TOA
PAYOH VETS toapayohvets.com Date: 14 February, 2013
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Trust & Audit: A rare case of a
hamburger tumour inside the mouth of an old dog
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS Date: 14 February, 2013 |
toapayohvets.com
Be Kind To Pets Veterinary Education Project 2013-0131 |
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Blog 1286.
Good dental hygiene is very important for people
and dogs as some oral tumours form when the
mouth is not clean. Yearly dental check ups will
be ideal. In February 2013, I encountered a case
of a dog with bleeding in the mouth and face.
"Oro-nasal fistula also known as malar
abscess or carnaissal abscess," I said to the
two interns very confidently as this was a
common problem in old dogs that seldom if ever
was sent for dental check ups or scaling.
I was 50% correct. There was a large oral tumour shaped like an oval elongated tumour! Veterinary medicine throws surprising oral tumours to me even after 40 years of practice! The dog was eating food under this tumour which expanded to fit the length and width and height of the oral cavity. The length of this tumour was estimated to be 10.5 cm long. I doubt I will ever see another case similar to this. Dr Daniel operated to remove this "hamburger" tumour using electro-surgery. I was present for a few seconds during surgery as this was his case and I had confidence he would be able to perform this surgery. "There was a lot of bleeding," he told me when I audited this case on Feb 12, 2013 (yesterday) and phoned the owner as well. He packed the back of the mouth with gauze swabs to prevent inhalation of blood into the lungs. Around 90% of the length of the tumour was excised electrically and then the remnants. He electro-coagulated the bleeders in the remnants so that there would be no more bleeding. Electro-cautery was effective in preventing bleeding. The 50% calculated dosage of domitor and ketamine IV anaesthesia was just sufficient for surgery, with top up of isoflurane gas via the mask. This formula is now used by the vets for IV anaesthesia. It took some time to convince vets that this is a safe and effective formula as all vets have their own judgments and preferences of using various anaesthetics. Stocking a variety of anaesthetics is very costly as they expire and so I don't permit associate vets to order their favourite or their vet professors' choice. A veterinary surgery must be able to sustain its profitability and most associate vets don't bother with this aspect as they are not accountable for the bottom line. Histology confirmed it is non-cancerous. It is known as a ossifying fibroma, originating from the soft palate according to the operating vet. There was also oro-nasal fistula which I diagnosed on first visual inspection and the rotten teeth black teeth as you can see from the image, were also extracted. Blood test had not shown any abnormal findings and so this dog was fit for anaesthesia and survived without any problems. In this case, the profuse bleeding from the excised tumour could be inhaled into the lungs and cause death by asphyxiation if electro-cautery had not been used to seal all bleeders successfully. From my phone call, the gentleman owner of this dog is most happy. As far as the dog owner is concerned, his old Chihuahua is OK and eating and that surgical outcome is what matters in the final analysis. "How long has this tumour exist?" I asked him. "I don't know as I don't look inside the mouth," he said. This is a very rare case of a "hamburger" oral tumour. Yearly dental check up of your dog over 3 years of age with your vet will prevent most oral tumours and rotten loose teeth. MY COMMENTS ON MANAGEMENT OF THIS CASE: 1. Electro-surgery was the correct choice. 2. IV anaesthesia with top up IV would be the choice in this case as isoflurane gas use by mask was not practical. However, the IV anaesthesia at 50% had lasted a sufficient amount of time to complete 90% of the surgery and isoflurane gas top up was effective in this case. IV anaesthesia top up, the drugs would be injected with the IV drip or the syringe with the drugs would be attached to the IV catheter. This webpage: http://www.bekindtopets.com/dogs/20130214ossifying_fibroma_oral_dog_toapayohvets.htm |
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Wednesday 13 February 2013
11. Internship. An ossifying fibroma inside an old dog's mouth
Saturday 9 February 2013
Wednesday 6 February 2013
9. Internship. A Terrapin with Swollen Eye Can Go Home
Swollen Eye Terrapin
Owner had bought 2 hatchling terrapins last September. They
were fed with pellets, anchovies and shrimp. The water was changed daily
however they were not put under the sun often. They had rocks in their tank for
resting.
In December, owner started to notice that one of the
terrapin wasn’t eating and it had both swollen eyes while the other one was
thriving healthily. The sick terrapin was sent to Toa Payoh Vets on 22 January
2013 with the complaint of both swollen eyes.
So it was treated
with daily change of fresh water, sunbathing for 30 minutes, multivitamin
supplement and daily antibiotic eye drops on each eye.
After 13 days of treatment, on 6th February the
left eye was partially open however the third eyelid was slightly prolapsed. Though
the improvement is very slight but persistency in treatment plan will
eventually yield results. So it was sent home to continue with the treatment on
7th February.
In conclusion, the terrapin had conjunctivitis and usually
for cases like this it takes a long time to heal. The other tank mate at home
had grown big and healthy.
