A Client’s View:
My Golden Retriever, Beau, who is 12 years old, has always had ear issues. Even when he was a little puppy and we lived in New Orleans, we seemed to always be treating him for one ear malady or another. So when I noticed him scratching his ear more than usual and even rubbing his ear against the carpet, I wasn’t surprised. However, I was surprised when I inspected his ear. It was huge!
There was a big pocket in his ear that seemed to be full of liquid. The swollen area was slightly warm to the touch. Beau has typical Golden ears in that they are floppy and very furry so it wasn’t until I touched and held his ear that I realized the extent of the problem. I immediately called Animal Hospital of North Asheville for an appointment.
Dr. Duncan confirmed my suspicion that Beau had an ear infection and then went on to explain to me that Beau also had an ear hematoma, which are often caused by ear infections and increased shaking of the head. We talked over all our options, including surgery, while Dr. Duncan and Dot fed a very happy Beau lots of treats. Because I wanted a quick and definitive treatment, I decided to move forward with surgery.
I brought Beau in for his surgery a few days later. Beau absolutely loves his trips to the animal hospital! He sees it as an opportunity to get loved on by as many people as possible, eat lots of treats, and socialize with as many dogs as possible. Beau is a very trusting, laidback guy, and he just takes it for granted that everyone loves him – and I have to admit, they do!
Before surgery, Beau got to spend some time in the waiting area with one of his favorite people, Dot. She and I had lots of fun making him do his ‘Elvis’ impression. There is a certain place on his face that when scratched causes him to lift his lip in an Elvis sneer. Dot and I were cracking up and Beau soaked in the attention.
When it was time for Beau to receive his pre-surgery drugs to relax him (although I don’t know how he could be more relaxed!), I was invited to accompany him to the treatment area to a nice glassed in area with his bed in it where I could sit with him as long as I wanted to. I petted him and talked to him as the drugs took effect until I got a phone call and had to return to work. I left confident that he was in good hands.
As the day went on, I never got the chance to be worried about Beau. I received phone calls from Dr. Duncan and Dot letting me know how my big guy was doing. Even though I had to leave him to go to work, I never once felt disconnected from what was going on. It was also nice that I could have stayed with him the whole time except while he was actually in surgery or recovery, if my work situation had allowed.
Later that evening, I went back to the hospital to see Beau and bring him home once he was ready for discharge. He was groggy from the drugs and he looked both funny and adorable with his head all wrapped up in a bandage. As always, he was quite happy to see me, so I sat by his bed while the staff monitored him and he became more and more alert.
As we waited for Beau to become steadier on his feet, Lorraine, the Patient Care Coordinator at AHNA, talked to me about the medication that I would have to give Beau for the next week and the special care that he would need. She also explained that Beau might whine a bit for the first 24 hours after surgery, that the whining would not be an indication of pain because he was on strong medication to prevent pain, and that some dogs whine because they don’t understand why they feel “funny” from the pain medications. I’m so glad that Lorraine explained this to me! Beau did indeed whine, and it was reassuring to know that what he needed was love and attention from us.
We followed all of Dr. Duncan’s and Lorraine’s instructions and Beau’s ear is now fully healed! His fur has grown back on his ear and you would never know that there was anything amiss with his ear.
I’m so grateful to every team member who took such excellent care of Beau that day. This is his second surgery at AHNA (the first was to remove a mass from his side), and both experiences were smooth and pleasant for Beau. I have no doubt that when it’s time for me to take him to the hospital again he will be just as excited to visit everyone at AHNA as he has always been.
From the Staff Point of View:
Good Morning Beau and Brandi! Today is a big day, the day Dr. Duncan surgically corrects Beau's ear problem. Beau has an aural hematoma, which will be explained a little later. On the morning of surgery, many things take place before the actual surgery.
After being greeted by our client care team, Brandi and Beau joined Dr. Duncan's exam room assistant, Dot, to begin the check in. Beau was in pretty good spirits but he did wonder where the famous cookies were that he normally gets when he comes to visit. Unfortunately, he wasn’t able to have any cookies this morning since he would be receiving anesthesia later.
