article #2 ce clinical approach to patients with...

pistaxis (from the Greek epi, “on,” andstazo, “to fall in drops”) is defined as hem-orrhage originating from the nose.1 Epi-

staxis is a frequent clinical complaint that mayresult from local (intranasal) or systemic (extra-nasal) causes and often requires extensive med-ical and surgical evaluations to reveal the causeand allow treatment. This article reviews thesignalment, history, physical examination, dif-ferential diagnosis, diagnostic plan, and therapyfor epistaxis in dogs and cats.

SIGNALMENT AND HISTORYInformation about a patient’s signalment and

history may help guide the diagnostic workup.For example, immune-mediated thrombocy-topenia, which can cause epistaxis, occurs mostcommonly in young to middle-aged femaledogs.2 Nasal tumors are more common in ani-mals older than 8 years of age, although nasallymphoma may occur in younger cats.3–5 Fungalrhinitis is seen most often in dogs younger than7 years of age.6 Nasopharyngeal polyps occurmore often in young cats than in older cats.Brachycephalic cats are more susceptible thanmesocephalic cats to chronic viral respiratory

infections.7 A history ofbleeding after tooth loss orelective neutering may indi-cate a congenital coagulationfactor defect or platelet disor-

Clinical Approach to Patients with EpistaxisTracy Gieger, DVM, DACVIM (Internal Medicine and Oncology)Nicole Northrup, DVM, DACVIM (Oncology)University of Georgia

Article #2

ABSTRACT:

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Epistaxis is a common disorder that can have a local or systemic origin. Extensive evalua-tion of patients is often required to determine the diagnosis and includes serologic stud-ies, radiographic imaging, tissue culture, endoscopy with biopsy, and, rarely, surgery. Thisarticle reviews the history, physical examination, differential diagnosis, and diagnostic planfor dogs and cats with epistaxis. Supportive care is instituted until an underlying causecan be identified; therapy, which focuses on management of the underlying cause, isbriefly discussed.

der such as von Willebrand’s disease (vWD).2,8,9

Intact dogs (especially males) that roam are sus-ceptible to transmissible venereal tumors, whichcan be localized in the nose.10

Information about a patient’s environment,vaccination and heartworm status, tick expo-sure, and medications is essential. Outdoor petsare more susceptible than indoor pets to nasaltrauma, parasitic and fungal infections, antico-agulant rodenticide toxicity, and foreign bodyinhalation.7,11–13 Owners should be questionedabout travel to areas endemic for fungi, rick-ettsial organisms, Leishmania spp, and Hepato-zoon spp. Drugs given currently or in the pastshould be reviewed. Aspirin and otherNSAIDs, for example, inhibit platelet function.Trimethoprim–sulfamethoxazole, penicillins,and other antibiotics may cause immune-medi-ated platelet destruction. Chemotherapeuticagents, estrogens, and phenylbutazone maycause myelosuppression and thrombocytopenia.Immune-mediated thrombocytopenia is anuncommon sequela to vaccination.2,9,12–14

An accurate description of the character andchronicity of the epistaxis can help narrow thedifferential list. Intranasal foreign bodies, neo-plasia, dental disease, and fungal rhinitis oftenbegin with unilateral nasal discharge or epi-staxis that becomes bilateral as the disease dis-rupts the nasal septum. Many patients withthese disorders have other clinical signs such as

E

COMPENDIUM 30 January 2004

January 2004 COMPENDIUM

Clinical Approach to Epistaxis 31CE

sneezing, stertorous respiration, gagging or dysphagia,halitosis, and pawing at the face. Bilateral epistaxis mayoccur with intranasal diseases but often indicates sys-temic causes such as coagulopathies, hypertension,hyperviscosity, thrombocytopenia, and thrombocy-topathia.2,3,6,7,9,11–16 Nasal trauma results in acute-onsetand often severe bleeding that resolves with supportivemeasures and does not recur. Hemostatic abnormalitiesrelated to thrombocytopenia, platelet function, or clot-ting factor defects may cause acute-onset epistaxis thatdoes not resolve without appropriate therapy.2,8,9,14

Inhalation of foreign bodies, most commonly woodsplinters or grass awns, often causes an acute-onset epi-staxis, sneezing, and pawing at the face. If foreignobjects remain lodged in the nasal cavity, chronic nasaldischarge may result from granuloma formation.

Chronic or intermittent epistaxis is more commonwith oronasal fistulas, fungal rhinitis, and nasal tumors;often, these diseases begin with mucoid nasal dischargethat later progresses to epistaxis. A history of dental dis-ease may support oronasal fistula formation as causingepistaxis. Allergic rhinitis may cause seasonal nasal dis-charge and epistaxis.7,11–13,15,17

Some patients with nasal disease may not have epi-staxis or nasal discharge initially and can present withclinical signs unrelated to the nasal cavity. Central ner-vous system abnormalities, such as disorientation orblindness, may be seen in hyperviscosity syndromes ornasal tumors invading the brain.3,7,11,15,18 Polyuria andpolydipsia are seen with hyperadrenocorticism, chronicrenal failure, and hyperthyroidism, which uncommonlycause epistaxis secondary to hypertension.11–13,15,17

PHYSICAL EXAMINATIONA careful, thorough physical examination is essential

to prioritize the diagnostic differentials in dogs and cats.The face should be examined for visual or palpableasymmetry and bony defects (Figure 1), which mostoften result from neoplasia or severe fungal rhinitis. Aglass slide or tuft of hair may be held up to the patient’snose to document airflow through the nostrils and mayhelp localize the disease. The eyes should be examined,with gentle retropulsion because mass lesions may pro-duce epiphora, exophthalmos, third eyelid prolapse, anddeviation of the globe. The anterior chamber should beevaluated for uveitis and hemorrhage, and the fundus forchorioretinitis, hypertensive retinopathy, and hypervis-cosity (i.e., tortuous retinal vessels, retinal hemor-rhages).7,11,13,15 Ulceration and depigmentation of the

nasal planum may be seen with aspergillosis or squamouscell carcinoma of the nasal planum.6,19 Polypoid massesextending from the nares are found with rhinosporidio-sis, phaeohyphomycosis, cryptococcosis, and, rarely,tumors.16,20–22 Cats with nasal cryptococcosis often have acharacteristic convexity of the nose (Roman nose).16

The mouth should be visually inspected and palpatedfor palate deformity or masses, oronasal fistulas, andloose teeth. Regional lymph nodes should be palpatedfor enlargement caused by infection, inflammation, ormetastatic neoplasia. A thorough evaluation of the skinand mucous membranes, body cavities, and joints isindicated to search for evidence of coagulopathy. Ani-mals with petechia, mucosal bleeding, melena, or fundichemorrhages are likely to have a defect of primaryhemostasis (platelets), whereas those with hemarthrosis,hematomas, or bleeding into body cavities are likely tohave a defect of secondary hemostasis (coagulation fac-tors). Melena and hematemesis may occur when bloodfrom the nasopharynx is swallowed.2,8,9,11–15

DIFFERENTIAL DIAGNOSISThe differential diagnosis for epistaxis can be divided

into local (intranasal) and systemic (extranasal) causes(see box on p. 32). Local disease may progress and pro-duce systemic complications that can exacerbate bleeding.

