Thursday, March 24, 2011

The importance of a good oral exam cannot be underestimated!

I was recently presented with an interesting case. A woman called us, frantic, screaming that her dog was choking and that she needed directions to our ER. We obliged her, and after getting lost twice, she made it to our door. She handed over a tiny (less than 1 pound!) puppy.

Now, mostly when people call and tell us that their dog is choking - it's not. Usually, it's a severe reverse sneeze or kennel cough or heart failure. It is rarely ever choking. This puppy did appear to be choking, though. She kept stretching her neck out and gagging. Fortunately, her gums were pink, and she did not appear to be suffering severe oxygen deprivation. I examined her briefly - a wiggly, alert, tiny little puppy that fit in one hand. After my exam, I popped her in the oxygen tank and went to talk with her owner.

Ms Smith had obtained the puppy 1 week earlier. In that week, she had noticed no problems when the puppy ate. Tonight, she was in the middle of eating her dinner (dry dog kibble soaked in water) when she began to gag and cough. When it did not subside within a few minutes, her owner became understandably worried. Otherwise, there had been no other problems.

Since this happened in the midst of eating and quite suddenly, choking did seem likely. I looked in puppy's mouth as best I could, but she was squirming, screaming, and gagging. On very cursory exam, I saw no abnormalities. There was not a cleft hard palate, there was nothing at the back of the throat, and the mouth looked normal. We gave a tiny, tiny dose of butorphanol for sedation and xrays, as I was thinking perhaps some kibble had lodged in the trachea. Xrays were normal, however. Nothing in the trachea.

Perplexed, I went back to my tiny patient - who continued to gag and stretch her neck out intermittently. Loathe to do it, I gave her the tiniest dose of Propofol imaginable to knock her out enough to let me look down her throat. It's lucky that I did so, because the answer was there! Although her hard palate was normal, she had a cleft in her soft palate! I had never seen a cleft soft palate without a concurrent hard palate. But sure enough, there was a 3 cm slit in her soft palate, communicating with her sinuses. Every time she breathed, the opening flared open. I realized that she had likely snorted food up into her sinus cavities! We swabbed out the small amount of food back there and swabbed the cleft to ensure that it was not obstructed. I counseled the owner that surgery would likely be necessary, as this would not close on its own.

It was a potent reminder of why a thorough physical exam is absolutely necessary to figure out a health problem! Without the sedated oral exam, I would not have found the reason for the puppy's gagging behavior. Hopefully, his owner will have surgery conducted to fix this defect, and the puppy will live a long, happy life!


Megan said...

I had a case a few months ago where a young couple brought in their dog for coughing and having a poor appetite. I did my usual exam and didn't spy anything obvious, so was about to recommend some chest x-rays when something told me to look inside her mouth more closely. I cranked open her mouth as wide as she would let me, and from way in the back of her oropharynx out popped a plum-sized pedunculated black necrotic tumor that was attached to the base of her tongue. She must have been intermittently inhaling it and coughing it back up, causing her clinical signs. The owners felt terrible that they never saw it, but I could easily have missed it too... Poor dog!

The Homeless Parrot said...

Good catch, Megan. I saw something very similar recently, and it's bothering me...

A 10 year old cat came in with severe inspiratory dyspnea, no appetite. I had seen him 9 months previously for coughing and lethargy. PE was unremarkable other than a fever and runny eyes. He was outdoor, not vaccinated, so I figured URI and dispensed Viralys and discussed supportive care.

Now, he was cyanotic and couldn't breathe. The owner declined diagnostics and requested euthanasia. After he was gone, I was able to open his mouth and look all the way down his throat (he was breathing like an upper airway obstruction). He had a lobulated, nasty looking tan mass growing either from his pharynx or the base of his tongue.

I really hope it wasn't there 9 months ago, because if it was, I missed it! It was so far down there that sedation would have been needed to see it. Still, it bothers me!