Ears and oral surgery Flashcards
Which nerves and arteries are important to consider when attempting auricular surgery?
-> Caudal auricular artery (behind the ear)
-> Maxillary artery
-> Auriculopalpebral branch of facial nerve (runs in close association to the ear - loss of blink reflex if damaged)
-> Facial nerve
-> Sympathetic nerve runs through the tympanic bulla (cats with middle ear disease often have horner’s syndrome because the sympathetic nerve is affected)
What are reasons to consider surgery to the external ear canal?
-> End stage otitis externa
-> Neoplasia
-> Trauma
What is the most common reason for performing a total ear canal ablation and lateral bulla osteotomy?
End stage otitis externa
Is otitis externa a surgical disease?
No! - have to try and do medical management prior to consideration of surgery
Structural changes - mucosal hyperplasia, cartilage thickening/ossification
What neoplasia might be common around/in the ear? And what are the factors to consider for surgery?
Ceruminous gland adenoma/adenocarcinoma
- includes hyperplastic “inflammatory” polyps of the ceruminous gland, slow to metastasise
Squamous cell carcinoma
- locally aggressive, penetrate ear canal
Factors to consider:
- Diagnosis and stage of disease
- Local extend of disease (potential for infiltrative disease beyond ear canal)
- Location of lesion within ear canal
What do we worry about with an animal that has had blunt trauma to the ear?
Avulsion of the external ear canal
- Auricular cartilage at annular cartilage junction
- Entire external ear canal at meatus
So either between vertical canal and horizontal canal or more commonly where the horizontal canal disconnects from the bulla.
How is ear canal avulsion presenting in acute and chronic forms? How do we diagnose?
Acute: swelling
Chronic: fistula
Diagnosis: Otoscopy, fistulogram, CT
A dog presents with an ear canal avulsion where it has avulsed from the bulla - which surgical procedure is recommended?
Total ear canal ablation
A dog present with an ear canal avulsion where only the vertical ear canal is affected - which surgical procedure is recommended?
Vertical ear canal resection
What are the preoperative considerations for ear canal surgery?
-> Contaminated or dirty surgery - perioperative antibiotics
-> Thorough preoperative cleansing!
-> Preoperative treatment - with severe inflammation - aggressive systemic therapy (AB, short course corticosteroids) may substantially reduce inflammation
What are the indications for a vertical ear canal resection?
-> Isolated neoplasia of the proximal vertical canal (no structural changes to horizontal canal)
-> Traumatic avulsion of vertical ear canal
Benefit: a lot of function still retained, dog can still hear
What are the indications for a total ear canal ablation?
-> Severe end-stage otitis externa
-> Neoplasia
-> Trauma
How do you explain to an owner what a total ear canal ablation means anatomically, is hearing still intact?
A total ear canal ablation is a salvage procedure but end of ear canal = end of problem.
Externally the dog will not change and no one will be able to see the dog had a total ear canal ablation.
It will be deaf - the bone conductance is still present as the ossicles will still be there but there is just no air conductance anymore, therefore deaf. In most cases the dogs have been deaf anyway.
When a total ear canal ablation is being performed, which other procedure has to also be performed in combination, because of which anatomical part?
Have to do a lateral bulla osteotomy in combination with a total ear canal ablation because the bulla is often involved
CT scan important!
What are the postoperative considerations after a total ear canal ablation and lateral bulla osteotomy?
-> Place a drain using a vacutainer (change every 2-3 hours), bandage over drain, monitor the drainage
-> Systemic antibiotic therapy - C&S of both ears, 3-4 weeks (osteomyelitis)
-> Monitor/treat facial palsy
-> Histologic examination of of ear canal
Which complications can occur after auricular surgery?
-> Facial palsy
-> cellulitis/drainage, dehiscence, vestibular injury, fistulation, haematoma, fatal haemorrhage
A dog with otitis media associated with otitis externa and a cat with polyp in middle ear - Which surgical procedure is recommended?
Ventral bulla osteotomy
Otopharyngeal polyps - what are they? which animal & age do we see them in?