Local ProcessesLocal processes are the most common cause of epi-

staxis. Blood vessels may rupture after direct trauma or

Figure 1. Facial deformity in a dog with intranasalundifferentiated carcinoma. Note the third eyelid protrusion,exophthalmos, and deviation of the globe caused by a tumor.

COMPENDIUM January 2004

Clinical Approach to Epistaxis32 CE

Causes of Epistaxis2–40

Local processes

Trauma

Neoplastic or benign massesEpithelial: adenocarcinoma, undifferentiated

carcinoma, squamous cell carcinoma, polypsMesenchymal: chondrosarcoma, fibrosarcoma,

hemangiosarcoma, osteosarcoma, melanomaRound cell: lymphoma, transmissible venereal tumor,

mast cell tumor, plasmacytoma

InfectionFungal: cryptococcosis, aspergillosis, penicilliosis,

rhinosporidiosis, pythiosis, phaeohyphomycosisParasitic: nasal mites (P. caninum), nasal nematode

(E. boehmi), L. serrata, Cuterebra species, Leishmaniaspecies

Bacterial: primary (Bordetella, Pasteurella, Mycoplasma species) or secondary

Viral: feline viral rhinotracheitis and calicivirus

Inflammatory diseaseLymphoplasmacytic: primary or secondary (e.g., to

neoplasia, fungal disease, parasites)Eosinophilic: allergic rhinitis

Dental diseaseTooth root abscessOronasal fistula

Foreign body

Vascular malformation

Systemic processes

Thrombocytopenia

Decreased productionInfectious: ehrlichiosis, FeLV, FIV, Rocky Mountain

spotted fever, hepatozoonosis, septicemia,endotoxemia, leishmaniasis

Drugs: cytotoxic agents, estrogens, sulfa drugs,methimazole, phenobarbital

Neoplasia: myelophthisis secondary to myeloproliferative or lymphoproliferative diseases,hyperestrogenism (secondary to Sertoli cell andgranulosa cell tumors)

Other causes: bone marrow aplasia, cyclic

thrombocytopenia, myelofibrosis, myelodysplasia,toxins, osteosclerosis, idiopathic

Increased destructionImmune mediated: idiopathic or secondary to drugs,

neoplasia, infection, vaccinesMicroangiopathy: shearing of platelets, associated

with hemangioma or hemangiosarcoma

SequestrationNeoplasia: large vascular tumors, lymphoma Splenomegaly or splenic torsionHepatomegaly

Increased consumptionDICVasculitis: rickettsial infections, neoplasia, heartworm

disease, bacteremia, uremia, cutaneous and renalglomerular vasculopathy of greyhounds

Hemorrhage

ThrombocytopathiaCongenital: vWD, platelet procoagulant activity

deficiency in German shepherds, Glanzmann’sthrombasthenia in Great Pyrenees, basset houndand foxhound thrombopathia, others

Acquired: vWD (associated with hypothyroidism),uremia, dysproteinemia (associated with multiplemyeloma, ehrlichiosis, leishmaniasis), drugs(NSAIDs, phenothiazines), polycythemia vera

Coagulation factor deficiencyCongenital: hemophilia A (factor VIII deficiency) and

B (factor IX deficiency), othersAcquired: anticoagulant rodenticide toxicity, liver

failure, DIC

Increased capillary fragilityHypertension: primary or secondary to chronic

renal failure, glomerulonephropathies,hyperadrenocorticism, hyperthyroidism,hypertrophic cardiomyopathy, pheochromocytoma

Hyperviscosity syndrome: secondary to multiple myeloma, ehrlichiosis, polycythemia (primary orsecondary to hypoxia or neoplasia), leukemias

HyperlipidemiaThromboembolic diseaseNeoplastic invasion of blood vessels

erosion by infection, inflammation, or neoplasia. Traumais generally readily diagnosed on the basis of acute onset,history, and other signs. A thorough evaluation for centralnervous system, cardiovascular, and orthopedic injuries isindicated because head trauma severe enough to result inepistaxis often damages other organ systems.7,11–13,15

Inhalation of foreign bodies (commonly grass awns,wood splinters, and small household objects) can resultin acute onset of sneezing, head rubbing, and pawing atthe face. If objects are not sneezed out, swallowed, orremoved endoscopically, granuloma formation mayresult and lead to an often protracted course of nasal



discharge, sneezing, and epistaxis. Foreign bodies pres-ent for longer than a few hours may become covered bymucus, blood, or granulation tissue and may be over-looked during rhinoscopy.7,11–13,15,23,24

Nasal tumors should be the primary diagnostic differ-ential in older animals with an intermittent, progressivehistory of nasal discharge and epistaxis.7,11–13,15 Thesetumors are locally invasive and destructive (Figures 2and 3) and sometimes result in clinically detectablemetastasis to regional lymph nodes and the lungs.3 Indogs, carcinomas make up approximately two-thirds ofintranasal cancers, the remainder being sarcomas and,rarely, round cell tumors.3,5 Feline intranasal tumors aremostly lymphomas and carcinomas; lymphomas usuallyaffect younger cats (mean age: 9.6 years) and adenocar-cinomas older cats (median age: 14.9 years).4 Benigntumors are uncommon except for nasopharyngeal polypsin cats. The workup for nasal tumors ideally includescomputed tomography (CT) or magnetic resonanceimaging (MRI) and biopsy.3

Nasal aspergillosis and penicilliosis, with similar clini-cal appearances, are distinguished only by tissue culture.6

