FIND OUT WHY
This is a very long post…sorry…I'm looking for suggestions. I have many more radiographs and pics, too many to post.
(history is from memory as I forgot to bring file home).
Gizmo is a 15 -16 YO MC shih tzu. He has never had dental work. He presented on April 5th with a 2 day history of anorexia. On PE I found a prominent “gland” right submandibular (unsure if L.N. or salivary gland) w/ edematous swelling extending ventrally. Rest of PE was normal. We took neck films awake that day (attached). FNA of area showed PMNs. He wouldn't allow good oral exam, but from what I could see teeth looked ok, no excessive halitosis or gingival irritation. No drooling present either.
We ran bloodwork (CBC/CHEM/T4, UA) gave him a metacam injection and started him on Clavamox and discussed anesthesia/dental and more xrays.
She returned a few days later. Still not eating, can't get ANY clavamox into him. Bloodwork was ALL fine!! so we gave him a Convenia injection and another injection of Metacam and sent her home with Metacam to continue at home. He was hydrated and had not lost any weight (she was getting SOME food into him). When I saw him this day, the edematous swelling had subsided, and I think if I wasn't looking for abnormalities in the submandibular area I wouldn't have picked up on anything that day.
Dental was sheduled this past Tuesday. We took full mouth films, and additional neck, open mouth, chest and abdominal films. Some of those are attached. I attached both the initial lateral neck and the one at the dentistry – you can see the difference.
Dental exam was surprisingly unremarkable for this 15 YO dog. Gums were all fine, pockets all normal. He had a few incidental teeth that needed extraction (mandibular incisors, 411, 105), he had a few retained roots (but gums quiet around area so I left), and lots of ankylosis and root resorption, but not affecting crown. There is no mandible expansion or irreguularities on palp..
I was on phone with owner during procedure explaining that I really couldn't find anything when my tech called me over to look at the drainage that was coming out of the right maxillary salivary papilla when she was holding the cheek out to clean the teeth (pics attached). it was thick material. I took cytology of the drainage…normal looking epithelial cells – NO PMNs or bacteria (he had convenia 8 or 9 day prior) mostly mucous like strands/material.
I flushed the papilla with a 23g catheter and IVF and got copious amounts of the material out…flushed until I could not express anymore material.
I was hoping I had dislodged any blockage and it would begin to drain normally, and problem would resolve……WRONG
Friday when I rechecked him. He had not lost weight, but owner said he still wasn't eating (she is getting some chicken breast into him). He seems scared to eat. She is not getting metacam into him either. She said he is opening his mouth fine, running around fine, but just won't eat. Runs to food bowl, then walks away. On exam (now that I knew it was there) I was able to express the same material from the papilla. THere was no edema in the neck, but the salivary gland area on the right side felt firm compared to the left side.
SO I boostered the Convenia, gave him another metacam injection, and told the owner to get the metacam into him (syringe feed A/D if necessary) and try to apply warm compresses to area to soften (and hopefuly facilitate drainage).
SO: Brett said DDX: infection, immune mediated inflammation (15 YO dog?), obstructing sialolith, necrotizing sialometaplasia (infarction).
I did not culture bc he was already on antibiotics at dental, and I saw no bacteria. I don't see sialolith (do you?) I don't even know what/how to dx an infarction or immune mediated inflammation.
$ is MAJOR factor in this case…she wont afford a CT or other advanced imaging…I barely got to do the dental. I might be able to culture or sent cytology on the samples I saved…I haven't sent any of the rads to a radiologist either (d/t $).
Suggestions on how I should (blindly) continue to try to treat/diagnose????