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.

Minnie's Menacing Gracile Grimace

When I bought JVC about 6 years ago there were quite a few breeders who used our clinic. One of the breeders I met back then bred and raised Dobermans, Ms. White. Ms. White would breed and raise several litters a year. She cared about her puppies but she wasn’t very familiar with the breed. I really feel that one of the most important aspects of a Veterinarians job is to educate. I do a lot of talking to my clients about their pets. Shoot, I think I do a lot of talking period. I love to hear about my clients family, their pets, their hobbies, how their pets got their names, how their pets are doing in every aspect of their lives, everything. I feel compelled to talk about diet, exercise, preventative care, breed specific concerns, the whole gamut of every aspect of my pets, and much of my client’s life. I wear the hat of veterinarian, therapist, behaviorist, psychologist, nutritionist, etc, etc. I have some strong suits and some weaker suits. For example I really enjoy surgery, but I am not so great in reproductive medicine. My predecessor was what we “newbies” call an ”old timer”. Back 30 plus years ago we Vets did a lot of reproductive medicine. Remember 30 plus years ago Vets saw just as many cows, pigs, and horses as they did dogs, and honestly, they probably didn’t see many cats. They could teach me a thing or two, (probably a million) things about reproduction.

Well, Ms. White came in one day with her newest litter of Dobie pups. Now I have already admitted to you that I LOVE the puppy visits. Nothing in the world makes me happier than a puppy. I devote a huge block of my schedule when I see a “litter exam” coming in. I need extra time to hug, kiss, cuddle, smother, smell, and coo over puppies. When we entered the exam room Ms. White pointed out that one of the pups (they were about 6 weeks old) had an odd quizzical look. This little female puppy had a pretty severe head tilt. It was definitely noticeable, but she still had all of the charm, joy, and happiness of the rest of her littermates. Ms. White asked me if I thought that she would “out grow this condition?” I told her that “I couldn’t be sure, but I thought that there was a good possibility that she might.” I asked her if she “thought that the puppy had improved over the last few weeks?” She replied “no, I don’t think so.” I gave the puppy a thorough exam, to make sure that if this was a congenital defect that there weren’t any others we didn’t know about. I didn’t find anything but a sweet, exuberant, playful puppy who just had a crooked neck. I kissed all of the puppies goodbye and told Ms. White to call me if she had any questions or concerns.

4 weeks later I saw that Ms. White was on the appointment record to see another doctor for a euthanasia. I made sure that I stuck around until she got there to see who she was bringing in to euthanize. My greatest fears came true when she came in with her crooked necked puppy.

I interjected and brought her and the puppy immediately into an exam room. She began to explain to me that she had sold the rest of the puppies but couldn’t sell this one because of her head tilt. She also told me that her husband would not let her keep this puppy. So now comes the hard part for me. I have in the past jumped in to try to save a pet from being euthanized by its owner only to have the following happen; 1. I get really angry clients yelling at me, because I have "intervened in an already difficult decision" and “they have MADE THEIR MINDS UP AND SAID THEIR GOODBYES!” 2. I have had clients tell me to “mind my own business” like this clinic isn’t my business? I remind them it is. 3. they say to me “I work for them and I will do what they tell me to do.” That’s my favorite one so far. “Buddy,” I sarcastically replied, “I don’t work for you, and my conscious is not for sale.” He left, he reported me to the State Medical Board, and I still think he is an A-Hole. He can report me to the State Board for that too. 4. I have had some clients cry, and thank me for giving them an option that saves their pets life, because they didn’t think anyone could help them. 5. I have had clients march out, drive down the street to the neighbor vet in my town and have their pet euthanized there. So I took a deep breath and told Ms. White that we do not euthanize healthy pets at this practice. I then very quickly, before she could get a word in, followed up my statement with “you can sign her over to us and we will find her a home.”

I waited on the edge of my seat, and braced myself for an attack. She looked, paused, and then handed over the puppy. I think that she was relieved to have the offer on the table.

We named her “Minnie”. She stayed with us at the front desk for a week or two. During that time, Dr. Wilson, the previous JVC owner, came in and saw her. He immediately looked at me and said, ”You know that dog will be perfectly normal and outgrow that, don’t you?” I replied, “I hope so.”

Within two weeks one of our favorite friends and clients, CB, came in. She saw Minnie and immediately fell in love with her. She announced to all of us that she was “going home right now to tell her husband that she was bringing her home.” I think she wanted it to sound like she was being respectful and considerate in asking for his blessing, but in reality we all, husband included, knew she had made up her mind, and the matter was not up for discussion. She came in the next day and brought Minnie home.

2011 Pets With Santa, Murray on the left and Minnie on the right.

Over the next few months, we received photos, phone calls, and the funniest stories I have ever heard. She told me that Murray, her dog, was having a tough time convincing himself that he was happy to have a puppy in the house. Minnie would play, and pester, and bite, jump, romp, and annoy him until he snipped back as recourse to dissuade her. Problem is, all puppies just think they are playing back; finally. So they continue the annoyances until the play resumes again. Then there was the whole pool fiasco. See, Murray the lab loves to swim, so he jumps into the pool all the time, for a quick cool off dip. Of course, Minnie thinks that whatever her big brother can do, she can do. Labs float, Dobes don’t. So down to the bottom she went, and into the water her mom went after her. After re-learning that same lesson over and over again, CB finally decided she had to do something. So she bought her a child’s wading pool. Minnie loves her pool! She lays in it all day and avoids the deep section.

Within 4 months Minnies head tilt disappeared completely. She remains one of the happiest, sweetest, gentlest girl I have ever met. She truly is one of my favorite patients. And her mom, well, we all love CB too. We are really lucky to have such great clients who help us make happy endings.

Minnie in her 2011 costume, with Murray