These infections are generally confined to the nasal cav-ity and paranasal sinuses, where they cause turbinatedestruction and erosion of the nasal mucosa and thusnasal discharge and epistaxis (Figures 4 to 7). Most

patients are dogs younger than 7 years of age. Intermit-tent, chronic nasal discharge and epistaxis, nasal planumulceration and depigmentation, and facial pain second-ary to bone destruction are seen in dogs.6,7,11–13 No singletest is diagnostic for nasal aspergillosis or penicilliosis,and false-positive and -negative results occur often.These fungi are common in the environment, so positiveserologic and culture results may be misleading. Of dogswith nasal tumors, 40% reportedly had positive cultureresults for either Aspergillus or Penicillium spp; therefore,the workup for these infections should include a searchfor neoplasia. Evaluation of history, signalment, rhino-scopic findings (i.e., presence of white, yellow, or greenfungal mats), culture, and histopathology documentinginfiltration of fungal hyphae into tissues is essential fordiagnosis. Therapy most often involves topical localinfusion of clotrimazole; systemic antifungal agents arerarely indicated.6,25

Fungal rhinitis caused by Cryptococcus neoformans ismore common in cats than in dogs.16 The organism isinhaled, induces nasal granuloma formation, and candisseminate into the central nervous system and otherorgans. Granulomas appear as polyps protruding fromthe nose or as intranasal polyps, leading to a characteris-tic convex shape (Roman nose) over the bridge of thenose.7,15,16 Many cats present with signs related only tothe nasal cavity and then develop systemic signs. Diag-nosis is based on identification of the organism in nasal

Figure 2. CT scan of a dog with intranasaladenocarcinoma. Note that the mass fills the entire right sideof the nasal cavity and bulges into the left side, thus causingdeviation of the vomer.

Figure 3. Rhinoscopic image of the dog in Figure 2.Biopsy of the mass revealed adenocarcinoma.



Figure 5. CT scan of the dog in Figure 4. Noteinvolvement of the sinuses (arrows), the presence of abnormal softtissue opacities in both sides of the nasal cavity, and destructionof the turbinates.

discharge or histologic tissues and/or serology. Wright’sstain and India ink may be used for cytologic identifica-tion. Detection of cryptococcal capsular antigen by thelatex agglutination test is sensitive and specific for diag-nosis and useful for therapeutic monitoring. Therapymay include surgical debulking of large lesions in addi-tion to systemic antifungal therapy.16

Rhinosporidiosis and phaeohyphomycosis are uncom-mon, generally localized fungal diseases that often pres-ent with polypoid masses protruding from the nose andmay be well controlled with surgery or antifungal ther-apy.20–22 The rare nasopharyngeal pythiosis affects ani-mals in subtropical climates and is difficult to treat.26

Infestations include disease caused by Pneumonyssoidescaninum, a small (1 mm) mite that infests the caninenasal cavity and sometimes causes head shaking, violentsneezing, nasal discharge, and epistaxis; other animalsare asymptomatic. Diagnosis is based on observation ofmites during rhinoscopy or of parasite ova in nasal flushfluid or fecal flotations.11–13,27 Successful treatment withivermectin has been reported. The nematode Eucoleusboehmi infests the nasal mucosa and sinuses; worms arelarge (1.5 to 4 cm), visible endoscopically,28 and treatedwith ivermectin. Cuterebra larvae may be found in thenasal cavity; therapy consists of removal of the organ-ism.11,27 Dogs become infected with Linguatula serrata, a

nasal parasite, by ingesting viscera of infected sheep andcattle. Leishmania is a protozoan that produces a sys-temic illness secondary to induction of hyperglobuline-mia, vasculitis, and organ dysfunction and may causeepistaxis because of inflammatory and ulcerative lesionsin the nasal mucosa.29

Lymphoplasmacytic rhinitis can be a primary diseaseentity, and it often accompanies neoplastic and fungalrhinitis. Diagnosis depends on ruling out other diseaseson the basis of a workup and histologic evidence ofinfiltration of mature lymphocytes, plasma cells, andother inflammatory cells into the nasal mucosa and sub-mucosa. Immunosuppressive doses of corticosteroidsand, in some cases, other immunosuppressive therapiesare used. If the animal’s condition worsens despite ther-apy or only a minimal response to therapy is achieved,reevaluation for another disease process is indicated.30

Allergic rhinitis is a hypersensitivity response to anti-gens; as in lymphoplasmacytic rhinitis, underlying dis-eases must be excluded. If a relationship between a par-ticular antigen and onset of clinical signs is identified,therapy could include removal of the offending sub-stance. Biopsy reveals eosinophilic inflammation.Steroids and antihistamines are useful.30,31

Animals with oronasal fistulas or tooth root abscesses

Figure 4. Endoscopic image of a dog with fungal rhinitis.Biopsy samples of the yellow plaque were diagnostic for nasalaspergillosis.



may develop nasal discharge or epistaxis.7,11–13,15 A peri-odontal probe should be used to examine all maxillaryteeth to identify disease sites and to look for communi-cation between these areas and the nasal cavity.

Occasionally, animals develop sporadic, self-limitingepistaxis associated with environmental humiditychanges (i.e., dry air) or mild, intermittent epistaxisrelated to a small intranasal ulceration with no underly-ing etiology. Cats with upper respiratory infectionsuncommonly develop chronic nasal discharge andsneezing and thus intermittent epistaxis.7 Rupture ofarteriovenous malformations is a rare cause of sudden-onset epistaxis.32 Bleeding can also occur after repeatedviolent sneezing of any cause.

Systemic ProcessesPrimary hemostatic defects (platelet plug formation)

include thrombocytopenia and thrombocytopathia.2,9,14

Epistaxis is often associated with platelet defects andlikely related to the paucity of tissue between the bloodvessels and nasal mucosa.9 Mechanisms of thrombocy-topenia include decreased production, increased destruc-tion, sequestration, and increased consumption. Sponta-neous bleeding is uncommon unless the platelet count is30,000/µl or less. Decreased platelet production canresult from neoplastic conditions that lead to myelo-phthisis or hyperestrogenemia as well as from viral, rick-ettsial, protozoal, parasitic, or bacterial infections; drugs;toxins; idiopathic factors; or immune-mediated destruc-tion of megakaryocytes. Increased platelet destructionmay be immune-mediated (primary or secondary) orrelated to microangiopathy (seen with hemangiosar-

coma). Platelet sequestration in the spleen, liver, or largevascular tumors results in thrombocytopenia. Increasedplatelet consumption occurs with disseminated intravas-cular coagulopathy (DIC), vasculitis, and severe hemor-rhage. Thrombocytopathia may be primary (vWD) orsecondary to uremia, dysproteinemias (e.g., associatedwith ehrlichiosis and multiple myeloma), or use of drugssuch as NSAIDs.

