A 13-year-old female domestic shorthair cat presented to the veterinarian after the owners noticed blood on furniture and on the cat's food bowl. The cat had a history of excessive grooming that was attributed to flea allergy. Blood tests revealed a mild elevation in glucose and a regenerative anaemia. A Bipedicle Mucoperiosteal Flap was used to treat palatine arterial haemorrhage secondary to hard palate ulceration in three cats.
A 13-year-old female domestic shorthair cat presented to the veterinarian after the owners noticed blood on furniture and on the cat's food bowl. The cat had a history of excessive grooming that was attributed to flea allergy. Blood tests revealed a mild elevation in glucose and a regenerative anaemia. A Bipedicle Mucoperiosteal Flap was used to treat palatine arterial haemorrhage secondary to hard palate ulceration in three cats.
A 13-year-old female domestic shorthair cat presented to the veterinarian after the owners noticed blood on furniture and on the cat's food bowl. The cat had a history of excessive grooming that was attributed to flea allergy. Blood tests revealed a mild elevation in glucose and a regenerative anaemia. A Bipedicle Mucoperiosteal Flap was used to treat palatine arterial haemorrhage secondary to hard palate ulceration in three cats.
A 13-year-old female neutered domestic shorthair cat presented to the referring veterinarian after the owners had noticed blood on furniture and on the cats food bowl. The cat had a history of excessive grooming that was attributed to flea allergy. The cat was being treated every three weeks with topical fipronil 1 . Ulcers on the hard palate were identified and the cat was referred to the Valentine Charlton Cat Centre. Further physical examination findings were pale mucous membranes, a heart rate of 240 beats per minute, a grade IV/VI systolic heart murmur and alopecia over the ventral abdomen. A linear ulcer (2 x 0.5cm) was present on the left side of the hard palate midway between the midline and the dental arcade (Fig 1a). A second, circular (0.8cm diameter) ulcer on the right side of the hard palate was noted caudal to the central incisors (Fig 1a). Diagnostic Tests Blood tests revealed a mild elevation in glucose and a regenerative anaemia (Table 1). The cat was blood typed 2 (blood type A) and a 50mL type A blood transfusion was given prior to surgery. Treatment At surgery, the cat was placed in dorsal recumbency with the jaws taped open for maximal exposure of the hard 6 Aust Vet Practit 37(1) March 2007 CASE STUDIES Use of a Bipedicle Mucoperiosteal Flap to Treat Arterial Haemorrhage from Palatine Ulcers in Three Cats CJ Bailey, PLC Tisdall a , JA Beatty b , A Lingard b and VR Barrs b North Shore Veterinary Specialist Centre 64 Atchison Street, Crows Nest, NSW 2065 a Veterinary Specialist Centre PO Box 307, North Ryde, NSW 1670 b Valentine Charlton Cat Centre Faculty of Veterinary Science, University of Sydney, NSW 2006 Aust Vet Practit 37(1) March 2007 6 ABSTRACT Anovel surgical treatment for palatine arterial haemorrhage secondary to hard palate ulceration is described in three cats. The owners first noticed external haemorrhage in all cases. Determination of the exact site of haemorrhage was not always possible on visual inspection because bleeding was intermittent. Severe anaemia was present in all cats and two cases required blood transfusion. Surgery was performed to ligate the palatine arteries and cover the ulcerated regions of hard palate with sliding bipedicle mucoperiosteal flaps. The flaps remained viable and stopped ongoing haemorrhage from the erosive lesions successfully in all cases. [Bailey CJ et al (2007) Aust Vet Practit 37:6] Ph: 02 9436 1213. Fax: 02 9906 5710 Email: cjbailey@iprimus.com.au 1 Frontline, Merial 2 Rapid Vet-H Feline desk-top blood typing kits, Agrolab, Switzerland (Australian distributor IDEXX laboratories)