They are a common cause of otopharyngeal disease in younger cats
Inflammatory polyps originating from middle ear, nasopharynx or eustachian tube.
Clinical features: non-neoplastic masses - inflammatory components: they are well vascularised fibrous connective tissue (inflammatory cells present).
Suspected that it is related to calici, coronavirus or herpesvirus infections.
What are the clinical signs of nasopharyngeal obstruction?
-> Chronic nasal discharge
-> Sneezing
-> Gagging
-> Stertorous breathing
What are the clinical signs of middle ear disease?
-> Head tilt
-> Nystagmus
-> Horner’s Syndrome
What are the clinical signs of otitis externa?
-> Discharge
-> Scratching
-> Shaking
How do we diagnose otopharyngeal polyps?
-> Physical exam: GA, otic, nasopharynx, biopsy
-> Imaging: Advanced imaging - CT
Why don’t we just “pull out” polyps as a treatment option?
They have a high recurrence rate if they are removed by traction-avulsion. Recurrence up to 50%
How do we treat a cat with polyps?
Medical management: Corticosteroids to reduce inflammation
Surgical management: Ventral bulla osteotomy; then traction. Surgery of ear canal. Soft palate incision.
What are the complications that can occur with surgery to remove polyps?
-> Horner’s Syndrome (up to 80%) - have to discuss with owner that surgery won’t fix horner’s.
-> Facial nerve paralysis (ear canal surgery)
-> Peripheral vestibular syndrome (aggressive curettage, preoperative neurological defects)
Recurrence is always possible but much less likely with surgery.
What are the 5 salivary glands and which one is often affected with salivary disease?
Parotid
Mandibular
Sublingual (often affected)
Zygomatic
Buccal
Which 3 types of salivary disease are commonly seen?
Generally non-neoplastic which are most common
-> Sialoceles (common)
-> Inflammation (sialoadenitis, adenosis)
-> Calculus (sialoliths)
What is a mucocele?
Accumulation of saliva within the tissue
- disruption of a salivary duct
- secondary sialoadenitis (inflammation of the gland)
What are the 3 conditions/locations in which a sialocele from the sublingual salivary gland may occur?
-> Cervical sialocele: caudal to mandible in the rostral ventral neck
-> Sublingual sialocele (ranulas): adjacent to/ underneath base of tongue
-> Pharyngeal sialocele: swelling at back of pharynx near tonsillar crypts
All 3 can occur from a disruption in the sublingual salivary gland!
Which breeds are predisposed to sialoceles?
German shepherds
Poodles
What is the characteristic location and presentation of a sialocele in a dog?
-> Soft to firm, often non-painful, non-inflamed swelling caudal to the angle of the mandible. May encompass part of the ventral neck or cross the midline
-> Elongated fluid accumulations underneath or adjacent to tongue
-> Pharyngeal protrusion
How do we diagnose a sialocele?
Diagnosis is confirmed by FNA - clear to honey-coloured viscid saliva
(sticky test between fingers)
How do we treat a sialocele?
Sialoadenectomy (has to be sublingual & mandibular salivary gland as the mandibular is closely associated with the sublingual!)
Sublingual salivary glands are most commonly affected and therefore clinically most important.
Salivary gland neoplasia - which salivary glands are most commonly affected in cats and dogs?
Dogs: Parotid gland
Cats: Mandibular gland
Which anatomical structures are involved in a primary congenital cleft palate and a secondary congenital cleft palate?
Primary: Lip+/- premaxilla
Secondary: hard and soft palates (may be accompanied by primary cleft palate)
What can cause an acquired cleft palate (oronasal fistula)?
-> Dental disease
-> Trauma (penetrating injury, bite wounds)
-> Oral disease
How do we evaluate (diagnose) oropharyngeal trauma?
- Thorough oral exam
- Radiographs cervical/thoracic region
- Scoping low yield
- CT
- Surgical exploration (debridement)
How do we treat pharyngeal injuries?