Secondary hemostatic (coagulation factor) defectsusually result in bleeding into body cavities and ecchy-mosis but occasionally produce mucosal bleeding andepistaxis. These disorders include congenital abnormali-ties such as hemophilia A (factor VIII deficiency) and B(factor IX deficiency) and acquired coagulopathies suchas anticoagulant rodenticide toxicity (resulting in loss offactors II, VII, IX, and X) and hepatic failure (withdecreased coagulation factor production). Increased cap-illary fragility with subsequent rupture can result fromhypertension, neoplasms invading blood vessels, hyper-viscosity syndromes, hyperlipidemia, and thromboem-bolic disease.2,9,14

Figure 6. Lateral oblique radiograph of a dog with nasalaspergillosis. Note increased opacity within the left frontal sinusand destruction and irregularity of the frontal bone (arrows).

Figure 7. Open-mouth ventrodorsal radiograph of a dogwith nasal aspergillosis. Increased soft tissue opacity is visiblewithin both sides of the nasal cavity, and the normal trabecularpattern of the turbinates is absent.The left side is more severelyaffected.



DIAGNOSTIC PLANA detailed history and physical examination are essen-

tial for a proper diagnostic plan (see box on this page). Iffindings strongly indicate intranasal disease, first testsmay focus on the nasal cavity. An initial minimum data-base, including complete blood cell count (CBC) withplatelet count, chemistry profile, and urinalysis, isneeded before induction of anesthesia. A coagulogramand buccal mucosal bleeding time (BMBT) are requiredbefore nasal biopsy because of possible severe complica-tions of a coagulopathy. Examination of oral and nasalcavities with an endoscope or dental mirror with lightsource, radiographs of the nasal cavity and thorax, CTor MRI of the nasal cavity, flushing of the nose, cytol-ogy of nasal discharge, staining with India ink (forCryptococcus organisms), fungal serology, and nasalbiopsy will most likely yield diagnostic information.Nasal cultures are infrequently useful because bacterialcontaminants are usually abundant in the nose.7,23,33–35

Clinical signs and initial laboratory data may supportthe possibility of systemic disease.

Complete Blood Count, IncludingPlatelet Count

The CBC is normal in many cases of epistaxis, butabnormalities may help pinpoint the cause. Regenerativeanemia (significant reticulocytosis) indicates bone mar-row response to bleeding and usually occurs within 3 to5 days of blood loss; with chronic epistaxis, iron defi-ciency with nonregenerative anemia may occur.36

Leukocytosis is generally nonspecific and may resultfrom chronic inflammation or infection. Leukopeniamay result from infections, cytotoxic drug administra-tion, immune-mediated disease, or sepsis.37 Increaseddestruction or consumption, sequestration, or decreasedproduction of platelets can cause thrombocytopenia.Evaluation of a blood smear may be useful until labora-tory test results are available: normal dogs and cats have10 to 15 platelets per 100× oil immersion field (1platelet per oil immersion field indicates a platelet countof approximately 20,000/µl). Macroplatelets suggestregeneration associated with peripheral platelet destruc-tion or consumption; these platelets may be more func-tional than normal, which explains why dogs withplatelet counts less than 10,000/µl often do notbleed.2,9,14 A bone marrow aspirate or core biopsy is indi-cated in cases of unexplained nonregenerative anemia,thrombocytopenia, or leukopenia or when abnormalcells are found in circulation.

Chemistry ProfilePanhypoproteinemia may result from chronic blood

loss. Hyperglobulinemia may occur secondary to neo-plasia or chronic infections. Serum protein elec-trophoresis can document a monoclonal or polyclonalgammopathy. Monoclonal gammopathies occur withmultiple myeloma, chronic ehrlichiosis, lymphoma,

Clinical Approach to Patients withEpistaxis7,11–13,15,30,33–35

Initial evaluationCompletion of these tests should help the clinicianlocalize the disease to the nasal cavity and rule outsystemic processes:

HistoryPhysical examinationCBC, including platelet countSerum chemistry panelUrinalysisCoagulation panel, with tests for clotting factors if

coagulation results are abnormalBMBT, with von Willebrand’s factor assay if BMBT

results are abnormalRickettsial serology: Ehrlichia, Rickettsia, Borrelia sppFecal flotation for detection of parasite ovaIndirect blood pressure measurementCytology of nasal discharge to examine for

Cryptococcus sppCryptococcus LCATViral testin (cats): FeLV, FIV, ± herpesvirus, calicivirusThoracic radiographyHeartworm serology

Secondary evaluationIf initial tests do not reveal evidence of systemic disease,epistaxis can be localized to the nasal cavity. Generalanesthesia is required for the following procedures:a

Oral examinationNasal radiography, CT, or MRIRhinoscopyNasal biopsy (even if lesions are not seen via

diagnostic imaging or rhinoscopy)Culture of deep biopsy specimens for fungi and

bacteriaNasal cavity flush for parasite ova, foreign bodies, and

tissueaIf these procedures yield inconclusive results, referral for CTor MRI is indicated. If mass lesions are present and biopsy isinconclusive for neoplasia or fungal disease, another biopsyprocedure may be indicated. Rhinotomy and turbinectomy areconsidered only when repeated biopsies of mass lesions giveinconclusive results or when foreign bodies cannot be removedendoscopically.



leukemias, and macroglobulinemia.18 Evidence of renal, hepatic, or endocrinedisease that can cause or exacerbate epistaxis may be present, and abdominalultrasonography, endocrine testing, and other diagnostic tests may be required.