PALATINE ULCERS palate. Both palatine arteries were ligated blindly at the caudal extent of the hard palate with simple interrupted 3/0 poliglecaprone 25 3 sutures (Fig 1b). An incision was then made along the lateral margin of the palatine mucosa immediately adjacent to the left dental arcade. The lateral edge of the ulcer was incised to enable elevation of the mucoperiosteum with a periosteal elevator, leaving the caudal and rostral bases intact to create a bipedicle mucoperiosteal flap. This flap was transposed over the linear ulcer deficit then sutured to the incised medial edge of the ulcer using simple interrupted 4/0 poliglecaprone 25 sutures 3 (Figs 1c & 1d). The lateral palatine bone was left to granulate. A short unipedicle mucoperiosteal flap was elevated and transposed to cover the circular ulcer on the right side (Fig 1e). Amoxycillin-clavulanic acid 4 was administered (8.75 mg/kg sc) at the time of surgery followed by a seven-day course (12.5 mg/kg po bid). An Elizabethan collar was applied post-operatively to prevent overgrooming. Excess salivation was noted in the first 24 hours but no further haemorrhage was observed. Analgesia was provided with buprenorphine 5 0.01mg/kg sc qid and soft food was introduced 24 hours after surgery. Two weeks after surgery the mucoperiosteal flap appeared intact and viable, the exposed hard palate had a bed of granulation tissue and the PCV was 0.34L/L. In addition to flea control, a food elimination diet was recommended to further investigate the overgrooming. Three months post-operatively the mouth had completely healed. CASE 2 Case History and Clinical Examination A 14-year-old female neutered domestic shorthair cat was presented to the referring veterinarian because the owners noticed profuse bleeding from the cats mouth. A palatine ulcer was identified extending longitudinally for 2cm on the right side of the hard palate and crossing the midline at the rostral aspect (Fig 2). Haemorrhage appeared to originate from the linear part of the ulcer. At initial presentation blood tests (Table 1) revealed mild anaemia and pre-renal azotaemia (urine specific gravity >1.055). Twenty-four hours later the PCV had decreased to 0.19L/L and the cat was referred to the Veterinary Specialist Centre, North Ryde. Abnormalities noted on physical examination were the ulcer, a grade II/VI systolic heart murmur and the presence of flea dirt in the coat. Aust Vet Practit 37(1) March 2007 7 7 Aust Vet Practit 37(1) March 2007 HAEMATOLOGY AND BIOCHEMISTRY Parameter Case 1 Case 2 Case 3 Reference Range Haematocrit (L/L) 0.15 0.270.19 0.10 0.30-0.45 Total Plasma Protein (g/L) 71 74 84 59-78 Red Cell Count (x10 12 /L) 3.55 n/a 2.60 6.0-10.0 Hb (g/L) 50 n/a 27 80-140 MCV (fl) 42.3 n/a 38.5 40-45 MCH (pg) 14.1 n/a 10.4 13-17 MCHC (g/L) 333 n/a 270 310-350 Platelets (x10 9 /L) n/a 478 634 200-700 Uncorrected Reticulocytes % 3.6 n/a 9 0-1.0 Absolute reticulocyte count (x10 9 /L) 128 n/a 234 50 White Blood Cell count (x10 9 /L) 18.2 n/a 12.2 8.0-14.0 Neutrophils (x10 9 /L) 9.65 n/a 11.71 3.76-10.8 Lymphocytes (x10 9 /L) 6.01 n/a 0.24 1.6-7.0 Monocytes (x10 9 /L) 0.18 n/a 0.24 0.08-0.56 Eosinophils (x10 9 /L) 1.82 n/a 0.00 0.16-1.4 Basophils (x10 9 /L) 0.36 n/a 0.00 0-0.14 Bands (x10 9 /L) 0.18 n/a 0.00 0-0.42 Urea (mmol/L) 6.92 37 13.7 7.2-10.7 Creatinine (mol/L) 126 167 214 90-180 Glucose (mmol/L) 10.4 9.4 8.90 3.6-6.6 ALT (IU/L) 25 43 47 <60 ALP (IU/L) 23 37 76 <50 FIV status n/a n/a Negative TABLE 1: Haematology and biochemistry. n/a = not available. 3 Monocryl, Ethicon 4 Clavulox, Pfizer 5 Temgesic, Reckitt Benckiser
PALATINE ULCERS Aust Vet Practit 37(1) March 2007 8 8 Aust Vet Practit 37(1) March 2007 FIGURE 1b: Ligation of the left and right major palatine arteries in the region where they exit the palatine foramina of the hard palate. FIGURE 1a: Erosive lesions on hard palate of Case 1. L=left, R=right. Arrow points to smaller lesion. FIGURE 1c: Elevation of a bipedicle mucosal flap. FIGURE 1d: Mucosal flap transposed medially and sutured to cover the palatine ulcer. FIGURE 1e: Short unipedicle mu- cosal flap covering smaller ulcer. Arrows point to exposed areas left to granulate. FIGURE 2: Erosive lesions on hard palate of Case 2, appearing as mirror image of Case 1. FIGURE 3a: Erosive lesions on hard palate of Case 3, similar to Case 2. FIGURE 3b: Healed mucosal flap in Case 3, 11 months post-operatively.
