Thursday, October 7, 2010

Cleft Palate - It's either there, or it’s not. (It was)

Let me tell you about an interesting (and strange) case I had a few weeks ago. A young couple (actually, they weren’t all that young, but now that I’m 50, everyone seems young.)( Sigh.) brought their 7 month old kitten in for a second opinion. Their little kitty had a snotty nose and had been sneezing for weeks. The nasal discharge was primarily from the right nostril. The previous veterinarian prescribed antibiotics, which helped a little, but never cleared it up completely. So he tried a second course of antibiotics, which again caused a little improvement, but it went right back to the profuse sneezing and nasal discharge as soon as the antibiotics were through. So he tried a different antibiotic. The owners were getting frustrated at this approach (you can’t really blame them), so they brought the cat to my hospital, Manhattan Cat Specialists.

I examined the kitty, and found her to be a bright, energetic, healthy little thing. Except for the snotty right nostril. While standing on the exam table, she sneezed and sprayed our wall with the nasal discharge. Lovely.

Young cats often develop polyps in their nasal cavity, and these lead to chronic snotty nose and noisy breathing. I was thinking that this might be the case with this kitten, but listening to her breathe, it didn’t sound like a polyp. Cats with polyps breathe like bulldogs or pugs, i.e. very noisy. You can hear them across the room. This kitty was breathing normally. On my examination, however, I found the problem right away: in the roof of her mouth was a tiny little hole! This is known as a cleft palate.

A cleft palate is a congenital defect; kittens are born with it. If the hole is big, food that is taken into the mouth will go through that hole into the nasal cavity, irritating the sinuses and causing infection, which is what was happening here. I pointed out the hole to the clients. There was much oohing and aahing.

Treatment requires surgical repair. This is something that I have only attempted once, 20 years ago, and I didn’t feel comfortable repairing this one myself. I recommended a well-known referral center (whose name I will withhold). This center has a department specifically for oral/dental problems in cats.

A few days later, I received a faxed report from the doctor that examined the kitten. To my great surprise, they said that they anesthetized the cat, examined the mouth thoroughly, probed every tooth, and concluded that there was no cleft palate! Since this cat did not have a surgical disease, they concluded, they did not do any surgery, and they were going to send her back to me for further investigation of the cause of her respiratory problems.

Okay, this is weird. This is not some subjective interpretation of an ultrasound image, where two doctors differ in opinion. This is a hole. Either it’s there or it’s not. So I called and spoke to the doctor. He happened to be an intern. He told me in person (well, on the phone) that he looked and there simply wasn’t a cleft.

Silence.

I can hear him breathing on the phone. I know what he’s thinking. He’s thinking I’m crazy. Meanwhile, I know what I’m thinking. I’m thinking he’s crazy.

I call the owner. He said he thought it was weird, because he saw the hole with his own eyes during our exam. We thought, hmmm, it was so small. Maybe it closed up? But the cat still had the snotty nose and the sneezing. In the end, we decided to schedule the cat for rhinoscopy, a procedure where you look up the nostril using a rhinoscope – a long rigid tube with a light source and camera on the end.

The cat comes in the following week. We anesthetize her and start preparing her for the rhinoscopy. As we open her mouth to insert the tracheal tube, what do I see on the roof of the mouth? The freakin’ cleft! Grrrrrr!!!


Fortunately, I had my trusty iPhone with me, and took a picture of the cleft, as you can see. I also took a picture with a wire inserted into it, so there is no mistaking it.



To be complete, we continue with the rhinoscopy, just to rule out a foreign body or tumor (highly unlikely) as the cause of the cat’s nasal problem.

I am a strong proponent of the rule that “thou shalt not speak ill of another veterinarian”, there really is no way around this one. Again, this is not a case of differing subjective opinions. It’s like pregnancy: either you are, or you’re not. This cat has a cleft. So I contacted the head of this referral institute by e-mail and by voice mail. My e-mail was very direct. Photos were attached.

I received a response instantly. The head of the institute was clearly embarrassed and contrite. He agreed to see the cat again, and to set things right. The problem now, though, is that cleft palates are rare in cats, and no one in their dental department had ever really done one. But…they were going to ask the surgeons in their surgery department if they wanted to tackle it. (They tried to convince me to recommend to the client a CT scan of the head to get a really good look inside the nasal cavity, because they had a super high-powered state-of-the-art top-of-the-line new CT scanner. I told him to knock it off; the cat’s problem is the cleft, so just fix it, dammit. He sheepishly backed down.)

The following day, I heard from one of their surgeons. She said that she hadn’t done one, but she had been reading about them and that she saw the photos, saw that it was a small one, and was up to the challenge. They agreed to do this at a major discount. I give them credit for that.

Well, this story has a happy ending. The surgeon successfully repaired the cleft, as you can see.

 
There’s a nice little row of dissolvable sutures in the palate. The cat’s nasal discharge and sneezing immediately resolved. The owners said that the cat is not only no longer sneezing and slinging snot everywhere, but she is just happier in general; a totally different cat.

I love when cases end like this.
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