Author: drbenjamino

Generosity in the Workplace
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Generosity in the Workplace

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Jelly of the Month

Christmas Vacation – Jelly of the Month Club

Do you ever feel like Clark Griswold or do you sometimes feel like Clark’s boss Frank Shirley?

While we may not be in the same situation as Clark and Frank, generosity in the workplace can go a long way. In Christmas Vacation, Clark was dependent on his boss’ generosity and Frank had no idea how his generosity affected others – until he was abducted by Eddie and stood in Clark’s shoes.

Generosity can take many different forms. It is not just about doling out financial rewards at the “end of the year” office party, generosity can be manifested all year round. Merriam-Webster defines generosity as “the quality of being kind, understanding, and not selfish”. The word “quality” means that this is something that becomes part of who we are, not who we are during the holiday season.

Also, they use three words to describe this quality: kindness, understanding, and unselfish. This means that it is not just about giving tangible items, while this may be one part. It can be giving of one’s time and knowledge to both staff members and clients/patients. Taking the extra time to train staff members to excel in their field. Providing a means (CE lectures, etc) to improve your staff’s knowledge base. Generosity can also be extended beyond your staff and current clients and infiltrate into the community. Does your business sponsor events in the community?

While one of the key principles of generosity is not expecting a return, no one can deny the way generosity permeates into the culture of an organization as the leadership team acts from this spirit of generosity. Expect others in your team to emulate this quality and it may even become infectious within your organization.

As the current year ends and a new year begins, think of different ways you can display generosity to both your staff and clients. I would propose that generosity should be more like the “jelly of the month club”, as spoken by Eddie: “Clark, that’s the gift that keeps giving the whole year”.

-Kevin Benjamino DVM, DACVS

Copyright 2015

When to Consider a Total Hip Replacement???
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When to Consider a Total Hip Replacement???

Frankie and Ball

While the thought of a total hip replacement can conjure up thoughts of discomfort, pain and prolonged recovery, most of the time this is not the case. In dogs, total hip replacements have been performed for over 25 years and typically have great success when performed by the experienced surgeon with an experienced team. There are many reasons for total hip replacements in the dog, but the most common reason is as a treatment for canine hip dysplasia.

When considering whether a total hip replacement may be an option for your pet, a consultation with a boarded veterinary surgeon who is experienced in this procedure is the first place to start. Typically your family veterinarian can guide you in this process and make a referral to a surgical center that they trust.  When you are faced with this possible treatment option, you will be overwhelmed with questions and the biggest being, “is this the right thing to do for my pet?” My goal is to try to answer some of the commonly asked questions by owners. While I may be biased since I am a veterinary surgeon, I have also been on the owner side of the equation with my own dog with bilateral hip dysplasia (see Frankie’s Journey).

What are the common indications (reasons) why a total hip replacement would be recommended?

This is one of the biggest questions that I hear and there are actually many reasons that a total hip replacement may be recommended. The most common reason is chronic hip dysplasia. While we see hip dysplasia less than a few decades earlier, we do still see this potentially debilitating disease with some frequency. Hip dysplasia refers to a hereditary issue that induces laxity (looseness) within the hip. This looseness causes subluxation or luxation of the affected hip. Subluxation refers to movement of the femoral head partially out of the acetabulum. Think of a ball and socket joint and the ball(femoral head) is popping out of the socket(acetabulum) with movement. Luxation refers to the femoral head completely coming out of the acetabulum. This alone can cause pain and lameness in puppies and young dogs. In some dogs, they learn to navigate without much discomfort, but the joint will start to develop chronic arthritic changes and cartilage wear that go on to cause pain and discomfort. While we term a total hip replacement an end stage procedure, this just means that in dogs with chronic hip dysplasia and arthritis we always try medical/conservative management prior to surgery. There are dogs that, despite medical management and rehabilitation, are still painful and require surgical intervention; or dogs that need to be on medications continuously for the rest of their lives to be comfortable which would also qualify as a total hip replacement candidate.

Frankie's pre-operative x-rays. Bilateral hip dysplasia.

Frankie’s pre-operative x-rays. Bilateral hip dysplasia.

Other indications for a total hip replacement would include fractures associated with the hip, especially when associated with the femoral head and neck. Traumatic hip luxations are another indication. This is where the hip “pops” out of the joint due to excessive force, such as a dog that has been hit by a car. We do see congenital, chronic hip luxations and acute, non-traumatic luxations, however these cases tend to be at a heightened risk of complications with a total hip replacement. Your surgeon will review the options if your dog has this type of condition. Another indication would be for avascular necrosis of the femoral neck – this is a condition where the blood supply to the femoral neck is altered and reduced during the growth phase. Subsequently the femoral neck and head undergoes cell death (necrosis) which leads to deformation and eventual fracturing. This is more commonly seen in small breed dogs.

