Oral cavity Surgery Flashcards
What characteristics of the oral cavity promote or deter its healing?
- Review
How can anesthesia be done for most oral surgery?
- By working around the endotracheal tube
- If that’s not the case, intubation can be performed via tracheostomy
What medications can be given to reduce pharyngeal swelling (which can lead to dyspnea and suffocation postop)
- Corticosteroids to prevent or treat swelling
How can you minimize aspiration during oral surgery and recovery (5 reasons)?
- Pack off pharynx during surgery (Count sponges)
- Aspirate blood out of pharynx before recovery
- Head down during recovery
- Extubate late so a good swallowing reflex
- Extubate with cuff slightly inflated
Why do you need to be careful with electrocautery when doing oral surgery?
- Oxygen and electrocautery = explosion
Preop preparation for oral surgery (4 main things)
- Cross match prior to major oral surgery as the mouth is vascular!
- Antibiotics (prophylactic indicated; continue postop only if needed therapeutically)
- Clip and scrub (if surgery in the mouth, no clipping needed; rinse mouth with dilute antiseptic solution)
- Sponges (count) in oropharynx to prevent aspiration
What type of suture for oral surgery?
- Absorbable suture
Where should knots be for oral surgery?
- Either in the oral or nasal cavity where they won’t block healing of the tissues in-between
How many layers to close for oral surgery?
- Multiple layers
Other principles of oral surgery
- GENTLE tissue handling
- Avoid closing under tension and avoid electrocautery (both delay healing)
- Avoid or prepare for major vessels
What is the #1 cause of dehiscence after oral surgery?
- Tension
What is the primary goal of closing oral defects, and how is this accomplished?
- Goal is to do so without tnesion
- Most often accomplished with flaps of mucosa (labial, buccal, pharyngeal), full-thickness palatal flaps, and releasing incisions
How do you deal with hemorrhage from the oral cavity?
- Know where the major blood vessels to the mouth are located. Any of them can be ligated as there is plenty of collateral circulation
Describe the route of the major blood supplies to the palate, mandible, and maxilla
- Review in Fossum
What is the common artery from which the blood supply to the palate, mandible, and maxilla arises?
- Carotid artery
What can you use if an artery has retracted into bone?
- Bone wax packed into the opening; this tamponades the vessel
Can you ligate the carotid artery in dogs or cats? If so, can you do unilateral or bilateral?
- In dogs you can do bilateral ligation
- Cat will die from even unilateral carotid artery ligation as cats lack the collateral circulation to the brain
Feeding after oral surgery - what needs to be communicated to the client beforehand?
- Be clear that postop care includes not allowing hte patient to chew on anything hard (food, toys, sticks, etc.) for a period of time
- Warn them in advance so they can make the house/yard safe before the pet returns home
After oral surgery, what is the preferred consistency of food?
- Review the old notes - I forgot already ;p
After oral surgery, how soon can feeding usually be started?
- Review the old notes
- I forgot already ;)
What can you place if oral feeding can’t be started due to a fragile repair that needs to be protected?
- Esophagostomy tube
When is dehiscence most common post-op?
- 3-5 days post-op
When would you repair an oral dehiscence?
- Delay repair until tissue is healthy again, which may take several weeks
Primary cleft palate - what structures are involved?
- Lip and premaxilla
Secondary cleft palate - what structures are involved?
- Hard palate and soft palate
When to repair cleft palate?
8 weeks of age
What are five reasons we wait to repair a cleft palate until 8 weeks of age?
- Gives time to improve body condition
- Better metabolism of anesthetic drugs
- Larger area to work
- Less fragile tissue
- Less risk of malocclusion
What are four things that should be communicated to a client pre-op for cleft palate?
- Preop management can be intensive and include tube feeding every 2 hours with risk of acute aspiration
- Surgery is performed when the dog is 8 weeks old or more
- Multiple surgeries may be required! Often a portion of the cleft will heal after the first surgery but a part will dehisce and require another procedure
- Recommend neutering (a different surgery) as well because the cleft palates can be hereditary
Can you tell the difference between oral neoplasia based on appearance?
- You CANNOT
What are the most common benign oral tumors?
- Epulides (acanthomatous ameloblastoma)
What tissue gives rise to the epulides?
- Odontogenic epithelium
What is the most common epulis, and what is unique about it that may be hard to distinguish from a malignant neoplasia?
- Acanthomatous epulis is most common; it invades bone
What are other types of epulides?
- Fibromatous epulis
- Ossifying epulis
Malignant oral tumors (that all invade bone)
- Malignant melanoma
- Squamous cell carcinoma
- Fibrosarcoma
- Osteosarcoma
- Chondrosarcoma
Which is the fastest oral tumor to metastasize?
- Malignant melanoma
Appearance of malignant melanoma?
- May be pigmented; some are not
Squamous cell carcinoma behavior in cats vs dogs
- More aggressive in the cat mouth than in the dog mouth
How does true extent to an oral tumor compare to what we see grossly?
- Typically much greater
Why does resecting the part of the oral tumor that you can see NOT often resolve the problem?
- Most oral tumors (even benign ones) invade bone
What question does grading answer?
- What is it?
How can you grade an oral neoplasia?
- Incisional biopsy or sometimes FNA
What question does staging answer?
- Where is it?
Where do we look to stage oral tumors?
A. Bone via imaging (local invasion)
B. Draining lymph nodes via FNA/biopsy (metastasis)
C. Lungs via Imaging (metastasis)
Overall diagnostic plan for possible oral neoplasma
- Grading to answer what it is
- Staging to answer where it is
- Assess overall health via labwork as indicated by the patient’s condition
What determines the order of a work-up for our patient?
