Woody's Honk and Wink. Eyelid agenesis and cleft palate defect in a cat.

This is Woody. He is about 4 months old. He was brought to me last week from the good people at Animal Rescue, Inc. in New Freedom PA.

They originally thought that he might have a nasopharyngeal polyp because he had this constant funny little nasal sound. It sounded a bit like a cross between a stuffy nose and a goose honk. It was a very good guess on their part. They were almost right on the money with their presumption. They were in the right anatomical area, but Woody was missing something, instead of in possession of something extra.

Woody is about as sweet, gentle, loving, affectionate, and adorable as a kitten can be. His story is like so many other kittens at the rescue. Brought in as a baby, raised by volunteers, and now old enough to be looking for a home of his own.

But his path is not so simple and straightforward.

This is Woody.
He is missing the lateral (outside) 2/3rds of his upper eyelid.

Woody was born without complete eyelids.

Sounds crazy, doesn't it?

It is actually a condition called eyelid agenesis.

Eyelid agenesis is very rare in dogs but seen occassionally in cats. In some cases the loss of the lid is mild and only appears to be a cosmetic defect. But for some cats it causes pain, ocular discharge and can even lead to blindness as the hair sweeps over the sensitive cornea with each blink.

This is a picture of my kitty Magpie.
Her eyelids are normal.

I used pictures of my cat Magpie to illustrate what normal looks like. So you will see a picture of Woody and then followed by it will be a picture of either Magpie, or another normal kitten.

This is Woody's right eye.
It too is missing the lateral 2/3rds of the upper eyelid.

Magpie.

Magpie, falling asleep despite my annoying obsessive picture taking.

Woody's eyelid abnormality are what we call an incidental finding. They are not causing him any problems, and although they are not normal, they do not require any intervention on our part, YET.

But the honking sound, that we have to identify.

With a very quick peak, and  a calm gentle tolerant patient we got our first look at the source of the noise.

Woody's mouth.

The above two photos are of the inside of Woody's mouth. What the vet would call an "oral cavity" exam.

Woody is fully awake and this shot is incredibly hard to without drugs.

The right side (it is actually Woody's left side) of the roof of his mouth has a huge open defect.

 This is a sedated kitten before I put the endotracheal tube in their mouth and hook them up to the general anesthesia gas that we use to provide a well controlled plane of anesthesia.The left and right sides of the tissue above the tongue are uniform and symmetrical. The round opening is the soft palate that guides food and water to the back of the mouth. During eating and swallowing the arytenoids shut off the vocal/air tube that goes to the trachea so food doesn't go down the wrong pipe.

The structures of the base of the back of the mouth are specifically designed to direct food, water, and air into the correct tube.

The little pointed tip like structure visible just above the center of the tongue is the epiglottis.
This is looking down into the larynx from the mouth.

Woody is scheduled for surgery in two weeks. I will try to rebuild the soft palate, pharynx, and larynx into a functioning tunnel that will prohibit him from getting food and water pushed up into his nose and segregate these anatomical areas so he won't be prone to regurgitation, oral and nasal cavity aspiration and disease.

Have I ever done this before? No.

Does he need to have this surgery done? Yes.

Am I a little scared? Yes.

I will keep you all posted. Cross your fingers for me.

If the surgery is successful Woody will be looking for a home. If you are interested in adopting him, OR, if you have any pet questions, OR, if you are a surgeon and you would like to assist, (or perform Woody's surgery,,I am happy to pass him off to an expert ;-)), please find me at Pawbly.com. on Twitter @FreePetAdvice, or @pawbly.

Woody had surgery yesterday (September 30, 2013).

He did great!

I closed most of the soft palate defect. I was unable to close it completely for three reasons. First, it is almost impossible to get far enough back in the throat to place sutures and get access to the tissue with the needle. Second, he didn't have a tear for me to correct. He was missing the tissue that was supposed to be there. I couldn't just sew up the two halves of a laceration. I had to use what he was given, and that was not much. He had a hole, and no extra loose ends to collect and package. Third, The tissue swells with trauma, even the precise surgical trauma of a scalpel. I was very concerned that Woody be able to breathe on his own, and if needed I had to be able to replace his endotracheal tube if needed. The tube has to be placed in the very back of the throat. If there is severe or significant swelling you cannot visualize the opening of the trachea from the esophagus.

