Taffy's Tongue Tumor. Part Three of the Mass Removal Series.

Taffy is a 13 year old long haired orange tabby. He has been struggling with a decreasing appetite for months. His mom has been trying every kind of food and every kind of texture to try to convince him to eat. It has been a roller coaster ride that has been full of frustration and worry.

His first visit to the vet revealed an irregular ulcerative red spot under his tongue. Despite trying antibiotics and watching to wait and see over time the mass had grown to cover over half of his tongue. Taffy's tongue was swollen making ti hard to hold in his mouth. The mass was painful and the pain made Taffy reluctant to eat, and he was now drooling constantly. The decreased food intake was causing weight loss and muscle loss. The muscle loss was causing him to have more and more difficulty in getting up and walking. (Quick cat tip: cats often show weakness in their back legs. They will walk plantigrade (with the hocks (ankles) dropped. So instead of walking on their back toes they walk on the foot from the toes to the ankle. If you notice this in your cat go to the vet. This is also one of the first signs we see in diabetic cats). He needed relief quickly or he was going to continue to slip downhill and that down hill slope will get progressively steeper as you slide into the abyss. At some point your pet will not be able to crawl out of that abyss.

I saw Taffy for his surgery a few days later. Before surgery I gave him another thorough examination, reviewed his pre-op history and diagnostics and took some x-rays to make sure that there wasn't any evidence of cancer. We thought that the lesion under the tongue might be cancer so we look very hard everywhere else to see if it has spread. IF the cancer had spread his prognosis would be much worse and the surgery might be done just for de-bulking, temporary relief purposes, instead of getting clear margins. All of these thing are vitally important points to discuss before surgery.

My point is to be proactive and not wait until that mass is your pets death sentence.

Induction agent being delivered to put Taffy under anesthesia.

After Taffy was sedated to be intubated we could see for the first time the complete source of his pain.

Intubating for inhalant anesthesia.

Looking down the throat to see where to put the endotracheal tube.

Looking to check before placing the endotracheal tube.

My very good friend, and fellow veterinarian, referred Taffy to me specifically because at our clinic we have a laser that we can use to remove masses. The laser reduces the bleeding and surgical time and she believed was the best tool to try to remove Taffy's tumor.

Taffy's tumor was in a tough spot. All the way in the back half of the underside of the tongue. Until he was under anesthesia completely we weren't really sure how big or how deep it was. Many times in surgery it is as much discovery and examination as it is attempt to surgically correct and/or remove. (That's why it is sometimes very hard to give a definitive estimate for services). I was not sure I was going to be able to remove this with even the laser, and I was not sure what "IT" was to begin with.

We began surgery with the laser. Removing the mass was made much easier with the laser but there is only so much tissue that you can remove at the base of the tongue and it is a fine line between enough to get Taffy comfortable and able to eat again and too much tissue removed and the tongue becomes non-functional.

Ready to be draped in for surgery.

OUCH!

Ready for surgery!

Begin lasering.

After the mass was lasered off the tongue was sutured closed. The tongue is essentially one large muscle, and muscle bleeds readily. In order to reduce the normal trauma that the tongue encounters as it moves in the mouth and rubs against the teeth I had to close the surrounding tissue.

The tongue is sutured and the mouth should be much more comfortable. I expect that with a few days of antibiotics and pain management that he will be back to eating voraciously.

The tissue should be sent out for a biopsy to diagnose the lesion and help treat it appropriately. The biopsy will also assist in prognosis and future treatment should it recur.

To adress the chance that the lesion might be related to dental disease we cleaned and polished the teeth. Taffy's owners will also be instructed on how to brush them and be advised to do this daily.

Taffy is part three of the "wait until the last minute" mass removal. This series was written to remind us all that medicine is often a juggling act. We are always juggling risk versus consequence. The important thing to remember is that the plan will change as the patient changes. Don't be afraid to re-assess, re-think, and change course.

Be proactive and try not to use age as a reason to deny possible life saving treatment.

If you have any questions or comments about this blog, or any aspect of veterinary care please leave me a comment. You can also find me, and a whole bunch of other pet experts at Pawbly.com. We are happy to help you and your pet live a long healthy life together.

How Do You Blink With Cauliflower In Your Eye? Eyelid Tumors

One of the most common eye problems that we see are eyelid tumors. I see a lot of these. Most commonly they are seen in older dogs.

Luckily, in most cases the masses (I prefer the term 'mass' to 'tumor' although in veterinary medicine they are used synonymously), are benign cosmetic eyelid defects. In almost all cases we choose to monitor these masses very closely after they first are noticed. 