- Order varies with patient condition, whether the mass is discovered when the patient is awake or under anesthesia, and client’s input
- Often more than one logical order of tests
- When planning a logical sequence, take into account which tests require sedation or anesthesia and which do not
What is a reasonable order of dx if dog is presented for an oral mass found by the client, who doesn’t want to pursue treatment if dog has metastatic cancer?
- Logical to do chest radiographs and lymph node FNA first (fast, easy, no anesthesia requierd) as these look for mets, and the presence of mets is a deal breaker for this client
Reasonable approach if you discover an oral mass during a routine dental
- Incisional biopsy first with client’s permission because dog is under anesthesia
- FNA lymph nodes at the same time (can be done with dog is awake, but it is easier when the dog is anesthetized)
What do you want to do before resecting a malignancy in the mouth?
- Grade and stage
- There is little room for obtaining clean margins in the mouth, and we know the first time we excise the mass is our best chance to cure the patient
Preop Client Communication for Oral tumor patients
- Discuss what patient will look like, show photos of other patients that have had similar surgery
- Prep owner for post-op care, particularly feeding protocol, no chewing on anything
- Whether or not follow-up chemotherapy or radiation will likely be needed
- Prognosis based on tumor grade and stage
Preop Patient preparation for oral tumors
- Type and cross-match if bone resection is planned
- Antibiotics
- Clipping only needed if lip/cheek resection will be included
- What steps will you take to avoid aspiration of blood during oral surgery (review)?
Who will do most oral tumor cases?
- Surgeon and/or oncologist
What should the rDVM need to be able to speak with a client in general terms about?
A. What to expect cosmetically
B. Post-op care (see earlier guidelines in notes)
C. Prognosis
What are the terms for removal of the mandible and maxilla?
- Mandibulectomy and maxillectomy
Comparison of how dogs vs cats handle mandibulectomy and maxillectomy?
- Dogs in general handle it quite well, but cats do not in general
Closure of oral surgery sites
- Multiple layers to distirbute tension
- Absorbable suture (PDS vs monocryl due to longer half-life)
- Often they use polyglactin 910 (braided absorbable Vicryl due to softness)
- Avoid lifting the lip after surgery
Prognosis for epulides
- Surgery can be curative
Median survival after removal of oral OSA, malignant melanoma, and maxillary FSA?
- ~8-9 months
Median survival after removal of mandibular FSA?
- 12 months approximately
Median survival after removal of SCC?
- 18 months
- Surgery can be curative
How can recurrent tumors compare to the original?
- More regressive
How soon after resection of large portions of maxilla or mandible can dogs start eating?
- Most eating the day after surgery
Owner satisfaction with partial mandibulectomy or maxillectomy
- 85% satisfied with decision for surgery
- 85% noted INCREASED appetite postop (only 50% noticed pre-op decrease)
- 100% felt pet’s appearance was acceptable once hair grew back
- ~25% overheard negative comments
What determines surgical success for oral neoplasia removal?
Depends on removing affected tissue, not just the visible oral mass!
In order to perform an effective excisional surgery, want to know what the mass is and degree of invasion into bone
What is a sialocele?
- Fluctuant, non-painful swelling caused by an accumulation of saliva that has leaked out of a salivary gland or duct
- Location varies with salivary gland/duct affected
What is the saliva in a sialocele walled off by?
- Granulation tissue
Does the sialocele have a secretory lining or not?
- Not sure
- I don’t think so
- It’s just a leak in the gland or duct
Cytology of FNA of a sialocele
- Low cell count and stain positive for mucous
Rate of recurrence of sialocele with drainage alone?
- High rate of recurrence and risk of infection with repeated aspiration
Treatment for sialocele
- Excise (surgery) and drain the sialocele or marsupialize it
Who tends to do sialocele surgery?
- Experienced surgeon
Which two salivary glands are often removed together due to their intimate anatomical association?
- Mandibular salivary gland and sublingual salivar gland
- It’s okay to remove both
What is the name for a sialocele under the tongue?
- Ranula
What can happen emergently with a ranula?
- The pet can’t breathe due to a sialocele under the tongue that is so large it obstructs the airway
Emergency treatment for a ranula
- Lance the sialocele so it can drain
Definitive treatment of ranula
- Excise the sublingual and mandibular salivary glands
Cervical sialocele
- Maybe the mandibular and sublingual?
Zygomatic sialocele location
- Ventral to the globe
Marsupialization for treatment of ranula
- What is the risk?
- Creating a permanent opening to the outside
- Still have a risk of recurrence because the salivary glands are still in place
How is marsupialization done?
- lateral wall of the ranula is excised
- The cut edge of the ranula is sutured to the sublingual mucosa to keep the pocket open and allow the leaking saliva to drain into the oral cavity
What is the surgery for removal of the tongue called?
- Glossectomy
WHen is glossectomy indicated?
- Neoplasia or irreparable trauma (paper shredder injury)
What parts of the tongue can be removed?
- Entire free portion of the tongue and parts of the base can be removed
How do dogs eat after clossectomy?
- Dogs learn to suck in food or toss chunks to the back of the mouth
Reported quality of life in dogs with major glossectomy?
- Reported to be excellent
How to repair a tongue laceration?
- After debridement and lavage, close with multiple layers whenever possible to better distribute tension and use absorbable suture
Type of suture for tongue repair
- Absorbable suture
What should you think about as a dfdx before sticking a mass in the neck?
- Could be a thyroid carcinoma, which tends to bleed quite a bit