8. Internship. Oro-nasal fistula in an Old Chihuahua
This
text describes the processes of how a vet diagnoses & treats a case of oral
tumours with tooth root abscess and oronasal fistula in an older Chihuahua.
These processes form part of the Standard Operating Procedures at Toa Payoh
Vets.
Owner
noticed that the dog had swelling on the right side of the cheek for more than
two weeks and later brought the dog to Toa Payoh Vets.
The
patient: Chihuahua, Male, 10 years old, Singapore
There was swelling on the right side of the cheek
however the appetite was still normal. The swelling had been there for more
than two weeks. It seems like the old dog had oronasal fistula and tooth root
abscess.
Life has not ended for this old dog as it was given
a second chance by its owner. He had once been abandoned and later he found
home with this kind hearted Singaporean who flew him all the way from
Australia. He had journey far to reach his home sweet home.
The dog’s mouth is seldom examined by most dog
owners and bad breath is usually tolerated by many Singaporean dog owners. They
also seldom pay attention to the mouth part of their pet as long as the dog is
eating without a problem.
Dental check up is not usually done and tartar will
usually build up and rotten teeth fall off. Many owners are not bothered or are
ignorant that dogs also need to have regular dental check up and dental care.
However, the younger generation of Singaporeans are better educated and more
concerned about the welfare of the old pets.
Back to my case.
One fine day on
late January 2013, the owner of a male, 10-year-old Chihuahua noticed a
swelling on the right cheek and brought it to Toa Payoh Vets.
At Toa Payoh Vets, Dr Daniel Sing was on duty. I was present. “This looks like a case of tooth root abscess as you can see that the teeth are rotten and filled with tartar. There may also be oronal fistula. It is an abnormal communication between the oral and nasal cavities involving the soft palate, hard palate, premaxilla, or the lip” said Dr. Daniel.
Is it a case of
tooth root abscess and oronasal fistula?
“So what are the
treatment options available?” asked the owner.
“For this case,
we would recommend to go through surgery to remove all the affected teeth and
clean the abscess” explained Dr. Daniel.
“But then how
would my dog eat without teeth” the owner said.
“Don’t worry, the
dog can eat soft canned food or even boiled chicken breast and porridge”
The
financial
costs and risk must be explained fully before any operation is done.
But the owner must give his consent and that is where personality and
financial conflicts come in. He must also be aware of the risk involve
especially in older dogs.
Blood test
Health screening is strongly advised before
anaesthesia and surgery for all patients, esp. in the older dog.
Anaesthetic risks are much higher in old dogs. There is always the possibility that the older dog may die on the operating table. When the owner hears that the dog may die on the operating table, he may decide not to get the surgery done. Some deem the vet incompetent and consulted another vet. A health screening should be suggested by the vet to let the owner knows whether the risks are high or not. "I advise a blood test to screen the health of the Chihuahua," Dr Daniel said. The owners must consent to take the anaesthetic risk if they give permission for the surgery as in this case. No surgeon can guarantee zero risk in any anaesthesia, whether in people or animal.
The total WBC 16.6 (normal
6.0-17.0)
Neutrophils 50.8%, Lymphocytes 19.2%,
Monocytes 24.6%, Eosinophils 1.1%, Basophils 4.2%. The platelets count is 520
which is slightly above normal (normal 200-500)
This blood test indicates that the liver and
kidneys were functioning normally.
"OK," the owner consented to the surgery. Antibiotics were given to the dog.
IV anaesthesia
without Intubation.
Anaesthesia. What
type? IV, gas or both? IV anaesthesia is shorter acting than gas anaesthesia.
Intubation (a breathing tube connects anaesthetic gas and oxygen to the dog)
is usually done in dental extraction.
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After
the dog had been anaesthetised, I discover that there was a big tumour about
the size of palm size dough growing from the soft palate. This tumour occupied
the whole oral cavity and the plan now had changed. We had to remove the tumour
and the teeth as well. Therefore we can’t intubate the dog as the tumour is
obstructing the endotracheal tube.
“Call
the owner and inform him about the tumour and the plan to remove it and ask for
his consent”
The
owner gave his permission to proceed and the surgery continued.
Dormitor
IV at 25% of calculated dosage for young healthy dog was sufficient for
electro-sugical excision. Dental extraction was done after that.
The
old dog survived the anaesthesia and that was what mattered most for the owner.
It is not always possible for every old dog to survive anaesthesia during
surgery. Therefore it is wiser to remove the tumour when it is smaller and when
the dog is younger.
Histology
“Is
the soft palate tumour cancerous or not?” the owner asked.
“Nobody
can tell from the physical appearance,” I said. “The tumour needs to be
analysed by the laboratory and the tumour cells can be seen under the
microscope if there are any. This is the process of histology. Do you wish to
get the tumour sent for histology?”