PALATINE ULCERS Diagnostic Tests and Treatment The cat was blood typed on admission (blood type A). The PCV had increased to 0.24L/L before surgery (TPP 76g/L). Since the cat was clinically stable, blood transfusion was not performed. At surgery, a biopsy was taken from the cranial edge of the linear ulcer and submitted for histopathology. A similar surgical technique to that used in Case 1 was performed: horizontal mattress sutures using 4/0 polydioxanone 6 were placed at the caudal aspect of the ulcer to ligate the right palatine artery. The bipedicle mucoperiosteal flap was transposed over the linear ulcer deficit on the right side and sutured to the incised medial edge of the ulcer, using simple interrupted 4/0 polydioxanone sutures. Post-operative care, including analgesia, antimicrobial therapy, feeding and provision of an Elizabethan collar, was similar to Case 1. Monthly topical flea control with fipronil was prescribed. On histopathology the biopsy tissue was composed of hyperplastic stratified squamous oral epithelium with underlying dense connective tissue. Within the connective tissue there was interspersed granulation tissue. There was no evidence of a neoplastic process, haemosiderosis or an ischaemic cause such as a thrombosed vessel. The cat re-presented four days after discharge because the owner had noticed bleeding from the mouth. The mucoperiosteal flap was intact and viable with no evidence of haemorrhage from that site. However, a small focal point of haemorrhage appeared to originate from a small ulcer on the left side of the rostral hard palate. Blood tests revealed a PCV of 0.26L/L and TPP of 76g/L. Surgery was performed to ligate the left palatine artery and appose the ulcer edges with 4/0 polydioxanone horizontal mattress sutures. At examination four weeks later, the mouth had completely healed. No recurrence of the ulcer occurred. The cat developed an invasive mandibular lesion two years later and was euthanased. CASE 3 Case History and Clinical Examination A seven-year-old male domestic short hair cat presented for lethargy and inappetence. The owner had noticed a small amount of blood on the cats lips and firm black faeces had been observed. Physical examination revealed a heavy flea burden, very pale mucous membranes and ulceration of the hard palate in an L-shape (3 x 0.5cm on right side of hard palate with a short narrow extension across to the left side at the rostral margin; Fig 3a). Diagnostic Tests Severe regenerative anaemia was identified on haematology with results consistent with iron deficiency anaemia secondary to chronic blood loss (Table 1). Treatment The cat was typed, treated with fipronil and given a 50mL type A blood transfusion before surgery. Both palatine arteries were ligated and the linear ulcer was covered with a sliding bipedicle mucoperiosteal flap as described for the previous cases. The short narrow ulcer on the right side was small enough to have the edges apposed using horizontal mattress sutures without creating excessive tension. Post-operative care was the same as for Case 1 with the addition of ferrous sulphate 81.5mg po sid and topical imidocloprid 7 every four weeks. The PCV 10 days post surgery was 0.26L/L and the mouth was healing well. Eleven months post- operatively there had been no recurrences of palatine ulceration but the residual healed areas were still visible (Fig 3b). DISCUSSION Palatine arterial haemorrhage in the cat was first reported in 1990 (Wildgoose 1990). In that case, a small erosion was located on the hard palate level with the anterior aspect of the second premolar tooth, 4 to 5mm from the midline. Profuse haemorrhage was identified from the erosion which overlaid the right major palatine artery. Haemorrhage was controlled with electrocautery (Wildgoose 1990). Menrath & Miller (1995) subsequently reported a cat with a bleeding palatine erosive lesion that resulted in severe blood loss anaemia. They postulated that the pathogenesis of these lesions was excessive licking/grooming as a result of a pruritic skin condition. The cat was given a blood transfusion and horizontal mattress sutures were placed across the width of the erosion (Menrath & Miller 1995). Many aetiologies can cause ulcerative lesions in the oral cavity of the cat but, typically, these do not result in significant oral haemorrhage. Aetiologies of oral ulcerative lesions in the cat include eosinophilic granuloma complex (Frost & Williams 1986, von Tscharner & Bigler 1989, Pedersen 1992), Calicivirus infection (Hoover & Kahn 1975, Pedersen 1992), neoplasia such as squamous cell carcinoma (Frost & Williams 1986, Pedersen 1992), immune-mediated diseases such as pemphigus vulgaris and systemic lupus erythematosus (Manning et al 1982, Pedersen 1992), ingestion of caustic substances and trauma (Pedersen 1992). The three cases in the current series all presented with evidence of bleeding from the mouth that was detected by the owners. However, if the cat has been repeatedly swallowing the blood, external haemorrhage may not be apparent and the extent of blood loss anaemia may be profound by the time the cat is presented to the veterinarian. Therefore, lethargy, inappetence and/or melaena may be the main presenting signs and a full physical examination should be performed on all cases to detect ulcerative lesions of the hard palate and the initiating cause of pruritis. The clinical appearance of all three lesions was similar, demonstrating longer linear erosions with defined edges on one side of the hard palate and smaller, short erosions at the rostral aspect on the opposite side. Case 2 demonstrated that haemorrhage was not limited to the larger lesion, as a second procedure was required to cover the smaller erosion. This highlights the difficulty associated with