UrinalysisMetabolic, neoplastic, and infectious diseases that result in epistaxis can also

cause glomerulonephropathies with subsequent proteinuria.38 A urinary pro-tein:creatinine ratio should be determined when proteinuria and an inactiveurine sediment are found. Bladder mucosal bleeding and hematuria may beseen with thrombocytopenia and thrombocytopathia.2,9,14

Hemostatic StudiesBMBT is a useful in-hospital test of platelet function and is reliable when

platelet counts are higher than 100,000/µl. Abnormal results should prompt asearch for a cause of thrombocytopathia, including von Willebrand’s titer and

evaluation for secondary causes of platelet function defects. Coagulation studies,such as partial thromboplastin time (for the intrinsic clotting cascade), prothrom-bin time (for the extrinsic clotting cascade), and activated clotting time (for theintrinsic clotting cascade and platelet function), should be considered if plateletabnormalities have been ruled out. If coagulograms are abnormal, tests for specificclotting factors and PIVKA (proteins inhibited by vitamin K antagonists) shouldbe considered. A coagulogram should also include fibrinogen, fibrin degradationproducts, and an antithrombin III concentration to reveal evidence of DIC.2,9,14

Thoracic RadiographsThoracic radiographs are usually normal in patients with intranasal disease

but can uncover systemic fungal disease and metastatic neoplasia. They shouldbe obtained before use of anesthesia and further workup.15

SerologyEhrlichiosis and Rocky Mountain spotted fever are diagnosed via immuno-

fluorescent antibody testing.39 Aspergillus spp antibody titers are nonspecific butsupport a diagnosis of fungal rhinitis when positive in a patient with a positivefungal culture as well as historical, radiographic, histologic, cytologic, andendoscopic signs of nasal aspergillosis. A negative Aspergillus spp titer does notrule out the disease.6 A latex agglutination test for Cryptococcus spp capsularantigen is useful for diagnosis and therapeutic monitoring.16 Tests for FeLVand FIV are indicated when viral status is unknown.40 Thyroxine levels shouldbe part of the minimum database for cats older than 6 years of age. Heartwormtesting is indicated in areas with endemic disease.

Supportive care is needed untilthe underlying cause can be

identified and treated.

Fecal FlotationFecal flotation can reveal parasite ova, which may be

swallowed when parasites infest the nasal cavity.27

Blood PressureWhen hypertension is suspected as a contributing

cause of epistaxis, blood pressure is commonly evaluatedby using indirect Doppler or oscillometric methods.12,13

Documented hypertension should prompt endocrinetesting and a search for the primary cause via abdominaland cardiac ultrasonography.

ImagingImaging studies are performed before rhinoscopy to

avoid difficulties in interpreting iatrogenic lesions (i.e.,bleeding induced by biopsy). Images should be examinedfor asymmetry, mass lesions, bony lysis, increased fluiddensity, loss of turbinates, dental abnormalities, andradiodense foreign bodies. This information can indicatedisease location, demonstrate severity, and guide biopsyprocedures. Nasal radiographs require general anesthesiafor proper positioning and should include lateral,oblique, open-mouth ventrodorsal, intraoral, and frontalsinus views. Dental radiographs are indicated for sus-pected tooth root abscesses. A tympanic bulla series isneeded for cats with suspected nasopharyngeal polyps.CT and MRI are superior to radiography for nasal dis-ease because they allow visualization of and contrastbetween bony and soft tissue lesions and they can imageall areas of the mouth, pharynx, and nose, includingturbinates, nasal septum, cribriform plate, and sinuses,

which allows assessment of disease extent. Uptake ofcontrast material by tumors can distinguish them frommucus, although not all tumors enhance after use of con-trast material. CT or MRI is essential for planningradiotherapy for neoplasia.3,5,7,12,13,34,35

RhinoscopyRhinoscopy allows visualization of foreign bodies,

mass lesions, turbinate erosion, fungal plaques, oronasalfistulas, and nasal parasites.23,24,33,34 A 1992 study exam-ined the usefulness of rhinoscopy and rhinoscopy-assisted mucosal biopsy in 119 dogs. In 83% of evaluablecases, rhinoscopy with biopsy provided a definitive diag-nosis; in 10 cases, rhinoscopy alone provided a definitivediagnosis (foreign bodies, oronasal fistula, and P. can-inum infection). Although prolonged hemorrhage afterbiopsy was the most common complication, it occurredin only two dogs, one of which died.23

If a coagulopathy has been ruled out, rhinoscopy isperformed after the imaging studies, with the animalunder general anesthesia and use of a cuffed endotra-cheal tube. When a foreign body is strongly suspected,rhinoscopy may be performed as one of the first tests(Figures 8 and 9). Instruments such as dental mirrors,spay hooks, and otoscopes provide limited visualizationof the nasal cavity and oropharynx but may assist in



Figure 8. CT scan of a 3-year-old female pug withacute-onset epistaxis. A soft tissue to mineral hollow sphericaldensity is seen within the right choana (arrows). Note lysis of thehard palate ventral to the object.

Figure 9. Endoscopic examination of the dog in Figure 8revealed the presence of a foreign body—a popcornkernel. The object is being retrieved with a grasping forceps.

diagnosis of foreign bodies and large tumors. Rigid(1.9- or 2.7-mm external diameter) or flexible (3.2- or6.6-mm external diameter) endoscopes are required fora full examination and are useful for retrieving foreignbodies and collecting biopsy and deep tissue specimensfor culture. The largest scope available that fits thepatient is generally preferred.

Narrow rigid scopes are best for visualization throughexternal nares. The distance from the medial canthus tothe nostril opening should be identified before entryinto the nose, and the scope should not be advancedpast this point to avoid cribriform plate penetration.The least-affected side should always be examined first,and the evaluation should begin ventrally and move dor-sally in case of iatrogenic hemorrhage. Each nasal mea-tus should be evaluated, with the scope advanced as cau-dad as possible without causing hemorrhage. A flexiblescope is retroflexed and introduced into the pharynx,hooked above the soft palate, and then advanced ros-trally to allow visualization of the choanae.24

The oropharynx and oral cavity should be thoroughlyevaluated. The entire nasal cavity including the frontalsinuses (if possible) should be examined for masses, for-eign bodies, fungal or inflammatory plaques, parasites,and polyps. The presence of blood, excess mucus, andinflamed mucosa can interfere with visualization oflesions and foreign objects. Saline flushes may be used totry to clear mucus or blood but may further impair theview. Endoscopic visualization of the full nasal cavity isnot possible, and lesions may be overlooked.7,23,24,33,34

Nasal Swabs, Flushing, and BiopsyResults of cytologic studies of nasal discharge are gen-

erally nonspecific, but these assays should be performed

early in a workup in cats because Cryptococcus organismscan easily be identified when stained with India ink.16

Nasal cavity flushing is performed with the animalunder anesthesia, after the oropharynx has been packedwith gauze sponges and the head is positioned ventrallyto avoid aspiration of blood or fluid. Sponges shouldalways be counted before placement in the oropharynxto ensure that all are removed at the end of the proce-dure, before extubation. A flexible endoscope or redrubber catheter retroflexed behind the soft palate maybe used to flush approximately 100 ml of sterile salinerostrally through the nose. The fluid, collected in abowl, is evaluated via cytologic studies; pieces of tissuemay be submitted for histopathology. Foreign bodiesmay be retrieved, and parasitic ova in the fluid may beevident by microscopy.7,34,35

Biopsy should follow rhinoscopy. The clinician shouldtry to sample the most obvious lesion first because sub-sequent bleeding often precludes further visualization. A“blind” method may be used if visualization is difficultbecause of hemorrhage or the patient ’s small size.Biopsy instruments include alligator or pituitary-cupforceps (Figure 10). Before the forceps is advanced intothe nose, it should be marked with tape at the premea-sured distance between the medial canthus and theexternal nares to avoid cribriform plate penetration(Figure 11). For mass lesions, a closed instrument ispassed toward the lesion; when the mass is reached (i.e.,resistance is felt), the instrument is opened to grasp apiece of the lesion.