Prior to surgery, the exam room assistants begin the admittal process by obtaining that patient’s weight, family contact information, history of how the patient is feeling recently and if any medications or food have been given. The surgeon gives the patient a physical exam and answers any questions the family may have prior to surgery.
One of the many things we are proud of at AHNA is the ability to have families stay with their pets while at AHNA. Brandi and Beau stayed together in one of our new patient glass pods. It was their very own room while Beau was at the hospital. The nursing team is able to monitor the patients while giving families room to relax. Each patient is provided soft, clean and comfortable bedding, water, and whatever else they need to have a low stress stay. Human family members are also provided with comfortable chairs, water or soda, and magazines to help pass the time. It helps decrease both the family and the patient's stress by being able to stay together, and Beau really enjoyed having his mom there. Whether a patient is in the hospital for a surgical or dental procedure or for an illness, our nursing staff monitors and records vitals, administers medications, and observes the patients while they stay with us. They work hand in hand with the veterinarians to give individual care to each patient. The nurses also spend time comforting patients, reassuring them, keeping them company, walking dogs outside in our dog walk area, cuddling with the dogs and cats, and keeping the beds neat and clean among numerous other tasks. Beau rested with his mom before his surgery.
About 30 minutes before his surgery time, Beau received an injection of a mild tranquilizer to help him relax, and a narcotic to help prevent pain. After Beau was relaxed from his pre-medications, he joined Jen, our lead surgery technician, in the surgery prep area. Once a patient is moved to surgery prep, we want all our attention focused on the patient, so families are asked to wait in the treatment room or waiting room. In this area, Beau is prepared for surgery. With Mick’s help, Jen starts by shaving an area on Beau's leg to place the intravenous catheter. The hair is clipped to allow us to see the vein and clean the skin for placement of the IV catheter.
After the catheter was placed, Beau received a short acting IV injection to make him immediately fall asleep. This injection allows an endotracheal tube to be placed for the delivery of oxygen and the gas anesthesia that will keep him under anesthesia for the procedure. He was also hooked up to the monitors that record his respiratory and heart rates, temperature, oxygen saturation, and blood pressure. This allows the technicians and doctor to monitor, adjust vitals and drugs as needed. Beau also received fluids through his IV catheter to help support his kidneys.
Before surgery the ear must be shaved and cleaned for the incision site. Jen patiently shaves Beau's ear (see above photos). You can see how swollen the ear is. (photo below) Poor Beau. He is asleep so it doesn't bother him to have it shaved.
After the cleaning of the surgery site, Jen injects a local anesthetic to numb the nerve that supplies the ear. Even though he’s asleep during the surgery and won’t feel anything, this injection, called a nerve block, will allow a lower plane of general anesthesia (safer) and prevent any discomfort in the ear when he wakes up. The whole time Jen is monitoring and recording Beau's vitals.
Once finished in the surgery prep area, Jen accompanies Beau into the sterile surgery suite with Dr. Duncan.
Dr. Duncan Explains Aural Hematomas (ear hematomas):
Ear hematomas are caused by increased shaking of the head or trauma to the ear flaps. Discomfort from an ear infection is the most common cause of the head shaking and scratching or rubbing the ears. The ear flap contains two layers of cartilage with small blood vessels between them, so the centrifugal force of shaking or the trauma of scratching or rubbing can cause rupture of these very small blood vessels resulting in pooling of blood between the layers of cartilage. This accumulation of fluid can be reabsorbed by the body, but it is a very slow process. Meanwhile, there is pain due to pressure of fluid within the space.
Diagnosis of an ear hematoma is relatively easy based on clinical signs and palpation of the ear. Ear swabs and ear otoscopy are very important diagnostic tools to check for infections of the ear canal or other underlying causes such as ear polyps. Video otoscopy, where the ear canal and drum can be seen on a screen, is a specialized instrument that helps us to visualize the deeper ear canal and ear drum to identify abnormalities that may not be possible with a simple handheld otoscope. We are fortunate to have this technology available to our patients at AHNA so that we can fully examine the ear drum and detect middle ear infections.
