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.

Disney's Dilemma

A few years ago a very nice woman came into the clinic with her not very nice dog Disney. Disney was all black, about 40 pounds, and had a long fluffy full coat. She was always overweight even though she always tried to hide it all under a big full jet black coat. I tried many, many, times to convince Mrs. Nicks that Disney was overweight and needed a strict diet, (i.e. no more table scraps), but I knew that she lived with her elderly mother, who she cared for, and between the loneliness of caring for a mom with dementia, and the mom with dementia not ever remembering not to feed Disney table scraps, it was pretty much a lost cause.

The first two years of knowing Ms. Nicks and Disney we had the routine examinations, vaccinations, repetitive pleading of trying to get some weight off Disney, etc. etc. then one day Ms. Nicks called me to tell me that Disney was going outside trying to pee but only a few drops were coming out. And she kept going to the door, and Ms. Nicks kept taking her out, but all Disney could produce were a few drops of urine. I told her to bring Disney in right away. I was expecting to find that Disney had cystitis, (inflammation of the urinary bladder). So all I needed was a few drops of urine, and all Disney needed was an anti-inflammatory and an antibiotic and we were on the mend.

When Disney arrived I gave her an examination. I cannot ever express to the new vets out there how absolutely imperative it is to always give a full complete comprehensive examination.  Instead of finding an empty flaccid small sensitive bladder low in the pelvis, I found a very large full distended painful bladder that took up almost the entire caudal (back half of the) abdomen.  I took a gasp and swallowed the horrified look in my heart. We next went to x-ray. I was hoping to not find anything obstructing her ability to urinate, like a tumor, stones lodged in the neck of the bladder, etc. I was afraid to try to manually express her bladder by pushing too hard on it. You see at this point the bladder has been so distended for so long that often it is a thin weak balloon, and any amount of pressure can cause it to rupture. If the bladder ruptures it will spill the urine into the abdomen and the urine acts like caustic acid to the sensitive peritoneum (the lining of the inside of your abdominal wall). My next plan was to try to sedate Disney to place a urinary catheter. My first priority was to relieve her bladder distension and then try to figure out why this was happening to her. We placed an i.v. catheter collected our blood work and then gave some i.v. sedation. Within minutes there was a flood of dark pungent urine everywhere. I took a deep sigh of relief for Disney. We sutured the catheter in place and started her on the aggressive i.v. fluids I knew she needed to start correcting all of her kidney and electrolyte abnormalities. The next few days Disney seemed to feel more and more like herself. Which in Disneys terms meant she was less and less of a cooperative patient. When she was feeling well enough to not be able to be handled at all I called her mom and sent her home.

During her time in the hospital we ruled out everything except a neurogenic cause to her problem. This meant that the root of her inability to empty her bladder was because she either couldn’t squeeze the muscle of her bladder wall down tight enough to empty, or she couldn’t open the valves that keep the bladder shut. So I started her on all of the medications I could to try to tell her nerves and muscles to work the way they were supposed to. This plan worked for a few months.

Over the next year there were many interrupted evenings of meeting Disney at the clinic to try to repeat the procedures we had tried so successfully the first time. Each time it became harder and harder to get her relief. Until finally one evening I told Ms. Nicks that I would have to open up her abdomen and try to empty her bladder from the inside. I remember crying with her in the surgery room. I knew that Ms. Nicks knew that I was having as much of a difficult time making the decision as I was. I knew that my only hope of getting Disney off of the surgery table alive was with a urinary catheter being placed from inside the balloon instead of my usually threading it through the urogenital opening.  I looked into Ms. Nicks eyes, both of us sobbing, and she said to me, “I know you want to know why she can’t urinate, and I know you want to try to help her again, but I can’t put her through any more”. It was a hard painful decision for all of us. Ms. Nicks had lost her mom a few months ago, and she was losing her last companion. I knew that putting Disney under general anesthesia and exploring her abdomen and bladder might fill in some of the answers I had not been able to get before. But I also knew that we were at the end of her or her mom’s ability to treat her. I lowered my head and told her mom that I was so sorry. I then said goodbye to Disney and injected the pink syrup into her i.v. catheter. I turned off her monitors and I cried over her as she died.

I have talked to Ms. Nicks many times since that day. She still comes to our Christmas parties, and she still drops in to say hello every so often. I have even called her to see if she would be interested in helping us by fostering a dog. But she always tells me that she still isn’t ready for another dog yet. And I understand, and tell her that we miss Disney too. Even though I am pretty sure Disney never liked me back.

If you would like tolearn more about neurogenic anuria and cystitis please see the link below;
http://tinyurl.com/3fwekct