What types and sizes of dogs are candidates for a total hip replacement?

We generally think of total hip replacement for larger dogs, which used to be the case. The typical dogs that receive this type are surgery are the retriever and shepherd breeds, since we see hip dysplasia in these dogs more commonly. The standard weights of dogs tend to be 40 pounds and over, however that is changing. With the onset of smaller instrumentation and implants, we now can implant a total hip replacement in a dog as small as five pounds and in some cats.

Isn’t my dog too young for a total hip replacement?

While there are certain age related requirements, there aren’t any exact age requirements. Most of the requirements are based on growth plate closure associated with the femur and in particular the greater trochanter, which generally is closed at around 9-10 months of age (older in giant breed dogs). Some clients will ask, “isn’t my one year old Golden Retriever too young?” My response is “no” if the patient is painful and not responding to the conservative management. The implants themselves have a life span of >15 years, generally exceeding the life expectancy of the pet.

The converse of whether the pet is too young for a replacement is the questions as to whether the pet is too old for the procedure. With older dogs, we need to look at the entire health of the patient and ensure that the patient does not have any other related or unrelated illnesses. Total hip replacements still may be recommended in our geriatric patients.

Frankie's post operative radiographs. Left total hip replacement.

Frankie’s post operative radiographs. Left total hip replacement.

What should I expect on my initial consultation for a total hip replacement?

Every surgeon conducts their examinations differently, so here is a brief overview of a standard consultation that I would perform. Obtaining an accurate history is imperative, so be sure to be upfront with what you are seeing at home, when lameness started, what side is most affected, and ALL medications that your pet may be on or may have tried in the past related to treating lameness.

A full physical examination will be conducted looking at general health, orthopedic and neurologic health. During the general examination we are looking for any other issues that may be just as or more important than your pet’s lameness. Some examples are dental disease (potential infection source), heart murmur/cardiac disease, masses palpated on skin, abdomen or on rectal examination, and skin health. Skin infections (even mild) NEED to be treated prior to surgical consideration due to implants being used.

A full orthopedic exam is needed to rule out any other common orthopedic disease such as cranial cruciate ligament (ACL) tears, medial patella laxations, etc., which may require surgical treatment before considering a total hip replacement. A complete neurologic examination is also needed as neurologic disease would be cause for concern.

Below is a summary of the initial consultation:

– Complete examination

– Sedated X-rays. Most patients (even the best behaved patients) will require sedation for radiographs (x-rays) of the hips. We use these x-rays for measurements of implants, so they must be PERFECT. Remember that the reason your pet is seeing a surgeon is because of hip pain, and the positioning of the x-rays may cause some discomfort, so the kindest way to acquire radiographs is with sedation.

– Blood work: Complete Blood Count (CBC), Chemistry profile, and Urinalysis. This needs to be performed at the MOST 30 days prior to surgery to ensure that your pet is a good anesthetic candidate.

– In older patients, additional diagnostics may be recommended such as chest radiographs and an abdominal ultrasound to get a complete health screen.

Assuming your pet is a good candidate for a total hip replacement the procedure will be described to you in detail along with the potential complications, recovery period/rehabilitation, and overall outcome. If for some reason a total hip replacement is not a good choice or another issue is found, other treatment options will be reviewed in depth. I always mention to owners to allot enough time for the consultation since a lot is performed on that first visit.

Will both hips need a replacement?

Every surgeon may have a differing of opinions on this. My thoughts reflect the more conservative viewpoint of 20% of dogs with disease in both hips, need hip replacements in both hips. We tend to see a large amount of patients compensating very well when one hip is replaced. That being said there are some dogs that do require both be performed. The typical time frame for performing surgery on the second side is about six months (sooner in a small number of patients).

Are there other hip procedures other than a total hip replacement?

There are four main surgeries available for hip dysplasia in the dog. The first two have strict time frame/age requirements. The first is called a Juvenile Pubic Symphodesis (JPS) which is a procedure that fuses a growth plate that allows the acetabulum (cup/socket) to cover the femoral head (ball) better. This must be performed in dogs under 6 months of age, before the growth plate closes on it’s own. The second procedure is called a Double/Triple Pelvic Osteotomy (DPO). This is performed ideally in dogs under 10-12 months of age and prior to development of any arthritis. This procedure improves the coverage of the acetabulum over the femoral head and can be very effective in dogs with subluxation rather than luxations.

The two main surgical interventions for adult dogs with hip dysplasia are the Total Hip Replacement (THR), which is the scope of this article and the Femoral Head Ostectomy (FHO). The femoral head ostectomy is a procedure where the femoral head is removed and not replaced. This removes the painful source of the femoral head as it contacts the surface of the acetabulum. This is performed with a degree of frequency in small breed dogs and cats, but is considered in some cases of larger breed dogs. There are some cases where this procedure is the best option, however it has been seen that overall use and function of the limb is diminished when compared to a successful total hip replacement. In some studies, an unsatisfactory result (decreased range of motion and decreased muscle mass) has been described in as high as 40% of cases where a FHO was performed.