Figure 10. Biopsy forceps. Figure 11. Blind nasal biopsy. The instrument seen inFigure 10 was used. Before the forceps was introduced into thenose, it was marked with tape at a premeasured distancebetween the medial canthus and the external nares to avoidcribriform plate penetration. Note that the patient’s head isventroflexed and an endotracheal tube is in place.

At least 6 to 10 pinch biopsy samples should beobtained to increase the probability of obtaining a diag-nostic sample. If lesions are not seen via imaging orrhinoscopy, multiple biopsy samples throughout thenose should be obtained. Most such specimens are small(about 5 × 5 mm), so pieces of tissue should be placed inmarked cassettes (i.e., right and left sides) before put-ting them in formalin. Occasionally, blind biopsy of thenose yields larger pieces of turbinate, usually accompa-nied by significant bleeding. A larger core biopsy speci-men may be obtained from a mass lesion by using theplastic sleeve of an IV catheter or spinal needle or alarge polypropylene male dog urinary catheter. Thesleeve is cut at a 45˚ angle to allow penetration of themass and is fitted to a 12- or 20-ml syringe. Negativepressure is applied to the syringe while the mass ispunctured so that a core of tumor remains in the sleeve.3

Incisional or Tru-Cut biopsy or aspiration of hardpalate defects or areas of facial deformity may help deter-mine a diagnosis. Touch preparations of the biopsy tissueon slides for cytologic examination may hasten the diag-nosis and are especially helpful for fungal identification.

Clinicians should be aware that most nasal tumors areaccompanied by severe inflammation, which oftenmakes cytologic (and sometimes histologic) diagnosisdifficult. Client education is essential before biopsybecause many patients with nasal disease must undergorepeated procedures. If biopsy of mass lesions does notsupport a diagnosis of neoplasia, another endoscopicbiopsy and more aggressive biopsy techniques, such assinus trephination or rhinotomy, may be indicated.

Complications of nasal biopsy that should be antici-pated include life-threatening hemorrhage, aspiration ofblood, and neurologic signs in the case of cribriformplate penetration. Careful monitoring and treatment ofhemorrhage and pain should be instituted. Digital pres-sure and packing the nasal cavity with sponges are help-ful for mild hemorrhage until bleeding subsides. Extracaution is needed to ensure that all blood clots are suc-tioned or removed from the pharynx before extubation.IV fluid support should be provided to replace volume

loss. Severe or intractable bleeding necessitates flushingthe nose with dilute epinephrine (1:100,000); packingthe entire nasal cavity and pharynx with sponges or tam-pons; applying ice packs or cold saline flushes to thenose; and, rarely, carotid artery ligation.7,12,13,23,24,33,34

CultureNasal cultures are generally not recommended because

primary bacterial rhinitis is rare and secondary over-growth of normal nasal flora is common. If needed, cul-tures may be obtained via nasal swabs, flushing, or tissueculture; the last is most likely to reveal true nasal cavityflora. A superficial nasal swab is likely to yield growth ofnormal flora, including Escherichia coli, Streptococcus spp,and Pasteurella spp. Growth of one or two species morelikely represents an abnormality, whereas growth of mul-tiple bacteria is usually normal, so the laboratory shouldbe advised to report all growth. Antibiotic treatment mayimprove clinical signs and can give a false sense of dis-ease resolution, with an ultimate delay in definitive diag-nosis and therapy. Growth of Aspergillus and Penicilliumshould be interpreted in light of other findings, such as

the presence of fungal plaques, radiographic evidence ofbony destruction, and presence of organisms infiltratingtissues, for a diagnosis of fungal rhinitis, as these organ-isms may represent normal flora or may cause a second-ary infection related to an underlying neoplasm.6,7,33–35

Exploratory Rhinotomy with TurbinectomyIf all the tests just described do not lead to a definitive

diagnosis, or a foreign body cannot be removed viarhinoscopy, options include repeating the tests imme-diately or in 1 to 2 months or pursuing exploratoryrhinotomy.34,35 Although some clinicians may pursuemedical therapy for infectious or inflammatory causes(e.g., antibiotics for bacterial rhinitis and corticosteroidsfor inflammatory rhinitis) before diagnostics, the under-lying disease will likely progress. Antibiotics andcorticosteroids may eliminate clinical signs but ulti-mately delay diagnosis and may hasten the patient’sdemise, especially if neoplasia or fungal rhinitis exists.



In young animals, epistaxis most commonly results fromtrauma, foreign body inhalation, or fungal rhinitis; in older

patients, neoplasia is the top diagnostic differential.

Exploratory rhinotomy may be the only way to defini-tively diagnose small tumors or foreign bodies.34,35 Ifaspergillosis is strongly suspected, catheters can beplaced in the sinuses at the same time for future anti-fungal therapy.6,25 Potential benefits of surgery must out-weigh potential complications, including hemorrhage,subcutaneous emphysema, inadvertent entry into thebrain, and recurrent nasal cavity infections.33–35

TREATMENTThe goal of treatment is to control epistaxis until a

definitive diagnosis and therapeutic plan for the primarycause can be determined. Treatments including cage rest,ice packs, application of pressure to the nose, and seda-tion may help control hemorrhage. Use of sedatives suchas acepromazine, diazepam, and butorphanol at lowdoses may help relieve anxiety, but care should be takento avoid causing hypotension. In animals that have suf-fered trauma or are obtunded, blood should be suctionedfrom the oropharynx to prevent its aspiration. Instillationof phenylephrine (10 mg/ml; 0.1 ml in 1 ml of 0.9%NaCl) into the nose may resolve hemorrhage. In severecases, general anesthesia and packing the nasal cavity andoropharynx with dilute (1:100,000) epinephrine-soakedsponges or tampons or ligation of the external carotidartery on the affected side or both sides may help controlbleeding. In animals with severe acute hemorrhage, IVfluid therapy and packed erythrocytes may be needed.12,35

If a coagulopathy is suspected, transfusions of wholeblood or fresh-frozen plasma or both are indicated. Inthrombocytopenic animals, transfusions rarely supplyadequate platelet numbers to stop bleeding.2,9,14

REFERENCES1. Stedman TL: Stedman’s Medical Dictionary. Baltimore, Williams & Wilkins,

1990.