This is Woody's left eye from above. He is missing the lateral (outside) half of the upper eyelid. This is beginning to cause a few problems. He has hair rubbing on the cornea. Every time he blinks those hairs brush across the cornea, and over time this will cause irritation and could cause eventual scarring. He also has an incomplete blink. There literally isn't enough eyelid to close over the eye. Over time the area that isn't covered by the eyelids will scar and dry out. This will cause an ulcer and this can significantly impact his vision. 

Woody's left eye is worse than the right.

The closure of the cleft palate.

The correction of the left eye.
A conjunctival flap was taken from the bottom lid to create an eyelid and fill the missing gap of tissue.
To be completely honest I have never done this before. If it fails miserably I will let you know..(I always have a plan B ready. I haven't made it yet, but I will if I have to).

LOOK!! the eye closes!

Waking up. 

Thank you to everyone who sent well wishes!

Woody will be back in two weeks for a re-check.

Atresia Ani, What Happens If You Are Born Unable To Poop?

I received this question anonymously yesterday.

Dear Dr. Magnifico:

I am a breeder and  I have a female pup recently born without an anus.  As of right now she is in no immediate stress due to this.  My local vet is suggesting euthanasia.  Do you have any experience with young puppies having this condition and if surgery is an option ?  I did a search on vets that may have experience with this condition and your name came up. 

As a responsible breeder I know euthansia needs to be considered.  However more times than most compassion takes over and I want at least try to look into corrective surgery before I take that step.  Should this be an option the puppy would be placed as a rescue, with a responsible owner.

My reply;

Hello,

Thanks for your question.

There are a few very important points to discuss and consider as you face this pups dilemma.

Atresi Ani is the anatomical condition that your puppy has. It  is an embryologic anamoly (fancy way of saying a birth defect). It occurs when the colon fails to meet and fuse with the anus. 

I know that sounds confusing but in fetal development there are two tubes, the intestine and the anus that develop as tunnels and advance toward each other. When the two tunnels meet they are supposed to fuse and make one long tunnel that leads from the mouth to the anus. This allows food to go in and feces to go out.

When the tubes do not fuse the resultant puppy ends up with a pouch for a gut and an anus. The feces get packed into a  colon that cannot empty. This is a life threatening disaster. It can only be treated two ways, surgery or death/euthanasia.

In my 15 years of veterinary medicine I have seen it twice. Once in a puppy and again in a kitten. Both times the babies were euthanized. In both cases the diagnosis was made tragically too late to have surgery be a viable option.

Without knowing the age of the puppy it is hard for me to provide guidance on what to do, but one thing is certain IF you want to try to save this pup you need to find a surgeon willing to do this surgery ASAP. The longer that feces stays in the closed colon the more it dilates and stretches and causes significant damaging results to the puppy. 

With these cases I always feel like you have to try because you have absolutely nothing to lose.

There is a very good article explaining this surgery. I have attached it as a link,

http://veterinarynews.dvm360.com/dvm/article/articleDetail.jsp?id=658805

Update; April 19, 2013.

A week later I was able to put the breeder of this puppy in touch with the veterinarian that I spent so many early days with. His practice was close enough to her home for her to bring her one week old puppy into see him. That day he surgically opened the anatomical congenital defect and saved that puppies life.

A very thankful mom sent me a note that her puppy would be adopted out to a safe wonderful home. She actually asked if I wanted her. I was very touched by her sweet offer and appreciative note. I wish her puppy a  long happy healthy life.

Blue, and His Many Miracles. His PRAA heart defect, and how his regurgitation identification was the key to his diagnosis.

We met “Blue” four weeks ago when his mom came in to try to understand why he was vomiting so much? It seemed that he was always hungry and would eat voraciously, and then a few minutes later would “vomit” up most of the food he had just eaten.

In the scary Third Year of Vet school we all take “Gastroenterology.” It, (if you go to Virginia-Maryland) is taught by the ever-challenging Dr. Leib. One of the first things he drills into our brains is that you need to distinguish “vomiting,” from “regurgitation.” “Vomiting” means that you are emptying the contents of your stomach through your mouth. This is what most of us have encountered with food poisoning, motion sickness, the "oops, I had too much to drink" episode. “Regurgitation” is expulsion of the contents that haven’t made it to your stomach yet because they are being held in your esophagus. This means the food never gets to your stomach and your stomach isn’t doing its "heave-ho-muscular-squeezing" action to force out the contents it doesn’t want. Regurgitation is a passive looking "food-just –seems-to fall-out of your mouth" action, whereas, vomiting is a muscular contraction of your stomach to expel its contents. Sometimes it takes a lot of explaining and some funny looking demonstrations to identify which of these is happening in a pet. For Blue it was the most important diagnostic key for us to uncover. For Blue it was the difference between “most likely easily treatable” and “really really bad.”