The total hip replacement is a procedure that replaces both the femoral side (femoral head and neck) and the acetabulum. This procedure when successfully performed allows for normal, uninhibited movement of the new hip and generally allows for a full recovery. This procedure has been done in many working dogs (police dogs, service dogs, etc.) in which the dog is able to resume its normal “job”.

Are “cementless” implants better than “cemented” implants?

There are definitely pluses and minuses to both systems. “Cementless” implants are also thought of as press fit and have a surface where the bone grows into the implant. “Cemented” implants are held in place by a polymerizing bone cement and is as strong as it will be once it solidifies and dries. We do see a slightly higher risk of infection around the implants with the cemented implants as well as what is termed “aseptic” loosening. Where the bone anatomy allows, we strive to use the “cementless” implants.

What are the potential risks and complications that could occur after a total hip replacement?

During the initial consultation we always cover potential complications. While the total hip replacement procedure has a high success rate, there are always potential complications. The first type of complication would involve implant complications, which can be exacerbated if the post-operative instructions are NOT strictly followed. Our patients, after all, are dogs and will not regulate their activity appropriately, herein lies the owner’s responsibility. If the patient is too active the more common type of complications are implant shifting, luxation of the hip, fracturing of the femur, femoral stem subsidence, and seroma formation. The first three complication would require another surgery. Other complications could include infection (short and long term), aseptic loosening of the implants, etc.

What is the outcome for my pet after a total hip replacement? 

In general, the outcome for the total hip replacement patient is quite good. Ideally the success rate of total hip replacements in the appropriate patient is around 92-95%. The return of function is typically very good and restoration of normal range of motion and improved musculature. The typical recovery/rehabilitation period is about 3 months in total, however it is a gradual ramping up of activity. As I tell my owners, if I can do it with my own dog, you can do it!!

– Frankie one day after a total hip replacement.

– Frankie (and Vinnie) 1 and 1/2 years after his total hip replacement.

The Importance of Direct Communication
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The Importance of Direct Communication

Jacksonville Beach

Now before I get started, I will say that this is a topic that I personally struggle with on a daily basis (ask my wife). The more technology advances the more difficult it becomes to have direct, meaningful communication. Maybe it isn’t more difficult, but the alternative of indirect communication becomes easier and easier. I was walking on the beach recently (where the photo above came from) and saw a couple enjoying the sunrise and the waves. On a closer look (no I am not acting as the creepier version of Rob Lowe on the DirectTV ads) both were fully absorbed in their online life on their cell phones. Maybe they were “liking” that video of a singing and dancing cat, who wouldn’t?! It baffled me to think of coming to the beach for a breathtaking sunrise, only to be checking out Facebook; to each their own.

The real question is how often do we find ourselves, like the beach goers, exchanging quality time that could be spent building a relationship with a loved one, co-worker, or client with increasing our online presence? I am not saying that our online presence is to be ignored, it is a great tool that can help build relationships and improve our marketplace visibility. What I am saying is to be careful that we are not exchanging real relationship building opportunities for our mobile devices. Think of this way, Jon Acuff writes in “Do Over” about being present and gives the following scenario (albeit paraphrased): Each of us have been on the receiving or the giving end of the following scenario, you are in the middle of a conversation and either you or the other party pulls out their phone and scrolls through the contents. Who knows what they are doing, probably checking the weather or “liking” a post from a friend, but whatever it is, they have effectively put you on “pause”. Without speaking a word they have said “hang on a minute, because this is more important than what we are currently discussing”. This scenario happens on a daily basis and I am just as guilty of it as the next person.

The applications can be made to ones personal life, however I will let you formulate your own “real life” examples – I never pretend to be a psychologist. What are the professional correlations? Think of your business relationships (staff and clients) as you would your personal relationships for a minute, both demand time and nurturing or at some point when you look up from your computer or mobile device, they may be gone as well as an opportunity. Remember, the art of personal communication cannot not be captured in a text, email, or hitting “like” on social media; it requires time, attentiveness, and work for both parties involved. So much can be gained by a person’s facial expression and body language that gets missed with the indirect communication described above. In your professional life, try devoting more time to one-on-one direct communication, it WILL payoff!

Kevin Benjamino DVM, DACVS
Copyright @ 2015

Events + Response = Outcome
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Events + Response = Outcome

Sunrise in Florida

EVENTS + RESPONSE = OUTCOME  (E + R = O)

Whether you are a football fan or not, this simple formula can change your life. If you are a hermit (or just don’t like sports) you may not have heard a little bit of Ohio State’s football team’s tumultuous journey this past year, just in case read the link below. If nothing else, it will at least give you some inspiration. Some may say that sports are over-rated and hold no real life application, but to those nay-sayers it at least gives us tremendous insight into the word “Teamwork” which is invaluable to any business and life in general, which is a topic for future discussion. No one wants to be that lone vessel floating away in the current of life, everyone needs a “team”.