2. Couto CG: Disorders of hemostasis, in Nelson RW, Couto CG (eds): SmallAnimal Internal Medicine, ed 2. St. Louis, Mosby, 1998, pp 1197–1206.

3. Lana SE, Withrow SJ: Nasal tumors, in Withrow SJ, MacEwen EG (eds):Small Animal Clinical Oncology, ed 2. Philadelphia, WB Saunders, 2001, pp370–377.

4. Mukaratirwa S, van der Linde-Sipman JS, Gruys E: Feline nasal and para-nasal sinus tumors. J Feline Med Surg 3:235–245, 2001.

5. Theon AP, Madewell BR, Harb MF, et al: Megavoltage irradiation of neo-plasms of the nasal and paranasal cavities in 77 dogs. JAVMA 202(9):1469–1475, 1993.

6. Sharp NJH: Canine nasal aspergillosis/penicilliosis, in Greene CE (ed): Infec-tious Diseases of the Dog and Cat, ed 2. Philadelphia, WB Saunders, 1998, pp404–407.

7. Forrester SD, Jones JC, Noftsinger MH: Diagnostically evaluating cats withnasal discharge. Vet Med: 543–551, 2002.

8. Brooks M: Hereditary bleeding disorders in dogs and cats. Vet Med 90:555–564, 1999.

9. Tvedten H, Kociba G: Hemostatic abnormalities, in Willard MD, TvedtenH, Turnwald GH (eds): Small Animal Clinical Diagnosis by Laboratory Meth-ods, ed 2. Philadelphia, WB Saunders, 1994, pp 75–89.

10. MacEwen EG: Transmissible venereal tumor, in Withrow SJ, MacEwen EG(eds): Small Animal Clinical Oncology, ed 2. Philadelphia, WB Saunders,2001, pp 651–656.

11. Forrester SD, Noftsinger MH: Initial approach in dogs with nasal discharge.Vet Med: 521–527, 2002.

12. Mahony O: Bleeding disorders: Epistaxis and hemoptysis, in Ettinger SJ,Feldman EC (eds): Textbook of Veterinary Internal Medicine, ed 5. Philadel-phia, WB Saunders, 2000, pp 213–217.

13. Dhupa N, Littman MP: Epistaxis. Compend Contin Educ Pract Vet 14(8):1033–1041, 1992.

14. Feldman BF, Thomason KJ, Jain NC: Quantitative platelet disorders. Vet ClinNorth Am 18(1):35–49, 1988.

15. Hawkins EC: Clinical manifestations of nasal disease, in Nelson RW, CoutoCG (eds): Small Animal Internal Medicine, ed 2. St. Louis, Mosby, 1998, pp206–213.

16. Jacobs GJ, Medleau L: Cryptococcosis, in Greene CE (ed): Infectious Diseasesof the Dog and Cat, ed 2. Philadelphia, WB Saunders, 1998, pp 383–390.

17. Taylor SM: Polyuria and polydipsia, in Ettinger SJ, Feldman EC (eds): Text-book of Veterinary Internal Medicine, ed 5. Philadelphia, WB Saunders, 2000,pp 85–89.

18. Werner LL, Turnwald GH: Immunologic and plasma protein disorders, inWillard MD, Tvedten H, Turnwald GH (eds): Small Animal Clinical Diagnosisby Laboratory Methods, ed 2. Philadelphia, WB Saunders, 1994, pp 248–256.

19. Rogers KS, Helman RG, Walker M: Squamous cell carcinoma of the caninenasal planum: Eight cases (1988–1994). JAAHA 31:373–378, 1995.

20. Wallin LL, Coleman GD, Froeling J, et al: Rhinosporidiosis in a domesticcat. Med Mycol 39:139–141, 2001.

21. Michaud AJ: Phaeohyphomycotic rhinitis due to Exophiala jeanselmei in adomestic cat. Feline Pract 21(1):19–21, 1993.

22. Wilson RB, Pope R, Sumrall R: Canine rhinosporidiosis. Compend ContinEduc Pract Vet 11(6):730–732, 1989.

23. Forbes Lent SE, Hawkins EC: Evaluation of rhinoscopy and rhinoscopy-assisted biopsy in diagnosis of nasal disease in dogs: 119 cases. JAVMA201(9):1425–1429, 1992.

24. Willard M, Radlinsky MA: Endoscopic examination of the choanae in dogsand cats: 118 cases. JAVMA 215(9):1301–1305, 1999.

25. Davidson AP, Pappagianis D: Treatment of nasal aspergillosis with topicalclotrimazole, in Bonagura JD (ed): Kirk’s Current Veterinary Therapy XII.Philadelphia, WB Saunders, 1995, pp 899–901.

26. Foil CS: Miscellaneous fungal infections, in Greene CE (ed): Infectious Dis-eases of the Dog and Cat, ed 2. Philadelphia, WB Saunders, 1998, pp 420–422.

27. Kaufman J: Parasitic Infections of Domestic Animals: A Diagnostic Manual.Basel, Switzerland, Birkhauser Verlag, 1996.

28. Campbell BG, Little MD: Identification of the eggs of a nematode (Eucoleusboehmi) from the nasal mucosa of North American dogs. JAVMA 198(9):1520–1523, 1991.

29. Juttner C, Rodriguez Sanchez M, Rollan Landeras E, et al: Evaluation of thepotential causes of epistaxis in dogs with natural visceral leishmaniasis. VetRec 149:176–179, 2001.

30. Hawkins EC: Disorders of the nasal cavity, in Nelson RW, Couto CG (eds):Small Animal Internal Medicine, ed 2. St. Louis, Mosby, 1998, pp 230–237.

31. McDougal BJ: Allergic rhinitis: A cause of recurrent epistaxis. JAVMA171(6):545–546, 1977.

32. Thomas WB, Schueler RO, Kornegay JN: Surgical excision of a cerebral arte-riovenous malformation in a dog. Prog Vet Neurol 6(1):20–23, 1995.