identification of the exact site of haemorrhage. Also, at the time of presentation many of these cases do not display active haemorrhage. Aust Vet Practit 37(1) March 2007 10 10 Aust Vet Practit 37(1) March 2007 6 PDS II, Ethicon 7 Advantage, Bayer PALATINE ULCERS Therefore, diagnosis is often made by pattern- recognition, in which cats presented with a regenerative anaemia and a palatine ulcer are assumed to be bleeding from the ulcer. The consistent finding was that the erosions overlay the major palatine arteries in the hard palate. The right and left major palatine arteries, which are branches of the maxillary arteries, are the main blood supply to the hard palate (Evans & Christensen 1979). They exit the palatine foramina of the hard palate at the level of and medial to the distal cusp of the upper fourth premolar (Orsini & Hennet 1992) and course forward in the palatine sulcus just medial to midway between the dental arcade and the midline (Bezuidenhout 2003). They become more superficial as they course rostrally to lie closely under the oral mucosa. Asmall branch passes through the oval palatine fissure between the canine teeth before the artery travels to the back of the incisor teeth where the vessel anastomoses with its fellow (Evans & Christensen 1979). An understanding of the regional anatomy was important for performing the surgical procedure, especially because the major palatine arteries are not directly visible. Ligation of the bases of the major palatine arteries was attempted with the dual aim of reducing intra-operative haemorrhage whilst elevating the mucoperiosteal flap and to stop ongoing haemorrhage from the palatine erosions. The mucosa of the hard palate remained viable and healed in all three cases indicating that sufficient collateral circulation exists after ligation of the major palatine arteries. Abipedicle mucoperiosteal flap was transposed over the larger ulcerated regions to provide a robust coverage of the ulcerated area. Electrocautery had been previously described in the treatment of palatine arterial haemorrhage (Wildgoose 1990) but that case involved only a small lesion and the extensive use of electrocautery in the oral cavity can be detrimental to wound healing (Fossum 2002). The use of tightly- approximated broad horizontal mattress sutures placed across the width of the erosion has also been described for the treatment of this condition (Menrath & Miller 1995). However, for larger lesions, it is not possible to appose the mucosal edges with sutures as the mucosa is not compliant and undue tension may result in wound dehiscence (Fossum 2002). The mucoperiosteal flap used in the current study for the closure of the longer linear erosive lesions was bipedicle because it supplied a better blood supply than that which would be provided from a narrow single base. The flap needed to be undermined sufficiently to allow enough mobility to be transposed medially without tension. The principles of atraumatic tissue handling were adhered to reduce the chance of dehiscence (Fossum 2002). The exposed area of the hard palate immediately adjacent to the dental arcade was left to heal with granulation tissue. Histopathology was performed on Case 2. The microscopic appearance of the tissue was consistent with the previously proposed pathogenesis of repetitive trauma from excessive licking/grooming in this particular case (Menrath & Miller 1995). The feline tongue has numerous well-developed harsh conical papillae that provide an effective rasping action for grooming and prehension (Dyce et al 1987, Menrath & Miller 1995). In the process of licking/grooming, the tongue is thought to repeatedly impinge on the hard palate in a backward rasp-like fashion with the cross- sectional shape of the tongue preferentially contacting either side of the midline over the regions of the major palatine arteries (Menrath & Miller 1995). The continual abrasion of the epithelium may result in the eventual erosion into the major palatine arteries and cause substantial haemorrhage (Menrath & Miller 1995). A possible explanation for the asymmetrical appearance of the lesions is the cats preferentially grooming to the left or right. It is unclear as to why so few feline cases with pruritis or overgrooming develop bleeding palatine ulcers and why the condition was not recognised in the literature prior to 1990 (Wildgoose 1990). Affected cats may be those that overgroom constantly. Another possible explanation for the disease pathogenesis is extension of the inflammatory process secondary to trauma-induced mucosal ulceration to involve the palatine arteries and surrounding tissues, resulting in arteritis or periarteritis of the palatine arteries. The histopathology for Case 2 was consistent with repetitive trauma rather than arteritis/periarteritis but histo- pathological anlayisis of biopsies from a larger number of cases would be useful. The haemorrhage from the palatine ulcers may be severe enough to warrant a blood transfusion as in two of the present cases. Whilst a definitive pathogenesis is not proven for these three cases, the surgical technique described proved effective in arresting ongoing haemorrhage in cats with significant anaemia. The presence of fleas or flea dirt and/or the history of overgrooming in the present case series were consistent with the previously proposed pathogenesis of repetitive abrasion from the tongue. Therefore, the authors recommend that subsequent to the surgery, an Elizabethan collar is applied to stop overgrooming in the short-term. Cats should be treated with effective flea parasiticides and other causes of pruritic skin disease should be investigated (e.g. dietary elimination trials and intradermal allergen skin testing). 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