Unfortunately, many times we cannot dictate the EVENTS in our life, both the good events and the bad. Everyone has a mix of good and bad events (even the people that seem to have all the luck).  In some respects, this part of the equation is uncontrollable (not totally). The totally controllable variable is the way we RESPOND and we determine that part!  We all know the people that seem happy throughout all types of life events, as well as the people who drag you down and are out-right depressing through both the good and the bad life events (these individuals can suck the life right out of you). In the end the outcome or result of the event will be molded by our response. In bad events, it can be particularly hard to see something positive and it requires an act of our will. In good events, this response is easier, but we must also make a conscious effort to acknowledge and give credit where it is due.

Business Application:

We have all been there, where one of our patients may not have had the desired outcome, such as developing a catastrophic complication or worse may arrested or past away during a procedure. This type of event (for veterinarians and physicians alike) will happen and is something that not only deals a firm blow to the owner and family, but also affects us as well. Once this event has occurred, often the next step is communication with owner/family. It is extremely important that this be handled appropriately and with compassion. If not, the emotion with these types of events can spiral in a whirlwind of misplaced accusations and resentment of and for both parties.

Another less intense example:

We have all had those days where we wonder “why did I get up this morning”? When everything seems to go wrong from the minute you step out of bed. Maybe you stepped on a vomited hairball in bare feet (kidding, I’ve done that) or maybe the toilet overflowed right before you were going to leave, or you pulled a muscle during your morning workout.  Whatever the cause, your mood is less than stellar when you come into work on Monday morning. As you walk into work, there are five charts of client callbacks and it isn’t even 8:15am yet! Oh yeah, you have three emergency transfers from the emergency room and an 8:30am recheck appointment (that showed up early) and standard new patient appointments starting at 9:00am. It is at that point that you need to stop yourself and think -“I can’t control WHAT I need to do, but how can I respond positively to these events?” My gut response may be to turn around and walk back to my car, however that would be a less-than desirable response. Remember your team (whether you are a boss, associate, or employee) is dependent on you and your positive response will not only help you get through the day, but inspire the team to rally around you and help you through these events. You may also notice that a positive response may start to determine the events that occur in your life. The events in our life are not left to fate, if so both Warren Buffett and Bill Gates were extremely lucky.  Instead their decisions and responses helped mold the events in their lives.

While these events may sound extreme, I think we have all been through our own version of them. We all know that the days can be very, very long when we respond poorly. Inspire yourself and the team around you with a positive response – I promise, you WILL see results!

The Power of Ohio State’s Positive Thinking

 

Kevin Benjamino DVM, DACVS

Copyright @2015

Seeing the Forest Through the Trees
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Seeing the Forest Through the Trees

Bainbridge Island

One of my main reasons for starting this blog was to reach people who may be in need, in distress due to the current condition of their pet, or just plain curious about different disease mechanisms. I tried to address multiple surgical conditions in the dog and cat, because I am a surgeon and try to approach things in a calculated, methodical nature. My overall goal is to help people and pets.

I never in a million years thought I would be writing articles and/or blogs (some may wish I didn’t). I do want to thank the following that I do have to this website. Writing and grammar, not arguably I’m sure, have never been my strong suit. If you wondered if I was a little off, you probably could have guessed – I am LEFT handed. Yes folks, I follow in the footsteps of some famous people: Michelangelo, Ty Cobb, and the list goes on. You would have thought that being left handed would have made me right brained and lean towards, the arts, writing, etc, however I don’t and I am sure my high school English/grammar teacher would have a visceral, gut wrenching response to my writings (I am trying extra hard to paint a picture, just for her).

While I will continue writing posts about disease processes and various cases that are seen through the hospitals at Affiliated Veterinary Specialists, I would like to change focus from time to time, addressing topics that may surpass the practice of veterinary medicine and deviate into the emotional, communication, and management world. How many times have we found ourselves immersed in situations where we have been overwhelmed either with the medical condition of our pet or the declining medical condition of a loved one and thought “if only my doctor would listen to me, to my questions, and concerns”? At times we may feel like the tree falling in the middle of a dense forest – never heard or noticed. At times, we may be the doctor who is trying their best to communicate the gravity of a medical condition to a client or patient and don’t know how to chose our words properly or are rushed by the overbooked schedule we allow. It is not that there is fault to be given, but is there a better way, can we teach ourselves to be a more articulate, caring professional? Can we manage our time better to be a more caring and compassionate professional; for that matter can we maximize our time both at work and at home? How many times do we feel drained emotionally when we come home and don’t have enough compassion for the ones who are supposed to matter most to us? What is the bigger picture, can we “make out the forest through the trees”?

