiography of the suspect tooth.

RE: Unilateral epistaxis

Anthony Todd — Fri, 16 Dec 2016 01:52:07 GMT

I suppose there isn't a FB up the nostril and the suspect tooth isn't sensitive when tapped with the fingers end of the scissors?

[I'm sure you've done all this but it wasn't mentioned]

RE: Unilateral epistaxis

grumpyoldman — Fri, 16 Dec 2016 00:40:28 GMT

I do remember reading something in the CT book about a daily unilateral fluctuation in the thickness of some dogs nasal mucosal turbinate coverings, that is not always symmetrical and can sometimes be misleading. Maybe worth going on VIN and checking out Guillermo Couto's work on greyhound coagulopathies.

RE: Unilateral epistaxis

Andrew Kent — Thu, 15 Dec 2016 18:41:15 GMT

Hi Rob,

The dose of tranexamic acid is not really well defined but people tend to use 10-20mg/kg PO every 8-12 hours. The major reported side effect is vomiting but I use it fairly frequently without any observed adverse effects so far. I usually start at 10-15mg/kg PO every 8 hours and adjust depending on response.

I agree that the very unilateral nature does make us more suspicious of a unilateral disease but we do occasionally see systemic causes with unilateral signs, I suspect due to a focal predisposition (like a previously sub-clinical vascular lesion) on one side.

I would suggest to them that specialist review of the images would be very useful and that the cost would be minimal compared to the CT. If you really can't convince them feel free to send me the disk and I'll have a look at it with one of our imagers but may take a bit longer.

Andy