33. Hunt GB, Perkins MC, Foster SF, et al: Nasopharyngeal disorders of dogsand cats: A review and retrospective study. Compend Contin Educ Pract Vet



24(3):184–200, 2002.

34. Hawkins EC: Diagnostic tests for the nasal cavity and paranasal sinuses, inNelson RW, Couto CG (eds): Small Animal Internal Medicine, ed 2. St.Louis, Mosby, 1998, pp 214–224.

35. Forrester SD, Jones JC, Noftsinger MH: Identifying the cause of nasal dis-ease in dogs. Vet Med: 530–541, 2002.

36. Tvedten H, Weiss D: Erythrocyte disorders, in Willard MD, Tvedten H,Turnwald GH (eds): Small Animal Clinical Diagnosis by Laboratory Methods,ed 2. Philadelphia, WB Saunders, 1994, pp 31–51.

37. Latimer KS, Tvedten H: Leukocyte disorders, in Willard MD, Tvedten H,

Turnwald GH (eds): Small Animal Clinical Diagnosis by Laboratory Methods,ed 2. Philadelphia, WB Saunders, 1994, pp 52–61.

38. Barsanti JA, Lees GE, Willard MD, et al: Urinary disorders, in Willard MD,Tvedten H, Turnwald GH (eds): Small Animal Clinical Diagnosis by Labora-tory Methods, ed 2. Philadelphia, WB Saunders, 1994, pp 115–118.

39. Lappin MR: Polysystemic rickettsial diseases, in Nelson RW, Couto CG(eds): Small Animal Internal Medicine, ed 2. St. Louis, Mosby, 1998, pp1280–1287.

40. Lappin MR: Polysystemic viral diseases, in Nelson RW, Couto CG (eds):Small Animal Internal Medicine, ed 2. St. Louis, Mosby, 1998, pp 1294–1301.


ARTICLE #2 CE TESTThis article qualifies for 1.5 contact hours of continuing education credit from the Auburn University College of Veterinary Medicine. Subscribers who wish to apply this credit to fulfill state relicensure requirements should consult their respective stateauthorities regarding the applicability of this program.To participate, fill out the test form inserted at the end of this issue.

CE

1. A diagnosis of nasal aspergillosis is based on a. a positive Aspergillus titer.b. positive culture of Aspergillus from a nasal swab.c. the presence of Aspergillus on a cytology of nasal dis-

charge.d. radiographic evidence of turbinate destruction.e. tissue culture and radiographic, endoscopic, serologic,

and histologic findings.

2. Which method is best for avoiding puncture ofthe cribriform plate during a nasal biopsy?a. premeasuring the distance from the opening of the nos-

tril to the medial canthus of the eye, marking the instru-ment at this site, and then avoiding going past this mark

b. estimating the distance between the external naresand the frontal sinuses with skull radiographs, andthen taking care not to exceed the premeasured dis-tance with the biopsy instrument

c. entering the cribriform plate is a rare complication ofnasal biopsy, and no precautions are needed

d. avoiding advancement of the biopsy instrument pastany areas of resistance

e. performing biopsies to a depth of 3 cm, regardless ofpatient size

3. Which condition is most likely to result inchronic, intermittent epistaxis in a 12-year-oldgolden retriever?a. traumab. nasal mite infestationc. nasal adenocarcinomad. arteriovenous malformation rupturee. vWD

4. ______ should be performed before anesthesiaand nasal biopsy.a. A thorough history and physical examinationb. BMBTc. Thoracic radiographyd. Chemistry profile, CBC, platelet count, and urinalysise. all of the above

5. Which statement about CT and MRI of the nasalcavity in the workup of epistaxis is true? a. CT and MRI allow visualization of bony and soft tis-

sue structures of the nasal cavity and oropharynx.b. CT and MRI are essential for radiotherapy planning in

cases of neoplasia.c. CT and MRI are superior to radiography because

they document the presence of bony lysis withoutsuperimposition of overlying structures.

d. CT and MRI can determine whether a tumor hasinvaded the cribriform plate.

e. all of the above

6. Which statement about foreign body inhalationis true? a. Foreign body inhalation occurs in dogs of all ages and

most commonly results in acute-onset epistaxis.b. Foreign bodies may be overlooked during rhinoscopy

because they are quickly covered with mucus andblood clots, so a degree of suspicion and careful en-doscopic examination may be required.

c. If foreign bodies are not sneezed out or otherwiseremoved, they can result in chronic nasal dischargesecondary to granuloma formation.

d. Foreign bodies may be removed from the nose byflushing (if they are small enough), with a grasping for-ceps via endoscopy, or, rarely, by a surgical procedure.

e. all of the above

7. Which abnormality is least likely related to adefect in primary hemostasis (i.e., platelets)?a. petechiated mucous membranesb. hemarthrosisc. retinal hemorrhagesd. gingival mucosal bleedinge. epistaxis

8. Which statement regarding nasal tumors in dogsand cats is not true?a. Carcinoma is the most common type of nasal tumor

in dogs.b. Nasal lymphoma is more common in younger cats,

and nasal adenocarcinoma occurs more often inolder cats.

c. Radiation therapy is often a primary treatment ofnasal tumors in dogs and cats.

d. Nasal tumors are locally invasive and highly metasta-tic, with up to 80% of animals developing pulmonarymetastasis.

e. Benign nasal tumors are rare but occur more com-monly in cats than in dogs.

9. Which statement about nasal cryptococcosis isnot true?a. The LCAT is useful for both diagnosis and monitor-

ing response to therapy.b. Nasal cryptococcosis is more common in cats than in

dogs.c. The organism is inhaled and can disseminate into the

eyes and central nervous system.d. Treatment consists of surgical debulking of lesions;

systemic antifungal therapy is rarely indicated.e. Nasal cryptococcosis is readily diagnosed by visualiz-

ing the organism in an India ink–stained preparationof nasal discharge.

10. Which statement about platelet evaluation indogs and cats is not true? a. Normal dogs and cats have 10 to 15 platelets per oil

immersion field.b. The BMBT is an in-hospital test of platelet function

and is reliable if the platelet count is greater than100,000/µl.

c. Macroplatelets indicate platelet regeneration and maybe more functional than normal platelets.

d. Thrombocytopenia rarely results from chronic hem-orrhage.

e. Rickettsial diseases such as ehrlichiosis rarely resultin thrombocytopenia.



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