Obviously, there are a lot of topics to discuss and with time and diligence we will cover the big topics. I will try to pull from my own life lessons and the life lessons of others, both professionally and personally (and I will try to make them short and light if possible). As a professional, there are times I do my job well and there are certainly times that I could have communicated differently or acted differently for a more desired outcome. I do expect that some of my future topics will leave me open and vulnerable. I am always open to constructive criticism. For me this altered direction is about self improvement as well – ask my wife how well I separate work and home life, on second thought don’t.

I will leave with this one thought (OK it will be a long thought, I am long-winded). I remember vividly January 1, 2000 sitting in the packed waiting room of a hospital emergency room, while my grandfather was being admitted for congestive heart failure. Being twenty-one years old and that it was New Year’s Day, this wasn’t exactly what I had in mind to say the least. I would have rather been home watching bowl games and celebrating the new year with my friends and family, however I learned a very important lesson that I have taken with me since that lonely day. It was just me in the waiting room filled with people waiting their turn, some in more serious condition than others (many nursing their New Year’s Eve hangover). I can remember the scene like it was yesterday: an elderly man in a wheelchair came up to me and we exchanged the normal small talk and discussing the football games that were being played that day. He asked me where I went to school and what my plans were after school. My answer was well rehearsed, since I knew that I wanted to be a veterinarian from a very early age. I told him my current status of having applied to various veterinary schools when he abruptly stopped me and gave me this word of advice: “No matter what you do, if you are able to help people and animals ALWAYS treat that opportunity as a blessing and a privilege”. It was obvious that he had his run in with the medical profession and I am sure he had both positive and negative experiences. He was right, I was blessed, I had my veterinary school interview at Ohio State University (where I would eventually attend) the day before my grandfather passed away – it was his dream that I go to veterinary school. That man, whom I do not know his name and can barely remember his face, touched a young man that day and it is my goal to impact others in a similar way.

Kevin Benjamino, DVM, DACVS

Copyright 2015

Laryngeal Paralysis
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Laryngeal Paralysis

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Spring and summer bring about so many good things: the beach, warm weather, family gatherings, to name a few; and then some bad things: bugs, sweltering heat and humidity, allergies, and the list goes on. For your pets, especially your older retrievers and short nosed (brachycephalic) breeds like the pug and bulldog, the heat and humidity can spell danger due to airway conditions. For more information on the brachycephalic dog breathing issues, see my other post  http://wp.me/p2vvxS-2R . This article will focus on a condition called laryngeal paralysis which typically affects our large breed dogs, such as the Labrador Retriever and similar breeds, although it has been seen in cats (rarely) and is a defined disease process in horses.

What is laryngeal paralysis?

Laryngeal paralysis can be as bad as it sounds. The larynx is at the back of the mouth and allows the passage of air into the windpipe (trachea). In the video below, it mimics swinging doors and the cartilages (arytenoid cartilage) that form the larynx will open when breathing “in” (inspiration) and open when breathing “out” (expiration). It remains closed during other actions, like eating and swallowing, thus stopping food, water, saliva from going down the trachea. There is a muscle that controls the opening of these cartilages. The muscle (cricoarytenoideus dorsalis muscle) sits on top of the cartilages on both sides and actively contracts to open the cartilages during inspiration. The opening of the cartilages when exhaling is passive as the air blows open the cartilages. Laryngeal paralysis is a condition where the nerves that feed this muscle are not working properly and the muscle atrophies and is nonfunctional – hence the larynx is paralyzed and can’t move normally.

What causes this condition???

In most dogs, we do not know the reason for this condition. We divide the condition into two general types: 1. congenital and 2. acquired. In congenital, this condition is usually seen at an early age and is thought to be hereditary. Some common breeds affected are Siberian Huskies, Bulldogs, Rottweilers, etc. In the second form (acquired), it simply means that the disease occurs secondary from other issues. When we think of causes we have to ask ourselves, what can cause damage/changes to the nerve (recurrent laryngeal nerve) that feeds the cricoarytenoideus dorsalis muscle? Conditions that we evaluate for typically are as follows: cervical (neck) tumors, chest/lung tumors, myasthenia gravis, peripheral neuropathies, previous neck (cervical) trauma, and endocrine diseases. Most of the time, we do not find a direct cause and suspect an undiagnosed peripheral neuropathy as the underlying cause. When we do not know the actual cause we term the disease “idiopathic”. Some recent studies (Stanley, et al) have shown that most (if not all) patients with idiopathic laryngeal paralysis will begin to display some generalized neurologic signs within 1-2 years following the diagnosis.

What are the signs of acquired laryngeal paralysis???

