Orofacial pain with enopthalmus

RE: Orofacial pain with enopthalmus

Jo Dyer — Thu, 10 Aug 2017 08:46:54 GMT

[quote user="Katie Blackburn"] I agree I think there is an otitis media issue here. He has a sunken eye with meiosis but a normal blink, is it possible to get partial Horners without facial nerve involvement? [/quote]

Horner's syndrome arises via damage to the sympathetic trunk at any point between the chest and the eye, causing meiosis, ptosis and enophthalmos. I saw it in a cat recently that was associated with a brachial plexus tumour, which was a new one on me!

RE: Orofacial pain with enopthalmus

Evelyn Barbour-Hill — Wed, 09 Aug 2017 22:18:04 GMT

Thank you for the update. It seems that in consultation with the owner you've reached a very reasonable plan.

RE: Orofacial pain with enopthalmus

Katie Limb — Wed, 09 Aug 2017 21:02:09 GMT

Thank you all for your advice. I agree I think there is an otitis media issue here. He has a sunken eye with meiosis but a normal blink, is it possible to get partial Horners without facial nerve involvement?

The owner refuses more diagnostics and he has improved again, so we are risking low dose meloxicam with the view to a shorter but hopefully more comfortable life.

RE: Orofacial pain with enopthalmus

Evelyn Barbour-Hill — Sat, 05 Aug 2017 15:00:35 GMT

[quote user="Jo Dyer"]

[quote user="Evelyn Barbour-Hill"]

[quote user="Jo Dyer"]It won't have been caused by ear cleaning. [/quote]

With respect – it could have been.

[/quote]

With respect Evelyn, I disagree.

Ear cleaning by a veterinary surgeon would never be on my differential list as a cause or aggravating factor for severe orofacial pain. If you have evidence to the contrary then I would be happy to reconsider.

Moreover, I think it would be quite hurtful for a clearly conscientious and competent forum newbie to be told that their care may have caused damage. Even if there was a high likelihood of that, (which there isn't), I think it would be better to put it much more tactfully, and much lower down the differential list. In this way we can be mutually supportive and not put newbies off posting on here (both the ones that post, and the ones that read the responses).

Sermon over

[/quote]

Jo, nobody suggested that the ear cleaning was the cause of severe orofacial pain. I suggested that the ocular symptoms – which we think comprise Horner's syndrome, it's not quite possible to be sure from the description – which only appeared after the ear cleaning – could have arisen from the cleaning process. Which they certainly could. Even with the most scrupulously careful procedure. There can always be an unsuspected hole in the tympanum and some substances can diffuse across the tympanum. And, depending on the method of cleaning, it's not impossible to accidentally puncture the tympanum. This does not reflect upon either the conscientiousness or the competence of the poster.

As I said, I suspect that there may be several different things going on here, and the point is that the apparent Horner's syndrome may not necessarily relate directly to the original cause of pain, although of course it may.

[quote user="Jo Dyer"]I think it would be better to put it much more tactfully, and much lower down the differential list.[/quote]

I wasn't compiling a differential list at all, let alone one arranged by likelihood. I was remarking, in passing before we got to the main business, that it was a reasonable possibility, which it is. I could have dressed it up in a whole paragraph of diplomatic verbiage, but what would be the point?

Katie, if you did actually find my remarks hurtful and you think I could have been more tactful, well, I apologise to you personally. You've handled everything well up to this point. I am indeed trying to be supportive, but my point is that despite all the useful diagnostic suggestions from other members you are too constrained in your ability to make a diagnosis and so to give any treatment if you can't at least do radiography and a few other investigations. I stand by my suggestion that you go ahead and do them anyway, unless the cat is to be euthanised quite soon. (What is the owner's attitude or opinion, by the way?)

RE: Orofacial pain with enopthalmus

Jo Dyer — Sat, 05 Aug 2017 11:03:03 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Jo Dyer"]It won't have been caused by ear cleaning. [/quote]

With respect – it could have been.

[/quote]

With respect Evelyn, I disagree.

Sermon over

RE: Orofacial pain with enopthalmus

Thomas Johnson — Fri, 04 Aug 2017 14:58:32 GMT

[quote user="Katie Blackburn"]I don't feel I can keep this poor cat on burenophine indefinitely but he certainly appears to be in pain with something in his ear, retrobulbar, TMJ region. The owner can't afford MRI, or X-rays.[/quote]

I don't have much to add as far as diagnostics and possible causes of the pain,. I'm not sure from your post if you mean that the buprenorphine appears to control the pain enough to stop him pawing at his face, or just enough to allow him to eat. If it controls the pain well then I wouldn't have too many concerns about keeping him on it long-term, obviously if he is still pawing at his face then as you say it isn't fair to just leave him on that.

RE: Orofacial pain with enopthalmus

Evelyn Barbour-Hill — Fri, 04 Aug 2017 10:09:34 GMT

[quote user="Jo Dyer"]It won't have been caused by ear cleaning. [/quote]

With respect – it could have been.

RE: Orofacial pain with enopthalmus

Jo Dyer — Fri, 04 Aug 2017 07:43:46 GMT

[quote user="Alistair Graham-Evans"]

Has this cat got Horners syndrome?

If so then probably pathology related to middle ear disease.

Unlikely to respond to anything cheap and simple unfortunately.

Brevity not impolite - in a hurry!

[/quote]

I'd second this - likely otitis interna due to ascending infection from the pharynx. X-rays of the bullae would give more information but as far as I am aware, bulla surgery is the only option for these and in a 21-year old cat with renal failure that does not sound practical or kind.

It won't have been caused by ear cleaning.

RE: Orofacial pain with enopthalmus

Alistair Graham-Evans — Fri, 04 Aug 2017 02:33:11 GMT

Has this cat got Horners syndrome?

If so then probably pathology related to middle ear disease.

Unlikely to respond to anything cheap and simple unfortunately.

Brevity not impolite - in a hurry!

RE: Orofacial pain with enopthalmus

Evelyn Barbour-Hill — Thu, 03 Aug 2017 21:49:54 GMT

There may be several things going on here.

Thanks Bill, that's something else to look into, I didn't know that.

Katie, you may have damaged the middle or inner ear while cleaning the canal. But obviously that's not the whole story.

The way forward? Well, if you don't want to recommend euthanasia and you are determined to try to do your best for this cat, you are hopelessly constrained if you can't even do some radiography.

I'd suggest just going ahead and doing some radiography anyway. (And if you are fortunate enough to have in-house MRI, do that as well). I'd want to have another GA session, endoscope the nasopharynx, examine the ear canals again, radiograph the teeth and extraction sites and the TMJ and the skull generally (you'll need intra-oral views), probe anything you can probe (for instance, the alveolus of the extracted canine tooth and maybe you can probe the orbit too), get a basic haematology or even just a white cell count, maybe some kidney parameters and calcium (kudos to Bill) if you have in-house biochemistry available.

If for some reason that's impossible I'd let the owner request euthanasia.

I'll leave it to others to suggest empirical trials of various analgesics, a glucocorticoid, gabapentin, etc.........

One clue: anything wrong in the retrobulbar region is more likely to make the eye protrude rather than retract.

RE: Orofacial pain with enopthalmus

Bill Nolan — Thu, 03 Aug 2017 20:33:27 GMT

Probably not at all related, especially given the unilateral signs, however there are reports of humans with CKD /uraemia developing facial pruritus. Or, indeed, as a result of hyper Ca++. This assumes though the occular and aural issues are a result of the pruritis, and not the other way around. I'm sure vets who are much smarter with more experience will suggest something more sensible