A Thorn in the Side

by Dave Sauter, DVM

The initial complaint was a trickle of blood from Sampson’s nose. Not a common problem in horses, and this particular case had a very unusual cause. Sampson’s unexpected story is the subject of today’s article and it illustrates just how tough horses can be.

The medical term for a bloody nose is epistaxis. Like many symptoms, there can be different causes. One of the more common causes in the horse is head trauma. A good solid blow to the head can, not surprisingly, cause a bloody nose, not unlike a good punch to a human nose. Sometimes there might be evidence of the trauma, such as an abrasion somewhere on the horse’s face, but often there are no marks whatsoever. With trauma, the bleeding is often from one nostril only, the side where the blow occurred. Sometimes the trauma is more central and the bleeding occurs from both nostrils. The bleeding generally is fairly minor; however, with more severe trauma, the skull can suffer fractures and the bleeding can be much greater.

There are many other possible causes for epistaxis. Here are a few examples:

· Ethmoid hematoma – Within the nasal cavity, toward the back, is an elaborate labyrinth of tissues called turbinates. These complex folds function in the cleaning, humidifying, and warming of the air the horse breathes. Rarely, the ethmoid turbinate develops into a hematoma, the cause of which is unknown. Because the hematoma generally happens only on one side, the bleeding only occurs from one nostril and it tends to be intermittent. The nasal discharge can be frank (plain) blood or mixed with mucus. There might be a foul smell to the breath. Sometimes there are noisy breathing sounds due to the discharge within the nasal cavity. Headshaking can be another symptom. As the hematoma grows in size, the shape of the facial bones can be altered.

· Tumors – These can occur either in the nasal cavity or in the paranasal sinuses. This, too, generally results in bleeding from just one nostril. As the tumor grows in size, the nasal passageway can be narrowed, resulting in restricted breathing sounds. The shape of the facial bones can also be altered by the expanding tumor.

· Fungal infections in the guttural pouch – Guttural pouches are large outpouchings of the auditory (Eustachian) tubes which connect the nasopharynx to the middle ear. Very large blood vessels line the guttural pouches. Fungal infections are rare, but when they do occur the fungus can erode the lining of the vessels, resulting in severe hemorrhage, which in some cases may be life-threatening.

Let’s get back to Sampson. On the day his problem started, he didn’t come up to the barn in the evening like usual. His owner noticed a trickle of blood coming out of both nostrils, and he did have some swelling on the bridge of his nose. The nose bleed was his only symptom at this stage. He was alert, eating, drinking, defecating, and urinating normally. Two days later, the nose bleed happened again, also from both nostrils.

Up to this point, head trauma seemed very possible as an explanation for Sampson’s symptoms. Over the next few days, however, things started to get a little strange. First, Sampson’s voice started to change. Other than the odd hoarse horse (for example, a foal separated from its mare or a herd-bound horse separated from its pasture mates, either of which might vocalize enough to become hoarse), a voice change is an unusual symptom.

Next, Sampson developed foul-smelling breath. The odor was not from his mouth but from both of his nasal passages. It was so strong smelling that it could be easily detected from 10 feet away. At this point, he did not have a cough and was still eating and drinking well, but he did seem a bit depressed and less active.

The next step in trying to determine the cause of all these symptoms was to get a look inside Sampson’s head. One method to get a direct look into the nasal passages, pharynx and guttural pouches is by utilizing a flexible endoscope. A videoendoscope is a flexible tube with a lens on the tip that converts its image into an electrical signal that is sent up the tube to a processor that converts the electrical signal back into a video image that can be projected onto a screen. Sampson’s nasal passages and guttural pouches appeared normal. Most of the nasopharynx looked fine...however, his throat was not.

Sampson’s epiglottis, arytenoid cartilages, and vocal folds were horribly inflamed, bleeding, and had torn surfaces covered in blood, pus, and necrotic tissues. The lesions were impressive, something you don’t want to hear uttered by your veterinarian. At first it looked like some sort of aggressive tumor such as squamous cell carcinoma. On further investigation, a foreign-looking structure was found. Initially, it looked like a wood splinter, but later it was clear that there were thorns on its surface. A grasping forceps was passed through the videoendoscope and used to latch onto the structure. It had to be torn free from where the thorns had embedded into the throat surfaces. It turned out to be an over blackberry stem more than 3 inches long with over half a dozen spiny thorns on it.

The last follow-up endoscopy done several weeks later showed that Sampson’s throat had healed almost completely. He is feeling more like himself, although his voice has not quite returned to normal. This case has been interesting not just because it is so unusual, but also because it illustrates how tough and resilient horses can be. It is truly remarkable how good Sampson looked while thorns were embedded deep in his throat, tearing his flesh and getting infected. His poor epiglottis, which normally flips over the airway to protect it, was getting raked over those thorns every time he swallowed, resulting in a deep ulceration of its surface. Yet he somehow managed to carry on without much complaint.

Still, it must have been a phenomenal relief when that prickly blackberry stem was removed.