Typically, this affects our larger breed dogs, with the Labrador Retriever being the poster child for this disease. The dogs affected are generally middle to older in age, and either male or female. The most common signs noticed is difficulty breathing, especially when exercising or excited and gagging/coughing when eating/drinking. This is a progressive disease, so signs usually begin with mild changes and become more severe, which can be over months to years. You may also notice a change in the pitch of your dogs bark (voice). Most of the time, we can arrive at a presumptive diagnosis just listening to your pet breathing. As the disease progresses, the affected dog becomes more at risk, and can have a respiratory emergency if not managed appropriately, which can be fatal. Below is a video (the audio is most important) of a dog with laryngeal paralysis:

What diagnostics are involved with laryngeal paralysis???

To begin, a thorough general and neurologic examination is needed for your pet. At minimum, a complete blood work, including a thyroid screening panel, and chest (thoracic) x-rays are needed. The importance of these is to look for other disease processes that may be going on and to ensure that the major organs are functioning appropriately. Why the thyroid panel? Hyopthyroidism (low thyroid hormone production) can cause various neuromuscular issues. With the chest x-rays we are looking for any masses, changes to the esophagus size (megaesophagus) and signs of aspiration pneumonia, which can be seen secondary with laryngeal paralysis. Because most of the patients I see with this condition are older and we are assessing for surgery, I highly recommend an abdominal ultrasound by an experienced ultrasonographer to look for any other concurrent diseases. Bear in mind, if your pet is in a respiratory crisis some of these steps may be done out of order to adequately stabilize the patient.

The best way to confirm the suspected diagnosis of laryngeal paralysis is to look directly at the larynx and assess the functioning of the laryngeal cartilages. This is typically done by inducing a light plane of anesthesia and looking at the back of the mouth. The proper assessment is sort of an art and takes practice to be comfortable making the diagnosis. In addtion to evaluating the larynx, time is taken to look at the rest of the oral cavity for other potential causes. As a surgeon, my preference is to do this examination directly prior to surgery to minimize the amount times the pet needs to undergo anesthesia.

Below is a video demonstrating laryngeal paralysis. The laryngeal opening can be seen and you will notice that it is not moving much at all during the phases of breathing.

How can I treat my pet once laryngeal paralysis is diagnosed???

Probably the better questions is when do I treat? Once a diagnosis is made, then a decision needs to be made. Since this is a progressive disease, if only one side of the larynx is affected then surgical options will most likely be delayed. The most typical treatment for idiopathic laryngeal paralysis is surgical. To date, there is no medical therapy that will restore the function of the larynx. Conservative management will typically incorporate ways to keep your pet cool (air conditioned environment), sedation possibly, and decreasing environmental allergens. If, during our pre surgical diagnostics, we find other issues, changes may be made to the treatment plan. There are some findings that may make your veterinarian reconsider your pet being a good surgical candidate, such as an enlarged esophagus (megaesophagus). The main reason to proceed forward with surgery is to improve your pets quality of life for however long that may be, as well as improve your (as the owner) life by providing more quality time together. There are risks both with surgery and without surgery.

The standard procedure to open the airway is called an arytenoid lateralization (laryngeal tie-back). This is a procedure that pulls one side of the laryngeal cartilages back, permanently opening one side of the larynx. In effect, we override the normal muscular action of the larynx. We gain access to the larynx by an incision made on the side of the neck. None of the work is done within the mouth. There are other procedures that remove the arytenoid cartilage portion of the larynx to permanently open the larynx from within the mouth, called an arytenoidectomy. This procedure, in my opinion, has not been evaluated as much as the “tie-back” procedure.

Below is a picture of an arytenoid lateralization. Notice the difference on the opening from the previous video.

Tie back

What are the risks with and without surgery and what is the typical outcome?

No procedure is without inherent risks, unfortunately. The risks and benefits of any procedure must always be weighed and discussed with your veterinarian and veterinary surgeon. The most common post-operative complication is aspiration pneumonia. Recent literature cites about a 12-15% risk of aspiration pneumonia following surgery, with the most critical time period being the actual recovery from surgery and the immediate post-operative period. Some medications can be administered that help reduce vomiting, regurgitation and increasing the tone of the lower esophageal sphincter muscle – all aimed at lowering this risk. Most of the time aspiration pneumonia, if caught early, can be treated successfully with antibiotic therapy and supportive care (depending on severity). In a small number of patients, aspiration pneumonia can be fatal. Other complications are break down of the “tie-back” suture and incisional complications such as seroma and abscess/infection. Anesthesia complications can arise with any anesthesia/surgical event, however with proper screening, this risk can be minimized. My feeling is that even dogs prior to a “tie-back” procedure have a higher risk of aspiration pneumonia because the protective mechanism of the larynx is not functioning properly.

Surgically addressing this condition can be life saving and drastically improve the quality of your pets life. Most owners (~90%) are happy they made the decision to proceed forward with surgery and are pleased with the improved quality of life for their pet. If you notice any of these changes to your pet, please plan to see your veterinarian to see if they are a candidate for surgery. While the above article is long, it does not include everything related to this disease, if you have questions, just ask!!!