Correction of an ear hematoma is typically accomplished with surgery. Many different techniques can be performed. In Beau’s case, the procedure involved making an incision in the ear flap to drain the fluid, then placing sutures through the affected portions of the ear flap. These sutures create scar tissue to seal the cartilage back together with the goal of preventing fluid accumulation. The incision was left open to heal on its own. A light pressure bandage was placed around the head to help control bleeding. Sutures are usually removed in 2-4 weeks.
Post-operative pain management is very important. This may include anti-inflammatories, pain medications and antibiotics. In addition, treatment of any ear infection or any other underlying cause is imperative in prevention of future ear hematomas. The prognosis for complete recovery, just like Beau had, is very good.
Staff Point of View Continued:
Jen then finishes the surgery with cleaning and bandaging Beau's head. The bandage helps put pressure on the incision to reduce post-operative bleeding, and keeps Beau from shaking his head and reinjuring his ear.
Emily, one of our Certified Veterinary Technicians, sat with Beau after surgery in our recovery area. All of our patients who receive anesthesia have a technician sit with them, monitoring and recording vitals and keeping them warm and comfortable as they wake up. Emily removed the endotracheal tube once he was awake enough. Beau was nice and snuggly warm while lying on the warm water circulating mat, along with a warm air Bair hugger (blanket) on top of him. He enjoyed being cozy. Beau stayed in recovery until he was stable and awake enough to go back to bed. Once Beau was out of recovery, Brandi was able to sit with him until he was ready to go home.
When Beau was ready to go home, Lorraine went over Beau's discharge instructions with Brandi and made sure she knew what to watch for at home. Beau was a great patient. Brandi was a great support for Beau!
By: Dr. Susan Wootten
Jake is a beautiful and beloved 10 ½ year old neutered male Himalayan who has been a long term patient under the care of Dr. Plankenhorn at the Animal Hospital of North Asheville. His history over the last 7 months has shown us that we can see the same kind of hormonal imbalances in cats that we commonly see in dogs and people. Endocrinopathies are diseases that affect the glandular organs of the body and can cause hormonal imbalance. These glands include the pancreas, the thyroid gland, the pituitary gland, and the adrenal gland.
Jake’s problems began when he started having inappropriate urination in October of 2012. He was drinking more water, and urinating outside of his litter pan. Blood tests and a urinalysis were consistent with early Diabetes. Diabetes mellitus (sometimes known as sugar diabetes) is a commonly diagnosed disease in cats and ultimately can affect multiple organs. It occurs due to inadequate production of insulin by the beta cells in the pancreas or a resistance by the body to insulin. Insulin is secreted directly into the circulation and enables glucose or sugar to enter the cells where it is metabolized for energy. Without insulin, the cells cannot utilize glucose and elevated blood sugar levels result. In diabetic cats, this excessive amount of glucose is eliminated by the kidneys, which results in thirst and more frequent urination.
Diagnostic testing for diabetes includes testing for hyperglycemia (elevated blood sugar levels), and glucose or sugar in the urine. Because cats can experience elevated blood sugar due to stress, we sometimes use a blood Fructosamine level to tell the difference between a stress-induced high blood glucose level and a more persistent elevation as occurs in diabetes. Fructosamine testing gives an “average” glucose reading over the previous two weeks, rather than at a single point in time.
Dietary management and daily injections of insulin help to regulate most diabetic cats. Recent research has shown that the ideal diet for diabetic cats is a high-protein, low-carbohydrate diet as cats primarily metabolize protein, not carbohydrates, for glucose. Occasionally, an overweight diabetic cat may respond to dietary management alone and not require insulin to keep the blood glucose well controlled. Jake was started on this type of diet in October when he was diagnosed, and while it worked for a while, his blood glucose levels were not well controlled and he was started on Lantus Insulin injections in February 2013. Most cats need one or two injections a day depending on the type of insulin and their blood sugar levels. Fortunately, the amounts are very small, the needles are tiny, and most cats do not react to the injections. Jake tolerates his insulin injections very well. Blood glucose tests are then utilized to track how well the cat is responding to the insulin and how much will be needed. This testing can be performed in the hospital, or families can be taught how to obtain blood samples at home (commonly doing an ear prick) and check glucose level using a home glucose monitor for pets.