There are a few exceptions to this;

1. Any pet that is having problems blinking.
2. Having discharge from the eye. Of greatest concern is any yellow or green discharge, excessive blinking, or squinting.
3. Any mass that is growing rapidly or taking up more than 1/4 of the eyelid margin.
4. Having multiple masses on the eye.

All eyelid tumors should be seen by the veterinarian as soon as they are noticed. 

This is Cody's story of his eyelid mass.

His dad noticed a small mass on his lower eyelid many months ago. At that time we just decided to monitor it. That was until a few weeks ago when his dad thought that it began to cause Cody some discomfort. 

Pre-operatively Cody had a very thorough physical examination, pre-operative blood work, and we discussed post-operative concerns and recovery needs.

Cody is a very active but anxious boy. He is young, healthy, and the joy of his fathers' life.

In the exam room he is a flash of brown and white. He shakes, jumps, shivers, quivers and is completely unable to relax even a teensy-weensy bit. When you can finally grab him and try to hold him still his constant erratic motion transfers to his vocal chords where a squealing high pitched ear shattering bellow makes the ability to hold him impossible. Cody is a quark of an English Springer Spaniel flavor. (For an interesting read see any veterinary neurology text book and all of the, (shall I say) "unique" neurologic disorders Springers have).

I have seen him four times in the last 4 weeks to examine the mass on his lower right eyelid. Each trip has been met with the same unfortunate outcome. He cannot sit still, and I cannot adequately examine him. It is a fate that befalls some. We work around it, and we provide drugs to coerce compliance. Sometimes it is necessary, but always it is the last option. We scheduled surgery for this week.

The eyelid mass was visible grossly, but truth be told I was not able to identify how invasive it was while he was awake.

Clipping the eye for surgery.
Being patient and extra careful to  not tear the very fragile tissue.

When Cody was placed under general anesthesia I saw for the first time how large the mass was.

The mass finally completely visible.
It is a glandular sebum engorged cystic mass.
In essence it is much like a large pimple on the inside of the lower eyelid.

The preliminary surgery plan was to safely and easily visualize the eyelid mass, resect it completely, and then rebuild the eyelid so that it remained functional and was as cosmetically pleasing (fancy-pants way of saying "looked good after").

Laser removal of the eyelid mass.

I elected to remove the mass with our laser. The laser allow for a very precise cut with little to no bleeding. This causes less tissue trauma a very precise incision and a quicker procedure.

The mass was removed in its entirety. This was essentially a full eyelid thickness "v" shaped cut to remove the entire cyst completely. A "v" shaped hole in the bottom lid. 

This was essentially a full eyelid thickness "v" shaped cut to remove the entire cyst completely. A "v" shaped hole in the bottom lid what left behind.

To close the defect an incision in the outside (lateral) of the eyelid had to be made. If we did not do this the bottom lid would be shorter than the upper lid.

An excerpt from Slatter's Fundamentals of Veterinary Ophthalmology displays the surgery well.

To close the "v" we have to be very careful to use suture that will not irritate the eye. Take special care to not leave any knots that could rub against the eye.

The second page of the excerpt from Slatter's,
showing the three layer closure technique.

Suturing the inner layer of the eyelid.

To close the defect we do a three layer closure. Closing the skin that touches the eye, then the middle muscular layer, and finally the skin. We also have to make sure the eyelid margin is together and on the same level.

Closing the outer layer of the eyelid.

Making the lateral incision to allow enough tissue to make the lower lid the same length as the upper lid.

Closing the lateral incision after the lower lid has been advanced as much as is needed.

Suturing the lateral aspect of the reconstructed lower eyelid.

Surgery is finished.

The incisions are closed and the eye reconstruction is complete. A bit of pos-op swelling and bleeding is normal.

Cody awake after surgery. His surgery looks great! (if I do say so myself).

Post-operatively the eyes look very similar. There is no pulling on the eyelids, no asymmetry, no drooping of the lids, and little to no swelling.

Here is a cost break-down of Cody's eye mass;

Pre-op exam $50
Pre-op blood work for anesthesia $50-150
Anesthesia $100
Laser to remove $100
Eye ointment for post op $20
E-collar $20
I don't charge for my post-op rechecks. but everyone else in the world does (I think)
I hope this helps. Use it as a checklist at your vets.

Cody went home with an e-collar so that he will not rub his eye, and an antibiotic ointment to keep the eye comfortable lubricated and free from infection.

If you have a pet related question please find me, and the amazing group of pet loving experts, at Pawbly.com. Pawbly is free to use and open to all who need help, or want to help others.

If you have a pet in need of eyelid surgery and you are in the Maryland area stop by for a visit. Jarrettsville Vet is open 7 days a week. I am also on Twitter @FreePetAdvice.