Kevin Benjamino, DVM, DACVS

Copyright  2015

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Meet Faith!!!

Meet Faith!!!

Meet Faith!!!

Faith is an adult, mixed breed dog that came to Affiliated Veterinary Specialists – Orange Park from a local rescue group (SAFE Pet Rescue) in the Jacksonville, FL area. She was found and brought to a local shelter and had sustained multiple injuries. We suspect that her injuries were most likely caused by being hit by a car. Unfortunately, her injuries are chronic in nature, probably about 4 weeks old and she has learned how to scoot around and pull herself with her front end.

Left tibia/fibula fracture

Left tibia/fibula fracture

Right hip luxation

Right hip luxation

Her major injuries are a right hip luxation and left tibia/fibula fracture. She has normal neurologic function in the hind legs, however she has no support in the back legs……..until surgery. In addition to her orthopedic issues, she also is heartworm disease positive. The decision was made to address the orthopedic conditions in order to get her mobile and then focus on the heartworm disease. The heartworm disease always makes anesthesia more complicated, but with the proper precautions, she did great. Due to the chronicity of the hip luxation, a femoral head ostectomy was performed and the left tibia/fibula fracture was repaired.

Right femoral head ostectomy

Tibia/fibula fracture repair

Just two days after surgery she is starting to stand on her own and take some steps forward. She is very sweet and has determination. She will make a great addition to someone’s home when she recovered. It is exciting to know that she has been given a well deserved second chance. Please go to the SAFE Pet Rescue website:  http://www.safe-pet-rescue-fl.com or following them on Facebook: SAFE Pet Rescue to learn more about Faith and other adoptable dogs!!

Faith

Faith says “Hello”

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Pet Rehabilitation

Check out the new page on http://www.drbenjamino.com

Pet Rehabilitation.

Primary Lung Neoplasia (tumor)
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Primary Lung Neoplasia (tumor)

Primary lung tumors are cancers that we as veterinarians see with less frequency than in human medicine, when we are both looking for them and when we are not looking for them. What I mean by that statement is sometimes the patient (dog or cat) may be displaying signs associated with a tumor in the lungs and sometimes they are not and we find them during routine chest radiographs (x-rays). While lung cancer generally conjures up a visceral negative reaction in most people, many primary lung tumors can be managed successfully giving the patient a good quality of life for some time. We do find that dogs tend to have a better prognosis with primary lung tumors than do cats, unfortunately. What do I mean by primary lung tumor? A primary lung tumor is a tumor originating within the lung tissue that is the sole tumor versus metastatic nodules within the lungs, which are smaller tumors scattered in the lung due to a tumor originating from another organ.

What are signs of a lung tumor?

Unfortunately, many primary lung tumors do not have associated signs and we find them by chance if we are looking in the chest. The good and bad is that we would always prefer to provide treatment (surgery) in a patient that does not have signs, however the bad part is that these tumors can get very large before seeing signs. The most common signs seen are respiratory symptoms including coughing, exercise intolerance, excessive panting for a variable duration of time and variable frequency. Very rarely will a patient present with blood, fluid, or air in their chest due to the tumor. More infrequent would be presenting with a condition called hypertrophic osteopathy – swelling and pain in limb(s) related to a lung tumor.

How do we diagnose a lung tumor?

CT scan of the chest showing the lung tumor (see arrow)

CT scan of the chest showing the lung tumor (see arrow)

The typical way to diagnose a primary lung tumor is with radiographs (x-rays) of the chest. If a large solitary mass is seen, it is suspected to be a primary lung tumor. Another was to visualize a primary lung tumor would be to perform a CT (computed tomography) scan of the chest. A CT scan gives us excellent detail of the mass and allows a very in depth view of the rest of the lung tissue for evaluation. Some advocate for a fine needle aspirate of the mass (sticking an needle in the mass to get a representative sample of cells) prior to discussing surgery. Typically a solitary lung mass will be a pulmonary adenocarcinoma and a fine needle aspirate will only yield a diagnostic result only 60-70% of the time. Many believe (myself included) that surgery is the next step for a diagnosis. Prior to surgery a minimum staging database should be acquired. This includes (in addition to chest x-rays and/or chest CT scan) complete bloodworm with urinalysis and an abdominal ultrasound (or contrast CT scan). This is to evaluate body organ function and the presence of metastasis or other non-related issues, since most patients with a primary lung tumor fall into the geriatric age category, it is not uncommon to uncover other issues.

What is the treatment for a primary lung tumor?