We very quickly learned that Blue was regurgitating. He was having great difficulty getting the food, he so desperately wanted to eat, into his stomach. It is like torture. You eat and eat because you are legitimately starving. But you can’t get the food that you are devouring into your belly so that it can provide you with the nourishment you soo desperately need when you are a very young growing kitten.

At his first appointment it was very clear that he was underweight, undernourished, and desperately hungry. These are all tell-tale signs of a pet with regurgitation issues. Once we classify that you are truly regurgitating and not vomiting we can start to identify what is causing the problem. The big key is that the problem lies in front of, (or towards your mouth), and not from your stomach or below, (towards your tail). In most cases it is a problem in, or around, your esophagus.

Your esophagus is a muscular tube that pushes the food that your mouth swallows into the sac (aka your stomach) so your stomach can then churn and digest your food. If your tube (esophagus) doesn’t squeeze the food to your stomach then it just sits in the tube and the tube responds by getting wider and wider, like an over-inflated bicycle tube. The more air you try to put into your tube the more stretched it gets. This sometimes happens if you have an obstruction in your esophagus, or if something around your esophagus constricts it. This second scenario can happen if your heart doesn’t make the appropriate changes it needs to make after you are born. This is called a congenital (you are born with it) “vascular ring anomaly.” It is a malformation of the hearts vessels that entraps the esophagus and acts like a rubber band around the esophagus. The longer you keep a constrictive band around your highly dynamic muscular tube-like esophagus the more that tube will stretch and dilate in front of the tube. This is called a persistent right aortic arch, or PRAA. This anatomic “ring” occurs at the base of the heart and becomes apparent as babies switch from milk to solid foods. Affected patients become weaker and weaker and more malnourished as time goes on. You will die if it is not corrected surgically.

Back to Blue. Blue’s very unique diagnosis (this is the first any of us have ever seen), also came with a very unique story as to how he got to this point. So all the way back to the beginning we go.

Blue was brought in by his parent-mom after she witnessed his mom being hit and killed by a car. Blue was still in his mother’s mouth when she was hit with his umbilical cord still attached. He was taken home and bottle fed by his new mom. After a few weeks of being bottle fed they started to transition him from the kitten formula to solid food. It was then that he began to regurgitate. This brought him to us.

When he came into JVC we discovered that he most likely had a PRAA. The treatment for this is surgical correction ASAP. This surgery requires that we open the chest and remove the band of tissue acting like a tourniquet around the esophagus. Ok, if that doesn’t sound so incredibly difficult then please remember that Blue’s chest is about 2 inches by 2 inches, that the constrictive band is tiny, and that we have to keep his heart beating and the lungs working even while our fingers fumble around in a chest that is supposed to be a vacuum, (can’t be exposed to air, need a ventilator to do), and NONE of us Vets EVER go in the chest because very bad, scary, life ending things happen there. Without this surgery Blue will not live. Only a few Vets are qualified to perform this surgery, (or have ever done this before), and to have it done costs about $3000.

Blue’s mom realized that she couldn’t afford this and brought Blue in to have him euthanized. It is incredibly difficult, and so far for me impossible, to euthanize a treatable pet. I can’t do it. I always feel like I have to at least try. That day I told her that she could sign him over to us and we would TRY to find someone to do the surgery for him.

Jess my technician has taken over his care, and feeds him with a syringe every 2 hours. They have gotten very attached to each other. And the staff, led by Cindy has raised about $400 for his surgery.

This is an x-ray of Blue. He is lying on his side. We put some dye in his food and then had him eat it. The white is the dye. It stops at the base of the heart. then you can see it again in the stomach.

Blue’s surgery is scheduled for Monday Nov 14, 2011. Three Vets are donating their time and surgical skills to provide this. The very talented, skilled surgeons at VOSM, (Veterinary Orthopedic Sports medicine in Annapolis Junction, MD) will save his life.

It is one of the many cases that have been saved by my devoted, compassionate staff, and a few good friends.

If you would like to help contribute to Blue’s care, or any of the other pets in the care of JVC please see our website www.jarrettsvillevet.com, or call 410-692-6171, ask for Cindy and tell her that she is amazing, Jess, and Dr.H too! And if you REALLY want to make someones day call VOSM and tell them that the world is a better place because of people like them, who give even when they don't have to.

Thank-You for your generosity to those of you who have already donated and Thanks to everyone else for your well wishes.

Here is some information from Tams text book on Gastroenterology