Emergent - stabilise
- haemorrhage control
- pneumothorax
Definitive - wound debridement
- leave oral wound open
- deep tissue culture neck
- oesophageal feeding tube
- CT may direct further exploration
- antibiotics
-> Important to explain to owners that CT is very helpful in these cases
Oral neoplasia - what are 6 non-neoplastic disorders and how do we treat/diagnose?
- Gingival hyperplasia
- Eosinophilic granuloma complex
- Osteomyelitis
- Lymphocytic plasmacytic stomatitis
- Nasopharyngeal polyps
- Salivary mucoceles
-> Incisional biopsy!
What are the clinical signs with oral neoplasia?
- Pawing at face or mouth
- Difficulty chewing or swallowing
- Shifting food to one side of the mouth
- Halitosis
- Drooling
- Blood-tinged saliva or nasal discharge
- Visible swelling or distortion
How do we diagnose and stage oral neoplasia?
First step is incisional biopsy!
- oral exam (with anaesthesia)
- imaging
- histologic diagnosis (biopsy)
- staging (guided by diagnosis - assess local lymph nodes (excisional biopsy), systemic disease)
Oral neoplasia - what are malignant and benign examples in the dog?
malignant examples in the cat?
Dog - malignant disease:
- malignant melanoma
- SCC
- Fibrosarcoma
- Osteosarcoma
Dog - benign disease:
- Epulis - periodontal ligament tumours
either Acanthomatous ameloblastoma or Peripheral odontogenic fibroma
Cat - malignant disease:
- SCC
What does a malignant melanoma look like and in which dogs do we see them most commonly in?
- older male dogs
- heavily pigmented mucosa (variably pigmented or non-pigmented)
- gingiva, labial or buccal mucosa
- palate
- firm, vascular, rapidly growing masses
- necrosis and infection
- bone invasion and dental disruption is common
- early metastasis (lymph nodes and lungs)
- poor prognosis
What dies a SCC look like and in which dogs & cats do we see them most commonly in?
- older large breed dogs (papillary SCC young dogs)
- gingiva
- red, friable, ulcerated
- dental disruption and bony invasion
- older cats
- locally invasive with intramedullary extension
- distant metastasis possible
- maxilla, sublingual SCC = grave prognosis
- mandibular SCC = fair prognosis with excision
What is the location prognostic for a SCC? (rostral, caudal, tonsil, lingual)
Rostral = locally invasive, low metastasis
Caudal = invasive, high metastasis
Tonsil SCC = aggressive, high metastasis
Lingual SCC = aggressive
Which neoplasm has the propensity to be around the maxilla especially the canine tooth?
Fibrosarcoma
What does a fibrosarcoma look like and in which dogs or cats do we usually see them?
Older (7-8 years), large breed dogs
- pink/red, firm, fixed, multilobulated, smooth
- maxilla, gingiva and palate (canine tooth and 4th PM)
- locally invasive
-> histologically low grade - biologically high grade (doesn’t look that aggressive when they look at it histologically but we know that these tumours are extremely invasive - makes them challenging to treat)
Older cats, gingiva, locally invasive
In which dogs and where (anatomically in the mouth) are osteosarcomas usually seen?
Large breed dogs
- mandible
- locally invasive
- distant metastasis
- prognosis poor
What do we call the benign tumours of periodontal ligament?
Epuli
- epithelial or mesenchymal dental origin
- ameloblastoma
What are the postoperative considerations when oral surgery has been performed?
Pain management
- multimodal analgesia (opioids IM IV or CRI, local analgesia, NSAID’s)
Fluid therapy from 24-72 hours after surgery
- water and food intake is encouraged at 12-24 hours postop (meatball diet)
- enteral feeding tubes (extreme cases)
What can be some complications and side effects after oral surgery?
-> Facial swelling, emphysema, dehiscence, drooling, tongue deviation, nose drooping
-> Maxillectomy - mandibular canine tooth -> ulceration
-> Mandibulectomy - mandibular drift, mandibular instability, difficulty prehending food, ranula can sometimes develop after surgery