Excised lung tumor

Excised lung tumor

The standard treatment for a primary lung tumor is surgical removal. At this juncture (or earlier) your primary veterinarian may recommend that you consult with a board certified veterinary surgeon due to the intricacy of the procedure and the “around the clock” care your family member will require following surgery (if your veterinarian does not offer this service). Generally, surgical removal of the tumor is the standard of care for treatment of this disease. Smaller tumors can sometimes be removed by thoracoscopy (minimally invasive scoping of the chest), however a very experienced anesthesia team is need to provide one lung lobe ventilation to the pet. Usually the tumor is accessed by a lateral thoracotomy depending on the which side of the chest the tumor is located. The tumor is isolated and the affected lung lobe is removed (various techniques can be used). I prefer removal with a Thoracoabdominal (TA) stapling device. In all surgeries, a chest tube is placed for 12-24 hours following surgery.

What type of cancer is a primary lung tumor?

The most common tumor type is a pulmonary adenocarcinoma in both the dog and cat. When a histopathology report is generated, we usually look to see whether the tumor is well-differentiated or poorly differentiated, which can give us some indication regarding the metastatic nature of the tumor. Other types of tumors such as squamous cell carcinomas, sarcomas and benign tumors are very rare.

What is the prognosis for a primary lung tumor? 

The information on cats and prognosis after removal of a primary lung adenocarcinoma is limited, however the results seem to be not as favorable for this species. Also, the survival rate is very dependent on whether there is any sign of metastasis (lymph node involvement, nodules elsewhere, malignant effusion (fluid) in the chest and/or abdomen). In some reports, cats with signs of metastasis following surgical removal have a survival rate of < 3weeks.

Dogs with this disease tend to have a much more favorable prognosis with >50% of dogs with a solitary lung tumor (no metastasis) living > 1 year following surgery with good quality of life. Factors that can change our prognosis include large size of tumor, lymphatic involvement, pleural effusion, etc.

I always encourage my clients to speak with a board certified veterinary oncologist about follow-up care for these patients. More and more we are finding that we may be able to extend our pets quality of life with various chemotherapy options by slowing the recurrence or spread of disease following surgery.

Authored by:

Kevin Benjamino, DVM, DACVS

Copyright 2015

January 2015 Case of the Month – Happy New Year!!!
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January 2015 Case of the Month – Happy New Year!!!

Mieka

Happy New Year, 2015!!! Meet Mieka, she has made the January 2015 Case of the Month (COTM). Read on to hear about her story!!!

Mieka was selected for the COTM and rightfully so, her story began about a year ago and her total recovery took about 6 months. She is a sweet Pomeranian with a vivacious personality, as you will see in the videos below. She can be quite demanding, but with all that she has been through, we will let it slide.

Mieka presented when she was 7 months of age. She was adopted when she was 2-3 months old and according to her owners never really walked normally. As she developed and got older, her walking declined to the point that she would not place normal weight on the hind limbs and would walk with an arched back and her hind legs crossed. Below is a video of her at the initial presentation.

Based on the examination and x-rays taken, her diagnosis was complex with severe expression of congenital/hereditary diseases affecting both her stifles/knees, patellas (knee caps), and hips (hip dysplasia and bilateral hip luxation – out of socket).

It is fairly rare to see these conditions, this severe in such a young dog. We see knee cap/patella issues very commonly in small breed dogs – but not this severe. She has what is called medial patella luxation (Grade 4/4), this is where the knee cap slides inward and in her case both were permanently fixed in the wrong position. Due to the severity of the knee caps, the attachments points on the tibia were also malformed as well as the bottom part of the femur. As for her hips, she had severe hip dysplasia to the point where the hips would “pop” out of joint during motion. Here are some pictures and x-rays that show some of the deformities.

Note the hind limb deformities and the crossing over of her legs.

Note the hind limb deformities and the crossing over of her legs.

Note the positioning of the hind legs.

Note the positioning of the hind legs.

Note that her patellas are located inward and that on this x-ray the left hip is out of joint.

Note that her patellas are located inward and that on this x-ray the left hip is out of joint.

Not to bore with all the details of surgery, but four surgeries were planned for Mieka. We decided to start with the left side, however both were bad. We corrected the alignment in her knee by correcting the deformities in the tibia and the femur and then secured the patella. In order to correct the alignment, we had to cut the bones (tibia and femur) and adjusted with a plate and screws. Once she began to heal from that surgery, we addressed the hip by performing a femoral head ostectomy (removal of the femoral head).

Note the more normal appearance of the tibia, femur and patella.

Note the more normal appearance of the tibia, femur and patella.

With the assistance of the physical therapy department and the dedication of her owners, she rapidly began to improved. As soon as she was strong enough on the left side, the right side was tackled. The same procedures were performed on the right side as well as intense physical therapy following surgery. Below is Mieka about two months after the last surgery. You can see how demanding she can be as she makes herself known. We are thrilled to see her do well.

The shortness of this post underscores the journey Mieka endured. She has definitely earned a case of the month distinction and more. Way to go Mieka!!!