It
is best to get the owner’s permission to send the tumour for histology to
determine its state, as some owners may have budget constrain or do not wish to
spend more money.
Electro-Surgery
It
is unprofessional to give medication to the owner to treat the oral tumour as
some owners may insist on having them as an alternative to the high risk of
anaesthesia during surgery as it will not disappear.
Electro-surgical excision of the soft palate
tumour including extraction of molar teeth.
“The tumour can be removed from its stalk by
using electro-cauterizer to avoid losing too much blood,” said Dr. Daniel. Then
after removing the tumour, the dog started to wake up from anaesthesia, so it
had to be gassed with Isoflurane. When it was down, Dr. Daniel proceeded with
dental extraction of the molar and drainage of the pus.
Histology
Lab Result
The result of the histology came out and the
nodule is covered by squamous epithelium with overlying parakeratosis. At the
centre, there were irregularly-shaped trabeculae of woven and lamellar bone.
There is no evidence of malignancy. So this is good news for the owner is it
was not cancerous.
Conclusion:
The final diagnosis from the histology is
ossifying fibroma mass, with tooth root abscess and oronasal fistula. The dog
was put on antibiotic and two days after surgery it was allowed home.
BE KIND TO
YOUR OLDER DOG. EXAMINE YOUR OLDER DOG'S MOUTH WEEKLY FOR ORAL TUMOURS.
SMALL TUMOURS ARE EASIER TO REMOVE AND THERE IS A MUCH LOWER ANAESTHETIC RISK.
Tips & Advices:
Post
surgical management.
1.
Owner need to come back for review every 3 months for the
next 12 months. Owner needs to be advised and reminded by the vet but this is
seldom done by me.
2.
The mouth of older dogs must be checked by the owner daily
and any mouth tumour can be removed when it is small. In this case, the whole
oral cavity had been filled with the tumour. It could have existed for some
months without the owner seeing it.
3.
TIPS: old and unhealthy dogs (>5 years) must be given
25-50% of the calculated dosage of IV anaesthesia for younger dogs to lessen
risks of heart failure.
Prepared by,
Erica Chai Hui Ling
Monday 4 February 2013
5. Internship. “An Ounce of Prevention is Worth a Pound of Cure”
As the saying goes, this is
applicable to all kinds of disease and especially to the ones that recur.
Urolithisis or urinary calculi are the formation of mineral stones within the
urinary tract especially the lower urinary tract such as the bladder and the
urethra.
There are many factors that can
cause urolithisis in dogs such as urinary tract infection such as cystitis or
urethritis, breed disposition, diet, exercise, amount of water drank, age and
sex. The formation of different types of stones depends on various factors such
as pH of the urine, metabolic or anatomic abnormalities, and types of diet or
genetic predisposition. Small breed dogs such as Miniature Schnauzer, Lhasa
Apso, terrier, Shih Tzu and Miniature Poodle are predispose to stone formation
as compare to large breed dog. Besides that, there is a high incidence of
struvite uroliths in Miniature Schnauzer due to its genetic predisposition.
Often diets high in certain nutrient such as calcium, protein, oxalates will
also increase the risk of stones formation. Dogs fed solely on dry biscuits
will make the urine concentrated which will cause the crystals to precipitate
and favours the formation of stones.
There is no 100% cure to this disease
as it had 30-40% chance of recurrence. This will not only pose problem on the
animal but the owner as well. Animal that suffer from urolithiasis may have
severe discomfort and pain and may even face death if the kidney is damage or
if there is complete obstruction to the urinary tract. This will not only be
inhumane but this also involves a large sum of money for the treatment as this
may require emergency surgery. Surgery alone may range from $500-1500, and that
will be followed by warding fees, medicine, pre-operation blood test,
catheterisation, urinalysis, x-ray and many more. The total sum may reach a
whooping of $1500-2000. Besides that, how many surgeries can the animal endure
within few years of the episodes? Whereas prevention which consist of change of
diet, exercise, monthly urinalysis which range from $30-50 and x-ray every 3
months which range from $50-70 will definitely be cheaper and more economically
wise. This will not only put your pet out of misery but also save the life of
your beloved ones.
Here’s a summary of treatment
cost compare to its prevention:
Treatment
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Prevention
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Sedation
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$100-150
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Urine test
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$50-100
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Anaesthesia
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$200-300
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x-ray
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$50-70
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Cystotomy
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$500-1000
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Prescription diet
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$30-50
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Blood test
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$150-200
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Urine test
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$50-100
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Iv drip
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$50-100
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Suture material
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$20-40
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Stone analysis
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$150-200
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Medication
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$70-100
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Post-op nursing
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$100-150
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Total
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$1390-2340
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Total
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130-220
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In conclusion, many people may not want to follow and won’t
bother to consider this regime. However from economic point of view this would
be the best and not to forget other considerations like time, emotion, pain and
life of your pet.
Prepared by
Erica Chai Hui Ling
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