Jake seemed to be responding well to the insulin over the next 3 months, however, he started developing skin irritation that we did not believe was associated with his diabetes. He was brought in for examination by Dr. Wootten and was treated symptomatically with an appropriate course of antibiotic therapy and topical medication, but the skin condition continued to worsen. Jake then started having unexplained weight loss and progression of the skin changes that included non-healing sores, seborrhea (flaking skin), patchy hair loss, and thinning of the skin. Dr. Wootten and Dr. Plankenhorn collaborated on Jake’s condition and after performing further tests diagnosed Jake with an additional endocrinopathy or glandular organ problem, hyperadrenocorticism.
Hyperadrenocorticism, or Cushing’s disease, is a disease caused by increased circulating cortisol levels in the body. The paired adrenal glands normally produce and store cortisol which is released in times of stress and allows the body to respond appropriately (“fight or flight” hormone). In a healthy pet, the pituitary gland (located at the base of the brain) secretes a hormone called ACTH that stimulates the adrenal gland to secrete normal amounts of cortisol. In Cushing’s disease, this controlling mechanism is lost because there is either increased ACTH hormone from the pituitary gland (Pituitary dependent Cushing’s disease), or excessive amounts of cortisol released from the adrenal gland (primary adrenal tumor). Excessive cortisol levels in cats can cause many symptoms including increased thirst and urination, weight loss or weight gain, enlarged liver, curled ear tips, weakness, and skin changes as we were seeing in Jake.
A complete blood count and biochemistry profile were repeated on Jake at this time. While dogs with Cushing’s disease have some characteristic abnormalities on screening blood tests, cats frequently do not. Jake’s tests were overall normal except for his diabetes, but we knew there was more wrong with him. Diagnostic imaging with ultrasound was performed next. Naturally occurring Cushing’s disease is uncommon in cats, but when it occurs, 85% will have the pituitary dependent form and a small percentage will have an adrenal tumor that secretes too much cortisol. Adrenal tumors or enlargement cannot typically be seen on radiographs. Ultrasonography by an experienced veterinarian can be used to evaluate changes in adrenal size and shape. In Jake’s case, enlargement of the right adrenal gland was found by Dr. Earley.
In order to confirm the suspected diagnosis of Cushing’s disease, additional blood testing called a Low Dose Dexamethasone Suppression test was performed. This is a common screening test for Cushing’s disease in both dogs and cats. The pet is fasted overnight, a baseline blood sample is taken, a small amount of dexamethasone is administered intravenously, and 2 additional blood samples are taken 4 and 8 hours later. In normal animals, the injection of dexamethasone tells the pituitary and adrenal glands to stop making cortisol for a while, and the blood level goes down. If the cortisol levels are not adequately suppressed on the test, it is supportive of the diagnosis. Jake’s blood test results showed no effect from the injection, which supported the diagnosis of Cushing’s. Approximately 80-90% of feline patients diagnosed with Cushing’s disease have concurrent diabetes because cortisol interferes with the effects of insulin in the body. Successful treatment of Cushing’s disease is aimed at control of the symptoms the patient has and management of the concurrent diabetes.
Since his diagnosis, Jake has been taking a medication called Trilostane to help manage the excessive cortisol levels in his body. The most common physical examination findings in feline patients with Cushing’s disease are skin related. One of the more serious complications includes Feline Fragile Skin Syndrome where the skin is extremely thin, and can be torn or bruised easily making them more prone to secondary skin infections. Jake has been treated with antibiotic therapy and pain management for this particular complication. He proudly wears his “muscle shirt” at home to protect his fragile skin from trauma. It may take weeks to completely respond to the medical treatment of Cushing’s disease, but he already has more energy and is gaining weight. We are all hoping that Jake has a successful outcome with treatment!